6100-3 DBE Program Subcontractor Performance Form

OMB Control No: _________
Approved:
_________
Approval Expires: _________

Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Performance Form
NAME OF SUBCONTRACTOR1

PROJECT NAME

ADDRESS

BID/PROPOSAL NO.

TELEPHONE NO.

E-MAIL ADDRESS

PRIME CONTRACTOR NAME
CONTRACT
ITEM NO.

ITEM OF WORK OR DESCRIPTION OF SERVICES
BID TO PRIME

PRICE OF WORK
SUBMITTED TO
PRIME CONTRACTOR

Currently certified as an MBE or WBE under EPA’s DBE Program? ______ Yes ______ No

Signature of Prime Contractor

Date

Print Name

Title

___________________________________________
Signature of Subcontractor

__________________________________________
Date

___________________________________________
Print Name

__________________________________________
Title

Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor
to provide services pursuant to an EPA award of financial assistance.

1

EPA FORM 6100-3 (DBE Subcontractor Performance Form)

OMB Control No: _________
Approved:
_________
Approval Expires: _________

Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Performance Form

The public reporting and recordkeeping burden for this collection of information is estimated to average fifteen
(15) minutes. Burden means the total time, effort, or financial resources expended by persons to generate,
maintain, retain, or disclose or provide information to or for a Federal agency. This includes the time needed to
review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting,
validating, and verifying information, processing and maintaining information, and disclosing and providing
information; adjust the existing ways to comply with any previously applicable instructions and requirements; train
personnel to be able to respond to a collection of information; search data sources; complete and review the
collection of information; and transmit or otherwise disclose the information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number.
Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any
suggested methods for minimizing respondent burden, including the use of automated collection techniques to
the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave.,
NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the
completed EPA DBE Subcontractor Performance Form to this address.

EPA FORM 6100-3 (DBE Subcontractor Performance Form)