6100-4 DBE Program Subcontractor Utilization Form

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

Environmental
Protection Agency

Disadvantaged Business Enterprise Program
DBE Subcontractor Utilization Form
BID/PROPOSAL NO.

PROJECT NAME

NAME OF PRIME BIDDER/PROPOSER

E-MAIL ADDRESS

ADDRESS
TELEPHONE NO.

FAX NO.

The following subcontractors1 will be used on this project:
COMPANY NAME, ADDRESS, PHONE
NUMBER, AND E-MAIL ADDRESS

TYPE OF WORK TO BE
PERFORMED

ESTIMATE
D DOLLAR
AMOUNT

CURRENTLY
CERTIFIED
AS AN MBE
OR WBE?

I certify under penalty of perjury that the forgoing statements are true and correct. In the event of a
replacement of a subcontractor, I will adhere to the replacement requirements set forth in 40 CFR Part 33
Section 33.302(c).

Signature Of Prime Contractor

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 6100-4 (DBE Subcontractor Utilization Form)

Environmental
Protection Agency

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

Disadvantaged Business Enterprise Program
DBE Subcontractor Utilization 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 Utilization Form to this address.

EPA FORM 6100-4 (DBE Subcontractor Utilization Form)