Appendix G Personal Net Worth Statement

 
Appendix G
U.S. Department of
Transportation

Personal Net Worth Statement
For DBE/ACDBE Program Eligibility

OMB APPROVAL NO:
EXPIRATION DATE:

As of __________________
This form is used by all participants in the U.S. Department of Transportation’s Disadvantaged Business Enterprise
Programs as set forth in 49 CFR Parts 23 and 26 and must be submitted to determine whether an owner is economically
disadvantaged. Complete this form separately for: (1) each disadvantaged proprietor, (2) each limited partner who owns
51% or more interest and each general partner, and (3) each stockholder owning 51% or more of voting stock.
Do not make adjustments to your figures pursuant to the DBE Program Regulation. The agency you apply to will use the
information provided on this statement to determine your personal net worth. Please send form to appropriate Unified
Certification Program member, not U.S. DOT.
Full Name

Residence Address
reported to the IRS)

Business Name of Applicant Firm

(As

Business Address

City, State and Zip Code

City, State and Zip Code

Residence Phone

Business Phone

Marital Status: Married, Divorced, Never
Married, Widowed

Spouse’s Full Name

ASSETS

(Omit Cents)

LIABILITIES

(Omit Cents)

Joint
Asset?
Cash and Cash Equivalents
(Complete Section 1A)

$

Mortgages on Real Estate
Excluding Primary Residence
(Complete Section 2

$

Retirement Accounts (IRA, 401Ks, 403Bs,
Pensions, etc) (Report Full Value and
Complete Section 1B)

$

Loan on Life Insurance
(Complete Section 3)

$

Brokerage, Investment Accounts
(Complete Section 1C)

$

Notes, Obligations on Personal
Property (Complete Section 4)

$

Assets Held in Trust
(Complete Section 1D)

$

Notes & Accounts Payable to Banks
and Others (Complete Section 6)

$

Shareholder Loans & Other Receivables
(Complete section 1E)

$

Other Liabilities
(Complete Section 7)

$

Real Estate Excluding Primary Residence
(Complete Section 2)

$

Unpaid Taxes
(Complete Section 8)

$

Life Insurance (Cash Surrender Value Only)
(Complete Section 3

$

Other Personal Property and Assets
(Complete Section 4)

$

Other Business Interests
(Complete Section 5 )

$

Total Assets

$

Total Liabilities

$

ASSETS (Provide Current Account Statements)
SECTION 1A: Cash on Hand, Checking, Savings, Money Market, Certificates of Deposit
Name on Account
(including co-owners)

Type of Account
(checking,
savings, revolving
credit, IRA, other,
(explain)

Bank Name and
Address

Account
number

Account
Status
(joint, single,
trust)

Current Balance

Total
Section 1B: Retirement Accounts, IRA, 401Ks, 403Bs, Pensions
Name on Account
Type of
Bank Name and Address
(including co-owners)
Account

Account number

Current
Balance

Total
SECTION 1C: Brokerage/Investment Accounts
Name of Brokerage Firm And account number)

Type of Account

Market value
as of date of
form

Total
SECTION 1D: Assets Held in Trust: (Submit trust agreements and amendments, and document the valuation of assets)
Name of Settlor
Type of trust
Date Trust
Specific Assets held
Date and
Trustee
Names of
(revocable,
established
and Value
Method of
Beneficiaries
irrevocable,
Valuation
etc.)

Section 1E: Securities Not reported in Section 1C and Shareholder Loans, Promissory Notes and Other Receivables Not
Listed Above: Provide amount and describe:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

SECTION 2: Real Estate Owned (Including Personal Residence, Investment Properties, Personal Property
Leased or Rented for Business Purposes, Farm Properties, or any Other Income Producing property.
(List each parcel separately. Submit copies of deeds for each parcel, mortgage note, instrument of conveyance) Add
additional sheets if necessary.
Primary Residence

Property B

Property C

Type of Property
Address

Date Acquired and
Method of Acquisition
(purchase, inherit, divorce,
gift, etc.)
Names on Deed

Purchase Price
Present Market Value
Source of Market
Valuation
Name & Address of all
Mortgage Holders,
including

Mortgage Account
Number
Mortgage Balance As of
Date of Form:
Equity line of credit
Balance
Amount of Payment Per
Month/Year (Specify)

SECTION 3: Life Insurance Held
(Submit policies and most recent statement)
(Give face amount and cash surrender value of policies, name of insurance company and beneficiaries).
Insurance Company

Face
Value
Amount

Cash Surrender Amount

Beneficiaries

Loan on Policy Information

SECTION 4: Other Personal Property and Assets
(Other documentation may be required upon request, such as invoices, bill of sale, valuation documents, insurance
policies)
Total
Present
Value

Type of Property or Asset

Automobiles and Vehicles (including recreation vehicles,
motorcycles, boats, etc.) Include personally owned vehicles
that are leased or rented to businesses or other individuals.

Household Goods

Jewelry

Other (List)

Accounts and Notes Receivables
Total Present Value: $

____________

Total Liability: $

____________

Total Personal Property $

____________

Amount of
Liability

Is this asset
insured?

(Balance)

(If so, attach a
copy of the
policy)

Lien or Note
amount and Terms
of Payment
(Attach a copy of
the instrument)

SECTION 5: Other Business Investments, Other Businesses Owned (excluding applicant firm)
Sole Proprietorships, General Partners, Joint Ventures, Limited Liability Companies, Closely-held and Public Traded Corporations
(Provide the information below and submit business financial statements, balance sheets including net worth, Federal tax returns)

Name of Sole
Proprietorship,
partnership, Joint
Venture
(Indicate % of
ownership)

Address

Business
Value
in $

Date
Acquired

Names of Partners, Unit
holders, % of Ownership,
and Date Acquired

Primary scope of
Operations

Name of Corporation
or LLC

Address

Business
Value
in $

Date
Acquired

Name of Stockholders on
Certificates, Date Stock
Acquired, Total Outstanding
Shares of Stock or Units,
Market Value and Date of
Quotation/Exchange,

Primary scope of
Operations

LIABILITIES
SECTION 6: Notes and Accounts Payable to Bank and Others (Including Installment accounts)
(Submit copy of note/security agreement, and most recent account statement)
Name of
Borrower(s)

Name of
Noteholder(s)

Date of
Instrument

Original
Balance

Current
Balance

Payment
Amount and
Terms

How Secure/By Whom
Guaranteed, Collateral

SECTION 7: Other Liabilities
(Submit copy of most recent statement, or any other debt instrument)
Name of Individual
Name of
Description Name and Address
Obligated
Co-signer(s)
of Entity Owed

Date of
Obligation

Amount

Payment Amount and
Terms (frequency)

SECTION 8: Unpaid Taxes
(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches).
Name of Individual
Name of CoType of
Payable to Whom
Date Due
Amount
Property Attached with Tax
Obligated
signer(s)
Unpaid
Lien (if any)
Tax

SECTION 9: Transfer of Assets: Have you transferred, within 2 years of this personal net worth statement, transferred
assets to a spouse, domestic partner, relative, or entity in which you have an ownership or beneficial interest including a
trust? Yes No
(Provide a brief description of all transfers of assets within 2 years from date of application. List the names of individuals on deed,
title, note or other instrument receiving assets and relation to transferor.(Submit Bill of Sale or Invoice, transfer document (title,
deed, etc., date of transfer, estimate or valuation of the consideration received))

_________________________________________________________________________________________________________
AFFIDAVIT
I declare under penalty of perjury that the information provided in this application and supporting documents is complete, true and
correct. I certify that no assets have been transferred to any beneficiary for less than fair market value in the last two years. I
recognize that the information submitted in this application is for the purpose of inducing certification approval by a government
agency. I understand that a government agency may, by means it deems appropriate, determine the accuracy and truth of the
statements in the application, and I authorize such agency to contact any entity named in the application or this personal financial
statement, including the names banking institutions, credit agencies, contractors, clients, and other certifying agencies for the
purpose of verifying the information supplied and determining the named firm’s eligibility. I acknowledge and agree that any
misrepresentations in this application or in records pertaining to a contract or subcontract will be grounds for terminating any
contract or subcontract which may be awarded; denial or revocation of certification; suspension and debarment; and for initiating
action under federal and/or state law concerning false statement, fraud or other applicable offenses.
___________________________________

__________________

Signature (DBE/ACDBE Applicant)

Date

NOTARY CERTIFICATE: (Insert applicable state acknowledgment, affirmation, or oath)
In collecting the information requested by this form, the Department of Transportation (Department) complies with the provisions of the Federal Freedom of Information
and Privacy Acts (5 U.S.C. 552 and 552a). The Privacy Act provides comprehensive protections for your personal information. This includes how information is collected,
used, disclosed, stored, and discarded. Your information will not be disclosed to third parties without your consent. The information collected will be used solely to
determine your firm's eligibility to participate in the Department's Disadvantaged Business Enterprise Program as defined in 49 CFR section 26.5 and the Airport
Concession Disadvantaged Business Enterprise Program as defined in 49 CFR section 23.3. You may review DOT’s complete Privacy Act Statement in the Federal
Register published on April 11, 2000 (65 FR 19477).  

General Instructions for Completing the
Personal Net Worth Statement
for DBE/ACDBE Program Eligibility
IRAs) and other retirement accounts, including any deferred
compensation and pension plans in Section 1B.

Please do not make adjustments to your figures pursuant to
U.S. DOT regulations 49 CFR Parts 23 and 26. The agency
that you apply to will use the information provided on your
completed Personal Net Worth Statement to determine
whether you meet the economic disadvantage requirements
of 49 CFR Part 26. If there are discrepancies or questions
regarding your form, it may be returned to you to correct and
complete again.

Brokerage/Investment Accounts: Enter the name of
brokerage firm and account number; type of account and
current market value of the account as of the date of the
PNW statement.
Assets Held in Trust: Enter the specific assets held in trust,
the names of beneficiaries and trustees, and other
information. Complete Section 1D.

An individual's Personal Net Worth according to 49 CFR
Part 26 includes only his or her own share of assets held
separately, jointly, or as community property with the
individual’s spouse and excludes the following:

Securities Not Reported Above, including Shareholder
Loans, Promissory Notes, and Other Receivables not
listed: Enter amounts loaned to you from your firm, from or
any other business entity in which you hold an ownership
interest, and other receivables not listed above . Complete
Section 1E.

 Individual's ownership interest in the applicant firm;
 Individual's equity in his or her primary residence;
 Tax and interest penalties that would accrue if retirement
savings or investments (e.g., pension plans, Individual
Retirement Accounts, 401(k) accounts, etc.) were
distributed at the present time.

Real Estate: Complete Section 2, beginning with your
primary residence (be sure to identify it as your primary
residence); enter the type of property, address, method of
acquisition, date of acquired, names of deed, purchase price,
present fair market value, source of market valuation, name
and address of all mortgage holders, mortgage account
number, mortgage balance, equity line of credit balance, and
amount of payment, for all real estate held. Please ensure
that this section contains all real estate owned, including
rental properties, vacation properties, commercial properties,
personal property leased or rented for business purposes,
farm properties and any other income producing properties,
etc. Attach additional sheets if needed.

Be sure to indicate whether the figures reported are jointly
held.
If your personal net worth according to 49 CFR Parts 23 and
26 exceeds the $1.32 million cap and you, individually, or
you and other individuals are the majority owners of an
applicant firm, the firm is not eligible for DBE or ACDBE
certification. If the personal net worth of the majority
owner(s) exceeds the $1.32 million cap at any time after
your firm is certified, the firm is no longer eligible for
certification. Should that occur, it is your responsibility to
contact your certifying agency in writing to advise that your
firm no longer qualifies as a DBE or ACDBE. You must fill
out all line items on the Personal Net Worth Statement. If
necessary, use additional sheets of paper to report all
information and details. If you have any questions about
completing this form, please contact one of the UCP
certifying agencies.
Assets

Life Insurance: Enter the name of the insurance company,
the face value of the policy, cash surrender value,
beneficiary names, and any loans on the policy in Section 3.
Other Personal Property and Assets: Enter personal
property and other assets owned in Section 4. Personal
property includes motor vehicles, boats, trailers, jewelry,
furniture, household goods, collectibles, clothing, and
personally owned vehicles that are leased or rented to
businesses or other individuals. Enter the present value of
the personal property owned, amount of liabilities, and
whether the asset is insured. For accounts and notes
receivable, enter the total value of all monies owed to you
personally, if any. This should include shareholder loans to
the applicant firm, if any. If the asset is insured, please
attach a copy of the policy. Also attach a copy of any liens
or notes on the property and indicate in the space provided
the terms of payment. Total the present value and liabilities
at the bottom of the form.

All assets must be reported at their current fair market values
as of the date of your statement. Assessor’s assessed value
for real estate, for example, is not acceptable. Assets held
in a trust generally should be included.
Cash and Cash Equivalents: In Section 1A Enter the total
amount of cash or cash equivalents in bank accounts,
including checking, savings, money market, certificates of
deposit held domestic or foreign. Provide copies of the bank
statement.
Retirement Accounts, IRA, 401Ks, 403Bs, Pensions:
Enter the total present value of all accounts (including Roth

Other Business Investments/Other Businesses Owned
Interests: Enter information concerning any businesses you

value or consideration received. Submit documentation
requested on the form related to the transfer.

hold an ownership interest in, such as sole proprietorships,
partnerships, joint ventures, corporations, or limited liability
corporations (other than the applicant firm) in Section 5. Do
not reduce the value of these entries by any loans from the
outside firm to the DBE/ACDBE applicant business.

Affidavit
Be sure to sign and date at the statement. The Personal Net
Worth Statement must be notarized.

Liabilities
Mortgages on Real Estate: Enter the total balance on all
mortgages payable on real estate in section 2.
Loans on Life Insurance: Enter the total value of all loans
due on life insurance policies in Section 3.
Notes & Accounts Payable to Bank and Others: Enter the
name of borrowers, noteholders, date of note, original and
current balances, payment terms, and security/collateral
information in Section 6. The entries should include
automobile installment accounts. This should not, however,
include any mortgage balances as this information is
captured in section 2. Do not include loans for your business
or mortgages for your properties in Section 6. Submit copy
of note/security agreement, and the most recent account
statement)
Other Liabilities: Enter the total value due on all other
liabilities not classified in the previous entries. Report the
name of the individual obligated, names of co-signers, a
description of the liability, the name and address of the
entity owed, the date of the obligation, payment amounts and
terms. Note: Do not include contingent liabilities in this
section. Contingent liabilities are liabilities that belong to
you only if an event(s) should occur. For example, if you
have co-signed on a relative’s loan, but you are not
responsible for the debt until your relative defaults, that is a
contingent liability. Contingent liabilities do not count
toward your net worth until they become actual liabilities.
Unpaid Taxes: Enter the total amount of all taxes that are
currently due, but are unpaid in Section 8. Contingent tax
liabilities or anticipated taxes for current year should not be
included. Describe in detail the name of the individual
obligated, names of co-signers, the type of unpaid tax, to
whom the tax is payable, due date, amount, and to what
property, if any, the tax lien attaches. If none, state “NONE.”
You must include documentation, such as tax liens, to
support the amounts.
Transfers of Assets:
Transfers of Assets: Detail all asset transfers (within 2
years of the date of this personal net worth statement) to a
spouse, domestic partner, relative, or entity in which you have an
ownership or beneficial interest including a trust. Include a
description of the asset; names of individuals on the deed,
title, note or other instrument indicating ownership rights;
the names of individuals receiving the assets and their
relation to the transferor; the date of the transfer; and the