Information Collection

Report of DBE Awards and Commitments

IC 25080 under ICR 201209-2105-004 · OMB 2105-0510.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2105-0510 can be found here:

Documents and Forms

Document Name Document Type
Form DOT Form 4630 Report of DBE Awards and Commitments Form
DOT Form 4630 Uniform Report of DBE Awards/Commitments and Payments DBE uniform form.pdf Form
Appendix G Personal Net Worth Statement Appendix G.pdf Form and Instruction
Appendix F UNIFORM CERTIFICATION APPLICATION Appendix F.pdf Form and Instruction
Appendix B UNIFORM REPORT OF DBE COMMITMENTS Appendix B.pdf Form and Instruction
Final DBE Rept Frm Instructions.pdf DBE Form Instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Report of DBE Awards and Commitments	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 49 CFR Part 26 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DOT Form 4630	Uniform Report of DBE Awards/Commitments and Payments	DBE uniform form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix G	Personal Net Worth Statement	Appendix G.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix F	UNIFORM CERTIFICATION APPLICATION	Appendix F.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix B	UNIFORM REPORT OF DBE COMMITMENTS	Appendix B.pdf	Yes	Yes	Printable Only

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,250	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 85 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,800	0	1,800
Annual IC Time Burden (Hours)	309,000	300,000	9,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
DBE Form Instructions	Final DBE Rept Frm Instructions.pdf	11/16/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.