Form 6100-1b EPA DBE Certification Application (Limited Liability Com

Environmental Protection Agency

OMB Control No: ______
Approved:
______
Approval Expires: ______

EPA DBE Certification Application
For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE)
Under EPA’s Disadvantaged Business Enterprise (DBE) Program
For Limited Liability Company
Business Profile:
Name of applicant firm:___________________________________________________________________
Name of Managing Members and Titles:_____________________________________________________
EIN:_________________________ E-mail Address:_____________________________________________
Business Address:______________________________________________ County:___________________
City:_________________________________ State:_______________ Zip Code:______________________
Phone Number:___________________________ Fax Number:___________________________________
Mailing Address (if different than above):_________________________ County:___________________
City:_________________________________ State:_______________ Zip Code:______________________
What is the firm’s 4-digit primary North American Industrial Classification (NAIC) code? _________
Are you claiming disabled status? ___ Yes ___ No. (i.e., a United States citizen who has permanent or
temporary physical or mental impairment that substantially limits one or more of your major life
activities.) If yes, please submit documentation substantiating such disability.
Is your firm at least 51% owned by a Disabled American? ___ Yes ___ No.
Is your firm certified by the Small Business Administration under its 8(a) Business Development
Program? ___ Yes ___ No. If yes, provide PRO-Net number: ___________________________________
Is your firm certified by the Small Business Administration under its Small Disadvantaged Business (SDB)
Program? ___ Yes ___ No. If yes, provide PRO-Net number: _________________________________
Is your firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes,
provide State(s) and ID number(s): ____________________________________________________________
Is your firm certified by a State government, local government, Indian tribal government, or independent
private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying
entity: ______________________________________________________________________________________
Has your firm ever been denied certification by a Federal agency, State government, local government,
Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide a copy of
the prior determination of attempts to obtain certification: ______________________________________
EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

___________________________________________________________________________
Does your firm have any other certification as a disadvantaged business entity, i.e., MBE, DBE, WBE, etc.?
____ Yes ___ No. If yes, provide State(s) and ID number(s) _______________________________________

In accordance with 13 CFR §124.103, designated group members are presumed to be socially
disadvantaged. Designated group members are individuals who hold themselves out to be and are
identified by others as Black Americans, Native Americans (American Indians, Eskimos, Aleuts, or Native
Hawaiians), Hispanic Americans, Subcontinent Asian Americans, Asian Pacific Americans, and any other
groups designated by the Small Business Administration (SBA). If an individual is claiming to be a
member of a designated group, complete Section A of this application. If an individual is not claiming to
be a member of a designated group, complete Section B of this application. All applicants must complete
Sections C, D, and E of this application.

EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

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SECTION A

Eligibility Statement - Designated Group Members
Social Disadvantage
1.

List all individuals claiming disadvantaged status:
Name of Individual

Other Last
Names Used

U.S. Citizen
Y/N

Place of Birth

Group Membership

Sex
M/F

________________

__________

__________

___________

________________

____

________________

__________

__________

___________

________________

____

________________

__________

__________

___________

________________

____

________________

__________

__________

___________

________________

____

2.

Is at least 51% of each class of member interest unconditionally owned by one or more disadvantaged
individuals? ___ Yes ___ No.

3.

List all individuals claiming disadvantaged status.

Name of Individual

Other Last
Names Used

U.S. Citizen
Y/N

Place of
Birth

Group
Membership

Sex
M/F

__________________________

___________

________

___________

_______ ___

____

__________________________

___________

________

___________

__________

____

__________________________

___________

________

___________

__________

____

3a. If you are a naturalized United States Citizen, please provide the following as Attachment A-1:
(a) naturalization number; (b) date of citizenship; and (c) county, state and court.

SECTION B

Eligibility Statement - Non Designated Group Members
Social Disadvantage
1.

Is at least 51% of each class of member interest unconditionally owned by one or more disadvantaged
individual? ___ Yes ___ No.

EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

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2.

2a.

List all individuals claiming disadvantaged status:
Name of Individual

U.S. Citizen
Y/N

Race

Sex
M/F

_______________________________

________

________

_____

_______________________________

________

________

_____

_______________________________

________

________

_____

_______________________________

________

________

_____

If you are a naturalized Citizen, please provide the following as Attachment B-1:
(a) naturalization number; (b) date of citizenship; and (c) county, state and court.

For this section, each individual claiming social disadvantage must provide a separate response for
questions 3 through 5.

Social Disadvantage
3.

I, ____________________________________ have personally suffered social disadvantage based on
my identification as __________________________________.
(A claim of social disadvantage must include at least one objective feature that has contributed to
social disadvantage, such as race, ethnic origin, gender, physical handicap, long-term residence in
an environment isolated from the mainstream of American society, or other similar causes not
common to individuals who are not socially disadvantaged.)

4.

Document how your ability to compete in the free enterprise system has been impaired by such
things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses or
leases; restriction of your market to certain racial, ethnic or social groups; underemployment or
unemployment, etc., as compared to others in the same or similar line of business who are not socially
disadvantaged. Provide as Attachment B-2.

5.

Attach a narrative describing how you personally experienced social disadvantage in American
society. When writing your narrative, be as specific and detailed as possible. Where applicable, each
statement of alleged discrimination should be supported by documented evidence such as affidavits,
denials of loan applications, denials of employment opportunities (including non-selection for
particular jobs, denials of promotions, or unequal work environment or treatment), and documents to
support any formal action taken by you because of alleged discrimination. You must demonstrate
how your identification, as described in the paragraph above, has negatively impacted your entry
into or advancement in business. You must address disadvantage in education, employment, and
business history, where applicable. Examples of discrimination include, but are not limited to:
unequal access to colleges or professional schools; exclusion from professional or business
associations; being denied educational honors or recognition; experiencing discriminatory social
pressure which discouraged you from pursuing a professional or higher education or forced you into
non-professional or non-business fields; discrimination in employment opportunities or pay and
fringe benefits; unequal access to business credit or capital; and discrimination in the awarding,
bidding process, or negotiating of government or private sector contracts. Provide as Attachment B-3.

EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

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SECTION C
(All applicant firms must complete)

Economic Disadvantage
1.

Is the net worth of each individual(s) claiming disadvantaged status less than $750,000, excluding
your ownership interest in the applicant firm and equity in the individual(s) primary residence?
____ Yes ____ No.

2.

For individuals claiming disadvantaged status, list your personal net worth, excluding the
ownership interest in the applicant firm and the equity in the individual(s) primary residence.

3.

Name

Average 2-year
Income

Personal
Net Worth

Total
Assets

________________________________

______________

__________

__________

________________________________

______________

__________

__________

________________________________

______________

__________

__________

________________________________

______________

__________

__________

Each individual listed in number 2 above, certifies that because of racial and/or ethnic prejudice,
and/or cultural bias, his/her ability to compete in the free enterprise system has been impaired
due to diminished capital and credit opportunities as compared to others in the same or similar
line of business that are not socially disadvantaged.

SECTION D
(All applicant firms must complete)

Ownership
1.

If more than one class membership interest, provide information for each class:
Voting
a) Total number of interests authorized:
b) Total number of interests currently outstanding:

2.

_____
_____

Non- Total
Voting
______ _____
______ _____

List all individuals, entities, and/or trusts, which have a membership interest in the applicant
firm.
Name

Voting

Membership
Non-Voting

Percent
Total

___________________________ ____________________

______

__________

______

___________________________ ____________________

______

__________

______

EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

Title

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3.

Do disadvantaged individuals receive at least 51% of the annual distributions of dividends paid
on the membership interest of an LLC applicant firm? ____ Yes ____No ____ N/A. If no or not
applicable (N/A), please explain as Attachment D-1.

4.

Will disadvantaged individuals receive 100% of the unencumbered value of each share of
membership interest in the event that the interest is sold? ___ Yes ___ No. If no, please explain
as Attachment D-2.

5.

If the LLC dissolves, will disadvantaged individuals receive at least 51% of the retained earnings
and 100% of the unencumbered value of each membership he or she owns? ___Yes ___ No. If
no, please explain as Attachment D-3.

6.

Is ownership by any individual claiming disadvantaged status subject to conditions precedent,
conditions subsequent, executory agreements, voting trusts, shareholder agreements, or other
similar arrangements, which may impact the unconditional ownership of such individuals?
___ Yes ___ No. If yes, explain as Attachment D-4.

7.

Have there been any changes in ownership in the last year? ____ Yes ____ No. If yes, did
ownership affect the disadvantaged status of your firm? Please explain as Attachment D-5.

8.

For community property residents only. If you are a married disadvantaged owner, and your
spouse is not disadvantaged, please complete the chart below, and provide evidence that you
have a majority interest in the business.

9.

Name of Disadvantaged Owner

State of Residence

Percent Transferred

__________________________________

_______

_____________

__________________________________

_______

_____________

__________________________________

_______

_____________

__________________________________

_______

_____________

Has any individual(s) listed in number 2 above transferred any assets within two years, in full or
in part, to a spouse or any other person or entity, including a trust? ___ Yes ___ No. If yes,
provide the following information as Attachment D-6: the date of transfer; to whom the assets
were transferred; amount paid for the assets; and the market value of the assets at the time of
transfer. Individuals may exclude assets transferred to an immediate family member that are
consistent with the customary recognition of special occasions, such as birthdays, graduations,
anniversaries, and retirements. Individuals may also exclude any transfers to an immediate
family if for educational, medical, or essential support purposes.

EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

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SECTION E
(All applicant firms must complete)

Control
1.

List the titles of all officers, management members, and key managers and the hours devoted, by such
individual(s) to the management of the applicant firm.
Name

Title

____________________________

_______________________________

_____________________________

_______________________________

_____________________________

_______________________________

_____________________________

_______________________________

2.

Is the managing member or any disadvantaged full-time manager engaged in or plan to engage in
outside employment? ____ Yes ____ No. If yes, provide details as to the extent of outside
employment or other business dealings to include daily hours of employment, location, and
explanation as to how this outside employment does not conflict with the ability to manage and
control the daily operations of the application concern. Provide as Attachment E-1.

3.

Have any of the nondisadvantaged individuals involved in the management of the applicant firm,
and/or their immediate family members, had a prior business relationship with any individual
claiming disadvantaged status? This includes such relationships as employer-employee, supervisoremployee, co-workers, investor-employee, etc. ____ Yes ____ No. If yes, identify the person(s) and
the type of business relationship as Attachment E-2.

4.

Does any nondisadvantaged individual receive compensation in any form, including dividends, as a
director, officer, or employee that exceeds the compensation received by the disadvantaged
Management Member? ____ Yes ____ No. If yes, provide the total compensation received by the
disadvantaged management member, and the name(s) and the amount of the total compensation paid
to the nondisadvantaged individuals(s). If any nondisadvantaged individual is higher compensated,
provide a statement, which justifies the need for the nondisadvantaged individual(s) to receive a
higher compensation. Provide as Attachment E-3.

5.

Does the applicant firm operate in an industry, which requires bonding or professional licenses?
____ Yes ____ No. If yes, identify the qualifying individual(s) for the critical licenses, general
indemnity agreement, permits, certifications, and bonding required to operate the applicant firm on
Attachment E-4.

6.

List the names of all individuals who have access to the firm’s bank account.
Name

Title

___________________________________

___________________________________

___________________________________

___________________________________

EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

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7.

Does any individual(s), (other than the individual(s) claiming disadvantaged status) or entities
provide?
a)
b)
c)
d)
e)
f)

Financial support to the applicant firm
Subcontracts, Joint Ventures or Teaming Arrangements
Office space (rent or leased)
Equipment (rent or leased)
Employees (other than from employment agencies)
Business bank account

____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No

If you answered yes to any of the above, please provide details (i.e., names, titles, copies of agreements,
leases, etc.) of such arrangements as Attachment E-5.

EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

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Each person signing below:
1.

Certifies that the information provided with regard to my social and economic disadvantaged
status is true, accurate, and complete to the best of my knowledge and belief.

2.

Certifies that the information provided with regard to my ownership and control status is true,
accurate, and complete to the best of my knowledge and belief.

3.

Certifies that the information provided with regard to my status as a United States citizen is true,
accurate, and complete to the best of my knowledge and belief.

4.

Certifies that the information provided with regard to my individual disadvantaged status is true,
accurate, and complete to the best of my knowledge and belief.

5.

Certifies that the information provided, including that shown on documents accompanying this
application, is true, accurate and complete to the best of my knowledge and belief.

6.

Acknowledges that EPA, at its discretion, may give the information submitted to Federal, state,
and local agencies for determining violations of law.

7.

Acknowledges that EPA’s approval of an application does not affect the Government’s right to
pursue criminal prosecution for incorrect or incomplete information given on the application
form, even if correct information has been included in other materials submitted to EPA.

Name

SSN

Date

________________________

_______________________

______________________

________________________

_______________________

______________________

________________________

_______________________

______________________

________________________

_______________________

______________________

The public reporting and recordkeeping burden for this collection of information is estimated to average
three (3) hours. Burden means the total time, effort, or financial resources expended by persons to
generate, maintain, retain, 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 DBE Certification Form to this
address.

EPA DBE Certification Application (EPA Form 6100-1b)
(Limited Liability Company)

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