6100-1a EPA DBE Certification Application (Sole Proprietorship)

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 Sole Proprietorships
Business Profile:
Name of applicant firm:____________________________________________________________________
Name of Sole Proprietor and Title:____________________________________________________________
SSN of Sole Proprietor:_________________________ 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.
Are you certified by the Small Business Administration under its 8(a) Business Development Program?
___ Yes ___ No. If yes, provide PRO-Net number ______________________________________________
Are you certified by the Small Business Administration under its Small Disadvantaged Business (SDB)
Program? ___ Yes ___ No. If yes, provide PRO-Net number ____________________________________
Are you certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide
State(s) and ID number(s) ___________________________________________________________________
Are you 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 ____________________________________________________________________________________

EPA DBE Certification Application (Form 6100-1a)
(Sole Proprietorship)

Have you 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:
_________________________________________________________________________________________
_________________________________________________________________________________________
Do you 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 (Form 6100-1a)
(Sole Proprietorship)

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SECTION A

Eligibility Statement - Designated Group Members
Social Disadvantage
1.

As the proprietor claiming disadvantaged status, complete the following:
Name of Individual

Other Last
Names Used

Citizen
Y/N

Place of
Birth

Group
Membership

Sex

_________________

___________

________

___________

_______

_____

If you are not a U.S. citizen, stop here. You are not eligible to participate as a DBE under EPA’s
DBE Certification Program.
1a.

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
1.

1a.

As the proprietor claiming disadvantaged status, complete the following:
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, any individual claiming social disadvantage must provide a separate response for
questions 3 and 4.

Social Disadvantage
2.

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.)

3.

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

EPA DBE Certification Application (Form 6100-1a)
(Sole Proprietorship)

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unemployment, etc., as compared to others in the same or similar line of business who are not
socially disadvantaged. Provide as Attachment B-2.
4.

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.

SECTION C
(All applicant firms must complete)

Economic Disadvantage
1.

Is your net worth less than $750,000, excluding your ownership interest in the applicant
firm and your equity in your primary residence? ____ Yes ____ No.

2.

As the individual claiming disadvantaged status, list your personal net worth, excluding the
ownership interest in the applicant firm and the equity in the primary residence.

3.

Name

Average 2-year
Income

Personal
Net Worth

Total
Assets

________________________________

______________

__________

__________

I, ___________________________, certify that because of racial and/or ethnic prejudice, and/or
cultural bias, my 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.

EPA DBE Certification Application (Form 6100-1a)
(Sole Proprietorship)

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SECTION D
(All applicant firms must complete)

Ownership
1.

Have you, the individual claiming disadvantaged status, 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-1: 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 member if for educational, medical or essential support purposes.
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.

2.

Name of Disadvantaged Owner

State

Percent Transferred

____________________________

_______

__________________

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-2.

SECTION E
(All applicant firms must complete)

Control
1.

2.

Does any individual other than the Sole Proprietor manage or conduct daily business operations
of the applicant concern? If yes, provide name, title and dates.
Name/Title

Date

___________________________________________________

__________________________

___________________________________________________

__________________________

Are you engaged in or plan to engage in outside employment? ___ Yes ___ No. If yes, explain
as Attachment E-1.

EPA DBE Certification Application (Form 6100-1a)
(Sole Proprietorship)

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3.

If the answer to question 2 is yes, have any of the nondisadvantaged individuals involved in the
management of the applicant firm, or their immediate family members, had a prior business
relationship with you? This includes such relationships as employer-employee, supervisoremployee, co-workers, investor-employee, etc. ___ Yes ___ No ___ N/A. If yes, identify the
person(s) and the type of business relationship as Attachment E-2.

4.

List the total compensation from the applicant firm of all owners and/or key managers of the
firm. (If necessary, provide additional information as Attachment E-3).
Name/Title

Compensation from applicant firm
(Include salaries, bonuses, etc.)

_____________________________________

__________________________________

_____________________________________

__________________________________

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.

7.

Name

Title

____________________________________

_________________________________

____________________________________

_________________________________

Does any individual(s), (other than the Sole Proprietor) or entities provide:
a)
b)
c)
d)
e)

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).

___
___
___
___
___

Yes ___
Yes ___
Yes ___
Yes ___
Yes ___

No
No
No
No
No

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

EPA DBE Certification Application (Form 6100-1a)
(Sole Proprietorship)

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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 record keeping 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 EPA DBE Certification Form to this
address.

EPA DBE Certification Application (Form 6100-1a)
(Sole Proprietorship)

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