6100-1g EPA DBE Certification Application (Private and Voluntary

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 Private and Voluntary Organizations Controlled by Individuals
who are Socially and Economically Disadvantaged
Name of Organization:_____________________________________________________________________
Applicant concern is:

Corporation

Limited Liability Company

Partnership

Name of President/Managing Member/Managing Partner_______________________________________
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 standard industrial classification code? _______________________
Is the firm certified by the Small Business Administration under its 8(a) Business Development Program?
___ Yes ___ No. If yes, provide Pro-Net number______________________________________________
Is the firm certified by the Small Business Administration under its Small Disadvantaged Business (SDB)
Program? ___ Yes ___ No. If yes, provide Pro-Net number_____________________________________
Is the firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes,
provide State(s) and ID number(s) ___________________________________________________________
Is the 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
explanation/documentation:________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

EPA DBE Certification Application (EPA Form 6100-1g)
(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

Does the firm have any other certification as a disadvantaged business entity, i.e., MBE, DBE, WBE, etc?
___Yes ___ No. If yes, provide the 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.

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

___________________

___________

________

___________

_______

_____

___________________

___________

________

___________

_______

_____

___________________

___________

________

___________

_______

_____

SECTION B

Eligibility Statement - Non Designated Group Members
1.

List all individuals claiming disadvantaged status:
Name of Individual

U.S. Citizen
Y/N

Race

Sex
M/F

_______________________________

________

________

_____

_______________________________

________

________

_____

_______________________________

________

________

_____

_______________________________

________

________

_____

For this section, any individual claiming social disadvantage must provide a separate response for
questions 3 and 4.

EPA DBE Certification Application (EPA Form 6100-1g)
(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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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
unemployment, etc., as compared to others in the same or similar line of business who are not
socially disadvantaged. Mark as Attachment B-1.

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. Mark as Attachment B-2.

SECTION C
(All applicant firms must complete)

Economic Disadvantage
1.

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

2.

For individual(s) 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.
Name
Average 2-year
Personal
Total
Income
Net Worth
Assets
________________________________

______________

__________

__________

________________________________

______________

__________

__________

________________________________

______________

__________

__________

________________________________

______________

__________

__________

EPA DBE Certification Application (EPA Form 6100-1g)
(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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3.

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
Corporation:
1.

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

_____
_____

Non
Voting
______
______

Total
_____
_____

Limited Liability Company:
2.

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

Total
_____
_____

Partnership:
3.

Provide the name, title, and percentage of ownership for each partner of the firm. Does the
partnership agreement reflect the ownership of each partner? ___Yes ___No.
Name

Title

Ownership Percentage

___________________________

____________________

____________________

___________________________

____________________

____________________

___________________________

____________________

____________________

___________________________

____________________

____________________

Questions 4 through 8 are for Corporations & LLCs ONLY:
4.

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

Title

___________________________

Ownership %
Voting NonVoting
____________________ ______ _________

Total
_____

___________________________

____________________ ______ __________

_____

___________________________

____________________ ______ __________

_____

___________________________

____________________ ______ __________

_____

EPA DBE Certification Application (EPA Form 6100-1g)
(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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5.

Does the private or voluntary organization or its wholly-owned subsidiary receive at least 51% of the
annual distributions of dividends paid on the stock of a corporate applicant firm? ___Yes ___ No. If
no, please explain as Attachment D-1.

6.

Will the private or voluntary organization or its wholly-owned subsidiary receive 100% of the
unencumbered value of each share of stock owned in the event that the stock is sold? ___Yes ____
No. If no, please explain as Attachment D-2.

7.

If the private or voluntary organization dissolves, will the private or voluntary organization or its
wholly-owned subsidiary receive at least 51% of the retained earnings and 100% of the
unencumbered value of each share of stock owned? ___Yes ___ No. If no, please explain as
Attachment D-3.

8.

Is ownership by the private or voluntary organization or its wholly-owned subsidiary subject to
conditions precedent, conditions subsequent, executory agreements, voting trusts, shareholder
agreements, or other similar arrangements which may impact the unconditional ownership of the
private or voluntary organization? ___Yes ___No. If yes, explain as Attachment D-4.

Corporations, LLCs & Partnerships:
9.

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.

SECTION E
(All applicant firms must complete)

Control
Corporations Only:
1. The private or voluntary organization controls the board of directors by virtue of the fact that: (select
only one below)
___

a)

The private or voluntary organization owns at least 100% of all the voting stock of the
applicant concern.

___

b)

The private or voluntary organization owns at least 51% of all voting stock, is on the
Board of Directors, and no super majority voting requirements exist for shareholders to
approve corporate actions.

___

c)

The private or voluntary organization owns at least 51% of all voting stock, is on the
Board of Directors, and owns at least the percentage of voting stock needed to overcome
the super majority voting requirements which exist for shareholders to approve corporate
actions.

___

d)

The private or voluntary organization controls the Board of Directors through actual
numbers of voting directors.

___

e)

The private or voluntary organization controls the Board of Directors through weighted
voting and such voting is permitted by applicable state law.

EPA DBE Certification Application (EPA Form 6100-1g)
(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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Partnerships Only:
2.

Are partnership decisions determined by general partners? If no, explain as Attachment E-1.

Corporations, LLCs & Partnerships:
3.

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

Title

Hours

____________________________

_______________________________

__________

____________________________

_______________________________

__________

____________________________

_______________________________

__________

____________________________

_______________________________

__________

4.

Are the CEO, President, Managing Member, Managing Partner, members of the management team,
business committee members, officers or directors 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-2.

5.

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

6.

Name
_______________________________

Title
_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

Are the management and daily business operations of the concern controlled by the private or
voluntary organization through one or more disadvantaged individual members who possess
sufficient management experience of an extent and complexity to run the concern? ___Yes ___No. If
yes, provide documentation to verify management competency as Attachment E-3.

EPA DBE Certification Application (EPA Form 6100-1g)
(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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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 individual disadvantaged status is true,
accurate, and complete to the best of my knowledge and belief.

4.

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.

5.

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

6.

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, 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 DBE Certification Form to this
address.

EPA DBE Certification Application (EPA Form 6100-1g)
(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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