6100-4 DBE Subcontractor Utilization Form

OMB Control No:
Approved:
Approval Expires:

Disadvantaged Business Enterprise (DBE) Program
DBE Subcontractor Utilization Form
This form is intended to capture the prime contractor’s actual and/or anticipated use of identified certified DBE1
subcontractors2 and the estimated dollar amount of each subcontract. An EPA Financial Assistance Agreement
Recipient must require its prime contractors to complete this form and include it in the bid or proposal package.
Prime contractors should also maintain a copy of this form on file.
Prime Contractor Name
Bid/ Proposal No.

Project Name
Assistance Agreement ID No. (if known)

Point of Contact

Address
Telephone No.

Email Address

Issuing/Funding Entity:

I have identified potential DBE
___ YES
certified subcontractors
If yes, please complete the table below. If no, please explain:

Subcontractor Name/
Company Name

Company Address/ Phone/ Email

___ NO

Est. Dollar
Amt

Currently
DBE
Certified?

Continue on back if needed
1

A DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts certifications as
described in 40 CFR 33.204-33.205 or certified by EPA. EPA accepts certifications from entities that meet or exceed EPA certification standards as
described in 40 CFR 33.202.
2

Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide
services pursuant to an EPA award of financial assistance.

EPA FORM 6100-4 (DBE Subcontractor Utilization Form)

OMB Control No:
Approved:
Approval Expires:

Disadvantaged Business Enterprise (DBE) Program
DBE Subcontractor Utilization Form

I certify under penalty of perjury that the forgoing statements are true and correct. Signing this form does not
signify a commitment to utilize the subcontractors above. I am aware of that in the event of a replacement of a
subcontractor, I will adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c).
Prime Contractor Signature

Print Name

Title

Date

The public reporting and recordkeeping burden for this collection of information is estimated to average three (3) hours
per response. 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 through the use of automated
collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send
the completed form to this address.

EPA FORM 6100-4 (DBE Subcontractor Utilization Form)