6100-2 DBE Subcontractor Participation Form

OMB Control No:
Approved:
Approval Expires:

Disadvantaged Business Enterprise (DBE) Program
DBE Subcontractor Participation Form
An EPA Financial Assistance Agreement Recipient must require its prime contractors to provide this form to its
DBE subcontractors. This form gives a DBE1 subcontractor2 the opportunity to describe work received and/or
report any concerns regarding the EPA-funded project (e.g., in areas such as termination by prime contractor, late
payments, etc.). The DBE subcontractor can, as an option, complete and submit this form to the EPA DBE
Coordinator at any time during the project period of performance.
Subcontractor Name
Bid/ Proposal No.

Project Name
Assistance Agreement ID No. (if known)

Point of Contact

Address
Telephone No.

Email Address

Prime Contractor Name

Issuing/Funding Entity:

Contract
Item
Number

Description of Work Received from the Prime Contractor Involving
Construction, Services , Equipment or Supplies

Amount Received
by Prime
Contractor

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 6100-2 (DBE Subcontractor Participation Form)

OMB Control No:
Approved:
Approval Expires:

Disadvantaged Business Enterprise (DBE) Program
DBE Subcontractor Participation Form

Please use the space below to report any concerns regarding the above EPA-funded project:
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Subcontractor 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 6100-2 (DBE Subcontractor Participation Form)