Form Appendix G Appendix G Personal Net Worth Statement

U.S. Department of
Transportation

Personal Net Worth Statement
For DBE/ACDBE Program Eligibility

OMB APPROVAL NO:2105-0510
EXPIRATION DATE: mm/dd/yyyy

As of __________________

This form is used by all participants in the U.S. Department of Transportation’s Disadvantaged Business Enterprise (DBE) Programs. Each individual
owner of a firm applying to participate as a DBE or ACDBE, whose ownership and control are relied upon for DBE certification must complete this form.
Each person signing this form authorizes the Unified Certification Program (UCP) recipient to make inquiries as necessary to verify the accuracy of the
statements made. The agency you apply to will use the information provided to determine whether an owner is economically disadvantaged as defined in
the DBE program regulations 49 C.F.R. Parts 23 and 26. Return form to appropriate UCP certifying member, not U.S. DOT.
Name

Business Phone

Residence Address (As reported to the IRS)

Residence Phone

City, State and Zip Code

Business Name of Applicant Firm

Spouse’s Full Name
(Marital Status: Single, Married, Divorced, Union)

ASSETS

(Omit Cents)

LIABILITIES

(Omit Cents)

Cash and Cash Equivalents

$

Loan on Life Insurance
(Complete Section 5)

$

Retirement Accounts (IRAs, 401Ks, 403Bs,
Pensions, etc.) (Report full value minus tax and
interest penalties that would apply if assets were
distributed today) (Complete Section 3)

$

Mortgages on Real Estate
Excluding Primary Residence Debt
(Complete Section 4)

$

Brokerage, Investment Accounts

$

Notes, Obligations on Personal Property $
(Complete Section 6)

Assets Held in Trust

$

Notes & Accounts Payable to Banks
and Others (Complete Section 2)

$

Loans to Shareholders & Other Receivables
(Complete section 6)

$

Other Liabilities
(Complete Section 8)

$

Real Estate Excluding Primary Residence
(Complete Section 4)

$

Unpaid Taxes
(Complete Section 8)

$

Life Insurance (Cash Surrender Value Only)
(Complete Section 5)

$

Other Personal Property and Assets
(Complete Section 6)

$

Business Interests Other Than the Applicant Firm
(Complete Section 7 )

$

Total Assets

$

Total Liabilities

$

NET WORTH
Section 2. Notes Payable to Banks and Others
Name of Noteholder(s)

Original
Balance

Current
Balance

Payment
Amount

Frequency
(monthly, etc.)

How Secured or Endorsed Type of
Collateral

 U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility  Page 1 of 5 

Section 3. Brokerage and custodial accounts, stocks, bonds, retirement accounts. (Full Value) (Use attachments if necessary).
Name of Security / Brokerage Account / Retirement
Account

Market Value
Quotation/Exchange

Cost

Date of
Quotation/Exchange

Total Value

Section 4. Real Estate Owned (Including Primary Residence, Investment Properties, Personal Property Leased or Rented for Business
Purposes, Farm Properties, or any Other Income Producing property). (List each parcel separately. Add additional sheets if necessary).
Primary Residence

Property B

Property C

Type of Property
Address

Date Acquired and Method
of Acquisition (purchase,
inherit, divorce, gift, etc.)
Names on Deed

Purchase Price
Present Market Value
Source of Market Valuation
Name of all Mortgage
Holders

Mortgage Acc. # and
balance (as of date of form)
Equity line of credit balance
Amount of Payment Per
Month/Year (Specify)
Section 5. Life Insurance Held (Give face amount and cash surrender value of policies, name of insurance company and beneficiaries).
Insurance Company

Face Value

Cash Surrender Amount

Beneficiaries

Loan on Policy Information

 U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility  Page 2 of 5 

Section 6. Other Personal Property and Assets (Use attachments as necessary)
Total Present
Value

Type of Property or Asset

Amount of
Liability
(Balance)

Is this
asset
insured?

Lien or Note amount
and Terms of
Payment

Automobiles and Vehicles (including recreation vehicles, motorcycles,
boats, etc.) Include personally owned vehicles that are leased or rented to
businesses or other individuals.

Household Goods / Jewelry

Other (List)

Accounts and Notes Receivables
Section 7. Value of Other Business Investments, Other Businesses Owned (excluding applicant firm)
Sole Proprietorships, General Partners, Joint Ventures, Limited Liability Companies, Closely-held and Public Traded Corporations

Section 8. Other Liabilities and Unpaid Taxes (Describe)

Section 9. Transfer of Assets: Have you within 2 years of this personal net worth statement, transferred assets to a spouse, domestic
partner, relative, or entity in which you have an ownership or beneficial interest including a trust? Yes No If yes, describe.

I declare under penalty of perjury that the information provided in this personal net worth statement and supporting documents is complete, true and
correct. I certify that no assets have been transferred to any beneficiary for less than fair market value in the last two years. I recognize that the
information submitted in this application is for the purpose of inducing certification approval by a government agency. I understand that a government
agency may, by means it deems appropriate, determine the accuracy and truth of the statements in the application and this personal net worth
statement, and I authorize such agency to contact any entity named in the application or this personal financial statement, including the names
banking institutions, credit agencies, contractors, clients, and other certifying agencies for the purpose of verifying the information supplied and
determining the named firm’s eligibility. I acknowledge and agree that any misrepresentations in this application or in records pertaining to a contract
or subcontract will be grounds for terminating any contract or subcontract which may be awarded; denial or revocation of certification; suspension and
debarment; and for initiating action under federal and/or state law concerning false statement, fraud or other applicable offenses.
___________________________________

___________

Signature (DBE/ACDBE Owner)

Date

NOTARY CERTIFICATE:
(Insert applicable state acknowledgment, affirmation, or oath)

In collecting the information requested by this form, the Department of Transportation complies with Federal Freedom of Information and Privacy Act (5 U.S.C. 552 and 552a)
provisions. The Privacy Act provides comprehensive protections for your personal information. This includes how information is collected, used, disclosed, stored, and
discarded. Your information will not be disclosed to third parties without your consent. The information collected will be used solely to determine your firm's eligibility to
participate in the Disadvantaged Business Enterprise (DBE) Program or Airport Concessionaire DBE Programs as defined in 49 C.F.R. Parts 23 and 26. You may review
DOT’s complete Privacy Act Statement in the Federal Register published on April 11, 2000 (65 FR 19477).  

 U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility  Page 3 of 5 

General Instructions for Completing the
Personal Net Worth Statement
for DBE/ACDBE Program Eligibility
Please do not make adjustments to your figures pursuant to
U.S. DOT regulations 49 C.F.R. Parts 23 and 26. The
agency that you apply to will use the information provided
on your completed Personal Net Worth (PNW) Statement to
determine whether you meet the economic disadvantage
requirements of 49 C.F.R. Parts 23 and 26. If there are
discrepancies or questions regarding your form, it may be
returned to you to correct and complete again.

Brokerage and Custodial Accounts, Stocks, Bonds,
Retirement Accounts: Report total value on page 1, and on
page 2, section 3, enter the name of the security, brokerage
account, retirement account, etc.; the cost; market value of
the asset; the date of quotation; and total value as of the date
of the PNW statement.
Assets Held in Trust: Enter the total value of the assets held
in trust on page 1, and provide the names of beneficiaries
and trustees, and other information in Section 6 on page 3.

An individual’s personal net worth according to 49 C.F.R.
Parts 23 and 26 includes only his or her own share of assets
held separately, jointly, or as community property with the
individual’s spouse and excludes the following:

Loans to Shareholders and Other Receivables not listed:
Enter amounts loaned to you from your firm, from any other
business entity in which you hold an ownership interest, and
other receivables not listed above. Complete Section 6 on
page 3.

 Individual’s ownership interest in the applicant firm;
 Individual’s equity in his or her primary residence;
 Tax and interest penalties that would accrue if retirement
savings or investments (e.g., pension plans, Individual
Retirement Accounts, 401(k) accounts, etc.) were
distributed at the present time.

Real Estate: The total value of real estate excluding your
primary residence should be listed on page 1. In section 4 on
page 2, please list your primary residence in column 1,
including the address, method of acquisition, date of
acquired, names of deed, purchase price, present fair market
value, source of market valuation, names of all mortgage
holders, mortgage account number and balance, equity line
of credit balance, and amount of payment. List this
information for all real estate held. Please ensure that this
section contains all real estate owned, including rental
properties, vacation properties, commercial properties,
personal property leased or rented for business purposes,
farm properties and any other income producing properties,
etc. Attach additional sheets if needed.

Indicate on the form, if any items are jointly owned. If the
personal net worth of the majority owner(s) of the firm
exceeds $1.32 million, as defined by 49 C.F.R. Parts 23 and
26, the firm is not eligible for DBE or ACDBE certification.
If the personal net worth of the majority owner(s) exceeds
the $1.32 million cap at any time after your firm is certified,
the firm is no longer eligible for certification. Should that
occur, it is your responsibility to contact your certifying
agency in writing to advise that your firm no longer qualifies
as a DBE or ACDBE. You must fill out all line items on the
Personal Net Worth Statement.

Life Insurance: On page 1, enter the cash surrender value of
this asset. In section 5 on page 2, enter the name of the
insurance company, the face value of the policy, cash
surrender value, beneficiary names, and loans on the policy.

If necessary, use additional sheets of paper to report all
information and details. If you have any questions about
completing this form, please contact one of the UCP
certifying agencies.
Assets

Other Personal Property and Assets: Enter the total value
of personal property and assets you own on page 1. Personal
property includes motor vehicles, boats, trailers, jewelry,
furniture, household goods, collectibles, clothing, and
personally owned vehicles that are leased or rented to
businesses or other individuals. In section 6 on page 3, list
these assets and enter the present value, the balance of any
liabilities, whether the asset is insured, and lien or note
information and terms of payments. For accounts and notes
receivable, enter the total value of all monies owed to you
personally, if any. This should include shareholder loans to
the applicant firm, if those exist. If the asset is insured, you
may be asked to provide a copy of the policy. You may also
be asked to provide a copy of any liens or notes on the
property.

All assets must be reported at their current fair market values
as of the date of your statement. Assessor’s assessed value
for real estate, for example, is not acceptable. Assets held
in a trust should be included.
Cash and Cash Equivalents: On page 1, enter the total
amount of cash or cash equivalents in bank accounts,
including checking, savings, money market, certificates of
deposit held domestic or foreign. Provide copies of the bank
statement.
Retirement Accounts, IRA, 401Ks, 403Bs, Pensions: On
page 1, enter the full value minus tax and interest penalties
that would apply if assets were distributed as of the date of
the form. Describe the number of shares, name of securities,
cost market value, date of quotation, and total value in
section 3 on page 2.

Other Business Interests Other than Applicant Firm: On
page 1, enter the total value of your other business
investments (excluding the applicant firm). In section 7 on
page 3, enter information concerning the businesses you

 U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility  Page 4 of 5 

hold an ownership interest in, such as sole proprietorships,
partnerships, joint ventures, corporations, or limited liability
corporations (other than the applicant firm). Do not reduce
the value of these entries by any loans from the outside firm
to the DBE/ACDBE applicant business.

have co-signed on a relative’s loan, but you are not
responsible for the debt until your relative defaults, that is a
contingent liability. Contingent liabilities do not count
toward your net worth until they become actual liabilities.
Unpaid Taxes: Enter the total amount of all taxes that are
currently due, but are unpaid on page 1, and complete
section 8 on page 3. Contingent tax liabilities or anticipated
taxes for current year should not be included. Describe in
detail the name of the individual obligated, names of cosigners, the type of unpaid tax, to whom the tax is payable,
due date, amount, and to what property, if any, the tax lien
attaches. If none, state “NONE.” You must include
documentation, such as tax liens, to support the amounts.

Liabilities
Mortgages on Real Estate: Enter the total balance on all
mortgages payable on real estate on page 1.
Loans on Life Insurance: Enter the total value of all loans
due on life insurance policies on page 1, and complete
section 5 on page 2.
Notes & Accounts Payable to Bank and Others: On page
1, section 2, enter details concerning any liability, including
name of noteholders, original and current balances, payment
terms, and security/collateral information. The entries should
include automobile installment accounts. This should not,
however, include any mortgage balances as this information
is captured in section 4. Do not include loans for your
business or mortgages for your properties in this section.
You may be asked to submit copy of note/security
agreement, and the most recent account statement.

Transfers of Assets:
Transfers of Assets: If you checked the box indicating yes
on page 3 in this category, provide details on all asset
transfers (within 2 years of the date of this personal net
worth statement) to a spouse, domestic partner, relative, or
entity in which you have an ownership or beneficial interest
including a trust. Include a description of the asset; names of
individuals on the deed, title, note or other instrument
indicating ownership rights; the names of individuals
receiving the assets and their relation to the transferor; the
date of the transfer; and the value or consideration received.
Submit documentation requested on the form related to the
transfer.

Other Liabilities: On page 1, enter the total value due on all
other liabilities not listed in the previous entries. In section
8, page 3, report the name of the individual obligated, names
of co-signers, description of the liability, the name of the
entity owed, the date of the obligation, payment amounts and
terms. Note: Do not include contingent liabilities in this
section. Contingent liabilities are liabilities that belong to
you only if an event(s) should occur. For example, if you
. 

Affidavit
Be sure to sign and date the statement. The Personal Net
Worth Statement must be notarized

Paperwork Reduction Act Burden Statement

OMB CONTROLNUMBER: 2105-0510
EXPIRATION DATE: mm/dd/yyyy
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a
penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless
that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information
collection is 2105-0510. Public reporting for this collection of information is estimated to be approximately 2 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, completing and reviewing the collection of information. All responses to this collection of information are mandatory
under the DBE regulations, 49 CFR 26. 67(a)(2). Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Office of
the Secretary of Transportation, 1200 New Jersey Ave. SE, Washington, D.C. 20590.

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