Form 6100-3 DBE Subcontractor Performance Form

OMB Control No: 2090-0030
Approval Expires: XX/XX/XX

Disadvantaged Business Enterprise (DBE) Program
DBE Subcontractor Performance Form
This form is intended to capture the DBE1 subcontractor’s2 description of work to be performed and the price of
the work submitted to the prime contractor. An EPA Financial Assistance Agreement Recipient must require its
prime contractor to have its DBE subcontractors complete this form and include all completed forms in the prime
contractors bid or proposal package.
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

DBE Certified By: ____ DOT

Description of Work Submitted to the Prime Contractor
Involving Construction, Services , Equipment or Supplies

____ SBA

____ Other: _________________________________________

Price of Work
Submitted to the
Prime Contractor

Meets/ exceeds EPA certification standards?
____ YES ____ NO ____ Unknown

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 6100-3 (DBE Subcontractor Performance Form)

OMB Control No:
Approved:
Approval Expires:

Disadvantaged Business Enterprise (DBE) Program
DBE Subcontractor Performance 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

Subcontractor Signature

Print Name

Title

Date

The public reporting and recordkeeping burden for this collection of information is estimated to average 1 hour 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 6100-3 (DBE Subcontractor Performance Form)