6100-1i EPA DBE Certification Application (Concerns Owned by Com

Environmental Protection Agency

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

EPA DBE Certification Application
For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE)
Under EPA’s Disadvantaged Business Enterprise (DBE) Program
Community Development Corporation (CDC) Owned Concern
Name of Parent Community Development Corporation (CDC):
_________________________________________________________________________________
Address of Parent CDC: _____________________________________________________________
Name of wholly-owned subsidiary (if applicable): _______________________________________
Address of wholly-owned subsidiary: _________________________________________________
Name of applicant firm:
_________________________________________________________________________________
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 ____________________________________________________________
EPA DBE Certification Application (EPA Form 6100-1i)
(Community Development Corporation (CDC) Owned Concern)

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: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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)__________________
__________________________________________________________________________________

SECTION A

Eligibility Statement
Social and Economic Disadvantage
1.

A Community Development Corporation (CDC) is considered to be a socially and economically
disadvantaged entity if the parent CDC is a nonprofit organization responsible to residents of the
area it serves which has received financial assistance under 42 U.S.C. 9805, et seq.
Does the parent CDC of the applicant concern meet this criteria? ___Yes ___ No. If yes,
provide evidence of nonprofit organization and documentation of assistance as Attachment A-1.

SECTION B
Ownership

1.

Is the applicant concern at least 51 percent owned by a CDC or a wholly owned business
entity of a CDC? ____ Yes ____ No. If yes, please provide evidence of ownership as
Attachment B-1.

Corporations Only:
2.

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:

EPA DBE Certification Application (EPA Form 6100-1i)
(Community Development Corporation (CDC) Owned Concern)

Non
Total
Voting
_____ ______ _____
_____ ______ _____

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Limited Liability Companies Only:
3.

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

Partnerships Only:
4.

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 %

___________________________

____________________

____________________

___________________________

____________________

____________________

___________________________

____________________

____________________

___________________________

____________________

____________________

Questions 5 through 9 are for Corporations & LLCs ONLY:
5.

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

Title

___________________________

Ownership
Voting NonVoting
____________________ ______ _________

%
Total
_____

___________________________

____________________ ______ __________

_____

___________________________

____________________ ______ __________

______

___________________________

____________________ ______ __________

______

6.

Does the parent CDC 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 B-2.

7.

Will the parent CDC 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 B-3.

8.

If the corporation dissolves, will the parent CDC 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 B-4.

EPA DBE Certification Application (EPA Form 6100-1i)
(Community Development Corporation (CDC) Owned Concern)

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9.

Is ownership by the parent CDC 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 CDC? ___Yes ___No. If yes, explain as Attachment B-5.

Corporations, LLCs & Partnerships:
10. 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 B-6.

SECTION C

Control and Management
1.

List all individuals who manage or conduct daily business operations of the applicant
concern.
Name/Title

Date

___________________________________________________

_____________

___________________________________________________

_____________

___________________________________________________

_____________

___________________________________________________

_____________

2.

Are any of the individuals listed in question 1 engaged in or plan to engage in outside
employment? ___ Yes ___ No. If yes, explain as Attachment C-1.

3.

List the total compensation from the applicant firm of all owners and/or key managers of the
firm. (If necessary, provide additional information as Attachment C-2).

4.

Name/Title

Compensation from applicant firm
(Include salaries, bonuses, etc.)

___________________________________

__________________________________

___________________________________

__________________________________

___________________________________

__________________________________

___________________________________

__________________________________

Does the applicant firm operate in an industry which requires bonding or professional
licenses? ___ Yes ___ No. If yes, identify the qualifying individual(s) for the critical licenses,
general indemnity agreement, permits, certifications, and bonding required to operate the
applicant firm on Attachment C-3.

EPA DBE Certification Application (EPA Form 6100-1i)
(Community Development Corporation (CDC) Owned Concern)

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5.

6.

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

Title

___________________________________

_________________________________

___________________________________

_________________________________

___________________________________

__________________________________

___________________________________

__________________________________

Does any individual(s), or entities provide:
a)
b)
c)
d)
e)

Financial support to the applicant firm?
___ Yes ___ No
Subcontracts, Joint Ventures, or Teaming Arrangements? ___ Yes ___ No
Office space (rent or leased).
___ Yes ___ No
Equipment (rent or leased).
___ Yes ___ No
Employees (other than from employment agencies).
___ Yes ___ No

If the answer is yes to any of the above, please provide specific details (i.e., names, titles,
copies of agreements, leases, etc.) of such arrangements as Attachment C- 4.

EPA DBE Certification Application (EPA Form 6100-1i)
(Community Development Corporation (CDC) Owned Concern)

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Each person signing below:
1.

Certifies that the information provided with regard to the applicant firm’s social and
economic disadvantaged status is true, accurate, and complete to the best of his/her
knowledge and belief.

2.

Certifies that the information provided with regard to the applicant firm’s ownership and
control status is true, accurate, and complete to the best of his/her knowledge and belief.

3.

Certifies that the information provided with regard to his/her individual disadvantaged
status is true, accurate, and complete to the best of his/her 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 his/her
knowledge and belief.

5.

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

6.

Acknowledges that the 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
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 DBE Certification Application (EPA Form 6100-1i)
(Community Development Corporation (CDC) Owned Concern)

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