30-Day FRN of 08/13/2018

30-day_Notice_2018.pdf

Uniform Report of DBE Awards/Commitments and other DBE Program Collections

30-Day FRN of 08/13/2018

OMB: 2105-0510

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2105-0510 can be found here:

2021-12-09 - Reinstatement without change of a previously approved collection

Document [pdf]

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Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices
Federal Register by the Paperwork
Reduction Act of 1995.
DATES: Please submit comments by
October 12, 2018.
ADDRESSES: You may submit comments
identified by DOT Docket ID 2018–0041
by any of the following methods:
Website: For access to the docket to
read background documents or
comments received go to the Federal
eRulemaking Portal: Go to http://
www.regulations.gov. Follow the online
instructions for submitting comments.
Fax: 1–202–493–2251.
Mail: Docket Management Facility,
U.S. Department of Transportation,
West Building Ground Floor, Room
W12–140, 1200 New Jersey Avenue SE,
Washington, DC 20590–0001.
Hand Delivery or Courier: U.S.
Department of Transportation, West
Building Ground Floor, Room W12–140,
1200 New Jersey Avenue SE,
Washington, DC 20590, between 9 a.m.
and 5 p.m. ET, Monday through Friday,
except Federal holidays.
FOR FURTHER INFORMATION CONTACT:
Melissa Corder, 202–366–5853,
[email protected]; Office of Real
Estate Services, Federal Highway
Administration, Department of
Transportation, New Jersey Avenue SE.,
Washington, DC 20590–0001. Office
hours are from 6:15 a.m. to 3:45 p.m.,
Monday through Friday, except Federal
holidays.
SUPPLEMENTARY INFORMATION:
Title: Fixed Residential Moving Cost
Schedule.
Background: Relocation assistance
payments to owners and tenants who
move personal property for a Federal or
federally-assisted program or project are
governed by the Uniform Relocation
Assistance and Real Property
Acquisition Policies Act of 1970, as
amended (Uniform Act). 49 Code of
Federal Regulations (CFR), part 24, is
the implementing regulation for the
Uniform Act. 49 CFR 24.301 addresses
payments for actual and reasonable
moving and related expenses. The fixed
residential moving cost schedule is an
administrative alternative to
reimbursement of actual moving costs.
This option provides flexibility for the
agency and affected property owners
and tenants. The FHWA requests the
State Departments of Transportation
(State DOTs) to analyze moving cost
data periodically to assure that the fixed
residential moving cost schedules
accurately reflect reasonable moving
and related expenses. The regulation
allows State DOTs flexibility in
determining how to collect the cost data
in order to reduce the burden of
government regulation. Updated State

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fixed residential moving costs are
submitted to the FHWA electronically.
Respondents: State Departments of
Transportation (52, including the
District of Columbia and Puerto Rico).
Frequency: Once every 3 years.
Estimated Average Burden per
Response: 24 hours per respondent.
Estimated Total Annual Burden
Hours: 24 hours for each of the 52 State
Departments of Transportation. The
total is 1,248 burden hours, once every
3 years, or 416 hours annually.
Public Comments Invited: You are
asked to comment on any aspect of this
information collection, including: (1)
Whether the proposed collection is
necessary for the FHWA’s performance;
(2) the accuracy of the estimated
burdens; (3) ways for the FHWA to
enhance the quality, usefulness, and
clarity of the collected information; and
(4) ways that the burden could be
minimized, including the use of
electronic technology, without reducing
the quality of the collected information.
The agency will summarize and/or
include your comments in the request
for OMB’s clearance of this information
collection.
Authority: The Paperwork Reduction Act
of 1995; 44 U.S.C. Chapter 35, as amended;
and 49 CFR 1.48.
Issued On: August 7, 2018.
Michael Howell,
Information Collection Officer.
[FR Doc. 2018–17314 Filed 8–10–18; 8:45 am]
BILLING CODE 4910–22–P

DEPARTMENT OF TRANSPORTATION
[Docket No. DOT–OST–2018–0075]

Request for Comments of a Previously
Approved Information Collection(s)
Office of the Secretary, DOT.
Notice and request for
comments.

AGENCY:
ACTION:

In accordance with the
Paperwork Reduction Act of 1995, this
notice announces that the Information
Collection Request (ICR) abstracted
below is being forwarded to the Office
of Management and Budget (OMB) for
review and comment. A Federal
Register Notice with a 60-day comment
period soliciting comments on the
information collection was published on
June 4, 2018. One comment was
received that does not warrant any
adjustments to the forms.
DATES: Comments must be submitted on
or before September 12, 2018.
ADDRESSES: Send comments regarding
the burden estimate, including
suggestions for reducing the burden, to
SUMMARY:

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the Office of Management and Budget,
Attention: Desk Officer for the Office of
the Secretary of Transportation, 725
17th Street NW, Washington, DC 20503.
Comments are invited on: Whether
the proposed collection of information
is necessary for the proper performance
of the functions of the Department,
including whether the information will
have practical utility; the accuracy of
the Department’s estimate of the burden
of the proposed information collection;
ways to enhance the quality, utility and
clarity of the information to be
collected; and ways to minimize the
burden of the collection of information
on respondents, including the use of
automated collection techniques or
other forms of information technology.
FOR FURTHER INFORMATION CONTACT: Mr.
Marc Pentino, Departmental Office of
Civil Rights, Office of the Secretary, U.S.
Department of Transportation, 1200
New Jersey Avenue SE, Washington, DC
20590, (202) 366–6968, or at
[email protected].
SUPPLEMENTARY INFORMATION:
Title: Disadvantaged Business
Enterprise Program Collections.
OMB Control Number: 2105–0510.
Type of Request: Renewal of a
Previously Approved Information
Collection.
Abstract: The following information
collections are associated with the U.S.
Department of Transportation’s (DOT)
Disadvantaged Business Enterprise
(DBE) program: Uniform Report of DBE
Awards or Commitments and Payments,
Uniform Certification Application Form,
Annual Affidavit of No Change, DOT
Personal Net Worth Form, and
Reporting Requirements for Percentages
of DBEs in Various Categories. All five
collections were previously approved
under one OMB Control Number (2105–
0510) to allow DOT to more efficiently
administer the DBE program. The DBE
program is mandated by statute,
including Section 1101(b) of the Fixing
America’s Surface Transportation Act
(FAST Act) (Pub. L. 114–94) and 49
U.S.C. 47113. DOT’s final regulations
implementing these statutes are 49 CFR
parts 23 and 26. The information to be
collected is necessary because it helps
to ensure that State and local recipients
that let federally-funded contracts carry
out their mandated responsibility to
provide a level playing field for small
businesses owned and controlled by
socially and economically
disadvantaged individuals.
Uniform Report of DBE Awards/
Commitments and Payments
Affected Public: DOT financiallyassisted State and local transportation
agencies.

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Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices
Frequency: Once per year.
Number of Responses: One.
Total Annual Burden: 57,698 hours.

Number of Respondents: 1,250.
Frequency: Once/twice per year.
Number of Responses: One/two.
Total Annual Burden: 9,000 hours.
Uniform Certification Application Form
Affected Public: Firms applying to be
certified as DBEs.
Number of Respondents: 9,500.
Frequency: Once during initial
certification.
Number of Responses: One.
Total Annual Burden: 76,000 hours.

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Annual Affidavit of No Change
Affected Public: Certified DBEs.
Number of Respondents:
Approximately 38,465 certified DBE
firms.

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Personal Net Worth Form
Affected Public: Firms applying to be
DBEs.
Number of Respondents: 9,500.
Frequency: Once.
Number of Responses: One.
Total Annual Burden: 19,000 hours.
Percentage of DBEs in Various
Categories
Affected Public: States (through their
Unified Certification Programs).

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Number of Respondents: 53 (50 states,
plus the District of Columbia, Puerto
Rico, and the Virgin Islands).
Frequency: Once per year.
Number of Responses: One.
Total Annual Burden: 161.6 hours.
Authority: The Paperwork Reduction Act
of 1995; 44 U.S.C. Chapter 35, as amended;
and 49 CFR 1:48.
Issued in Washington, DC.
Charles E. James, Sr.,
Director, Departmental Office of Civil Rights,
U.S. Department of Transportation.
BILLING CODE 4910–9X–P

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Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

Personal Net Worth Statement
For DBE/ACDBE Program Eligibility

U.S. Department of
Transportation

OMB APPROVAL NO: £105-0510
EXPIRATION DATE: 8/31/2018

As of

This form is used by all participants in the U.S. Department of Transportation's Disadvantaged Business Enterprise (DBE) and Airport Concession DBE
(ACDBE) 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 certifying agency 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 certifying agency, not U.S. DOT.
Applicant Name:
Residence: (As reported to the IRS)
Address, City, State and Zip Code

Residence Phone

Business Name of Applicant Firm

Business Phone

Spouse's Full Name:

Marital Status: D Single, D Married, D Divorced, D Union

ASSETS

(Omit Cents)

LIABILITIES
Cents)

(Omit

Cash and Cash Equivalents

Loan on Life Insurance
(Complete Section 5)

Retirement Accounts (IRAs, 401 Ks, 403Bs. Pensions.
etc.) (Report full value minus Federal taxes and
penalties if applicable 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

Noles & Accounts Payable to
Banks and others
(Complete Section 2)

Loans from You to the Firm, Other Entities, Individuals,
& 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
Original
Balance

Current
Balance

Payment
Amount

Frequency
(monthly, etc.)

How Secured or Endorsed Type of Collateral

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Name of Noteholder(s)

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

Markel Value
Quotation/Exchange

Cost

Dale 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 C

Property B

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 Markel Valuation
Name of all Mortgage
Holders

Mortgage Ace. # 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).
Face Value

Cash Surrender Amount

Beneficiaries

Loan on Policy Information

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Insurance Company

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Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices
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

Automooiles and Vehicles (including recreation vehicles, motorcycles,
ooats, etc.) Include personally owned vehicles that are leased or rented
to ousinesses or other individuals.

Household Goods I Jewelry

Loans from owner to Firm, Other Entities, Individuals

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 Uaoility 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 vou have an ownership or beneficial interest includinq a trust? Yes o No o If ves, 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 oeen transferred to any oeneficiary 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.
NOTARY CERTIFICATE:
(Insert applicable state acknowledgment, affirmation, or oath)
Signature (DBE/ACDBE 01tv11er)

Date

Privacy Act
In co!!ecting the information requested by this form, the Department of Transportation complies with Federal Freedom of Information
how
15
used
The
Information
used so!e!y to
(DBE) Program
49 C.F .R. Parts
in
'<.,;on~~~'u"ct"c DBE Programs as defined
FR 19477).
review DOT's
Fed era!

U.S C. 552 and

Ito
I

~,-

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~~~~a)

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Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

General Instructions fot· 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 infom1ation provided
on your completed Personal Net Worth (PNW) Statement to
detennine 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
ret11med to you to correct and complete again.
An individual's personal net worth according to 49 C.F.R.
Parts 23 and 2o includes only his or her own share of assets
held separately, jointly, or as conununity property with the
individual's spouse and excludes the following
• Individual's ownership interest in the applicant finn;
• Individual's equity in his or her primary residence;
• Federal Tax and penalties, if applicable, that would
accrue if retirement savings or investments (e.g., pension
plans, Individual Retirement Accounts, 40l(k) accounts,
etc.) were distributed at the present time.
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, tl1e firm is not eligible for DEE or ACDEE certification.
If the personal net worth of the majority owncr(s) exceeds
the $1.32 million cap specified in §26.67(a)(2)(i) at any time
after your firm is certified, the firm is no longer eligible for
certification. Should iliat occur. it is your responsibility to
contact your certifying agency in writing to advise tllat your
firm no longer qualifies as a DEE or A CD BE. Yon must fill
out all line items on the Personal Net Worth Statement.

Assets Held in Trust: Enter the total value of the assets held
in tmst on page 1, and provide the names of beneficiaries
and tmstees, and other infonnation in Section o on page 3.
Loans fmm you to the firm, other Entities, Individuals,
and Other Receivables not listed: Enter current balances of
loans you have extended to tllis finn and to other entities or
individuals, plus interest payable on those loans; and other
receivables not listed above. Complete Section 6 on page 3.
Real Estate: The total value of real estate excluding your
primary residence should be listed on page I. In section 4 on
page 2, please list your primary residence in column I,
including the address. meU10d 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
infonnation for all real estate held. Please ensure that this
section contains all real estate owned, including rental
properties, vacation properties, connnercial properties.
personal property leased or rented for business purposes,
farm properties and any oilier income producing properties,
etc. Attach additional sheets if needed.

If necessary, usc additional sheets of paper to report all
information and details. If you have any questions about
completing this form, please contact ilie certifying agency.

Life Insurance: On page l, enter ilie cash surrender value of
this asset. In section 5 on page 2, enter ilic name ofilic
insurance company, ilic face value ofilic policy, cash
surrender value, names of beneficiaries, and loans on ilic
policy.

All assets must be reported at ilieir 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.

Other Personal Pmperty and Assets: Enter the total value
of personal property and assets you own on page I. Personal
property includes motor vehicles, boats, trailers, jewelry,
funliturc, household goods, collectibles, clotlling, and
personally owned vehicles tllat 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 anv
liabilities, whether ilie asset is insured, and lien or note ·
information and terms of payments. For accounts and notes
receivable, enter the total value of alimonies owed to you
personally, if any. Yon may also be asked to provide a copy
of any liens or notes on ilie property.

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, 401K~, 403Bs, Pensions: On
page l, enter ilie full value minus Federal ta" and penalties
that would apply if assets were distributed as of the date of
the fom1. 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 ilie total value of your oilier business
investments (excluding the applicant firm). In section 7 on
page 3, enter information concenling the businesses you

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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.

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices
hold an ownership interest in, such as sole proprietorships,
partnerships, joint ventures, corporations, or limited liability
corporations (other than the applicant finn). Do not reduce
the value of these entries by any loans from the outside firm
to the DBE/ACDBE applicant business.
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 notcholdcrs, 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.

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, tlte 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.
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 tlris 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 otl1er 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.
Subnrit documentation requested on tl1e fom1 related to the
transfer.
Affidavit
Be sure to sign and date the statement. The Personal Net
Worth Statement must be notarized.

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Other Liabilities: On page I, 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
tenus. Note: Do not include contingent liabilities in Uris
section. Contingent liabilities are liabilities that belong to
you only if an event(s) should occur. For example, if you

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Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

Appendix F

UNIFORM CERTIFICATION APPLICATION
DISADVANTAGED BUSINESS ENTERPRISE (DBE) I
AIRPORT CONCESSION DISADVANTAGED BUSINESS ENTERPRISE (ACDBE)
49 C.F.R. Parts 23 and 26

Roadmap for Applicants
1. Should I apply?
You may be eligible to participate in the DEE/ACD BE program if:
• The firm is a for-profit business that performs or seeks to perform transportation related work (or a concession
activity) for a recipient of Federal Transit Administration, Federal Highway Administration, or Federal Aviation
Administration funds.
• The finn is at least 51% owned by a socially and economically disadvantaged individual(s) who also controls it.
• The firm's disadvantaged owners are U.S. citizens or lawfully admitted permanent residents of the U.S.
• The firm meets the Small Business Administration's size standard and docs not exceed $23.9R million in gross
annual receipts for DBE ($56.42 million for ACDBEs). (Other size standards apply for ACD BE that arc
banks/financial institutions, car rental companies, pay telephone finns, and automobile dealers.)

2. How do I apply?
First time applicants for DBE certification must complete and submit this certification application and related
material to the certifying agency in your home state and participate in an on-site interview conducted by that
agency. The attached document checklist can help you locate the items you need to submit to the agency with your
completed application. lfyou fail to submit the required documents, your application may be delayed and/or denied.
Firms already certified as a DEE do not have to complete this form, but may be asked by certifying agencies outside
of your home state to provide a copy of your initial application form, supporting documents, and any other
information you submitted to your home state to obtain certification or to any other state related to your
certification.
3. Where can I send my application? [INSERT UCP PARTICIPATING MEJ\1BER CONTACT INFORMATION]
4. Who will contact me about my a1>plication and what are the eligibility standards? A transportation agency in
your state that performs certification functions will contact you. The agency is a member of a statewide Unified
Certification Program (UCP), which is required by the U.S. Department of Transportation. The UCP is a one-stop
certification program that eliminates the need for your finn to obtain certification from multiple certifying agencies
within your state. The UCP is responsible for certifying firms and maintaining a database of certified DBEs and
ACDBEs, pursuant to the eligibility standards found in 49 C.F.R. Parts 23 and 26.
5. Where can I find more information?
U.S. DOT-https://www.transportation.gov/civil-rights (This site provides useful links to the rules and regulations
governing the DEE/ACDBE program, questions and answers, and other pertinent information)
SEA-Small Business Size Standards matched to the North American Industry Classification System (NAICS):
http :1/www. census. gov/eos/www/naics/ and http://www. sba. gov/content/table-small-business-size-standards.

Under 49 C.F.R. §26.107, dated Febmary 2, 1999 and January 28, 2011, if at any time, the Department or a recipient has reason to believe that
any person or firm has willfully and knowingly provided incorrect information or made false statements, the Department may initiate suspension
or debarment proceedings against the person or fim1under 2 C.F.R. Parts 180 and 1200, Konprocurement Suspension and Department, take
enforcement action under 49 C.F.R. Part 31, Program Fraud and Civil Remedies, and/or refer the matter to the Department of Justice for criminal
prosecution under 18 U.S.C. 1001, which prohibits false statements in Federal programs.

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In collecting the information requested by this form, the Department of Transportation (Department) complies with the provisions of the Federal
Freedom oflnformation and Privacy Acts (5 U.S.C. 552 and 552a). 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. 1l1e information collected will be used solely to determine your tim1's eligibility to participate in the Department's
Disadvantaged Business Enterprise Program as defined in 49 C.F.R. §26.5 and the Airport Concession Disadvantaged Business Enterprise
Program as defined in 49 C.F.R. §23.3. You may review DOT's complete Privacy Act Statement in the Federal Register published on Aprilll,
2000 (65 FR 19477).

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

40125

INSTRUCTIONS FOR COMPLETING THE
DISADVANTAGED BUSINESS ENTERPRISE (DBE)
AIRPORT CONCESSIONS DISADVANTAGED BUSINESS ENTERPRISE (ACDBE)
UNIFORM CERTIFICATION APPLICATION
NOTE: All participating firms must be for-profit enterprises. If your firm is not for profit, then you do NOT qualify for
the DBE/ACDBE program and should not complete this application. If you require additional space for any question in
this application, please attach additional sheets or copies as needed, taking care to indicate on each attached sheet/copy
the section and number of this application to which it refers.
Section 1: CERTIFICATION INFORMATION
A. Basic Contact Information
(I) Enter the contact name and title of the person
completing this application and the person who will
serve as your finn's contact for this application.
(2) Enter lhe legal name or your finn, as inclicalecl in your
finn's Articles ofincorporation or charter.
(3) Enter the primary phone number of your firm.
(4) Enter a secondary phone number, if any.
(5) Enter your fim1's fax number, if any.
(6) Enter the contact person's email address.
(7) Enter your linn's website acldresses, if any.
(8) Enter the street address of the fnm where its offices
are physically located (not a P.O. Box).
(9) Enter the mailing address of your firm, if it is different
from your fm11' s street address.
B. Prior/Other Certifications and Applications
(10) Check the appropriate box indicating whether your
firm is currently certified in the DBE/ACDBE
programs, and provide the name of the certifying
agency that certified your finn. List the dates of any
site visits conducted by your home state and any other
slates or lJCP members. Also provide lhe names or
state/UCP members that conducted the review.
(II) Indicate whether your firm or any films owned by the
persons listed has ever been denied certification as a
DBE/ACDBE, 8(a), or Small Disadvantaged Business
(SDB) finn, or state and local MBE/WBE finn.
lnclicale ir lhe finn has ever been clecerlifiecllrom one
of these programs. Indicate if the application was
withdrawn or whether the firm was debarred,
suspended, or otherwise had its biddi11g privileges
denied or restricted by any state or local agency, or
Federal entity. If your answer is yes, identity the name
of the agency, am! explain fully the nature of the
action in the space provided. Indicate if you have ever
appealed this decision to the Department and if so,
attach a copy ofUSDOT's final agency decision(s).

A. Business profile:
(I) Give a concise description of the fnm's prinlary
activities, the product( s) or services the company
provides, or type of construction. If your company
otTers more than one product/service, list primmy
proclucl or service first (allach additional sheets i r
necessary). This description may be used in our UCP
online directory if you arc certified as a DBE.

B. Relationships and Dealings with Other Businesses

( 1) Check the appropriate box that indicates whether your
finn is co-located at any of its busi11ess locations, or
whether your finn shares a telephone numher(s), a
post otlice box, any otlice space, a yar~ warehouse,
other facilities, any equipment, financing, or any
otiice staff and/or employees with m1y other busi11ess,
organization or entity of any kind. If you answered
"Yes," then specify tl1e name of tl1e other finn( s) and
fully explain the nature of your relationship witl1 tl1ese
other businesses by identirying lhe business or person
with whom you have any tormal, intormal, written, or

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Section 2: GENERAL INFORMATION

(2) 1r you know lhe appropriate NAICS Code f(JT lhe
line(s) of work you identified in your business profile,
enter the codes in the space provided.
(3) State the date on which your fmn was established as
stated in your finn's Articles of Incorporation or
charter.
(4) Slate lhe elate each person became a rinn o\Vner.
( 5) Check the appropriate box describing the manner in
which you and each other owner acquired ownership
of your firm. If you checked "Other," explain in the
space provided.
( 6) Check the appropriate box that indicates whether your
linn is "for profit." If you checked "No," then you
do NOT quality for the DBE/ACDBE program and
should not complete this application. All participating
finns must be for-profit enterprises. Provide the
Federal Tax ID number as stated on your fm11's
Federal l2014

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A. Identify the majority owner of the firm holding 51%
or more ownership interest
( l) Enter the full name of the owner.
(2) Enter his/her title or position within your finn.
(3) Give his/her home phone number.
(4) Enter his/her home (street) address.
(5) Indicate this owner's gender.
(6) Iclenlify the owner's elhnic group membership. If you
checked "Other," specify this owner's ethnic
group/identity not otherwise listed.
(7) Check the appropriate box to indicate whether this
ow1rer is a U.S. citizen or a lawfully admitted
permanent resident. If this owner is neither a U.S.
cilizen nor a lawfully aclmillecl pennanenl resiclenl of
the U.S., then this owner is NOT eligible for
cerli1icalion as a DEE owner.
(8) Enter the number of years during which this owner has
been an owner of your fmn.
(9) Indicate the percentage of the total ownership this
person holcls ancl the clale acquirecl, inclucling (if
appropriate), the class of stock owned.
(10) Indicate the dollar value of tlris owner's initial
investment to acquire an ownership interest in your
finn, broken down by cash, real estate, equipment,
and/or other investment. Describe how you acquired
your business ancl allach clocumenlalion subslanlialing
this investment.

(3) (a) Check the appropriate box tlrat indicates whether
this owner owns or works for any other firm( s) that
has l!!.!Y relationship witlr your finn. lf you checked
"Yes," identify the name of the other business, the
nature of tire business relationslrip, and tire owner's
function at the finn.
(b) lf the owner works for any other finn, non-profit
organization, or is engaged in any other activity more
tlran l 0 hours per week, please identity tlris activity.
(4) (a) Provide the personal net worth of the owner
applying for certification in tire space provided.
Complete and attach the accompanying "Personal Net
Worth Statement for DEE/ACDEE Program
Eligibility" with your application. Note, complete this
section and accompanying statement only for each
owner applying for DEE qualification (i.e., for each
owner clainring to be socially and economically
disadvantaged).
(b) Check tire appropriate box that indicates whetlrer any
trust has heen created for the benefit of the
disadvantaged owner(s). If you answered "Yes," you
may be asked to provide a copy of the trust
instrument.
(5) Check the appropriate to indicate whether any of your
immediate family members, managers, or employees,
own, manage, or are associated with another company.
Immediate family member is defined in 49 C.F.R.
§26.5. If you answered "Yes," provide the name of
each person, your relationship to tlrem, the name of
the company, the type of business, and whether they
own or manage tire company.

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

persmmel who are responsible for the functions listed for
the finn. Submit resumes for each owner aud non-owner
identified belov.. Slate lhe mune of lhe individmtl, lille, race
and gender and pencentage ov.11ership if any. Circle the
frequency of each person's involvement as follows:
"always, frequently, seldom, or never" in each area.
Indicate whether any of the persons listed in this section
perfonn a management or supervisory function for any
other business. Identify the person, business, aud their
title/function Identify if any of the persons listed above
own or work for any otlrer finn(s) tlmt has a relationship
with this finn (e.g. ownership interest, shared office space,
financial investment, equipment, leases, personnel sharing.
etc.) If you answered ·'Yes," describe the natme of his/her
business relationship with that otlrer finn.
C. Inventory: Indicate finn inventory in these categories:
(1) Equipment and Vehicles

State the make and model, and current dollar value of
each piece of equipment and motor vehicle held and/or
used hy your tlnn. Indicate whether each piece is
either ov.ned or leased by your tlnn or ov.ner, whetlrer
it is used as collateral, and where this item is stored.
(2) Office Space
State tire street address of each office space held
and/or used by your firm. Indicate whether your firm
or mvner owns or leases the office space and the
current dollar value of that property or its lease.
(3) Storage Space
State the str·eet adch·ess of each storage space held
and/or used by your finn. Indicate whether your fmn
or ov.ner owns or leases the storage space and the
current dollar value of llial properly or ils lease.
Provide a signed lease agreement for each property.
D. Does your firm rely on any other firm for
management functions or employee payroll'!
Check the appropriate box that indicates whether your fum
relics on auy other tirm for management fimctions or for
employee payroll. If you answered "Yes," you may be
asked to explain the narure of that reliance and the extent to
which the other tlnn carries out such functions.
E. Financial/ Banking Information
State the name, City and State of your firm's bank. Identify
llie persons able lo sign checks on lliis account. Provide
hank authorization and signature cards.
Bonding Information. State your finn's bonding linlits both
aggregate and projecllimils.

each loau was made to your finn. Provide copies of signed
loan agreements and security agreements
G. Contributions or transfers of assets to/from your
firm and to/from any of its owners or another
individual over the past two years:
Indicate in the spaces provided, the type of contribution or
asset that was transferred, its current dollar value, the
person or firm from whom it was transferred, the person or
finn to whom it was tmnsfenec"'" the relationship between
tire two persons and/or finns, and tire date of tire transfer.
H Current licenses/permits held by any owner or
employee of your firm.
List the name of each person in your firm who holds a
professional license or penni!, the type of permit or license,
the expiration date of the permit or license, and issuing
State of the license or pennit. Attach copies of licenses,
license renewal forms, pennits, and haul authority forms.
l Largest contracts completed by your firm in the past

three years, if any.
List llie name of each owner or contractor for each contract,
tire name and location of tire projects wrder each contract,
the type of work perfonned on each contract, and the dollar
value of each contract.
J. Largest active _jobs on which your firm is currently
working.
For each active job listed, state the name of the prime
contractor and tire project nurnber, tire location, the type of
work perfonned, the project start date, the anticipated
completion date, mrd the dollar value ofthe contract.

Section 5: AIRPORT CONCESSION (A CD BE)
APPLICANTS
Cornplele llie entries in lliis sec lion if you are applying for
ACDRR certification. Indicate in Section A if you operate a
concession at the airport, aud/or supply a good or service to
an airport concessionaire. Indicate in Section B whether the
applicant finn owns or operates any off.ai:tpori locations,
providi:trg tire type of busi:tress, lease i:trfonnation,
address/location, mrd mrnual gross receipts generated.
Provide similar information in section C for any airport
concession locations the finn cunently owns or operates. If
tire applicmrt tlnn has mry affiliates, provide the requested
infonnation in Section D. Indicate whetlrer the ACDBE
linn is participating i:tr tmy joint venlttres, tmd if so, include
the original and any amended joint venture agreements.
AFFIDAVIT & SIGNATURE
The Affidavit of Certification must accompany your
application. Carefully read the attached affidavit in its
entirety. Fill in the required infomration tor each blmlk
space, and sign and date the affidavit i:tt tire presence of a
Notary Public, who must tlren notarize tire fonn.

State the name aud address of each source, the name of
person securing the loan, original dollar amount aud the
cunent balance of each loan, and tire pwpose for which
U.S. DOT Unifonn DBE/A CDBE Certification Application • Page 1011 of 15

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F. Sources, amounts, and purposes of money loaned to
your firm, including the names of persons or firms
guaranteeing the loan.

40127

40128

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

Section 1: CERTIFICATION INFORMATION
I am applying for certification as 0 DBE DACDBE

A. Basic Contact Information

(1) Contact person and Title: _ _ _ _ _ _ _ __

(2) Legal name offirm: _ _ _ _ _ _ _ _ _ __

(3) Phone#: (_) _ _ - _ _ _ (4) Other Phone#: ( _ ) _ _ - _ _ (5) Fax#: ( _ ) _ _ - _ _
(6) E-mail: _ _ _ _ _ _ _ _ _ _ _ _ _ _ (7) Firm Websites: _ _ _ _ _ _ _ _ _ _ _ _ __
(8) Street address of firm

(No P.O. Box):

(9) Mailing address of firm

(ifdifferenl)

City:

County/Parish:

State:

Zip:

City:

County/Parish:

State:

Zip:

B. Prior/Other Certifications and Applications
(10) Is your firm currently certified for any ofthe following U.S. DOT programs?

D DBE D A CD BE Names of certifying agencies: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

List the dates of any site visits conducted by your home state and any other states or UCP members:
Date _ _ _ Statc/UCP Member: _ _ _ _ _ Date _ _ _ Statc/UCP Member: _ _ _ _ _ __
(11) Indicate whether the firm or any persons listed in this application have ever been:
(a) Denied certification or decertified as a DBE, A CD BE, 8(a), SDB, MBE/WBE firm? D Y cs DNo
(b) Withdrawn an application for these programs, or debarred or suspended or otherwise had bidding privileges
denied or restricted by any state or local agency, or Federal entity? D Yes D No
If yes, explain the nature of the action. (l{}'OU appealed the decision to DOT or another agency, attach a copy of the decision)

Section 2: GENERAL INFORMATION
A. Business Profile: (1) Give a concise description of the tlm1' s primary activities and the product(s) or service(s)
it provides. If your company offers more than one product/service, list the primary product or service first. Please
use additional paper if necessary. This description may be used in our database and the UCP online directory if you
are certified as a DBE or ACDBE.

(2) Applicable NAICS Codes for this line of work include:______
I

I (4) J/We have owned this firm since: __/__/__

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(3) This firm was established on

_ __

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

40129

(5) Method of acquisition (Check all that appZv):
D Started new business
D Bought existing business
D Inherited business
D Gifted
D Merger or consolidation D Other (explain! _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(6) Is your firm "for profit"? DYes DNo---->
Federal Ta" ID# _ _ _ _ _ _ _ _ _ __
(7)
D
D
D

®STOP! If your finn is NOT for-profit, then you do NOT
qualify for tlris program and should not fill out tlris application.

Type of Legal Business Structure: (check all that apply):
Sole Proprietorship
D Limited Liability Partnership
Partnership
DCorporation
Limited Liability Company D Other, Describe _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(8) Number of employees: Full-time

Part-time

Seasonal

Tot..1.l _ _ __

(Provide a list of employees, their job titles, and dates of employment, to your application).

(9) Specify the firm's gross receipts for the last 3 years. (Sub mil complete copies ofthejirm 's Federal fax returnsfor
each year. If /here are affiliates or subsidiaries of the applicanl firm or owners, you must submit complete copies of these
firms' Federal tax returns).
Year _ _ _ Gross Receipts of Applicant Firm $ _ _ _ _ _ _ Gross Receipts of Affiliate Firms $_ _ _ __
Year
Gross Receipts of Applicant Firm $
Gross Receipts of Affiliate Firms $_ _ __
Gross Receipts of Affiliate Firms $_ _ _ __
Y car
Gross Receipts of Applicant Firm $
B. Relationships and Dealings with Other Businesses
(1) Is your firm co-located at any of its business locations, or does it share a telephone number, P.O. Box, office
or storage space, yard, warehouse, facilities, equipment, inventory, financing, office staff, and/or employees with
any other business, organization, or entity? 0 Y cs 0 No

If Yes, explain the nature ofyour relationship with these other businesses by identifYing the business or person with whom you
have any formal, informal, written, or oral agreement. Also detail the items shared

(2) Has any other firm had an ownership interest in your firm at present or at any time in the past?
DYes D No lfYes, explain_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

({(you answered "Yes" to any of the questions in (2) and/or (3)(a)-(f}, you may be asked to provide further details and explain
whether the arrangement continues).

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(3) At present, or at any time in the past, has your firm:
(a) Ever existed under different ownership, a different type of ownership, or a different name? 0 Yes 0 No
(b) Existed as a subsidiary of any other firm? 0 Yes 0 No
(c) Existed as a partnership in \vhich one or more of the partners are/were other finns? 0 Yes 0 No
(d) Owned any percentage of any other finn? 0 Yes 0 No
(e) Had any subsidiaries? DYes D No
(t) Served as a subcontractor with another finn constituting more than 25% of your finn's receipts? DYes D No

40130

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

Section 3: MAJORITY OWNER INFORMATION
A. Identify the majority owner of the firm holding 51% or more ownership interest.
(1) Full Name:

I (2) Title:
City:

(4) Home Address (Street and Number):

(5) Gender: 0 Male 0 Female
(6) Ethnic group membership (Check all that appZr):

0
0
0
0
(7)

(3) Home Phone #:
(
)---------Zip:

State:

(8) Number of years as owner: _ __
(9) Percentage owned: _____ %
Class of stock owned: _ _ __
Date acquired _ _ _ _ _ _ __
(10) Initial investment to

Black
0 Hispanic
Asian Pacific 0 Native American
Subcontinent Asian
Other (specifY) - - - - - - - - -

Type
Dollar Value
$
Cash
Real Estate $
Equipment $
$
Other
Describe how you acquired your business:
0 Started business myself
0 It was a gift from: _ _ _ _ _ _ _ _ _ _ _ __
0 1 bought it from: _ _ _ _ _ _ _ _ _ _ _ __
0 1 inherited it from: - - - - - - - - - - - - 0 Other - - - - - - - - - - - - - - - - - -

acquire ownership
interest in firm:

U.S. Citizenship:

0 U.S. Citizen
0 Lawfully Admitted Permanent Resident

(Attach documentation substantiating your investment)

B. Additional Owner Information
(1) Describe familial relationship to other owners and employees:

(2) Does this owner perform a management or supervisory function for any other business? 0 Yes 0 No
If Yes, identifY: Name of Business _ _ _ _ _ _ _ _ _ _ _ _ _ Function!Iitle: _ _ _ _ _ _ _ _ _ _ __
(3)(a) Does this owner own or work for any other firm(s) that has a relationship with this firm? (e.g.,
0 Yes 0 No
IdentifY the name of the business, and the nature of the relationship, and the owner's function at the firm:

ownership

inleresl, shared office space, financial inves/menls, equipmenl, leases, personnel shan·ng, e/c.)

(b) Does this owner work for any other firm, non-profit organization, or engage in any other activity more
than 10 hours per week? 1fyes, identifY this activity: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(4)(a) What is the personal net worth of this disadvantaged owner applying for certification?$._ _ _ __
(b )Has any trust been created for the benefit of this disadvantaged owner(s)? 0 Yes 0 No
(I,[ Yes, you may be asked fo provide a copy of the trust instrument).

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(5) Do any of your immediate family members, managers, or employees own, manage, or are associated with
another company? 0 Y cs 0 No IfY cs, provide their name, relationship, company, type of business, and
indicate whether they own or manage the company: (Please attach exira sheets, if needed): _ _ _ _ _ _ _ _ __

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

40131

Section 3: OWNER INFORMATION, Cont'd.
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the
firm (Attach separate sheets for each additional owner)
(1) Full Name:

(3) Home Phone#:

I (2) Title:
I

City:

(4) Home Address (Street and Number):
(5) Gender: 0 Male 0 Female
(6) Ethnic group membership (Check all that app~v)

0 Hispanic
0 Asian Pacific 0 Native American
0 Subcontinent Asian
0 Other (specifY) - - - - - - - - -

(

) ---------State:

Zip:

(8) Number of years as owner: _ __
(9) Percentage owned:
%
Class of stock owned: _ _ __
Date acquired _ _ _ _ _ __

0 Black

(7)

(10) Initial investment to

acquire ownership
interest in firm:

U.S. Citizenship:

0 U.S. Citizen
0 Lawfully Admitted Permanent Resident

Type
Cash
Real Estate
Equipment
Other

Dollar Value
$
$
$
$

Describe how you acquired your business:
0
Started business myself.
0
It \vas a gift from: _ _ _ _ _ _ _ _ _ _ _ __
0
I bought it from: _ _ _ _ _ _ _ _ _ _ _ __
0 I inherited it from: - - - - - - - - - - - - 0
Other - - - - - - - - - - - - - - - - - - ~4ttach

documentation substantiating your investment)

B. Additional Owner Information
(1) Describe familial relationship to other owners and employees:

(2) Does this owner perform a management or supervisory function for any other business? 0 Yes 0 No
If Yes, identifY: Name of Business: _ _ _ _ _ _ _ _ _ _ _ _ _ Funclion/TiUe: _ _ _ _ _ _ _ _ _ _ __
(3)(a) Does this owner own or work for any other firm(s) that has a relationship with this firm?

(e.g., awnerslnj>

interest, shared office space .financial investments, equipment, leases, personnel sharing, etc.) 0 Yes 0 No

IdentifY the name of the business, and the nature of the relationship, and the owner's function at the firm:
(b) Does this owner work for any other firm, non-profit organization, or is engaged in any other activity
more than 10 hours per week? If yes, identify this activity: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(4)(a) What is the personal net worth of this disadvantaged owner applying for certification?$_ _ _ __
(b) Has any trust been created for the benefit of this disadvantaged owner(s)? 0 Yes 0 No
(If Yes, you may be asked to provide a copy of the trust instrument).

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(5) Do any of your immediate family members, managers, or employees own, manage, or are associated
with another company? 0 Yes 0 No IfYes, provide their name, relationship, company, type of
business, and indicate whether they own or manage: (Please attach extra sheets, if needed): _ _ _ _ _ _ __

40132

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

Section 4: CONTROL
A. Identify your firm's Officers and Board of Directors (If additional space is required, attach a separate sheet):
Name
(1) Officers of the Company

(2) Board of Directors

Title

Date
Appointed

Ethnicitv

Gender

(a)
(b)
(c)
(d)
(a)
(b)
(c)
(d)

(3) Do any of the persons listed above perform a management or supervisory function for any other business?
D Yes D No lfYes, identity for each:
Person: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Title: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Business:
Function: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Person: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T i t l e : , - - - - - - - - - - - - - - - - - - - - - - Business:
Function: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(4) Do any ofthe persons listed in section A above own or work for any other firm(s) that has a relationship
with this firm? (e.g., ownership interest, shared office space, .financial investments, equipment, leases, personnel sharing, etc.)
D Yes D No lf Yes, identity for each:
FirmName: _ _ _ _ _ _ _ _ _ _ _ _ _ _ Person: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Nature of Business R e l a t i o n s h i p : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

B. Duties of Owners, Officers, Directors, Managers, and Key Personnel
1. Complete for all Owners who are responsible for the following functions of the firm (Atrach separate sheets as
needed)

A= Always
F = Frequently

S =Seldom
N =Never

A
A
A
A

F
F
F
F

A
A
A

F
F
F

A
A

F
F

Minority Owner (49% or less)
Name:
Title:
Percent Owned:
A
F
N
s

s
s
s
s
s
s

N
N
N
N

A
A
A
A

s
s
s
s
s
s

N
N
N

A
A
A

N
N

A
A

F
F
F

s
s
s
s
s
s

N
N
N
N

F
F
F
F
F
F

s
s
s
s
s
s

N
N
N

F
F
F

N
N

U.S. DOT Uniform DEE/ACD BE Certification Application • Page 1016 of 15

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Sets policy for company direction/scope
of operations
Bidding and estimating
Major purchasing decisions
Marketing and sales
Supervises field operations
Attend bid opening and lettings
Perform office management (billing,
accounts receivable/payable, etc )
Hires and fires management staff
Hire and fire field staff or crew
Designates profits spending or investment
Obligates business by contract/credit
Purchase equipment
Signs business checks

Majority Owner (51% or more)
Name:
Title:
Percent Owned:
A
F
N
s

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

2. Complete for all Officers, Directors, Managers, and Key Personnel who
functions of the firm (Artach separate sheets as needed)
Officer/Director/Manager/Key Pers01mel
Name:
A= Always
S =Seldom
Title:
N =Never
F = Frequently
Race and Gender:
Percent Owned:
Sets policy for company direction/scope A
F
N
s
of operations
F
N
Bidding and cstimating
A
s
F
N
Maior purchasing decisions
A
s
Marketing and sales
A
F
N
s
F
N
Supervises field opemtions
A
s
Attend bid opening and lcttings
A
F
s
N
F
N
Perform office management (billing,
A
s
accounts receivable/pavable, etc.)
Hires and fires management staff
A
F
N
s
Hire and fire field staff or crew
A
F
N
s
Designates profits spending or investment A
F
N
s
Obligates business bv contmct/crcdit
A
F
N
s
F
N
Purchase equipment
A
s
Signs business checks
A
F
N
s

40133

are responsible for the following
Officer/Director/Manager/ Key Pers01mel
Name:
Title:
Race and Gender:
Percent Owned:
A F
N
s
A
A
A
A
A
A

F
F
F
F
F
F

s
s
s
s
s
s

N
N
N
N
N
N

A
A
A
A
A
A

F
F
F
F
F
F

s
s
s
s
s
s

N
N

N
N
N
N

Do any of the persons listed in B 1 or B2 perform a management or supervisory function for any other business? TfY cs,
identifY the person, the business, and their title/function: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Do any of the persons listed above own or work for any other firm(s) that has a relationship with this firm? (e.g,
ownership inleres/, shared office space, financial inves/menls, equipment, leases, personnel sharing, etc.) If Yes, describe tl1e nature of
the business relationship: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

C. Inventory: Indicate your firm's inventory in the following categories (Please artach additional sheets if needed):
1. Equipment and Vehicles
Make and Model

Current
Value

Owned or Leased
by Firm or Owner?

Used as collateral?

Where is item stored?

l.
2.
3.

4.
5.
6.
7.

8.
9.

Owned or Leased by Firm or Owner?

Current Value of Property or Lease

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2. Office Space
Street Address

40134

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

3. Storage Space !Provide signed lease agreements for the properties listed)
Street Address

Owned or Leased by
Firm or Owner?

Current Value of Property or Lease

D. Does your firm rely on any other firm for management functions or employee payroll? D Yes D No

E. Financial/Banking Information (Provide bank authorization and signature cards)
Name of bank:
City and State: _ _ _ _ _ _ _ _ _ _ _ _ __
The following individuals are able to sign checks on this account: ___________________
Name of bank:
City and State: _ _ _ _ _ _ _ _ _ _ _ _ _ __
The following individuals are able to sign checks on this account: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Bonding Information: If you have bonding capacity, identify the firm's bonding aggregate and project limits:
Aggregate limit $
Project limit $ _ _ _ _ _ _ _ __
F. Identify all sources, amounts, and purposes of money loaned to your firm including from financial
institutions. Identify whether you the owner and any other person or firm loaned money to the applicant
DBE/ACDBE. Include the names of any persons or firms guaranteeing the loan, if other than the listed owner.
(l'rovide copies ofsigned loan agreements and security agreements).
N arne of Source

Address of Source

N arne of Person
Guaranteeing the
Loan

Original
Amount

Current
Balance

Purpose of Loan

!. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
G. List all contributions or transfers of assets to/from your firm and to/from any of its owners or another
individual over the past two years (Ailach additional sheets if needed):
Contribution/Asset

Dollar Value

From Whom
To Whom
Relationship Date of
Transferred
Transferred
Transfer
l. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
H. List current licenses/permits held by any owner and/or employee of your firm
(e.g. contractor, engineer, architect, etc.)(Attach additional sheets if needed):

Name of License/Permit Holder
Type of License/Permit
Expiration Date
State
l. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

U.S. DOT UniformDBE/ACDBE Certification Application • Page 1018 of 15

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3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

40135

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

I. List the three largest contracts completed by your firm in the past three years, if any:

Name of
Owner/Contractor

Name/Location of
Project

Type of Work Performed

Dollar Value of
Contract

1.-------------------------------------------------------------------------------2·-------------------------------------------------------------------------------

3·-------------------------------------------------------------------------------

J. List the three largest active jobs on which your firm is currently working:
Name of Prime
Contractor and Project
Number

Location of
Project

Type of Work

Project
Start Date

Anticipated
Completion
Date

Dollar Value
of Contract

1.--------------------------------------------------------------------------------

2·--------------------------------------------------------------------------------

3·--------------------------------------------------------------------------------

U.S. DOT Uniform DBE/A CD BE Certification Application • Page 1019 of 15

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Additional Information:

40136

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

SECTION 5- AIRPORT CONCESSION
(A CD BE APPLICANTS ONLY)
A. I am applying for A CD BE certification to: (check all that apply)
D Operate a concession at an airport D Supply a good or service to an airport concessionaire
B. Does the applicant firm own/operate any off-airport locations? DYes D No If"Yes, identify thefollowing
Address I Location

Type of Business
Lease
Lease
(e.g., F&B, News & Gift Retail, Duty Term Start Date
Free, Advertising. etc.)
(years)

Does the applicant firm currently own/operate any airport concession locations? DYes D No !{Yes, supply
the following information.
Airport Name

Concession Type Number of Number of
(e.g., F &B, News &
Leases
Locations
Gift, Retail, Duty Free,
Advertising, etc.)

D. Does the applicant firm have any affiliates? DYes D No
any locations owned1operated by affiliate firms.
Airport Name

Annual Gross
Receipts
Generated

Lease Type
(e.g. Direct Lease, Subcontract
Afanagement Agreement, etc. enter
all that apply to the leases listed)

!{Yes, provide the following information concerning

Concession Type Number of Number of
(e.g., F &B, News &
Leases
Locations
Gift, Retail, Duty Free,
Advertising, elc.)

Annual Gross
Receipts
Generated

E. Is the ACDBE applicant firm a participant in any joint ventures? DYes D No
any amended Joint Venture Agreements and any amendments to the agreements.

Lease Type
(e.g. Direct Lease, Subcontract
A1anagement Agreement, etc. enter
all that app~v to the leases listed)

!{Yes, attach all original and

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Annual Gross
Receipts Generated

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

40137

AFFIDAVIT OF CERTIFICATION
1his form must be signed and notarized for each owner upon which disadvantaged status is relied.

A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS
SUFFICIENT CAUSE FOR DENIAL OF CERTIFICATION, REVOCATION OF A PRIOR APPROVAL, INITIATION
OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR ENTITY
MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES AVAILABLE
PURSUANT TO APPLICABLE FEDERAL AND STATE LAW.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ (full name printed),
swear or affinn under penalty of law that Jam
_ _ _ _ _ _ _ _ _ _ _ _ (title) of the applicant firm
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ and that 1
have read and understood all of the questions in this
application and that all of the foregoing infonnation and
statements submitted in this application and its attachments
and supporting documents are true and correct to U1e best of
my knowledge, and Uml all responses to U1e questions are full
and complete, omitting no material information. The responses
include all material information necessary to fully and
accurately identify and explain the operations, capabilities and
pertinent history of the named firm as well as the ownership,
control, and affiliations thereof
J recognize that the infonnation submitted in this application is
for the purpose of inducing certification approval by a
government agency. 1 understand tlmt a government agency
may, by means it deems appropriate, determine the accuracy
and truth of the statements in the application, and I authorize
such agency to contact any entity named in the application, and
the named firm's bonding companies, banking institutions,
credit agencies, contractors, clients, and oU1er certifying
agencies for the purpose of verifying tl1e information supplied
and detennining tl1e named finn's eligibility.
I agree to submit to govemment audit, examination and review
of books, records, documents and files, in wlmtever form they
exist, of the named firm and its affiliates. inspection of its
places(s) of business and equipment, and to permit interviews
of its principals, agents. and employees. J understand that
refusal to permit such inquiries slmll be grounds for denial of
certification.
If awarded a contract, subcontract, concession lease or
sublease, I agree to prompUy and direcUy provide U1e prime
contractor, if any, and U1e Department, recipient agency, or
federal funding agency on an ongoing basis, current, complete
and accurate information regarding (1) work performed on tl1e
project; (2) payments; and (3) proposed changes, if any, to the
foregoing arrangements.

I certify that I am a socially and economically disadvantaged
individual who is an owner of tl1e above-referenced firm seeking
certification as a Disadvantaged Business Enterprise or Airport
Concession Disadvantaged Business Enterprise. In support of my
application, I certify tlmt I am a member of one or more of the
following groups, and tlmt I lmve held myself out as a member of
the group(s): (Check all tlmt apply):
0 Female 0 Black American 0 Hispanic American
0 Native American 0 Asian-Pacific American
0 Subcontinent Asian American 0 Other (specify)

I certify that I am socially disadvantaged because I have been
subjected to racial or eUnric prejudice or cultural bias, or have
suffered the effects of discrimination, because of my identity
as a member of one or more of tl1e groups identified above,
without regard to my individual qualities.
I further certify tlmt my personal net worth does not exceed
$1.32 million, and tlmt I am economically disadvantaged
because my ability to compete in the free enterprise system lms
been impaired due to diminished capital and credit
opportunities as compared to others in the same or similar line
of business who are not socially and economically
disadvantaged.
I declare under penally of peij ury Uml U1e infonnation
provided in tlris application and supporting documents is true
and correct.
Signature----.,---------(DBE/ACDBE Applicant)

(Date)

NOTARY CERTIFICATE

U.S. DOT Uniform DEE/A CD BE Certification Application • Page 1021 of 15

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I agree to provide written notice to the recipient agency or
Unified Certification Program of any 111aterial clmnge in the
infommtion contained in the original application within 30
calendar days of such change (e.g., ownership changes,
address/telephone number, personal net worth exceeding $1.32
million, etc.).

J 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 111ay be awarded; denial or revocation of certification;
suspension and debarment; and for initiating action under
federal and/or state law conccming false statement, fraud or
other applicable offenses.

40138

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

UNIFORM CERTIFICATION APPLICATION
SUPPORTING DOCUMENTS CHECKLIST
In order to complete your application for DBE or A CD BE certification, you must attach copies of all of the following
REQUIRED documents. A failure to supply any information requested by the UCP may result in your firm denied
DBE/ACDBE certification.

Required Documents (or All Applicants
l Resumes (that include places of employment with
corresponding dates), for all owners, officers, and key
personnel of the applicant firm
J Personal Net Worth Statement for each socially and
economically disadvantaged owners who the applicant firm
relics upon to satisfy the Regulation's 51% ownership
requirement.
J Personal Federal tax returns for the past3 years, if
applicable, for each disadvantaged owner
J Federal tax returns (and requests for extensions) filed by
the finn and its affiliates with related schedules, for the past 3
years.
J Documented proof of contributions used to acquire
ownership for each owner (e.g., both sides ofcancelled
checks)
l Signed loan and security agreements, and bonding forms
L List of equipment and/or vehicles owned and leased
including YIN numbers, copy of titles, proof of ownership,
insurance cards for each vehicle.
J Titlc(s), registration certificatc(s), and U.S. DOT numbers
for each truck owned or operated by your finn
J Licenses, license renewal fonns, pennils, and haul
authority forms
J Descriptions of all real estate (including office/storage
space, etc.) owned/leased by your finn and documented proof
of ownership/signed leases
J Documented proof of any transfers of assets to/from your
firm and/or to/from any of its owners over the past 2 years
J DBE/ACDBE and SEA 8(a). SDB, MBE/WBE
certifications, denials, and/or decertifications, if applicable;
and any U.S. DOT appeal decisions on these actions.
J Bank authorization and signatory cards
J Schedule of salaries (or other remuneration) paid to all
officers, managers, owners, and/or directors of the finn
J List of all employees, job titles, and dales of employment.
J Proof of warehouse/storage facility ownership or lease
arrangements

Minutes of all stockholders and board of directors meetings
- Corporate by-laws and any amendments
- Corporate bank resolution and bank signature cards
Official Certificate of Formation and Operating Agreement
with any amendments (for LLCs)

Optional Documents to Be Provided on Request
The certi[ving agency fo which you are appZving may require
the submission of the following documents. If requested to
provide these document, you must suppZv them with your
application or at the on-site visit.
L Proof of citizenship
Insurance agreements for each tmck owned or operated by
your firm
- Audited financial statements (if available)
- Tmst agreements held by any owner claiming
disadvantaged status
Year-end balance sheets and income statements for the
past 3 years (or life affirm, !{less than three years)

Suppliers
List of product lines carried and list of distribution
equipment owned and/or leased

Corporation or LLC
J Official Articles of Incorporation (5igned by the srate
ojjicial)
J Both sides of all corporate stock certificates and your
firm's stock tnmsfcr ledger
J Shareholders· Agrecment(s)
U.S. DOT Uniform DEE/A CD BE Certification Application • Page 1022 of 15

BILLING CODE 4910–9X–C

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Partnership or Joint Venture
J Original and any amended Partnership or Joint Venture
Agreements

Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices
Appendix B to Part 26—Uniform
Report of DBE Awards or Commitments
and Payments Form

sradovich on DSK3GMQ082PROD with NOTICES

Instructions for Completing the Uniform
Report of DBE Awards/Commitments and
Payments
Recipients of Department of Transportation
(DOT) funds are expected to keep accurate
data regarding the contracting opportunities
available to firms paid for with DOT dollars.
Failure to submit contracting data relative to
the DBE program will result in
noncompliance with Part 26. All dollar
values listed on this form should represent
the DOT share attributable to the Operating
Administration (OA): Federal Highway
Administration (FHWA), Federal Aviation
Administration (FAA) or Federal Transit
Administration (FTA) to which this report
will be submitted.
1. Indicate the DOT (OA) that provides
your Federal financial assistance. If
assistance comes from more than one OA,
use separate reporting forms for each OA. If
you are an FTA recipient, indicate your
Vendor Number in the space provided.
2. If you are an FAA recipient, indicate the
relevant AIP Numbers covered by this report.
If you are an FTA recipient, indicate the
Grant/Project numbers covered by this report.
If more than ten attach a separate sheet.
3. Specify the Federal fiscal year (i.e.,
October 1–September 30) in which the
covered reporting period falls.
4. State the date of submission of this
report.
5. Check the appropriate box that indicates
the reporting period that the data provided in
this report covers. For FHWA and FTA
recipients, if this report is due June 1, data
should cover October 1–March 31. If this
report is due December 1, data should cover
April 1–September 30. If the report is due to
the FAA, data should cover the entire fiscal
year.
6. Provide the name and address of the
recipient.
7. State your overall DBE goal(s)
established for the Federal fiscal year of the
report being submitted to and approved by
the relevant OA. Your overall goal is to be
reported as well as the breakdown for
specific Race Conscious and Race Neutral
projections (both of which include genderconscious/neutral projections). The Race
Conscious projection should be based on
measures that focus on and provide benefits
only for DBEs. The use of contract goals is
a primary example of a race conscious
measure. The Race Neutral projection should
include measures that, while benefiting
DBEs, are not solely focused on DBE firms.
For example, a small business outreach
program, technical assistance, and prompt
payment clauses can assist a wide variety of
businesses in addition to helping DBE firms.
Section A: Awards and Commitments Made
During This Period
The amounts in items 8(A)–10(I) should
include all types of prime contracts awarded
and all types of subcontracts awarded or
committed, including: professional or
consultant services, construction, purchase of
materials or supplies, lease or purchase of

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equipment and any other types of services.
All dollar amounts are to reflect only the
Federal share of such contracts and should be
rounded to the nearest dollar.
Line 8: Prime contracts awarded this
period: The items on this line should
correspond to the contracts directly between
the recipient and a supply or service
contractor, with no intermediaries between
the two.
8(A). Provide the total dollar amount for
all prime contracts assisted with DOT funds
and awarded during this reporting period.
This value should include the entire Federal
share of the contracts without removing any
amounts associated with resulting
subcontracts.
8(B). Provide the total number of all prime
contracts assisted with DOT funds and
awarded during this reporting period.
8(C). From the total dollar amount awarded
in item 8(A), provide the dollar amount
awarded in prime contracts to certified DBE
firms during this reporting period. This
amount should not include the amounts sub
contracted to other firms.
8(D). From the total number of prime
contracts awarded in item 8(B), specify the
number of prime contracts awarded to
certified DBE firms during this reporting
period.
8(E&F). This field is closed for data entry.
Except for the very rare case of DBE-set
asides permitted under 49 CFR part 26, all
prime contracts awarded to DBES are
regarded as race-neutral.
8(G). From the total dollar amount awarded
in item 8(C), provide the dollar amount
awarded to certified DBEs through the use of
Race Neutral methods. See the definition of
Race Neutral in item 7 and the explanation
in item 8 of project types to include.
8(H). From the total number of prime
contracts awarded in 8(D), specify the
number awarded to DBEs through Race
Neutral methods.
8(I). Of all prime contracts awarded this
reporting period, calculate the percentage
going to DBEs. Divide the dollar amount in
item 8(C) by the dollar amount in item 8(A)
to derive this percentage. Round the
percentage to the nearest tenth.
Line 9: Subcontracts awarded/committed
this period: Items 9(A)-9(I) are derived in the
same way as items 8(A)-8(I), except that these
calculations should be based on subcontracts
rather than prime contracts. Unlike prime
contracts, which may only be awarded,
subcontracts may be either awarded or
committed.
9(A). If filling out the form for general
reporting, provide the total dollar amount of
subcontracts assisted with DOT funds
awarded or committed during this period.
This value should be a subset of the total
dollars awarded in prime contracts in 8(A),
and therefore should never be greater than
the amount awarded in prime contracts. If
filling out the form for project reporting,
provide the total dollar amount of
subcontracts assisted with DOT funds
awarded or committed during this period.
This value should be a subset of the total
dollars awarded or previously in prime
contracts in 8(A). The sum of all subcontract
amounts in consecutive periods should never

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40139

exceed the sum of all prime contract amounts
awarded in those periods.
9(B). Provide the total number of all sub
contracts assisted with DOT funds that were
awarded or committed during this reporting
period.
9(C). From the total dollar amount of sub
contracts awarded/committed this period in
item 9(A), provide the total dollar amount
awarded in sub contracts to DBEs.
9(D). From the total number of sub
contracts awarded or committed in item 9(B),
specify the number of sub contracts awarded
or committed to DBEs.
9(E). From the total dollar amount of sub
contracts awarded or committed to DBEs this
period, provide the amount in dollars to
DBEs using Race Conscious measures.
9(F). From the total number of sub
contracts awarded or committed to DBEs this
period, provide the number of sub contracts
awarded or committed to DBEs using Race
Conscious measures.
9(G). From the total dollar amount of sub
contracts awarded/committed to DBEs this
period, provide the amount in dollars to
DBEs using Race Neutral measures.
9(H). From the total number of sub
contracts awarded/committed to DBEs this
period, provide the number of sub contracts
awarded to DBEs using Race Neutral
measures.
9(I). Of all subcontracts awarded this
reporting period, calculate the percentage
going to DBEs. Divide the dollar amount in
item 9(C) by the dollar amount in item 9(A)
to derive this percentage. Round the
percentage to the nearest tenth.
Line 10: Total contracts awarded or
committed this period. These fields should
be used to show the total dollar value and
number of contracts awarded to DBEs and to
calculate the overall percentage of dollars
awarded to DBEs.
10(A)–10(B). These fields are unavailable
for data entry.
10(C–H). Combine the total values listed on
the prime contracts line (Line 8) with the
corresponding values on the subcontracts
line (Line 9).
10(I). Of all contracts awarded this
reporting period, calculate the percentage
going to DBEs. Divide the total dollars
awarded to DBEs in item 10(C) by the dollar
amount in item 8(A) to derive this
percentage. Round the percentage to the
nearest tenth.
Section B: Breakdown by Ethnicity & Gender
of Contracts Awarded to DBEs This Period
11–17. Further breakdown the contracting
activity with DBE involvement. The Total
Dollar Amount to DBEs in 17(C) should equal
the Total Dollar Amount to DBEs in 10(C).
Likewise, the total number of contracts to
DBEs in 17(F) should equal the Total Number
of Contracts to DBEs in 10(D).
Line 16: The ‘‘Non-Minority’’ category is
reserved for any firms whose owners are not
members of the presumptively disadvantaged
groups already listed, but who are either
‘‘women’’ OR eligible for the DBE program on
an individual basis. All DBE firms must be
certified by the Unified Certification Program
to be counted in this report.

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Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices

sradovich on DSK3GMQ082PROD with NOTICES

Section C: Payments on Ongoing Contracts
Line 18(A–E). Submit information on
contracts that are currently in progress. All
dollar amounts are to reflect only the Federal
share of such contracts, and should be
rounded to the nearest dollar.
18(A). Provide the total number of prime
and sub-contracts where work was performed
during the reporting period.
18(B). Provide the total dollar amount paid
to all firms performing work on contracts.
18(C). From the total number of contracts
provided in 18(A) provide the total number
of contracts that are currently being
performed by DBE firms for which payments
have been made.
18(D). From the total dollar amount paid to
all firms in 18(A), provide the total dollar
value paid to DBE firms currently performing
work during this period.
18(E). Provide the total number of DBE
firms that received payment during this
reporting period. For example, while 3
contracts may be active during this period,
one DBE firm may be providing supplies or
services on all three contracts. This field
should only list the number of DBE firms
performing work.
18(F). Of all payments made during this
period, calculate the percentage going to
DBEs. Divide the total dollar value to DBEs
in item 18(D) by the total dollars of all
payments in 18(B). Round the percentage to
the nearest tenth.
Section D: Actual Payments on Contracts
Completed This Reporting Period
This section should provide information
only on contracts that are closed during this
period. All dollar amounts are to reflect the
entire Federal share of such contracts, and
should be rounded to the nearest dollar.
19(A). Provide the total number of
contracts completed during this reporting
period that used Race Conscious measures.
Race Conscious contracts are those with
contract goals or another race conscious
measure.
19(B). Provide the total dollar value of
prime contracts completed this reporting
period that had race conscious measures.
19(C). From the total dollar value of prime
contracts completed this period in 19(B),
provide the total dollar amount of dollars
awarded or committed to DBE firms in order
to meet the contract goals. This applies only
to Race Conscious contracts.
19(D). Provide the actual total DBE
participation in dollars on the race conscious
contracts completed this reporting period.
19(E). Of all the contracts completed this
reporting period using Race Conscious
measures, calculate the percentage of DBE
participation. Divide the total dollar amount
to DBEs in item 19(D) by the total dollar
value provided in 19(B) to derive this
percentage. Round to the nearest tenth.
20(A)–20(E). Items 21(A)-21(E) are derived
in the same manner as items 19(A)-19(E),
except these figures should be based on
contracts completed using Race Neutral
measures.
20(C). This field is closed.
21(A)–21(D). Calculate the totals for each
column by adding the race conscious and
neutral figures provided in each row above.

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21(C). This field is closed.
21(E). Calculate the overall percentage of
dollars to DBEs on completed contracts.
Divide the Total DBE participation dollar
value in 21(D) by the Total Dollar Value of
Contracts Completed in 21(B) to derive this
percentage. Round to the nearest tenth.
22. Name of the Authorized Representative
preparing this form.
23. Left blank for future use.
24. Signature of the Authorized
Representative.
25. Phone number of the Authorized
Representative.
**Submit your completed report to your
Regional or Division Office.

subject to the Regulatory Flexibility Act
(5 U.S.C. chapter 6).
Donna Hansberry,
Chief, Appeals.
[FR Doc. 2018–17286 Filed 8–10–18; 8:45 am]
BILLING CODE 4830–01–P

DEPARTMENT OF VETERANS
AFFAIRS
Privacy Act of 1974; System of
Records

BILLING CODE 4910–9X–P

Department of Veterans Affairs
(VA), Debt Management Center.
ACTION: Notice of modified system of
records.

DEPARTMENT OF THE TREASURY

SUMMARY:

[FR Doc. 2018–17301 Filed 8–10–18; 8:45 am]

Internal Revenue Service
Art Advisory Panel—Notice of
Availability of Report of 2017 Closed
Meetings
Internal Revenue Service,
Treasury.
ACTION: Notice.
AGENCY:

Pursuant to the Federal
Advisory Committee Act, and the
Government in the Sunshine Act, a
report summarizing the closed meeting
activities of the Art Advisory Panel
during Fiscal Year 2017 has been
prepared. A copy of this report has been
filed with the Assistant Secretary for
Management of the Department of the
Treasury.
DATES: Effective Date: This report is
available August 2, 2018.
ADDRESSES: The report is available at
https://www.irs.gov/compliance/
appeals/art-appraisal-services.
FOR FURTHER INFORMATION CONTACT:
Maricarmen R. Cuello, AP:SPR:AAS,
Internal Revenue Service/Appeals, 51
SW 1st Avenue, Room 1014, Miami, FL
33130, Telephone number (305) 982–
5364 (not a toll free number).
SUPPLEMENTARY INFORMATION: Pursuant
to 5 U.S.C. App. 2, section 10(d), of the
Federal Advisory Committee Act, and 5
U.S.C. 552b, of the Government in the
Sunshine Act, a report summarizing the
closed meeting activities of the Art
Advisory Panel during Fiscal Year 2017
has been prepared. A copy of this report
has been filed with the Assistant
Secretary for Management of the
Department of the Treasury.
It has been determined that this
document is not a major rule as defined
in Executive Order 12291 and that a
regulatory impact analysis is, therefore,
not required. Additionally, this
document does not constitute a rule
SUMMARY:

PO 00000

Frm 00160

Fmt 4703

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AGENCY:

The Privacy Act of 1974 (5
U.S.C. 522a (e) (4)) requires that all
agencies publish in the Federal Register
a notice of the existence and character
of their systems of records. Notice is
hereby given that the Department of
Veterans Affairs (VA) is modifying a
system of records entitled ‘‘Centralized
Accounts Receivable System/
Centralized Accounts Receivable OnLine System (CARS/CAROLS)
(88VA244)’’. This system was
previously called ‘‘Accounts Receivable
Records VA’’ (88VA244). This system
had also been previously numbered
‘‘88VA20A6’’.
DATES: Comments on this modified
system of records must be received no
later than September 12, 2018. If no
public comment is received during the
period allowed for comment, or unless
otherwise published in the Federal
Register by VA, the modified system
will become effective a minimum of 30
days after publication in the Federal
Register. If VA receives public
comments, VA shall review the
comments to determine whether any
changes to the notice are necessary.
ADDRESSES: Written comments may be
submitted through
www.Regulations.gov; by mail or handdelivery to Director, Regulation Policy
and Management (00REG), Department
of Veterans Affairs, 810 Vermont Ave.
NW, Room 1064, Washington, DC
20420; or by fax to (202) 273–9026 (not
a toll-free number). Comments should
indicate that they are submitted in
response to ‘‘Centralized Accounts
Receivable System/Centralized
Accounts Receivable On-Line System
(CARS/CAROLS)’’. Copies of comments
received will be available for public
inspection in the Office of Regulation
Policy and Management, Room 1063B,
between the hours of 8:00 a.m. and 4:30
p.m., Monday through Friday (except
holidays). Please call (202) 461–4902 for

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File Type	application/pdf
File Modified	2018-08-11
File Created	2018-08-11