Personal Net Worth

OMB APPROVAL NO: 2105-0586

EXPIRATION DATE: (pending)

U.S. Department of Transportation

DBE/ACDBE PNW Statement

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2105-0586. Public reporting for this collection of information is estimated to be approximately 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.

All responses to this collection of information are mandatory 49 CFR § § 26.67, 26.68; the nature and extent of confidentiality to be provided, if any (49 CFR §§ 23.35, 23.39, 26.83(d) and 26.109(b)]. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, (your agency name and address), Washington, D.C. 20590.

Privacy Act Statement (5 U.S.C. § 552a, as amended): 

AUTHORITY: 42 U.S.C. 2000d et seq., § 12101 et seq., 42 U.S.C. 6101 et seq.; 29 U.S.C. 794, 749d; 49 U.S.C. 47113; 42 U.S.C. 12101; 49 CFR Part 23; 49 CFR Part 26, and Executive Order 13160.

PURPOSE(S): DOT will use the information collected to respond to Disadvantaged Business Enterprise (DBE) and Airport Concession Disadvantaged Business Enterprise (ACDBE) inquiries and adjudicate appeals.

ROUTINE USE(S):  In accordance with DOT’s system of records notice, DOT/ALL–24 Departmental Office of Civil Rights System, 76 FR 71108 (Nov. 16, 2011), the information provided may be disclosed to the U. S. Department of Justice, including United States Attorney’s Offices, or other Federal agency conducting litigation or in proceedings before any court, adjudicative or administrative body, when it is necessary to the litigation and one of the following is a party to the litigation or has an interest in such litigation. A comprehensive list of routine uses can be found in DOT/ALL 24 and DOT’s General Statement of Routine uses, 75 FR 82138 (Dec. 29, 2010). 77 FR 42796 (July 20, 2012), 84 FR 55222 (Oct. 15, 2019).

DISCLOSURE: Provision of the requested information is voluntary; however, failure to furnish the requested information may result in the denial of a DBE or ACDBE application and an inability of the Department to process an appeal or inquiry from any party.

Instructions

An individual’s personal net worth according to 49 C.F.R. Parts 23 and 26 includes assets and liabilities that she or he owns or is deemed to own without regard to community property or equitable distribution laws.

If the personal net worth of the majority owner(s) of the firm exceeds the PNW cap posted online at https:/www.Transportation.gov/DBEPNW, as defined by 49 C.F.R. Parts 23 and 26, the firm is not eligible for DBE or ACDBE certification.

Provide all Worksheets. Provide documents to support each entry. If you have any questions about completing this form, contact the certifying agency.

Assets

Report assets at their current fair market values as of the date of your PNW form. In cases of joint ownership, report only the value of your ownership unless Worksheet directs otherwise. Do not report the value of the applicant firm.

Cash and Cash Equivalents: Enter total from Worksheet 1.

Investment Accounts and Individual Securities: Enter total from Worksheet 2.

Real Estate: Enter total from Worksheet 3.

Personal Property and Other Assets: Enter total from Worksheet 4.

Ownership in Other Businesses: Enter total from Worksheet 5.

Life Insurance: Enter total from Worksheet 6.

Amounts Owed to You: Enter total from Worksheet 7.

Assets Held in Trust: Enter total from Worksheet 8.

Transfers Within Preceding Two Years: If you transferred assets worth at least $20,000 in aggregate to related parties within the last two years, enter total from Worksheet 9. Exclude transfers to applicant or DBE.

Relatives include your spouse or domestic partner, children (whether biological, adopted, or stepchildren), siblings (including stepsiblings and those of the spouse or domestic partner), and parents (including stepparents and those of the spouse or domestic partner). Related entities include for-profit privately held companies of which any relative is an owner, officer, director, or equivalent; and family or other trusts of which you or any relative is grantor, trustee, or beneficiary, except when the transfer is irrevocable. See 49 C.F.R. 26.68(c)(7)-(9).

Liabilities

Report current balances. Report only your own, direct liabilities. Do not report guarantees or other contingent liabilities. Do not report business debt, debt secured by retirement assets, or any amount you owe, directly or indirectly, to the applicant or DBE.

Mortgages: Enter total from Worksheet 10.

Loans on Life Insurance: Enter total from Worksheet 11.

Other Liabilities: Enter total from Worksheet 12.

Other Information

Retirement Assets. Complete Worksheet 13 but do not enter value on PNW Statement.

Primary Residence. Complete Worksheet 14 but do not enter value on PNW Statement.

Declaration

You must sign and date the statement.

Personal Net Worth Statement

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.

Name
Residence (As reported to the IRS) Address, City, State, and Zip Code
Company’s Legal Name		Phone:
Marital Status: _____Single _____Married/Domestic Partnership		Business Phone:
Assets	(Omit Cents)	Liabilities	(Omit Cents)
1. Cash and Cash Equivalents (checking and savings accounts, CDs etc.) (Complete Worksheet 1)		10. Mortgages on Real Estate Other Than Primary Residence (Complete Worksheet 10)
2. Investment Accounts and Individual Securities (Complete Worksheet 2)		11. Loans on Life Insurance (Complete Worksheet 11)
3. Value of Your Ownership Interest in Real Estate, Excluding Primary Residence (Complete Worksheet 3)		12. Other Liabilities (Complete Worksheet 12)
4. Personal Property and Other Assets (Complete Worksheet 4)
5. Ownership in Other Businesses (Complete Worksheet 5)
6. Life Insurance (Cash Surrender Value) (Complete Worksheet 6)
7. Amounts Owed to You (Complete Worksheet 7)
8. Assets Held in Trust (Complete Worksheet 8)
9. Assets Transferred to Related Parties Within the Past Two Years (Complete Worksheet 9)
Total Assets:		Total Liabilities:
Personal Net Worth:__________________

Worksheets

Worksheet 1—List Cash and Cash Equivalents (checking or savings accounts CDs etc.) (Attach additional sheets as necessary)

Cash/Account	Balance

Total

Worksheet 2—Investment Accounts and Individual Securities (e.g., Brokerage and Custodial accounts, stocks, bonds) (Full Value) (Attach additional sheets as necessary)

Account or Security Name and Number	Value

Total

Worksheet 3—Real Estate Other than Primary Residence (Attach additional sheets as necessary)

	Property 1	Property 2	Property 3
Type of Property
Address
Date Acquired
Purchase Price
Present Market Value
Source of Market Valuation

Total

Worksheet 4—Personal Property and Other Assets (Attach additional sheets as necessary)

Type of Property or Asset	Is this asset insured?	Value
Vehicles (e.g., cars, trucks, recreational vehicles, motorcycles, boats, etc.) and titled in your name or of which you are the primary operator. (Itemize)
Household Property (total value)
Artwork (total value)
Jewelry (total value)
Other collectables (total value)
Amounts owed to you (e.g., loans to others, including companies) (Itemize)
Assets subject to the two-year transfer rule (see 49 CFR 26.68 (c)(7)-(9)
Other (e.g., livestock, farm equipment, greenhouse)

Total

Worksheet 5—Ownership in Other Business Investments (excluding applicant firm) Sole Proprietorships, General Partners, Joint Ventures, Limited Liability Companies, Closely-held and Public Traded Corporations. (Attach additional sheets as necessary)

	Business 1	Business 2	Business 3	Business 4
Business name
Address
Value

Total

Worksheet 6— Life Insurance (do not list term life insurance) (Attach additional sheets as necessary)

Policy	Insurance Company	Cash Surrender Amount

Total

Worksheet 7—Amounts Owed to You ( loans to other individuals and entities including applicant firm) (Attach additional sheets as necessary)

Debtor	Description	Balance

Total

Worksheet 8—Assets Held in Trust (Attach additional sheets as necessary)

Trust Name	Description/Additional Information	Value

Total

Worksheet 9— Assets Transferred to Related Parties Within the Past Two Years (Attach additional sheets as necessary)

Asset	Description	Value

Total

Worksheet 10—Mortgages on Real Estate Other Than Primary Residence (Itemize by loan, attaching additional sheets if necessary)

	Property 1	Property 2	Property 3
Type of Property
Address
Name of all Mortgage Holders
Loan Balance

Total

Worksheet 11— Loan on Life Insurance (do not list term life insurance) (Attach additional sheets as necessary)

Policy	Insurance Company	Loan Amount

Total

Worksheet 12—Other Liabilities (Attach additional sheets as necessary)

Type of Debt	Creditor	Amount of Liability (Balance)
Loans on Motor Vehicles (itemize)
Loans Secured by Property Other Than Real Estate or Vehicles
Loans Secured by Property Other Than Real Estate or Vehicles
Unpaid Taxes (fixed in amount and currently due)
Any Other Amount, Not Reported Above, That You Currently Owe (itemize and describe)

Total

Worksheet 13—Retirement Accounts (Attach additional sheets as necessary)

Account Name	Value

Total

Worksheet 14--Primary Residence

Address
Date Acquired
Purchase Price
Market Value
Source of Market Valuation

Declaration

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

___________________________________ ___________

^{Signature (DBE/ACDBE Owner) Date}