Personal Net Worth Statement

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OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

DBE/ACDBE Personal Net Worth (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 Sean Clayton, Departmental Office of Civil Rights, 1200 New
Jersey Ave, 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.

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

INSTRUCTIONS
An individual’s personal net worth (PNW) 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.

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/ACDBE.

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.

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 forprofit 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).

Provide all Worksheets. Retain copies of supporting
documents, as the certifier may require you to provide
additional information on a case-by-case basis to verify the
accuracy and completeness of the PNW statement. 49 CFR
26.68(b). Round to the nearest dollar. 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.

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/ACDBE.
Mortgages: Enter total from Worksheet 10.

Real Estate: Enter total from Worksheet 3.

Loans on Life Insurance: Enter total from Worksheet 11.

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

Other Liabilities: Enter total from Worksheet 12.

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.

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.

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OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

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 or
ACDBE 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 and ACDBE 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
Marital Status:

Single

Assets

Phone:
Married/Domestic Partnership

Business Phone:
Liabilities

(Omit Cents)

(Omit Cents)

1. Cash and Cash Equivalents
(checking and savings accounts,
CDs etc.)
(Complete Worksheet 1)

$ 0 Other Than Primary Residence

$0

2. Investment Accounts and
Individual Securities
(Complete Worksheet 2)

$0

11. Loans on Life Insurance
(Complete Worksheet 11)

$0

3. Value of Your Ownership Interest
in Real Estate, Excluding Primary
Residence
(Complete Worksheet 3)

$ 0 (Complete Worksheet 12)

4. Personal Property and Other
Assets
(Complete Worksheet 4)

$0

5. Ownership in Other Businesses
(Complete Worksheet 5)

$0

6. Life Insurance (Cash Surrender
Value)
(Complete Worksheet 6)

$0

7. Amounts Owed to You
(Complete Worksheet 7)

$0

8. Assets Held in Trust
(Complete Worksheet 8)

$0

9. Assets Transferred to Related
Parties Within the Past Two Years
(Complete Worksheet 9)

$0

Total Assets:

10. Mortgages on Real Estate
(Complete Worksheet 10)

12. Other Liabilities

0
$ ___

Total Liabilities:

$0

0
$ ____

Personal Net Worth: $ ____
0

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OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

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

Balance

$0

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

$0

Total
Worksheet 3—Real Estate Other than Primary Residence (Attach additional sheets as necessary)
Property 1

Property 2

Property 3

Type of Property
Percentage of Ownership

%

%

%

Address
Date Acquired
Purchase Price
Present Market Value
Source of Market Valuation

Total

$0

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OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

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)

Other (e.g., livestock, farm equipment, greenhouse)

Total

$0

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OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

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
$0

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

Cash Surrender
Amount

Insurance Company

$0

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

$0

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

Description of assets held/Additional
Information

Value

Total

$0

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OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

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

Description

Value

$0

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
$0

Total

Worksheet 11— Loan on Life Insurance (DO NOT LIST TERM LIFE INSURANCE) (Attach additional sheets as necessary)
Policy

Insurance Company

Loan Amount

Total

$0

Page 7 of 9

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

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

Unpaid Taxes (fixed in amount and
currently due)

Any Other Amount, Not Reported Above,
That You Currently Owe (itemize and
describe)

Total

$0

Page 8 of 9

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
U.S. Department of Transportation

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

Value

Total

$0

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

Page 9 of 9