OMB
Control
No:
______
Approved:
______
Approval
Expires:
______
Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
For
Partnerships
Business
Profile:

Name
of
applicant
firm:______________________________________________________________________

Name
of
Managing
Partner:__________________________________________________________________

EIN:___________________
Social
Security
Number
_________________
E­
mail
Address:_______________

Business
Address:______________________________________________
County:______________________

City:_________________________________
State:_______________
Zip
Code:________________________

Phone
Number:___________________________
Fax
Number:______________________________________

Mailing
Address
(
if
different
than
above):_________________________
County:_____________________

City:_________________________________
State:_______________
Zip
Code:________________________

What
is
the
firm's
4
digit
primary
North
American
Industrial
Classification
(
NAIC)
code?
____________

Are
you
claiming
disabled
status?
____
Yes
____
No
(
i.
e.,
a
United
States
citizen
who
has
permanent
or
temporary
physical
or
mental
impairment
that
substantially
limits
one
or
more
of
your
major
life
activities.)
If
yes,
please
submit
documentation
substantiating
such
disability.

Is
your
firm
at
least
51%
owned
by
a
Disabled
American?
____
Yes
____
No.

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?
___
Yes
___
No.
If
yes,
provide
PRO­
Net
number:
______________________________________

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
PRO­
Net
number:
____________________________________

Is
your
firm
certified
as
a
DBE
by
a
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s):
______________________________________________________

Is
your
firm
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
and
a
contact
point
at
the
certifying
entity:
____________________________________________________________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
1
Has
your
firm
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
a
copy
of
the
prior
determination
of
attempts
to
obtain
certification:
____________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Does
your
firm
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e.,
MBE,
DBE,
WBE,
etc.?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s):
_______________________________________

In
accordance
with
13
CFR
§
124.103,
designated
group
members
are
presumed
to
be
socially
disadvantaged.
Designated
group
members
are
individuals
who
hold
themselves
out
to
be
and
are
identified
by
others
as
Black
Americans,
Native
Americans
(
American
Indians,
Eskimos,
Aleuts,
or
Native
Hawaiians),
Hispanic
Americans,
Subcontinent
Asian
Americans,
Asian
Pacific
Americans,
and
any
other
groups
designated
by
the
Small
Business
Administration
(
SBA).
If
an
individual
is
claiming
to
be
a
member
of
a
designated
group,
complete
Section
A
of
this
application.
If
an
individual
is
not
claiming
to
be
a
member
of
a
designated
group,
complete
Section
B
of
this
application.
All
applicants
must
complete
Sections
C,
D,
and
E
of
this
application.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
2
SECTION
A
Eligibility
Statement
­
Designated
Group
Members
Social
Disadvantage
1.
Is
your
firm
at
least
51%
owned
by
a
U.
S.
citizen?
____
Yes
____
No.
If
your
firm
is
not
at
least
51%
owned
by
a
U.
S.
Citizen,
stop
here.
You
are
not
eligible
to
participate
as
a
DBE
under
EPA's
DBE
Certification
Program.

2.
List
all
individuals
claiming
disadvantaged
status.

Name
of
Individual
Group
U.
S.
Citizen
Other
Last
Place
of
Sex
Membership
Y/
N
Names
Used
Birth
M/
F
__________________________
___________
________
___________
_______
_____

__________________________
___________
________
___________
_______
_____

__________________________
___________
________
___________
_______
_____

2a.
If
you
are
a
naturalized
Citizen,
please
provide
the
following
as
Attachment
A­
1:
(
a)
naturalization
number;
(
b)
date
of
citizenship;
and
(
c)
county,
state
and
court.

SECTION
B
Eligibility
Statement
 
Non
Designated
Group
Members
1.
List
all
individuals
claiming
disadvantaged
status:

Name
of
Individual
U.
S.
Citizen
Race
Sex
Y/
N
M/
F
_______________________________
________
________
_____

_______________________________
________
________
_____

_______________________________
________
________
_____

1a.
If
you
are
a
naturalized
Citizen,
please
provide
the
following
as
Attachment
B­
1:
naturalization
number;
(
b)
date
of
citizenship;
and
(
c)
county,
state
and
court.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
3
For
this
section,
all
individuals
claiming
social
disadvantage
must
provide
a
separate
response
for
questions
3
and
4.

Social
Disadvantage
2.
I,
____________________________________
have
personally
suffered
social
disadvantage
based
on
my
identification
as
__________________________________.
(
A
claim
of
social
disadvantage
must
include
at
least
one
objective
feature
that
has
contributed
to
social
disadvantage,
such
as
race,
ethnic
origin,
gender,
physical
handicap,
long­
term
residence
in
an
environment
isolated
from
the
mainstream
of
American
society,
or
other
similar
causes
not
common
to
individuals
who
are
not
socially
disadvantaged.)

3.
Document
how
your
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
by
such
things
as
inability
to
obtain
adequate
bonding,
credit
or
financing;
inability
to
obtain
licenses
or
leases;
restriction
of
your
market
to
certain
racial,
ethnic
or
social
groups;
underemployment
or
unemployment,
etc.,
as
compared
to
others
in
the
same
or
similar
line
of
business
who
are
not
socially
disadvantaged.
Provide
as
Attachment
B­
2.

4.
Attach
a
narrative
describing
how
you
personally
experienced
social
disadvantage
in
American
society.
When
writing
your
narrative,
be
as
specific
and
detailed
as
possible.
Where
applicable,
each
statement
of
alleged
discrimination
should
be
supported
by
documented
evidence
such
as
affidavits,
denials
of
loan
applications,
denials
of
employment
opportunities
(
including
non­
selection
for
particular
jobs,
denials
of
promotions,
or
unequal
work
environment
or
treatment),
and
documents
to
support
any
formal
action
taken
by
you
because
of
alleged
discrimination.
You
must
demonstrate
how
your
identification,
as
described
in
the
paragraph
above,
has
negatively
impacted
your
entry
into
or
advancement
in
business.
You
must
address
disadvantage
in
education,
employment,
and
business
history,
where
applicable.
Examples
of
discrimination
include,
but
are
not
limited
to:
unequal
access
to
colleges
or
professional
schools;
exclusion
from
professional
or
business
associations;
being
denied
educational
honors
or
recognition;
experiencing
discriminatory
social
pressure
which
discouraged
you
from
pursuing
a
professional
or
higher
education
or
forced
you
into
non­
professional
or
non­
business
fields;
discrimination
in
employment
opportunities
or
pay
and
fringe
benefits;
unequal
access
to
business
credit
or
capital;
and
discrimination
in
the
awarding,
bidding
process,
or
negotiating
of
government
or
private
sector
contracts.
Provide
as
Attachment
B­
3.

SECTION
C
(
All
applicant
firms
must
complete)

Economic
Disadvantage
1.
Is
the
net
worth
of
each
individual(
s)
claiming
disadvantaged
status
less
than
$
750,000,
excluding
ownership
interest
in
the
applicant
firm
and
equity
in
the
individual(
s)
primary
residence?
____
Yes
____
No.

2.
For
individual(
s)
claiming
disadvantaged
status,
list
your
personal
net
worth,
excluding
the
ownership
interest
in
the
applicant
firm
and
the
equity
in
the
individual(
s)
primary
residence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
4
Name
Average
2­
year
Personal
Total
Income
Net
Worth
Assets
________________________________
______________
__________
__________

________________________________
______________
__________
__________

________________________________
______________
__________
__________

3.
Each
individual
listed
in
number
2
above,
certifies
that
because
of
racial
and/
or
ethnic
prejudice,
and/
or
cultural
bias,
my
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
due
to
diminished
capital
and
credit
opportunities
as
compared
to
others
in
the
same
or
similar
line
of
business
that
are
not
socially
disadvantaged.

SECTION
D
(
All
applicant
firms
must
complete)

Ownership
1.
Provide
the
name,
title,
and
percentage
of
ownership
(
class,
if
applicable)
for
each
partner
of
the
firm.
Does
the
partnership
agreement
reflect
the
ownership
of
each
partner?
____
Yes
____
No.

Name
Title
Ownership
Percentage
______________________
____________________
___________________________

______________________
____________________
___________________________

______________________
____________________
___________________________

______________________
____________________
___________________________

2.
Has
there
been
any
changes
in
ownership
in
the
last
year?
____
Yes
____
No.
If
yes,
did
ownership
affect
the
disadvantaged
status
of
your
firm?
Please
explain
as
Attachment
D­
1.

3.
For
community
property
residents
only.
If
you
are
a
married
disadvantaged
owner,
and
your
spouse
is
not
disadvantaged,
please
complete
the
chart
below,
and
provide
evidence
that
you
have
a
majority
interest
in
the
business
as
Attachment
D­
2.

Name
of
Disadvantaged
Partner
State
Percent
Transferred
______________________
____________________
_____________________

______________________
____________________
_____________________

______________________
____________________
_____________________

______________________
____________________
_____________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
5
4.
Has
any
individual(
s)
claiming
disadvantaged
status
transferred
any
assets
within
two
years,
in
full
or
in
part,
to
a
spouse
or
any
other
person
or
entity,
including
a
trust?
___
Yes
___
No.
If
yes,
provide
the
following
information
as
Attachment
D­
3:
the
date
of
transfer;
to
whom
the
assets
were
transferred;
amount
paid
for
the
assets;
and
the
market
value
of
the
assets
at
the
time
of
transfer.
Individuals
may
exclude
assets
transferred
to
an
immediate
family
member
that
are
consistent
with
the
customary
recognition
of
special
occasions,
such
as
birthdays,
graduations,
anniversaries
and
retirements.
Individuals
may
also
exclude
any
transfers
to
an
immediate
family
member
if
for
educational,
medical
or
essential
support
purposes.

SECTION
E
(
All
applicant
firms
must
complete)

Control
1.
List
the
name(
s)
of
all
Partners:

Name
Limited/
General
___________________________________
_____________________________

___________________________________
_____________________________

___________________________________
_____________________________

___________________________________
_____________________________

2.
Are
partnership
decisions
determined
by
general
partners?
If
no,
explain
as
Attachment
E­
1.

3.
Is
a
general
partner,
or
any
disadvantaged
full­
time
manager
engaged
in
or
plan
to
engage
in
outside
employment?
___
Yes
___
No.
If
yes,
explain
as
Attachment
E­
2.

4.
Have
any
of
the
nondisadvantaged
individuals
involved
in
the
management
of
the
applicant
firm,
partners,
or
their
immediate
family
members,
had
a
prior
business
relationship
with
any
individual
claiming
disadvantage
status?
This
includes
such
relationships
as
employer­
employee,
supervisoremployee
co­
workers,
investor­
employee,
etc.
___
Yes
___
No.
If
yes,
identify
the
person(
s)
and
the
type
of
business
relationship
as
Attachment
E­
3.

5.
List
the
total
compensation
from
the
applicant
firm
of
all
partners
and/
or
key
managers
of
the
firm.
(
If
necessary,
provide
additional
information
as
Attachment
E­
4).

Name/
Title
Compensation
from
applicant
firm
(
includes
salaries,
bonuses,
etc.)

_________________________________
___________________________________

________________________________
___________________________________

________________________________
___________________________________

________________________________
___________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
6
6.
Does
the
applicant
firm
operate
in
an
industry
which
requires
bonding
or
professional
licenses?
___
Yes
___
No.
If
yes,
identify
the
qualifying
individual(
s)
for
the
critical
licenses,
general
indemnity
agreement,
permits,
certifications,
and
bonding
required
to
operate
the
applicant
firm
as
Attachment
E­
5.

7.
List
the
names
of
all
individuals
who
have
access
to
the
firm's
bank
account.

Name
Title
______________________________
_____________________________

______________________________
_____________________________

______________________________
_____________________________

8.
Does
any
individual(
s),
(
other
than
the
individual(
s)
claiming
disadvantaged
status)
or
entities
provide:

a)
Financial
support
to
the
applicant
firm?
___
Yes
___
No
b)
Subcontracts,
Joint
Ventures
or
Teaming
Arrangements?
___
Yes
___
No
c)
Office
space
(
rent
or
leased).
___
Yes
___
No
d)
Equipment
(
rent
or
leased).
___
Yes
___
No
e)
Employees
(
other
than
from
employment
agencies).
___
Yes
___
No
f)
Provide
business
bank
account.
___
Yes
___
No
If
you
answered
yes
to
any
of
the
above,
please
provide
specific
details
(
i.
e.,
names,
titles,
copies
of
agreements,
leases,
etc.)
of
such
arrangements
as
Attachment
E­
6.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
7
Each
person
signing
below:

1.
Certifies
that
the
information
provided
with
regard
to
my
social
and
economic
disadvantaged
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

2.
Certifies
that
the
information
provided
with
regard
to
my
ownership
and
control
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
my
status
as
a
United
States
citizen
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

4.
Certifies
that
the
information
provided
with
regard
to
my
individual
disadvantaged
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

5.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

6.
Acknowledges
that
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
state
and
local
agencies
for
determining
violations
of
law.

7.
Acknowledges
that
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

Name
SSN
Date
________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001
,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
8
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1c)
(
Partnerships)
9
OMB
Control
No:
______
Approved:
______
Approval
Expires:
______
Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
Alaska
Native
Corporation
(
ANC)
Owned
Concern
Name
of
Alaska
Native
Corporation
(
ANC):
_______________________________________________

Address
of
ANC:
______________________________________________________________________

Name
of
President/
CEO:
__________________________________

EIN:
_________________________
E­
mail
Address:_________________________________________

Business
Address:______________________________________________
County:_______________

City:_________________________________
State:_______________
Zip
Code:__________________

Phone
Number:___________________________
Fax
Number:________________________________

Mailing
Address
(
if
different
than
above):________________________
County:_________________

City:_________________________________
State:_______________
Zip
Code:__________________

What
is
the
firm's
4­
digit
primary
North
American
Industrial
Classification
(
NAIC)
code?
_____________________________________________________________________________________

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?___
Yes
___
No.
If
yes,
provide
Pro­
Net
number:
_________________________________

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
number:
____________________

Is
your
firm
certified
as
a
DBE
by
a
U.
S.
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s):
________________________________________________

Is
your
firm
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
and
the
certifying
entity:
________________________________________________________________________________

Has
your
firm
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
explanation/
documentation:__________________________________________________
_____________________________________________________________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1e)
(
Alaska
Native
Corporations)
Do
you
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e.,
MBE,
DBE,
WBE,
etc?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s):
________________________________

Is
the
applicant
ANC
business
corporation
a
for
profit
corporation?
___
Yes
___
No.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1e)
(
Alaska
Native
Corporations)
2
Business
Eligibility
SECTION
A
Social
Disadvantage
1.
An
Alaska
Native
Corporation
that
that
meets
the
following
criteria
is
considered
socially
disadvantaged:

Alaska
Native
Corporation
or
ANC
means
any
Regional
Corporation,
Village
Corporation,
Urban
Corporation,
or
Group
Corporation
organized
under
the
laws
of
the
State
of
Alaska
in
accordance
with
the
Alaska
Native
Claims
Settlement
Act,
as
amended
(
43
U.
S.
C.
1601,
et
seq.).

Provide
documentation
that
the
applicant
entity
meets
these
criteria
as
Attachment
A­
1.

SECTION
B
Economic
Disadvantage
1.
Do
Alaska
Natives
and
descendants
of
Natives
own
a
majority
of
both
the
total
equity
of
the
ANC
and
the
total
voting
powers
to
elect
directors
of
the
ANC
through
their
holdings
of
settlement
common
stock?
___
Yes
___
No.
If
yes,
provide
verification
of
the
percentage
of
Alaska
Native
ownership
as
attachment
B­
1.

SECTION
C
Ownership
1.
Does
the
ANC
and
holders
of
its
settlement
common
stock
own
at
least
51%
interest
in
the
ANC?
Please
provide
documentation
as
attachment
C­
1.

2.
If
more
than
one
class
of
stock,
provide
information
for
each
class:
Voting
Non­
Total
Voting
a)
Total
number
of
shares
authorized:
_____
______
_____
b)
Total
number
of
shares
currently
outstanding:
_____
______
_____

3.
List
all
entities,
individuals,
and/
or
trusts
that
have
an
ownership
interest
in
the
applicant
firm.
Name
Title
Ownership
Percent
Voting
Non­
voting
Total
___________________________
____________________
______
_________
______

___________________________
____________________
______
__________
______

___________________________
____________________
______
__________
______

___________________________
____________________
______
__________
______

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1e)
(
Alaska
Native
Corporations)
3
4.
Have
there
been
any
changes
in
ownership
in
the
last
year?
___
Yes
___
No.
If
yes,
did
ownership
affect
the
disadvantaged
status
of
your
firm?
Please
explain
as
Attachment
C­
2.

SECTION
D
Control
and
Management
1.
Are
the
management
and
daily
business
operations
of
the
applicant
firm
controlled
by
the
ANC
through
one
or
more
disadvantaged
individual
members
who
possess
sufficient
management
experience
of
an
extent
and
complexity
to
run
the
concern?
___
Yes
___
No.
If
yes,
provide
documentation
to
verify
tribal
membership
and
management
competency
as
Attachment
D­
1.

2.
Are
members
of
the
management
team,
business
committee
members,
officers,
and
directors
engaged
in
any
outside
employment
or
other
business
interests
which
conflict
with
the
management
of
the
applicant
firm?
___
Yes
___
No.

3.
List
the
titles
of
all
officers,
directors,
management
members,
partners
and
key
managers
and
the
hours
devoted,
by
such
individual(
s)
to
the
management
of
the
applicant
firm.

Name
Title
Hours
____________________________
_______________________________
__________

____________________________
_______________________________
__________

____________________________
_______________________________
__________

____________________________
_______________________________
__________

4.
List
the
names
of
all
individuals
who
have
access
to
the
firm's
bank
account.

Name
Title
___________________________
__________________________

__________________________
__________________________

__________________________
__________________________

__________________________
__________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1e)
(
Alaska
Native
Corporations)
4
Each
person
signing
below:

1.
Certifies
that
the
applicant
firm
is
at
least
51%
owned
and
controlled
by
an
Alaska
Native
Corporation
(
ANC).

2.
Certifies
that
the
information
provided
with
regard
to
the
applicant
firm's
economic
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
the
applicant
firm's
ownership
and
control
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

4.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

5.
Acknowledges
that
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
state
and
local
agencies
to
determine
violations
of
law.

6.
Acknowledges
that
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

Name
SSN
Date
________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001
,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
EPA
DBE
Certification
Application
(
EPA
Form
6100­
1e)
(
Alaska
Native
Corporations)
5
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1e)
(
Alaska
Native
Corporations)
6
OMB
Control
No:
______
Approved:
______
Approval
Expires:
______
Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
Community
Development
Corporation
(
CDC)
Owned
Concern
Name
of
Parent
Community
Development
Corporation
(
CDC):
_________________________________________________________________________________

Address
of
Parent
CDC:
_____________________________________________________________

Name
of
wholly­
owned
subsidiary
(
if
applicable):
_______________________________________

Address
of
wholly­
owned
subsidiary:
_________________________________________________

Name
of
applicant
firm:
_________________________________________________________________________________

Applicant
concern
is:

Corporation

Limited
Liability
Company

Partnership
Name
of
President/
Managing
Member/
Managing
Partner:
________________________________

EIN:
_______________________
E­
mail
Address:
_______________________________________

Business
Address:
___________________________________________
County:
_______________

City:
_______________________________
State:
_______________
Zip
Code:
________________

Phone
Number:
__________________________
Fax
Number:
______________________________

Mailing
Address
(
if
different
than
above):
_______________________
County:
________________

City:
_______________________________
State:
_______________
Zip
Code:
________________

What
is
the
firm's
(
4­
digit)
primary
standard
industrial
classification
code?
__________________

Is
the
firm
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
number________________________________

Is
the
firm
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
number____________________

Is
the
firm
certified
as
a
DBE
by
a
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s)
___________________________________________________

Is
the
firm
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
and
a
contact
point
at
the
certifying
entity
____________________________________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1i)
(
Community
Development
Corporation
(
CDC)
Owned
Concern)
Has
your
firm
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
explanation/
documentation:
_____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Does
the
firm
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e.,
MBE,
DBE,
WBE,
etc?
___
Yes
___
No.
If
yes,
provide
the
State(
s)
and
ID
number(
s)__________________
__________________________________________________________________________________

SECTION
A
Eligibility
Statement
Social
and
Economic
Disadvantage
1.
A
Community
Development
Corporation
(
CDC)
is
considered
to
be
a
socially
and
economically
disadvantaged
entity
if
the
parent
CDC
is
a
nonprofit
organization
responsible
to
residents
of
the
area
it
serves
which
has
received
financial
assistance
under
42
U.
S.
C.
9805,
et
seq.

Does
the
parent
CDC
of
the
applicant
concern
meet
this
criteria?
___
Yes
___
No.
If
yes,
provide
evidence
of
nonprofit
organization
and
documentation
of
assistance
as
Attachment
A­
1.

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

Corporations
Only:

2.
If
more
than
one
class
of
stock,
provide
information
for
each
class:
Voting
Non
Total
Voting
a)
Total
number
of
shares
authorized:
_____
______
_____
b)
Total
number
of
shares
currently
outstanding:
_____
______
_____

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1i)
(
Community
Development
Corporation
(
CDC)
Owned
Concern)
2
Limited
Liability
Companies
Only:

3.
If
more
than
one
class
membership
interest,
provide
information
for
each
class:
Voting
Non
Total
Voting
a)
Total
number
of
memberships
authorized:
_____
______
_____
b)
Total
number
of
memberships
currently
outstanding:
_____
______
_____

Partnerships
Only:

4.
Provide
the
name,
title,
and
percentage
of
ownership
for
each
partner
of
the
firm.
Does
the
partnership
agreement
reflect
the
ownership
of
each
partner?
___
Yes
___
No.

Name
Title
Ownership
%

___________________________
____________________
____________________

___________________________
____________________
____________________

___________________________
____________________
____________________

___________________________
____________________
____________________

Questions
5
through
9
are
for
Corporations
&
LLCs
ONLY:

5.
List
all
entities,
individuals,
and/
or
trusts
which
have
an
ownership
interest
in
the
applicant
firm.

Name
Title
Ownership
%
Voting
NonVoting
Total
___________________________
____________________
______
_________
_____

___________________________
____________________
______
__________
_____

___________________________
____________________
______
__________
______

___________________________
____________________
______
__________
______

6.
Does
the
parent
CDC
or
its
wholly­
owned
subsidiary
receive
at
least
51%
of
the
annual
distributions
of
dividends
paid
on
the
stock
of
a
corporate
applicant
firm?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
B­
2.

7.
Will
the
parent
CDC
or
its
wholly­
owned
subsidiary
receive
100%
of
the
unencumbered
value
of
each
share
of
stock
owned
in
the
event
that
the
stock
is
sold?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
B­
3.

8.
If
the
corporation
dissolves,
will
the
parent
CDC
or
its
wholly­
owned
subsidiary
receive
at
least
51%
of
the
retained
earnings
and
100%
of
the
unencumbered
value
of
each
share
of
stock
owned?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
B­
4.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1i)
(
Community
Development
Corporation
(
CDC)
Owned
Concern)
3
9.
Is
ownership
by
the
parent
CDC
or
its
wholly
owned
subsidiary
subject
to
conditions
precedent,
conditions
subsequent,
executory
agreements,
voting
trusts,
shareholder
agreements,
or
other
similar
arrangements
which
may
impact
the
unconditional
ownership
of
the
CDC?
___
Yes
___
No.
If
yes,
explain
as
Attachment
B­
5.

Corporations,
LLCs
&
Partnerships:

10.
Have
there
been
any
changes
in
ownership
in
the
last
year?
___
Yes
___
No.
If
yes,
did
ownership
affect
the
disadvantaged
status
of
your
firm?
Please
explain
as
Attachment
B­
6.

SECTION
C
Control
and
Management
1.
List
all
individuals
who
manage
or
conduct
daily
business
operations
of
the
applicant
concern.

Name/
Title
Date
___________________________________________________
_____________

___________________________________________________
_____________

___________________________________________________
_____________

___________________________________________________
_____________

2.
Are
any
of
the
individuals
listed
in
question
1
engaged
in
or
plan
to
engage
in
outside
employment?
___
Yes
___
No.
If
yes,
explain
as
Attachment
C­
1.

3.
List
the
total
compensation
from
the
applicant
firm
of
all
owners
and/
or
key
managers
of
the
firm.
(
If
necessary,
provide
additional
information
as
Attachment
C­
2).

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

___________________________________
__________________________________

___________________________________
__________________________________

___________________________________
__________________________________

___________________________________
__________________________________

4.
Does
the
applicant
firm
operate
in
an
industry
which
requires
bonding
or
professional
licenses?
___
Yes
___
No.
If
yes,
identify
the
qualifying
individual(
s)
for
the
critical
licenses,
general
indemnity
agreement,
permits,
certifications,
and
bonding
required
to
operate
the
applicant
firm
on
Attachment
C­
3.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1i)
(
Community
Development
Corporation
(
CDC)
Owned
Concern)
4
5.
List
the
names
of
all
individuals
who
have
access
to
the
firm's
bank
account.

Name
Title
___________________________________
_________________________________

___________________________________
_________________________________

___________________________________
__________________________________

___________________________________
__________________________________

6.
Does
any
individual(
s),
or
entities
provide:

a)
Financial
support
to
the
applicant
firm?
___
Yes
___
No
b)
Subcontracts,
Joint
Ventures,
or
Teaming
Arrangements?
___
Yes
___
No
c)
Office
space
(
rent
or
leased).
___
Yes
___
No
d)
Equipment
(
rent
or
leased).
___
Yes
___
No
e)
Employees
(
other
than
from
employment
agencies).
___
Yes
___
No
If
the
answer
is
yes
to
any
of
the
above,
please
provide
specific
details
(
i.
e.,
names,
titles,
copies
of
agreements,
leases,
etc.)
of
such
arrangements
as
Attachment
C­
4.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1i)
(
Community
Development
Corporation
(
CDC)
Owned
Concern)
5
Each
person
signing
below:

1.
Certifies
that
the
information
provided
with
regard
to
the
applicant
firm's
social
and
economic
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

2.
Certifies
that
the
information
provided
with
regard
to
the
applicant
firm's
ownership
and
control
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
his/
her
individual
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

4.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

5.
Acknowledges
that
the
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
State,
and
local
agencies
to
determine
violations
of
law.

6.
Acknowledges
that
the
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

Name
SSN
Date
________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

The
public
reporting
and
record­
keeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
disclose,
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001
,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1i)
(
Community
Development
Corporation
(
CDC)
Owned
Concern)
6
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1i)
(
Community
Development
Corporation
(
CDC)
Owned
Concern)
7
OMB
Control
No:
____
Approved:
____
Approval
Expires:
____

Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
For
Corporations
Business
Profile:

Name
of
applicant
firm:
____________________________________________________

Name
of
President/
Chief
Executive
Officer:
____________________________________________________
EIN:_______________________________________
E­
mail
Address:________________________________

Business
Address:________________________________
County:__________________________________

City:_______________________________
State:
_________
Zip
Code:_______________________________

Phone
Number:____________________________
Fax
Number:
_________________________

Mailing
Address
(
if
different
than
above):_________________________
County:_______________________

City:_________________________________
State:_______________
Zip
Code:_______________________

What
is
the
firm's
4­
digit
primary
North
American
Industrial
Classification
(
NAIC)
code?
______________

Are
you
claiming
disabled
status?
___
Yes
___
No.
(
i.
e.,
a
United
States
citizen
who
has
permanent
or
temporary
physical
or
mental
impairment
that
substantially
limits
one
or
more
of
your
major
life
activities).
If
yes,
please
submit
documentation
substantiating
such
disability.

Is
your
firm
at
least
51%
owned
by
a
Disabled
American?
___
Yes
___
No.

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?
___
Yes
___
No.
If
yes,
provide
PRO­
Net
number:
______________________________________

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
PRO­
Net
number:
_______________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1d)
(
Corporations)
Is
your
firm
certified
as
a
DBE
by
a
U.
S.
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s):
____________________________________________________

Is
your
firm
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
the
certifying
entity:
____________________________________________________
Has
your
firm
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No
If
yes,
provide
a
copy
of
the
prior
determination
of
attempts
to
obtain
certification:
_____________________________________
____________________________________________________

Do
you
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e,
MBE,
DBE,
WBE,
etc?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s)
________________________________________

In
accordance
with
13
CFR
§
124.103,
designated
group
members
are
presumed
to
be
socially
disadvantaged.
Designated
group
members
are
individuals
who
hold
themselves
out
to
be
and
are
identified
by
others
as
Black
Americans,
Native
Americans
(
American
Indians,
Eskimos,
Aleuts,
or
Native
Hawaiians),
Hispanic
Americans,
Subcontinent
Asian
Americans,
Asian
Pacific
Americans,
and
any
other
groups
designated
by
the
Small
Business
Administration
(
SBA).
If
an
individual
is
claiming
to
be
a
member
of
a
designated
group,
complete
Section
A
of
this
application.
If
an
individual
is
not
claiming
to
be
a
member
of
a
designated
group,
complete
Section
B
of
this
application.
All
applicants
must
complete
Sections
C,
D,
and
E
of
this
application.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1d)
(
Corporations)
2
SECTION
A
Eligibility
Statement
­
Designated
Group
Members
Social
Disadvantage
1.
Is
your
firm
at
least
51%
owned
by
a
U.
S.
citizen?
___
Yes
___
No.
If
your
firm
is
not
at
least
51%
owned
by
a
U.
S.
citizen,
stop
here.
You
are
not
eligible
to
participate
as
a
DBE
under
EPA's
DBE
Certification
Program.

2.
List
all
individuals
claiming
disadvantaged
status:

Name
of
Individual
Other
last
U.
S.
Citizen
Place
of
Group
Sex
Names
Used
Y/
N
Birth
Membership
M/
F
___________________
___________
________
___________
_______
_____

a)
If
you
are
a
naturalized
citizen,
please
provide
the
following
as
Attachment
A­
1,
(
a)
naturalization
number;
(
b)
date
of
citizenship;
and
(
c)
county,
state
and
court.

SECTION
B
Eligibility
Statement
­
Non
Designated
Group
Members
1.
List
all
individuals
claiming
disadvantaged
status:

Name
of
Individual
U.
S.
Citizen
Race
Sex
Y/
N
M/
F
_______________________________
________
________
_____

a)
If
you
are
a
naturalized
citizen,
please
provide
the
following
as
Attachment
B­
1,
(
a)
naturalization
number;
(
b)
date
of
citizenship;
and
(
c)
county,
state
and
court.

For
this
section,
any
individual
claiming
social
disadvantage
must
provide
a
separate
response
for
questions
3
and
4.

Social
Disadvantage
2.
I,
____________________________________
have
personally
suffered
social
disadvantage
based
on
my
identification
as
__________________________________.
(
A
claim
of
social
disadvantage
must
include
at
least
one
objective
feature
that
has
contributed
to
social
disadvantage,
such
as
race,
ethnic
origin,
gender,
physical
handicap,
long­
term
residence
in
an
environment
isolated
from
the
mainstream
of
American
society,
or
other
similar
causes
not
common
to
individuals
who
are
not
socially
disadvantaged.)

3.
Document
how
your
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
by
such
things
as
inability
to
obtain
adequate
bonding,
credit
or
financing;
inability
to
obtain
licenses
or
leases;
restriction
of
your
market
to
certain
racial,
ethnic
or
social
groups;
underemployment
or
EPA
DBE
Certification
Application
(
EPA
Form
6100­
1d)
(
Corporations)
3
unemployment,
etc.,
as
compared
to
others
in
the
same
or
similar
line
of
business
who
are
not
socially
disadvantaged.
Provide
as
Attachment
B­
2.

4.
Attach
a
narrative
describing
how
you
personally
experienced
social
disadvantage
in
American
society.
When
writing
your
narrative,
be
as
specific
and
detailed
as
possible.
Where
applicable,
each
statement
of
alleged
discrimination
should
be
supported
by
documented
evidence
such
as
affidavits,
denials
of
loan
applications,
denials
of
employment
opportunities
(
including
non­
selection
for
particular
jobs,
denials
of
promotions,
or
unequal
work
environment
or
treatment),
and
documents
to
support
any
formal
action
taken
by
you
because
of
alleged
discrimination.
You
must
demonstrate
how
your
identification,
as
described
in
the
paragraph
above,
has
negatively
impacted
your
entry
into
or
advancement
in
business.
You
must
address
disadvantage
in
education,
employment,
and
business
history,
where
applicable.
Examples
of
discrimination
include,
but
are
not
limited
to:
unequal
access
to
colleges
or
professional
schools;
exclusion
from
professional
or
business
associations;
being
denied
educational
honors
or
recognition;
experiencing
discriminatory
social
pressure
which
discouraged
you
from
pursuing
a
professional
or
higher
education
or
forced
you
into
non­
professional
or
non­
business
fields;
discrimination
in
employment
opportunities
or
pay
and
fringe
benefits;
unequal
access
to
business
credit
or
capital;
and
discrimination
in
the
awarding,
bidding
process,
or
negotiating
of
government
or
private
sector
contracts.
Provide
as
Attachment
B­
3.

SECTION
C
(
All
applicant
firms
must
complete)

Economic
Disadvantage
1.
Is
the
net
worth
of
each
individual(
s)
claiming
disadvantaged
status
less
than
$
750,000,
excluding
ownership
interest
in
the
applicant
corporation
and
equity
in
the
individual(
s)
primary
residence?
____
Yes
____
No.

2.
For
individual(
s)
claiming
disadvantaged
status,
list
your
personal
net
worth,
excluding
the
ownership
interest
in
the
applicant
corporation
and
the
equity
in
the
individual(
s)
primary
residence.

Name
Average
2­
year
Personal
Total
Income
Net
Worth
Assets
________________________________
______________
__________
_______

3.
Have
any
individual(
s)
listed
in
number
2
above
transferred
any
assets
within
two
years,
in
full
or
in
part,
to
a
spouse
or
any
other
person
or
entity,
including
a
trust?
___
Yes
___
No.
If
yes,
provide
the
following
information
as
Attachment
C­
1:
the
date
of
transfer;
to
whom
the
assets
were
transferred;
amount
paid
for
the
assets;
and
the
market
value
of
the
assets
at
the
time
of
transfer.
Individual(
s)
may
exclude
assets
transferred
to
an
immediate
family
member
that
are
consistent
with
the
customary
recognition
of
special
occasions,
such
as
birthdays,
graduations,
anniversaries
and
retirements.
Individual(
s)
may
also
exclude
any
transfers
to
an
immediate
family
member
if
for
educational,
medical
or
essential
support
purposes.

4.
Each
individual
listed
in
number
2
above,
certifies
that
because
of
racial
and/
or
ethnic
prejudice,
and/
or
cultural
bias,
his/
her
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
due
to
diminished
capital
and
credit
opportunities
as
compared
to
others
in
the
same
or
similar
line
of
business
that
are
not
socially
disadvantaged.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1d)
(
Corporations)
4
SECTION
D
(
All
applicant
firms
must
complete)

Ownership
1.
If
more
than
one
class
of
stock,
provide
information
for
each
class:
Voting
Non
Total
Voting
a)
Total
number
of
shares
authorized:
_____
______
_____
b)
Total
number
of
shares
currently
outstanding:
_____
______
_____

2.
List
all
individuals,
entities,
and/
or
trusts,
which
have
an
ownership
interest
in
the
applicant
firm.

Name
Title
Voting
Ownership
Percentage
Non­
Voting
Total
________________
______
_____
____________
__________

3.
Do
disadvantaged
individuals
receive
at
least
51%
of
the
annual
distributions
of
dividends
paid
on
the
stock
of
a
corporate
applicant
firm?
___
Yes
___
No.
If
no,
please
explain
and
provide
as
Attachment
D­
1.

4.
Do
disadvantaged
individuals
own
51%
or
more
of
each
class
of
voting
stock
outstanding
and
51%
of
the
aggregate
of
all
stock
outstanding?
___
Yes
___
No.

5.
Will
disadvantaged
individuals
receive
100%
of
the
unencumbered
value
of
each
share
of
stock
owned
in
the
event
that
the
stock
is
sold?
___
Yes
___
No.
If
no,
please
explain
and
provide
as
Attachment
D­
2.

6.
If
the
corporation
dissolves,
will
disadvantaged
individuals
receive
at
least
51%
of
the
retained
earnings
and
100%
of
the
unencumbered
value
of
each
share
of
stock
he
or
she
owns?
___
Yes
___
No.
If
no,
please
explain
and
provide
as
Attachment
D­
3.

7.
Is
ownership
by
any
individual
claiming
disadvantaged
status
subject
to
conditions
precedent,
conditions
subsequent,
executory
agreements,
voting
trusts,
shareholder
agreements
or
other
similar
arrangements,
which
may
impact
the
unconditional
ownership
of
such
individuals?
___
Yes
___
No.
If
yes,
explain
as
Attachment
D­
4.

8.
Have
there
been
any
changes
in
ownership
in
the
last
year?
___
Yes
___
No.
If
yes,
did
the
change
in
ownership
affect
the
disadvantaged
status
of
your
firm?
Please
explain
as
Attachment
D­
5.

For
community
property
residents
only.
If
you
are
a
married
disadvantaged
owner,
and
your
spouse
is
not
disadvantaged,
please
complete
the
chart
below,
and
provide
evidence
that
you
have
a
majority
interest
in
the
business.

Name
of
Disadvantaged
Owner
State
of
Residence
Percent
Transferred
____________________________
____________
__________________

SECTION
E
EPA
DBE
Certification
Application
(
EPA
Form
6100­
1d)
(
Corporations)
5
(
All
applicant
firms
must
complete)

Control
1.
Disadvantaged
individuals
control
the
board
of
directors
by
virtue
of
the
fact
that
(
select
only
one
below):
____
a)
A
single
disadvantaged
individual
owns
100%
of
all
the
voting
stock
of
the
applicant
business.

____
b)
A
single
disadvantaged
individual
owns
at
least
51%
of
all
voting
stock,
is
on
the
Board
of
Directors,
and
no
super
majority
voting
requirements
exist
for
shareholders
to
approve
corporate
actions.

____
c)
A
single
disadvantaged
individual
owns
at
least
51%
of
all
voting
stock,
is
on
the
Board
of
Directors,
and
owns
at
least
the
percentage
of
voting
stock
needed
to
overcome
the
super
majority
voting
requirements
which
exist
for
shareholders
to
approve
corporate
actions.

____
d)
More
than
one
disadvantaged
individual
owns
at
least
51%
of
all
voting
stock,
all
such
individuals
serve
on
the
Board
of
Directors,
no
super
majority
voting
requirements
exist
for
shareholders
to
approve
corporation
actions,
and
the
disadvantaged
shareholders
can
demonstrate
they
have
made
enforceable
arrangements
to
permit
one
of
them
to
vote
the
stock
of
all
as
a
block
without
holding
a
shareholder
meeting.
____
e)
More
than
one
disadvantaged
individual
owns
at
least
51%
of
all
voting
stock,
all
such
individuals
serve
on
the
Board
of
Directors,
in
total
all
own
at
least
the
percentage
of
voting
stock
needed
to
overcome
the
existing
super
majority
voting
requirements
which
exist
for
shareholders
to
approve
corporate
actions,
and
the
disadvantaged
individuals
can
demonstrate
they
have
made
enforceable
arrangements
to
permit
one
of
them
to
vote
the
stock
of
all
as
a
block
without
holding
a
shareholder
meeting.

OR
____
f)
The
disadvantaged
individual(
s)
control
the
Board
of
Directors
through
actual
numbers
of
voting
directors.

____
g)
The
disadvantaged
individual(
s)
control
the
Board
of
Directors
through
weighted
voting
and
such
voting
is
permitted
by
applicable
state
law.

2.
List
the
titles
of
all
officers,
directors,
and
key
managers
and
the
hours
devoted
by
such
individuals
to
the
management
of
the
applicant
business.

Name
Title
Hours
_____________________
__________
_______

3.
Is
the
CEO,
President
or
any
disadvantaged
full­
time
manager
engaged
in
or
planning
to
engage
in
outside
employment?
___
Yes
___
No.
If
yes,
provide
details
as
to
the
extent
of
outside
employment
or
other
business
dealings
including
daily
hours
of
employment,
location
and
explanation
as
to
how
this
outside
employment
does
not
conflict
with
the
ability
to
manage
and
control
the
daily
operations
of
the
applicant
concern,
provide
as
Attachment
E­
1.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1d)
(
Corporations)
6
4.
Have
any
of
the
nondisadvantaged
individuals
involved
in
the
management
of
the
applicant
firm,
and/
or
stockholders,
officers,
directors
or
their
immediate
family
members,
had
a
prior
business
relationship
with
any
individual
claiming
disadvantaged
status?
This
includes
such
relationships
as
employer­
employee,
supervisor­
employee,
co­
workers,
investor­
employee,
etc.
___
Yes
___
No.
If
yes,
identify
the
person(
s)
and
the
type
of
business
relationship,
provide
as
Attachment
E­
2.

5.
Does
any
nondisadvantaged
individual
receive
compensation
in
any
form,
including
dividends,
as
a
director,
officer,
or
employee
that
exceeds
the
compensation
received
by
the
disadvantaged
President
or
CEO?
____
Yes
____
No.
If
yes,
provide
the
total
compensation
received
by
the
President
or
CEO,
and
the
name(
s)
and
the
amount
of
the
total
compensation
paid
to
the
nondisadvantaged
individual(
s).
If
any
nondisadvantaged
individual
is
more
highly
compensated,
provide
a
statement
that
justifies
the
need
for
the
nondisadvantaged
individual(
s)
to
receive
a
higher
compensation,
provide
as
Attachment
E­
3.

6.
Does
the
applicant
firm
operate
in
an
industry
that
requires
bonding
or
professional
licenses?
___
Yes
___
No.
If
yes,
identify
the
qualifying
individual(
s)
for
the
critical
licenses,
general
indemnity
agreement,
permits,
certifications,
and
bonding
required
to
operate
the
applicant
firm,
provide
as
Attachment
E­
4.

7.
List
the
names
and
titles
of
all
individuals
who
have
access
to
the
firm's
bank
account.

Name
Title
________________________
_______________________

8.
Do
any
individual,
(
other
than
the
individual(
s)
claiming
disadvantaged
status)
or
entities
provide:

a)
Financial
support
to
the
applicant
firm
___
Yes
___
No
b)
Subcontracts,
Joint
Ventures
or
Teaming
Arrangements
___
Yes
___
No
c)
Office
space
(
rent
or
leased)
___
Yes
___
No
d)
Equipment
(
rent
or
leased)
___
Yes
___
No
e)
Employees
(
other
than
from
employment
agencies)
___
Yes
___
No
If
you
answered
yes
to
any
of
the
above,
please
provide
specific
details
(
i.
e.,
names,
titles,
copies
of
agreements,
leases,
etc.)
of
such
arrangements,
provide
as
Attachment
E­
5.

Each
person
signing
below:

1.
Certifies
that
the
information
provided
with
regard
to
my
social
and
economic
disadvantaged
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

2.
Certifies
that
the
information
provided
with
regard
to
my
ownership
and
control
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
my
status
as
a
United
States
citizen
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

4.
Certifies
that
the
information
provided
with
regard
to
my
individual
disadvantaged
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

5.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1d)
(
Corporations)
7
6.
Acknowledges
that
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
state
and
local
agencies
to
determine
violations
of
law.

7.
Acknowledges
that
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

Name
SSN
Date
________________________
_______________________
______________________

The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1d)
(
Corporations)
8
OMB
Control
No:
______
Approved:
______
Approval
Expires:
______
Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
For
Limited
Liability
Company
Business
Profile:

Name
of
applicant
firm:___________________________________________________________________

Name
of
Managing
Members
and
Titles:_____________________________________________________

EIN:_________________________
E­
mail
Address:_____________________________________________

Business
Address:______________________________________________
County:___________________

City:_________________________________
State:_______________
Zip
Code:______________________

Phone
Number:___________________________
Fax
Number:___________________________________

Mailing
Address
(
if
different
than
above):_________________________
County:___________________

City:_________________________________
State:_______________
Zip
Code:______________________

What
is
the
firm's
4­
digit
primary
North
American
Industrial
Classification
(
NAIC)
code?
_________

Are
you
claiming
disabled
status?
___
Yes
___
No.
(
i.
e.,
a
United
States
citizen
who
has
permanent
or
temporary
physical
or
mental
impairment
that
substantially
limits
one
or
more
of
your
major
life
activities.)
If
yes,
please
submit
documentation
substantiating
such
disability.

Is
your
firm
at
least
51%
owned
by
a
Disabled
American?
___
Yes
___
No.

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?
___
Yes
___
No.
If
yes,
provide
PRO­
Net
number:
___________________________________

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
PRO­
Net
number:
_________________________________

Is
your
firm
certified
as
a
DBE
by
a
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s):
____________________________________________________________

Is
your
firm
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
and
a
contact
point
at
the
certifying
entity:
______________________________________________________________________________________

Has
your
firm
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
a
copy
of
the
prior
determination
of
attempts
to
obtain
certification:
______________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
___________________________________________________________________________
Does
your
firm
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e.,
MBE,
DBE,
WBE,
etc.?
____
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s)
_______________________________________

In
accordance
with
13
CFR
§
124.103,
designated
group
members
are
presumed
to
be
socially
disadvantaged.
Designated
group
members
are
individuals
who
hold
themselves
out
to
be
and
are
identified
by
others
as
Black
Americans,
Native
Americans
(
American
Indians,
Eskimos,
Aleuts,
or
Native
Hawaiians),
Hispanic
Americans,
Subcontinent
Asian
Americans,
Asian
Pacific
Americans,
and
any
other
groups
designated
by
the
Small
Business
Administration
(
SBA).
If
an
individual
is
claiming
to
be
a
member
of
a
designated
group,
complete
Section
A
of
this
application.
If
an
individual
is
not
claiming
to
be
a
member
of
a
designated
group,
complete
Section
B
of
this
application.
All
applicants
must
complete
Sections
C,
D,
and
E
of
this
application.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
2
SECTION
A
Eligibility
Statement
­
Designated
Group
Members
Social
Disadvantage
1.
List
all
individuals
claiming
disadvantaged
status:

Name
of
Individual
Other
Last
U.
S.
Citizen
Place
of
Birth
Group
Membership
Sex
Names
Used
Y/
N
M/
F
________________
__________
__________
___________
________________
____

________________
__________
__________
___________
________________
____

________________
__________
__________
___________
________________
____

________________
__________
__________
___________
________________
____

2.
Is
at
least
51%
of
each
class
of
member
interest
unconditionally
owned
by
one
or
more
disadvantaged
individuals?
___
Yes
___
No.

3.
List
all
individuals
claiming
disadvantaged
status.

Name
of
Individual
Other
Last
U.
S.
Citizen
Place
of
Group
Sex
Names
Used
Y/
N
Birth
Membership
M/
F
__________________________
___________
________
___________
_______
___
____

__________________________
___________
________
___________
__________
____

__________________________
___________
________
___________
__________
____

3a.
If
you
are
a
naturalized
United
States
Citizen,
please
provide
the
following
as
Attachment
A­
1:
(
a)
naturalization
number;
(
b)
date
of
citizenship;
and
(
c)
county,
state
and
court.

SECTION
B
Eligibility
Statement
­
Non
Designated
Group
Members
Social
Disadvantage
1.
Is
at
least
51%
of
each
class
of
member
interest
unconditionally
owned
by
one
or
more
disadvantaged
individual?
___
Yes
___
No.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
3
2.
List
all
individuals
claiming
disadvantaged
status:

Name
of
Individual
U.
S.
Citizen
Race
Sex
Y/
N
M/
F
_______________________________
________
________
_____

_______________________________
________
________
_____

_______________________________
________
________
_____

_______________________________
________
________
_____

2a.
If
you
are
a
naturalized
Citizen,
please
provide
the
following
as
Attachment
B­
1:
(
a)
naturalization
number;
(
b)
date
of
citizenship;
and
(
c)
county,
state
and
court.

For
this
section,
each
individual
claiming
social
disadvantage
must
provide
a
separate
response
for
questions
3
through
5.

Social
Disadvantage
3.
I,
____________________________________
have
personally
suffered
social
disadvantage
based
on
my
identification
as
__________________________________.
(
A
claim
of
social
disadvantage
must
include
at
least
one
objective
feature
that
has
contributed
to
social
disadvantage,
such
as
race,
ethnic
origin,
gender,
physical
handicap,
long­
term
residence
in
an
environment
isolated
from
the
mainstream
of
American
society,
or
other
similar
causes
not
common
to
individuals
who
are
not
socially
disadvantaged.)

4.
Document
how
your
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
by
such
things
as
inability
to
obtain
adequate
bonding,
credit
or
financing;
inability
to
obtain
licenses
or
leases;
restriction
of
your
market
to
certain
racial,
ethnic
or
social
groups;
underemployment
or
unemployment,
etc.,
as
compared
to
others
in
the
same
or
similar
line
of
business
who
are
not
socially
disadvantaged.
Provide
as
Attachment
B­
2.

5.
Attach
a
narrative
describing
how
you
personally
experienced
social
disadvantage
in
American
society.
When
writing
your
narrative,
be
as
specific
and
detailed
as
possible.
Where
applicable,
each
statement
of
alleged
discrimination
should
be
supported
by
documented
evidence
such
as
affidavits,
denials
of
loan
applications,
denials
of
employment
opportunities
(
including
non­
selection
for
particular
jobs,
denials
of
promotions,
or
unequal
work
environment
or
treatment),
and
documents
to
support
any
formal
action
taken
by
you
because
of
alleged
discrimination.
You
must
demonstrate
how
your
identification,
as
described
in
the
paragraph
above,
has
negatively
impacted
your
entry
into
or
advancement
in
business.
You
must
address
disadvantage
in
education,
employment,
and
business
history,
where
applicable.
Examples
of
discrimination
include,
but
are
not
limited
to:
unequal
access
to
colleges
or
professional
schools;
exclusion
from
professional
or
business
associations;
being
denied
educational
honors
or
recognition;
experiencing
discriminatory
social
pressure
which
discouraged
you
from
pursuing
a
professional
or
higher
education
or
forced
you
into
non­
professional
or
non­
business
fields;
discrimination
in
employment
opportunities
or
pay
and
fringe
benefits;
unequal
access
to
business
credit
or
capital;
and
discrimination
in
the
awarding,
bidding
process,
or
negotiating
of
government
or
private
sector
contracts.
Provide
as
Attachment
B­
3.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
4
SECTION
C
(
All
applicant
firms
must
complete)

Economic
Disadvantage
1.
Is
the
net
worth
of
each
individual(
s)
claiming
disadvantaged
status
less
than
$
750,000,
excluding
your
ownership
interest
in
the
applicant
firm
and
equity
in
the
individual(
s)
primary
residence?
____
Yes
____
No.

2.
For
individuals
claiming
disadvantaged
status,
list
your
personal
net
worth,
excluding
the
ownership
interest
in
the
applicant
firm
and
the
equity
in
the
individual(
s)
primary
residence.

Name
Average
2­
year
Personal
Total
Income
Net
Worth
Assets
________________________________
______________
__________
__________

________________________________
______________
__________
__________

________________________________
______________
__________
__________

________________________________
______________
__________
__________

3.
Each
individual
listed
in
number
2
above,
certifies
that
because
of
racial
and/
or
ethnic
prejudice,
and/
or
cultural
bias,
his/
her
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
due
to
diminished
capital
and
credit
opportunities
as
compared
to
others
in
the
same
or
similar
line
of
business
that
are
not
socially
disadvantaged.

SECTION
D
(
All
applicant
firms
must
complete)

Ownership
1.
If
more
than
one
class
membership
interest,
provide
information
for
each
class:
Voting
Non­
Total
Voting
a)
Total
number
of
interests
authorized:
_____
______
_____
b)
Total
number
of
interests
currently
outstanding:
_____
______
_____

2.
List
all
individuals,
entities,
and/
or
trusts,
which
have
a
membership
interest
in
the
applicant
firm.

Name
Title
Membership
Percent
Voting
Non­
Voting
Total
___________________________
____________________
______
__________
______

___________________________
____________________
______
__________
______

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
5
3.
Do
disadvantaged
individuals
receive
at
least
51%
of
the
annual
distributions
of
dividends
paid
on
the
membership
interest
of
an
LLC
applicant
firm?
____
Yes
____
No
____
N/
A.
If
no
or
not
applicable
(
N/
A),
please
explain
as
Attachment
D­
1.

4.
Will
disadvantaged
individuals
receive
100%
of
the
unencumbered
value
of
each
share
of
membership
interest
in
the
event
that
the
interest
is
sold?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
D­
2.

5.
If
the
LLC
dissolves,
will
disadvantaged
individuals
receive
at
least
51%
of
the
retained
earnings
and
100%
of
the
unencumbered
value
of
each
membership
he
or
she
owns?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
D­
3.

6.
Is
ownership
by
any
individual
claiming
disadvantaged
status
subject
to
conditions
precedent,
conditions
subsequent,
executory
agreements,
voting
trusts,
shareholder
agreements,
or
other
similar
arrangements,
which
may
impact
the
unconditional
ownership
of
such
individuals?
___
Yes
___
No.
If
yes,
explain
as
Attachment
D­
4.

7.
Have
there
been
any
changes
in
ownership
in
the
last
year?
____
Yes
____
No.
If
yes,
did
ownership
affect
the
disadvantaged
status
of
your
firm?
Please
explain
as
Attachment
D­
5.

8.
For
community
property
residents
only.
If
you
are
a
married
disadvantaged
owner,
and
your
spouse
is
not
disadvantaged,
please
complete
the
chart
below,
and
provide
evidence
that
you
have
a
majority
interest
in
the
business.

Name
of
Disadvantaged
Owner
State
of
Residence
Percent
Transferred
__________________________________
_______
_____________

__________________________________
_______
_____________

__________________________________
_______
_____________

__________________________________
_______
_____________

9.
Has
any
individual(
s)
listed
in
number
2
above
transferred
any
assets
within
two
years,
in
full
or
in
part,
to
a
spouse
or
any
other
person
or
entity,
including
a
trust?
___
Yes
___
No.
If
yes,
provide
the
following
information
as
Attachment
D­
6:
the
date
of
transfer;
to
whom
the
assets
were
transferred;
amount
paid
for
the
assets;
and
the
market
value
of
the
assets
at
the
time
of
transfer.
Individuals
may
exclude
assets
transferred
to
an
immediate
family
member
that
are
consistent
with
the
customary
recognition
of
special
occasions,
such
as
birthdays,
graduations,
anniversaries,
and
retirements.
Individuals
may
also
exclude
any
transfers
to
an
immediate
family
if
for
educational,
medical,
or
essential
support
purposes.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
6
SECTION
E
(
All
applicant
firms
must
complete)

Control
1.
List
the
titles
of
all
officers,
management
members,
and
key
managers
and
the
hours
devoted,
by
such
individual(
s)
to
the
management
of
the
applicant
firm.

Name
Title
____________________________
_______________________________

_____________________________
_______________________________

_____________________________
_______________________________

_____________________________
_______________________________

2.
Is
the
managing
member
or
any
disadvantaged
full­
time
manager
engaged
in
or
plan
to
engage
in
outside
employment?
____
Yes
____
No.
If
yes,
provide
details
as
to
the
extent
of
outside
employment
or
other
business
dealings
to
include
daily
hours
of
employment,
location,
and
explanation
as
to
how
this
outside
employment
does
not
conflict
with
the
ability
to
manage
and
control
the
daily
operations
of
the
application
concern.
Provide
as
Attachment
E­
1.

3.
Have
any
of
the
nondisadvantaged
individuals
involved
in
the
management
of
the
applicant
firm,
and/
or
their
immediate
family
members,
had
a
prior
business
relationship
with
any
individual
claiming
disadvantaged
status?
This
includes
such
relationships
as
employer­
employee,
supervisoremployee
co­
workers,
investor­
employee,
etc.
____
Yes
____
No.
If
yes,
identify
the
person(
s)
and
the
type
of
business
relationship
as
Attachment
E­
2.

4.
Does
any
nondisadvantaged
individual
receive
compensation
in
any
form,
including
dividends,
as
a
director,
officer,
or
employee
that
exceeds
the
compensation
received
by
the
disadvantaged
Management
Member?
____
Yes
____
No.
If
yes,
provide
the
total
compensation
received
by
the
disadvantaged
management
member,
and
the
name(
s)
and
the
amount
of
the
total
compensation
paid
to
the
nondisadvantaged
individuals(
s).
If
any
nondisadvantaged
individual
is
higher
compensated,
provide
a
statement,
which
justifies
the
need
for
the
nondisadvantaged
individual(
s)
to
receive
a
higher
compensation.
Provide
as
Attachment
E­
3.

5.
Does
the
applicant
firm
operate
in
an
industry,
which
requires
bonding
or
professional
licenses?
____
Yes
____
No.
If
yes,
identify
the
qualifying
individual(
s)
for
the
critical
licenses,
general
indemnity
agreement,
permits,
certifications,
and
bonding
required
to
operate
the
applicant
firm
on
Attachment
E­
4.

6.
List
the
names
of
all
individuals
who
have
access
to
the
firm's
bank
account.

Name
Title
___________________________________
___________________________________

___________________________________
___________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
7
7.
Does
any
individual(
s),
(
other
than
the
individual(
s)
claiming
disadvantaged
status)
or
entities
provide?

a)
Financial
support
to
the
applicant
firm
____
Yes
____
No
b)
Subcontracts,
Joint
Ventures
or
Teaming
Arrangements
____
Yes
____
No
c)
Office
space
(
rent
or
leased)
____
Yes
____
No
d)
Equipment
(
rent
or
leased)
____
Yes
____
No
e)
Employees
(
other
than
from
employment
agencies)
____
Yes
____
No
f)
Business
bank
account
____
Yes
____
No
If
you
answered
yes
to
any
of
the
above,
please
provide
details
(
i.
e.,
names,
titles,
copies
of
agreements,
leases,
etc.)
of
such
arrangements
as
Attachment
E­
5.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
8
Each
person
signing
below:

1.
Certifies
that
the
information
provided
with
regard
to
my
social
and
economic
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
my
knowledge
and
belief.

2.
Certifies
that
the
information
provided
with
regard
to
my
ownership
and
control
status
is
true,
accurate,
and
complete
to
the
best
of
my
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
my
status
as
a
United
States
citizen
is
true,
accurate,
and
complete
to
the
best
of
my
knowledge
and
belief.

4.
Certifies
that
the
information
provided
with
regard
to
my
individual
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
my
knowledge
and
belief.

5.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

6.
Acknowledges
that
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
state,
and
local
agencies
for
determining
violations
of
law.

7.
Acknowledges
that
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

Name
SSN
Date
________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
9
http://
www.
epa.
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Office
of
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Budget,
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Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1b)
(
Limited
Liability
Company)
10
OMB
Control
No:
______
Approved:
______
Approval
Expires:
______
Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
Native
Hawaiian
Organization
Owned
Concern
Name
of
Parent
Native
Hawaiian
Organization:
_________________________________________

Address
of
Parent
Native
Hawaiian
Organization:
_______________________________________

Name
of
wholly­
owned
subsidiary
(
if
applicable):
_______________________________________

Address
of
wholly­
owned
subsidiary:
__________________________________________________

Name
of
applicant
firm:
______________________________________________________________

Applicant
concern
is:

Corporation

Limited
Liability
Company

Partnership
Name
of
President/
Managing
Member/
Managing
Partner:
_______________________________

EIN:
_________________________
E­
mail
Address:
_____________________________________

Business
Address:
_____________________________________________
County:
_____________

City:
_________________________________
State:
_______________
Zip
Code:
_______________

Phone
Number:
___________________________
Fax
Number:
_____________________________

Mailing
Address
(
if
different
than
above):
________________________
County:
_______________

City:
_________________________________
State:
_______________
Zip
Code:
_______________

What
is
the
firm's
(
4­
digit)
primary
standard
industrial
classification
code?
_________________

Is
the
firm
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
Number________________________________

Is
the
firm
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
number___________________

Is
the
firm
certified
as
a
DBE
by
a
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s)
__________________________________________________

Is
the
firm
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
and
a
contact
point
at
the
certifying
entity
____________________________________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1h)
(
Native
Hawaiian
Organization
Owned
Concern)
Has
your
firm
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
explanation/
documentation:
_____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Does
the
firm
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e.,
MBE,
DBE,
WBE,
etc?
___
Yes
___
No.
If
yes,
provide
the
State(
s)
and
ID
number(
s):
__________________
__________________________________________________________________________________

Business
Eligibility
SECTION
A
Social
Disadvantage
1.
A
Native
Hawaiian
Organization
that
meets
the
following
criteria
is
considered
socially
disadvantaged:

Native
Hawaiian
Organization
means
any
community
service
organization
serving
Native
Hawaiians
in
the
State
of
Hawaii,
which
is
a
not­
for
profit
organization,
chartered
by
the
State
of
Hawaii.
A
Native
Hawaiian
Organization
is
controlled
by
Native
Hawaiians
whose
business
activities
will
principally
benefit
such
Native
Hawaiians.

Provide
documentation
that
the
applicant
entity
meets
these
criteria
as
Attachment
A­
1.

SECTION
B
Economic
Disadvantage
1.
Is
the
net
worth
of
all
individual(
s)
claiming
disadvantaged
status
less
than
$
750,000,
excluding
ownership
interest
in
the
applicant
firm
and
equity
in
the
individual(
s)
primary
residence?
____
Yes
____
No.

2.
For
individual(
s)
claiming
disadvantaged
status,
list
your
personal
net
worth,
excluding
the
ownership
interest
in
the
applicant
firm
and
the
equity
in
the
individual(
s)
primary
residence.

Name
Average
2­
year
Personal
Total
U.
S.
Income
Net
Worth
Assets
Citizen
(
Y/
N)

____________________________
______________
__________
_______
___________

____________________________
______________
__________
_______
___________

____________________________
______________
__________
_______
___________

____________________________
______________
__________
_______
___________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1h)
(
Native
Hawaiian
Organization
Owned
Concern)
2
3.
Each
individual
listed
in
number
2
above
certifies
that,
because
of
racial
and/
or
ethnic
prejudice,
and/
or
cultural
bias,
his/
her
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
due
to
diminished
capital
and
credit
opportunities
as
compared
to
others
in
the
same
or
similar
line
of
business
that
are
not
socially
disadvantaged.

4.
Personal
Financial
Statement
­
All
individuals
claiming
disadvantaged
status
and
his/
her
spouse,
please
provide
documentation
verifying
your
assets
and
liabilities
(
split
your
assets
and
liabilities,
if
married)
as
Attachment
B­
1.

5.
All
individuals
claiming
disadvantaged
status
or
individuals
owning
more
than
10%
of
the
concern
please
provide
the
following
documentation
as
Attachment
B­
2:

a)
Signed
copies
of
individual
Federal
income
tax
returns
filed
for
the
past
two
years,
including
all
W­
2
forms
and
all
schedules
and
attachments.
b)
Signed
and
dated
IRS
Form
4506
(
Request
for
Copy
or
Transcript
of
Tax
Form)

SECTION
C
Ownership
1.
Do
Native
Hawaiians
own
a
majority
of
both
the
total
equity
of
the
Native
Hawaiian
Organization
and
the
total
voting
powers
to
elect
directors
of
the
Native
Hawaiian
Organization?
___
Yes
___
No.
If
yes,
provide
verification
of
the
percentage
of
Native
Hawaiian
ownership
as
attachment
C­
1.

2.
Is
the
applicant
concern
at
least
51
percent
owned
by
a
Native
Hawaiian
Organization?
____
Yes
____
No.
If
yes,
please
provide
evidence
of
ownership
as
Attachment
C­
2.

Corporations
Only:

3.
If
more
than
one
class
of
stock,
provide
information
for
each
class:
Voting
Non
Total
Voting
a)
Total
number
of
shares
authorized:
_____
______
_____
b)
Total
number
of
shares
currently
outstanding:
_____
______
_____

4.
Please
provide
the
following
documentation
as
Attachment
C­
3:
a)
Copies
of
all
governing
documents,
such
as
the
concern's
constitution
or
business
charter.
b)
Copies
of
all
minutes
of
shareholders
meeting
electing
board
of
directors
and
minutes
of
last
shareholders
meeting.
c)
Copies
of
all
stock
certificates
(
front
and
back)
and
stock
register.
d)
Copy
of
the
current
Certificate
of
Good
Standing
from
state
where
concern
is
incorporated.
If
concern
conducts
business
in
a
state
other
than
where
it
was
incorporated,
a
copy
of
the
filing
as
a
Foreign
Corporation
and
a
current
Certificate
of
Good
Standing
from
that
state
are
required
as
well.

Limited
Liability
Companies
Only:

5.
If
more
than
one
class
membership
interest,
provide
information
for
each
class:
Voting
Non
Total
Voting
a)
Total
number
of
memberships
authorized:
_____
______
_____
b)
Total
number
of
memberships
currently
outstanding:
_____
______
_____

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1h)
(
Native
Hawaiian
Organization
Owned
Concern)
3
6.
Please
provide
the
following
documentation
as
attachment
C­
4:
a)
Copy
of
Operating
Agreement
b)
Copy
of
Articles
of
Organization
as
filed
with
the
state
Partnerships
Only:

7.
Provide
the
name,
title,
and
percentage
of
ownership
for
each
partner
of
the
firm.
Does
the
partnership
agreement
reflect
the
ownership
of
each
partner?
___
Yes
___
No.

Name
Title
Ownership
%

___________________________
____________________
____________________

___________________________
____________________
____________________

___________________________
____________________
____________________

___________________________
____________________
____________________

8.
Please
provide
a
copy
of
the
concern's
Partnership
Agreement
as
Attachment
C­
5.

Questions
9
through
13
are
for
Corporations
&
LLCs
ONLY:

9.
List
all
entities,
individuals,
and/
or
trusts
which
have
an
ownership
interest
in
the
applicant
firm.

Name
Title
Ownership
%
Voting
NonVoting
Total
___________________________
____________________
______
_________
_____

___________________________
____________________
______
__________
_____

___________________________
____________________
______
__________
______

___________________________
____________________
______
__________
______

10.
Does
the
parent
Native
Hawaiian
Organization
or
its
wholly
owned
subsidiary
receive
at
least
51%
of
the
annual
distributions
of
dividends
paid
on
the
stock
of
a
corporate
applicant
firm?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
C­
6.

11.
Will
the
parent
Native
Hawaiian
Organization
or
its
wholly
owned
subsidiary
receive
100%
of
the
unencumbered
value
of
each
share
of
stock
owned
in
the
event
that
the
stock
is
sold?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
C­
7.

12.
If
the
corporation
dissolves,
will
the
parent
Native
Hawaiian
Organization
or
its
wholly
owned
subsidiary
receive
at
least
51%
of
the
retained
earnings
and
100%
of
the
unencumbered
value
of
each
share
of
stock
owned?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
C­
8.

13.
Is
ownership
by
the
parent
Native
Hawaiian
Organization
or
its
wholly
owned
subsidiary
subject
to
conditions
precedent,
conditions
subsequent,
executory
agreements,
voting
trusts,
shareholder
agreements
or
other
similar
arrangements
which
may
impact
the
unconditional
ownership
of
the
Native
Hawaiian
Organization?
___
Yes
___
No.
If
yes,
explain
as
Attachment
C­
9.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1h)
(
Native
Hawaiian
Organization
Owned
Concern)
4
Corporations,
LLCs
&
Partnerships:

14.
Have
there
been
any
changes
in
ownership
in
the
last
year?
___
Yes
___
No.
If
yes,
did
ownership
affect
the
disadvantaged
status
of
your
firm?
Please
explain
as
Attachment
C­
10.

For
All
Concerns:

15.
Please
provide
copies
of
buy/
sell
agreements,
conditions
precedent,
conditions
subsequent,
executory
agreements,
voting
trusts,
shareholder
agreements
or
other
similar
arrangements,
which
may
impact
the
unconditional
ownership
of
the
disadvantaged
individuals
as
Attachment
C­
11.

SECTION
D
Control
and
Management
1.
List
all
individuals
who
manage
or
conduct
daily
business
operations
of
the
applicant
concern.

Name/
Title
Date
___________________________________________________
_____________

___________________________________________________
_____________

___________________________________________________
_____________

___________________________________________________
_____________

2.
Are
any
of
the
individuals
listed
in
question
1
engaged
in
or
plan
to
engage
in
outside
employment?
___
Yes
___
No.

3.
If
members
of
the
management
team,
business
committee
members,
officers,
and
directors
are
currently
employed
outside
the
applicant
concern,
provide
information
on
this
employment
and
evidence
that
the
activity
does
not
conflict
with
the
day­
to­
day
management
of
the
applicant
concern.
Please
indicate
the
number
of
hours
per
week
and
the
normal
working
hours
of
this
outside
employment
as
Attachment
D­
1.

4.
Please
provide
resumes
of
the
education,
technical
training
and
business
and
employment
experience,
including
employer's
names,
dates
of
employment,
for
general
manager,
officers,
and
key
employees
(
Please
account
for
any
missing
gaps
in
employment)
as
Attachment
D­
2.

5.
List
the
total
compensation
from
the
applicant
firm
of
all
owners
and/
or
key
managers
of
the
firm.
(
If
necessary,
provide
additional
information
as
Attachment
D­
3).

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

___________________________________
__________________________________

___________________________________
__________________________________

___________________________________
__________________________________

___________________________________
__________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1h)
(
Native
Hawaiian
Organization
Owned
Concern)
5
6.
Does
the
applicant
firm
operate
in
an
industry
which
requires
bonding
or
professional
licenses?
___
Yes
___
No.
If
yes,
identify
the
qualifying
individual(
s)
for
the
critical
licenses,
general
indemnity
agreement,
permits,
certifications,
and
bonding
required
to
operate
the
applicant
firm
on
Attachment
D­
4.

7.
List
the
names
of
all
individuals
who
have
access
to
the
firm's
bank
account.

Name
Title
___________________________________
__________________________________

___________________________________
__________________________________

___________________________________
__________________________________

___________________________________
__________________________________

8.
Do
any
individual(
s),
or
entities
provide:

a)
Financial
support
to
the
applicant
firm?
___
Yes
___
No
b)
Subcontracts,
Joint
Ventures
or
Teaming
Arrangements?
___
Yes
___
No
c)
Office
space
(
rent
or
leased).
___
Yes
___
No
d)
Equipment
(
rent
or
leased).
___
Yes
___
No
e)
Employees
(
other
than
from
employment
agencies).
___
Yes
___
No
If
the
answer
is
yes
to
any
of
the
above,
please
provide
specific
details
(
i.
e.,
names,
titles,
copies
of
agreements,
leases,
etc.)
of
such
arrangements
as
Attachment
D­
5.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1h)
(
Native
Hawaiian
Organization
Owned
Concern)
6
Each
person
signing
below:

1.
Certifies
that
the
information
provided
with
regard
to
the
applicant
firm's
social
and
economic
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

2.
Certifies
that
the
information
provided
with
regard
to
the
applicant
firm's
ownership
and
control
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
his/
her
individual
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

4.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

5.
Acknowledges
that
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
State,
and
local
agencies
to
determine
violations
of
law.

6.
Acknowledges
that
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

All
officers,
directors,
partners,
members
of
the
governing
board
and
owners
of
more
than
10%
must
sign
below.

Name
SSN
Date
________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

The
public
reporting
and
record­
keeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
disclose,
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
EPA
DBE
Certification
Application
(
EPA
Form
6100­
1h)
(
Native
Hawaiian
Organization
Owned
Concern)
7
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1h)
(
Native
Hawaiian
Organization
Owned
Concern)
8
OMB
Control
No:
______
Approved:
______
Approval
Expires:
______
Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
For
Sole
Proprietorships
Business
Profile:

Name
of
applicant
firm:_______________________________________________

Name
of
Sole
Proprietor
and
Title:______________________________________________

SSN
of
Sole
Proprietor:_________
E­
mail
Address:________

Business
Address:____________________________________________
County:_____________________

City:_________________________________
State:_______________
Zip
Code:______________________

Phone
Number:___________________________
Fax
Number:_____________________________________

Mailing
Address
(
if
different
than
above):_________________________
County:______________________

City:_________________________________
State:_______________
Zip
Code:______________________

What
is
the
firm's
4­
digit
primary
North
American
Industrial
Classification
(
NAIC)
code?
____________

Are
you
claiming
disabled
status?
____
Yes
____
No
(
i.
e.,
a
United
States
citizen
who
has
permanent
or
temporary
physical
or
mental
impairment
that
substantially
limits
one
or
more
of
your
major
life
activities.)
If
yes,
please
submit
documentation
substantiating
such
disability.

Is
your
firm
at
least
51%
owned
by
a
Disabled
American?
____
Yes
____
No.

Are
you
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?
___
Yes
___
No.
If
yes,
provide
PRO­
Net
number
______________________________________________

Are
you
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
PRO­
Net
number
____________________________________

Are
you
certified
as
a
DBE
by
a
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s)
_________________________________________________

EPA
DBE
Certification
Application
(
Form
6100­
1a)
(
Sole
Proprietorship)
Are
you
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
and
a
contact
point
at
the
certifying
entity
____________________________________________________

Have
you
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
a
copy
of
the
prior
determination
of
attempts
to
obtain
certification:
_________________________________________________________________________________________
Do
you
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e.,
MBE,
DBE,
WBE,
etc.?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s).

In
accordance
with
13
CFR
§
124.103,
designated
group
members
are
presumed
to
be
socially
disadvantaged.
Designated
group
members
are
individuals
who
hold
themselves
out
to
be
and
are
identified
by
others
as
Black
Americans,
Native
Americans
(
American
Indians,
Eskimos,
Aleuts,
or
Native
Hawaiians),
Hispanic
Americans,
Subcontinent
Asian
Americans,
Asian
Pacific
Americans,
and
any
other
groups
designated
by
the
Small
Business
Administration
(
SBA).
If
an
individual
is
claiming
to
be
a
member
of
a
designated
group,
complete
Section
A
of
this
application.
If
an
individual
is
not
claiming
to
be
a
member
of
a
designated
group,
complete
Section
B
of
this
application.
All
applicants
must
complete
Sections
C,
D,
and
E
of
this
application.

EPA
DBE
Certification
Application
(
Form
6100­
1a)
(
Sole
Proprietorship)
2
SECTION
A
Eligibility
Statement
­
Designated
Group
Members
Social
Disadvantage
1.
As
the
proprietor
claiming
disadvantaged
status,
complete
the
following:

Name
of
Individual
Other
Last
Citizen
Place
of
Group
Sex
Names
Used
Y/
N
Birth
Membership
_________________
___________
________
___________
_______
_____

If
you
are
not
a
U.
S.
citizen,
stop
here.
You
are
not
eligible
to
participate
as
a
DBE
under
EPA's
DBE
Certification
Program.

1a.
If
you
are
a
naturalized
United
States
Citizen,
please
provide
the
following
as
Attachment
A­
1:
(
a)
naturalization
number;
(
b)
date
of
citizenship;
and
(
c)
county,
state
and
court.

SECTION
B
Eligibility
Statement
­
Non
Designated
Group
Members
1.
As
the
proprietor
claiming
disadvantaged
status,
complete
the
following:

Name
of
Individual
U.
S.
Citizen
Race
Sex
Y/
N
M/
F
_______________________________
________
1a.
If
you
are
a
naturalized
Citizen,
please
provide
the
following
as
Attachment
B­
1:
(
a)
naturalization
number;
(
b)
date
of
citizenship;
and
(
c)
county,
state
and
court.

For
this
section,
any
individual
claiming
social
disadvantage
must
provide
a
separate
response
for
questions
3
and
4.

Social
Disadvantage
2.
I,
____________________________________
have
personally
suffered
social
disadvantage
based
on
my
identification
as
__________________________________.
(
A
claim
of
social
disadvantage
must
include
at
least
one
objective
feature
that
has
contributed
to
social
disadvantage,
such
as
race,
ethnic
origin,
gender,
physical
handicap,
long­
term
residence
in
an
environment
isolated
from
the
mainstream
of
American
society,
or
other
similar
causes
not
common
to
individuals
who
are
not
socially
disadvantaged.)

3.
Document
how
your
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
by
such
things
as
inability
to
obtain
adequate
bonding,
credit
or
financing;
inability
to
obtain
licenses
or
leases;
restriction
of
your
market
to
certain
racial,
ethnic
or
social
groups;
underemployment
or
unemployment,
etc.,
as
compared
to
others
in
the
same
or
similar
line
of
business
who
are
not
socially
disadvantaged.
Provide
as
Attachment
B­
2.

EPA
DBE
Certification
Application
(
Form
6100­
1a)
(
Sole
Proprietorship)
3
4.
Attach
a
narrative
describing
how
you
personally
experienced
social
disadvantage
in
American
society.
When
writing
your
narrative,
be
as
specific
and
detailed
as
possible.
Where
applicable,
each
statement
of
alleged
discrimination
should
be
supported
by
documented
evidence
such
as
affidavits,
denials
of
loan
applications,
denials
of
employment
opportunities
(
including
non­
selection
for
particular
jobs,
denials
of
promotions,
or
unequal
work
environment
or
treatment),
and
documents
to
support
any
formal
action
taken
by
you
because
of
alleged
discrimination.
You
must
demonstrate
how
your
identification,
as
described
in
the
paragraph
above,
has
negatively
impacted
your
entry
into
or
advancement
in
business.
You
must
address
disadvantage
in
education,
employment,
and
business
history,
where
applicable.
Examples
of
discrimination
include,
but
are
not
limited
to:
unequal
access
to
colleges
or
professional
schools;
exclusion
from
professional
or
business
associations;
being
denied
educational
honors
or
recognition;
experiencing
discriminatory
social
pressure
which
discouraged
you
from
pursuing
a
professional
or
higher
education
or
forced
you
into
non­
professional
or
non­
business
fields;
discrimination
in
employment
opportunities
or
pay
and
fringe
benefits;
unequal
access
to
business
credit
or
capital;
and
discrimination
in
the
awarding,
bidding
process,
or
negotiating
of
government
or
private
sector
contracts.
Provide
as
Attachment
B­
3.

SECTION
C
(
All
applicant
firms
must
complete)

Economic
Disadvantage
1.
Is
your
net
worth
less
than
$
750,000,
excluding
your
ownership
interest
in
the
applicant
firm
and
your
equity
in
your
primary
residence?
____
Yes
____
No.

2.
As
the
individual
claiming
disadvantaged
status,
list
your
personal
net
worth,
excluding
the
ownership
interest
in
the
applicant
firm
and
the
equity
in
the
primary
residence.

Name
Average
2­
year
Personal
Total
Income
Net
Worth
Assets
________________________________
______________
__________
__________

3.
I,
___________________________,
certify
that
because
of
racial
and/
or
ethnic
prejudice,
and/
or
cultural
bias,
my
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
due
to
diminished
capital
and
credit
opportunities
as
compared
to
others
in
the
same
or
similar
line
of
business
that
are
not
socially
disadvantaged.

SECTION
D
(
All
applicant
firms
must
complete)

Ownership
1.
Have
you,
the
individual
claiming
disadvantaged
status,
transferred
any
assets
within
two
years,
in
full
or
in
part,
to
a
spouse
or
any
other
person
or
entity,
including
a
trust?
___
Yes
___
No.
If
yes,
provide
the
following
information
as
Attachment
D­
1:
the
date
of
transfer;
to
whom
the
assets
were
transferred;
amount
paid
for
the
assets;
and
the
market
value
of
the
assets
at
the
time
of
transfer.
Individuals
may
exclude
assets
transferred
to
an
immediate
family
member
that
are
EPA
DBE
Certification
Application
(
Form
6100­
1a)
(
Sole
Proprietorship)
4
consistent
with
the
customary
recognition
of
special
occasions,
such
as
birthdays,
graduations,
anniversaries
and
retirements.
Individuals
may
also
exclude
any
transfers
to
an
immediate
family
member
if
for
educational,
medical
or
essential
support
purposes.

For
community
property
residents
only.
If
you
are
a
married
disadvantaged
owner,
and
your
spouse
is
not
disadvantaged,
please
complete
the
chart
below,
and
provide
evidence
that
you
have
a
majority
interest
in
the
business.

Name
of
Disadvantaged
Owner
State
Percent
Transferred
____________________________
_______
__________________

2.
Have
there
been
any
changes
in
ownership
in
the
last
year?
___
Yes
___
No.
If
yes,
did
ownership
affect
the
disadvantaged
status
of
your
firm?
Please
explain
as
Attachment
D­
2.

SECTION
E
(
All
applicant
firms
must
complete)

Control
1.
Does
any
individual
other
than
the
Sole
Proprietor
manage
or
conduct
daily
business
operations
of
the
applicant
concern?
If
yes,
provide
name,
title
and
dates.

Name/
Title
Date
___________________________________
____________________________

___________________________________
____________________________

___________________________________
____________________________

2.
Are
you
engaged
in
or
plan
to
engage
in
outside
employment?
___
Yes
___
No.
If
yes,
explain
as
Attachment
E­
1.

3.
If
the
answer
to
question
2
is
yes,
have
any
of
the
nondisadvantaged
individuals
involved
in
the
management
of
the
applicant
firm,
or
their
immediate
family
members,
had
a
prior
business
relationship
with
you?
This
includes
such
relationships
as
employer­
employee,
supervisoremployee
co­
workers,
investor­
employee,
etc.
___
Yes
___
No
___
N/
A.
If
yes,
identify
the
person(
s)
and
the
type
of
business
relationship
as
Attachment
E­
2.

4.
List
the
total
compensation
from
the
applicant
firm
of
all
owners
and/
or
key
managers
of
the
firm.
(
If
necessary,
provide
additional
information
as
Attachment
E­
3).

EPA
DBE
Certification
Application
(
Form
6100­
1a)
(
Sole
Proprietorship)
5
Name/
Title
Compensation
from
applicant
firm
(
Include
salaries,
bonuses,
etc.)

_____________________________________
__________________________________

_____________________________________
__________________________________

_____________________________________
__________________________________

_____________________________________
__________________________________

_____________________________________
__________________________________

5.
Does
the
applicant
firm
operate
in
an
industry
which
requires
bonding
or
professional
licenses?
___
Yes
___
No.
If
yes,
identify
the
qualifying
individual(
s)
for
the
critical
licenses,
general
indemnity
agreement,
permits,
certifications,
and
bonding
required
to
operate
the
applicant
firm
on
Attachment
E­
4.

6.
List
the
names
of
all
individuals
who
have
access
to
the
firm's
bank
account.

Name
Title
____________________________________
_________________________________

____________________________________
_________________________________

____________________________________
_________________________________

7.
Does
any
individual(
s),
(
other
than
the
Sole
Proprietor)
or
entities
provide:

a)
Financial
support
to
the
applicant
firm?
___
Yes
___
No
b)
Subcontracts,
Joint
Ventures
or
Teaming
Arrangements?
___
Yes
___
No
c)
Office
space
(
rent
or
leased).
___
Yes
___
No
d)
Equipment
(
rent
or
leased).
___
Yes
___
No
e)
Employees
(
other
than
from
employment
agencies).
___
Yes
___
No
If
you
answered
yes
to
any
of
the
above,
please
provide
specific
details
(
i.
e.,
names,
titles,
copies
of
agreements,
leases,
etc.)
of
such
arrangements
as
Attachment
E­
5.

EPA
DBE
Certification
Application
(
Form
6100­
1a)
(
Sole
Proprietorship)
6
Each
person
signing
below:
1.
Certifies
that
the
information
provided
with
regard
to
my
social
and
economic
disadvantaged
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

2.
Certifies
that
the
information
provided
with
regard
to
my
ownership
and
control
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
my
status
as
a
United
States
citizen
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

4.
Certifies
that
the
information
provided
with
regard
to
my
individual
disadvantaged
status
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

5.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

6.
Acknowledges
that
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
state
and
local
agencies
for
determining
violations
of
law.

7.
Acknowledges
that
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

Name
SSN
Date
________________________
___________________
_______________________

________________________
___________________
_______________________

________________________
___________________
_______________________

________________________
___________________
_______________________

The
public
reporting
and
record
keeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
EPA
DBE
Certification
Application
(
Form
6100­
1a)
(
Sole
Proprietorship)
7
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
Form
6100­
1a)
(
Sole
Proprietorship)
8
OMB
Control
No:
______
Approved:
______
Approval
Expires:
______
Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
Tribally
Owned
Businesses
Name
of
Indian
tribe:_______________________________________________________________

Address
of
tribe:___________________________________________________________________

Name
of
wholly­
owned
Subsidiary
(
if
applicable):____________________________________________________________

Address
of
wholly­
owned
Subsidiary:_______________________________________________________________________

Name
of
applicant
firm:____________________________________________________________

Applicant
concern
is:
Corporation
Limited
Liability
Company
Partnership
Name
of
President/
Managing
Member/
Managing
Partner:_______________________________

EIN:_________________________
E­
mail
Address:______________________________________

Business
Address:______________________________________________
County:_____________

City:_________________________________
State:_______________
Zip
Code:________________

Phone
Number:___________________________
Fax
Number:______________________________

Mailing
Address
(
if
different
than
above):________________________
County:________________

City:_________________________________
State:_______________
Zip
Code:________________

What
is
the
firm's
4­
digit
primary
North
American
Industrial
Classification
(
NAIC)
code?
__________________________________________________________________________________

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
number:________________________________

Is
your
firm
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
number:
____________________

Is
your
firm
certified
as
a
DBE
by
a
U.
S.
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s):
_________________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1f)
(
Tribally
Owned
Businesses)
Is
your
firm
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
and
the
certifying
entity:
____________________________________________________________________________

Has
your
firm
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
explanation/
documentation:____________________________________________________________
_____________________________________________________________________________________

Do
you
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e.,
MBE,
DBE,
WBE,
etc?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s):
________________________________

Is
the
applicant
firm
a
for
profit
business?
___
Yes
___
No.

Do
the
tribe's
articles
of
incorporation/
articles
of
organization/
partnership
agreement
contain
express
sovereign
immunity
waiver
language
or
a
"
sue
and
be
sued"
clause
which
designates
United
States
Federal
Courts
to
be
a
competent
jurisdiction
for
all
matters
relating
to
EPA's
DBE
Program?
___
Yes
___
No.
If
yes,
provide
a
complete
copy
of
the
documentation
as
attachment
D­
3.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1f)
(
Tribally
Owned
Businesses)
2
Business
Eligibility
SECTION
A
Social
Disadvantage
1.
An
Indian
tribe
that
meets
the
following
criteria
is
considered
socially
disadvantaged:

Indian
tribe
means
any
Indian
tribe,
band,
nation,
or
other
organized
group
or
community
of
Indians
which
is
recognized
as
eligible
for
the
special
programs
and
services
provided
by
the
United
States
to
Indians
because
of
their
status
as
Indians,
or
is
recognized
as
such
by
the
State
in
which
the
tribe,
band,
nation,
group
or
community
resides.

Provide
documentation
that
the
applicant
entity
meets
these
criteria
as
Attachment
A­
1.

2.
Provide
copies
of
the
tribe's
articles
of
incorporation
and
bylaws
as
filed
with
the
organizing
or
chartering
authority,
or
similar
documents
needed
to
establish
and
govern
a
non­
corporate
legal
entity
as
Attachment
A­
2.

SECTION
B
Economic
Disadvantage
1.
Has
the
tribe
previously
established
economic
disadvantage
to
qualify
as
DBE?
___
Yes
___
No.
If
yes,
provide
documentation
to
verify
disadvantaged
status
as
Attachment
B­
1.

If
no,
respond
to
the
following
questions
as
Attachment
B­
2:

a)
What
is
the
number
of
tribal
members
on
tribal
rolls
as
of
the
date
of
application?
b)
What
is
tribe's
present
unemployment
rate?
c)
What
is
the
per
capita
income
of
tribal
members
excluding
judgment
awards?
d)
What
is
the
percentage
of
the
local
Indian
population
below
the
poverty
level?
e)
What
is
the
total
tribal
income
for
the
applicant
tribe?
f)
What
are
the
tribe's
assets
as
disclosed
in
a
tribal
financial
statement?
g)
Provide
a
list
of
all
wholly
or
partially
owned
tribal
enterprises
or
affiliates
and
the
primary
industry
classification
of
each.
The
listing
should
include
the
members
of
the
tribe
who
manage
or
control
such
enterprises
by
serving
as
officers
or
directors.

2.
The
Indian
Tribe
must
also
submit
the
following
documentation
to
substantiate
a
claim
of
economic
disadvantage:

a)
A
copy
of
all
governing
documents
such
as
the
tribe's
constitution
or
business
charter.
b)
Evidence
of
its
recognition
as
a
tribe
eligible
for
the
special
programs
and
services
provided
by
the
United
States
or
by
its
state
of
residence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1f)
(
Tribally
Owned
Businesses)
3
SECTION
C
Ownership
Corporations
Only:

1.
Does
the
tribe
firm
own
at
least
51%
of
the
voting
stock?
____
Yes
____
No.
Please
provide
documentation
as
attachment
C­
1.

2.
Does
the
tribe
own
at
least
51%
of
the
aggregate
if
all
classes
of
stock?
___
Yes
___
No.
Please
provide
documentation
as
attachment
C­
2.

3.
If
more
than
one
class
of
stock,
provide
information
for
each
class:

Voting
Non­
Total
Voting
a)
Total
number
of
shares
authorized:
_____
______
______
b)
Total
number
of
shares
currently
outstanding:
_____
______
______

Non­
Corporate
Entities
Only:

4.
Does
the
tribe
own
at
least
51%
interest
in
the
firm?
___
Yes
___
No.
Please
provide
documentation
as
attachment
C­
3.

5.
If
more
than
one
class
membership
interest,
provide
information
for
each
class:

Voting
Non­
Total
Voting
a)
Total
number
of
memberships
authorized:
_____
______
_____
b)
Total
number
of
memberships
currently
outstanding:
_____
______
_____

For
Corporate
and
Non­
Corporate
Entities:

6.
Does
the
tribe
currently
own
51%
or
more
of
another
firm
under
the
same
primary
NAIC
code?
___
Yes
___
No.

7.
Within
the
last
two
years
has
the
tribe
owned
51%
or
more
of
another
firm
under
the
same
primary
NAIC
code
as
the
applicant?
___
Yes
___
No.

SECTION
D
Control
and
Management
1.
Are
the
management
and
daily
business
operations
of
the
tribe
controlled
by
the
tribe
through
one
or
more
disadvantaged
individual
members
who
possess
sufficient
management
experience
of
an
extent
and
complexity
to
run
the
concern?
___
Yes
___
No.
If
yes,
provide
documentation
to
verify
tribal
membership
and
management
competency
as
Attachment
D­
1.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1f)
(
Tribally
Owned
Businesses)
4
2.
Is
the
management
of
the
tribe
controlled
by
committees,
teams,
Boards
of
Directors,
or
one
or
more
members
of
an
economically
disadvantaged
tribe?
___
Yes
___
No.
Please
provide
documentation
as
attachment
D­
2.

Management
may
be
provided
by
non­
tribal
members
if
it
is
determined
that
such
management
is
required
to
assist
the
concern's
development,
provided
that
the
tribe
will
retain
control
of
all
management
decisions
common
to
Boards
of
Directors,
including
strategic
planning,
budget
approval
and
the
employment
and
compensation
of
officers.
However,
a
written
management
development
plan
must
exist
which
shows
how
disadvantaged
tribal
members
will
develop
managerial
skills
sufficient
to
manage
the
concern
or
similar
tribally­
owned
concerns
in
the
future.

3.
Are
members
of
the
management
team,
business
committee
members,
officers,
and
directors
engaged
in
any
outside
employment
or
other
business
interests
which
conflict
with
the
management
of
the
tribe?
___
Yes
___
No.

4.
List
the
titles
of
all
officers,
directors,
management
members,
partners
and
key
managers
and
the
hours
devoted,
by
such
individual(
s)
to
the
management
of
the
tribe.

Name
Title
Hours
____________________________
_______________________________
__________

____________________________
_______________________________
__________

____________________________
_______________________________
__________

____________________________
_______________________________
__________

5.
List
the
names
of
all
individuals
who
have
access
to
the
tribe's
bank
account.

Name
Title
___________________________
__________________________

__________________________
__________________________

__________________________
__________________________

__________________________
__________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1f)
(
Tribally
Owned
Businesses)
5
Each
person
signing
below:

1.
Certifies
that
the
information
provided
with
regard
to
the
applicant
firm's
social
and
economic
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

2.
Certifies
that
the
information
provided
with
regard
to
the
applicant
firm's
ownership
and
control
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
his/
her
individual
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

4.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate,
and
complete
to
the
best
of
his/
her
knowledge
and
belief.

5.
Acknowledges
that
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
state,
and
local
agencies
to
determine
violations
of
law.

6.
Acknowledges
that
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

Name
SSN
Date
________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1f)
(
Tribally
Owned
Businesses)
6
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1f)
(
Tribally
Owned
Businesses)
7
OMB
Control
No:
______
Approved:
______
Approval
Expires:
______

Environmental
Protection
Agency
EPA
DBE
Certification
Application
For
a
Minority
Business
Enterprise
(
MBE)/
Women­
owned
Business
Enterprise
(
WBE)
Under
EPA's
Disadvantaged
Business
Enterprise
(
DBE)
Program
For
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged
Name
of
Organization:_____________________________________________________________________

Applicant
concern
is:
Corporation
Limited
Liability
Company
Partnership
Name
of
President/
Managing
Member/
Managing
Partner_______________________________________

EIN:
_________________________
E­
mail
Address:
____________________________________________

Business
Address:_____________________________________________
County:_____________________

City:_________________________________
State:_______________
Zip
Code:______________________

Phone
Number:__________________________
Fax
Number:_____________________________________

Mailing
Address
(
if
different
than
above):_________________________
County:____________

City:_________________________________
State:_______________
Zip
Code:______________________

What
is
the
firm's
(
4­
digit)
primary
standard
industrial
classification
code?
_______________________

Is
the
firm
certified
by
the
Small
Business
Administration
under
its
8(
a)
Business
Development
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
number_____________________________________________

Is
the
firm
certified
by
the
Small
Business
Administration
under
its
Small
Disadvantaged
Business
(
SDB)
Program?
___
Yes
___
No.
If
yes,
provide
Pro­
Net
number_____________________________________

Is
the
firm
certified
as
a
DBE
by
a
Department
of
Transportation
recipient?
___
Yes
___
No.
If
yes,
provide
State(
s)
and
ID
number(
s)
___________________________________________________

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
Is
the
firm
certified
by
a
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
ID
number
and
a
contact
point
at
the
certifying
entity
____________________________________________________

Has
your
firm
ever
been
denied
certification
by
a
Federal
agency,
State
government,
local
government,
Indian
tribal
government,
or
independent
private
organization?
___
Yes
___
No.
If
yes,
provide
explanation/
documentation:________________________________________________________________

Does
the
firm
have
any
other
certification
as
a
disadvantaged
business
entity,
i.
e.,
MBE,
DBE,
WBE,
etc?
___
Yes
___
No.
If
yes,
provide
the
State(
s)
and
ID
number(
s)__________________________________

In
accordance
with
13
CFR
§
124.103,
designated
group
members
are
presumed
to
be
socially
disadvantaged.
Designated
group
members
are
individuals
who
hold
themselves
out
to
be
and
are
identified
by
others
as
Black
Americans,
Native
Americans
(
American
Indians,
Eskimos,
Aleuts,
or
Native
Hawaiians),
Hispanic
Americans,
Subcontinent
Asian
Americans,
Asian
Pacific
Americans,
and
any
other
groups
designated
by
the
Small
Business
Administration
(
SBA).
If
an
individual
is
claiming
to
be
a
member
of
a
designated
group,
complete
Section
A
of
this
application.
If
an
individual
is
not
claiming
to
be
a
member
of
a
designated
group,
complete
Section
B
of
this
application.
All
applicants
must
complete
Sections
C,
D,
and
E
of
this
application.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
2
SECTION
A
Eligibility
Statement
­
Designated
Group
Members
Social
Disadvantage
1.
List
all
individuals
claiming
disadvantaged
status:

Name
of
Individual
Other
last
U.
S.
Citizen
Place
of
Group
Sex
Names
Used
Y/
N
Birth
Membership
M/
F
___________________
___________
________
___________
_______
_____

___________________
___________
________
___________
_______
_____

___________________
___________
________
___________
_______
_____

___________________
___________
________
___________
_______
_____

SECTION
B
Eligibility
Statement
­
Non
Designated
Group
Members
1.
List
all
individuals
claiming
disadvantaged
status:

Name
of
Individual
U.
S.
Citizen
Race
Sex
Y/
N
M/
F
_______________________________
________
________
_____

_______________________________
________
________
_____

_______________________________
________
________
_____

For
this
section,
any
individual
claiming
social
disadvantage
must
provide
a
separate
response
for
questions
3
and
4.

Social
Disadvantage
2.
I,
____________________________________
have
personally
suffered
social
disadvantage
based
on
my
identification
as
__________________________________.
(
A
claim
of
social
disadvantage
must
include
at
least
one
objective
feature
that
has
contributed
to
social
disadvantage,
such
as
race,
ethnic
origin,
gender,
physical
handicap,
long­
term
residence
in
an
environment
isolated
from
the
mainstream
of
American
society,
or
other
similar
causes
not
common
to
individuals
who
are
not
socially
disadvantaged.)

3.
Document
how
your
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
by
such
things
as
inability
to
obtain
adequate
bonding,
credit
or
financing;
inability
to
obtain
licenses
or
leases;
restriction
of
your
market
to
certain
racial,
ethnic,
or
social
groups;
underemployment
or
unemployment,
etc.,
as
compared
to
others
in
the
same
or
similar
line
of
business
who
are
not
socially
disadvantaged.
Mark
as
Attachment
B­
1.

4.
Attach
a
narrative
describing
how
you
personally
experienced
social
disadvantage
in
American
society.
When
writing
your
narrative,
be
as
specific
and
detailed
as
possible.
Where
EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
3
applicable,
each
statement
of
alleged
discrimination
should
be
supported
by
documented
evidence
such
as
affidavits,
denials
of
loan
applications,
denials
of
employment
opportunities
(
including
non­
selection
for
particular
jobs,
denials
of
promotions,
or
unequal
work
environment
or
treatment),
and
documents
to
support
any
formal
action
taken
by
you
because
of
alleged
discrimination.
You
must
demonstrate
how
your
identification,
as
described
in
the
paragraph
above,
has
negatively
impacted
your
entry
into
or
advancement
in
business.
You
must
address
disadvantage
in
education,
employment,
and
business
history,
where
applicable.
Examples
of
discrimination
include,
but
are
not
limited
to:
unequal
access
to
colleges
or
professional
schools;
exclusion
from
professional
or
business
associations;
being
denied
educational
honors
or
recognition;
experiencing
discriminatory
social
pressure
which
discouraged
you
from
pursuing
a
professional
or
higher
education
or
forced
you
into
non­
professional
or
non­
business
fields;
discrimination
in
employment
opportunities
or
pay
and
fringe
benefits;
unequal
access
to
business
credit
or
capital;
and
discrimination
in
the
awarding,
bidding
process,
or
negotiating
of
government
or
private
sector
contracts.
Mark
as
Attachment
B­
2.

SECTION
C
(
All
applicant
firms
must
complete)

Economic
Disadvantage
1.
Is
the
net
worth
of
all
individual(
s)
claiming
disadvantaged
status
less
than
$
750,000,
excluding
ownership
interest
in
the
applicant
firm
and
equity
in
the
individual(
s)
primary
residence?
____
Yes
No
____.

2.
For
individual(
s)
claiming
disadvantaged
status,
list
your
personal
net
worth,
excluding
the
ownership
interest
in
the
applicant
firm
and
the
equity
in
the
individual(
s)
primary
residence.

Name
Average
2­
year
Personal
Total
Income
Net
Worth
Assets
________________________________
______________
__________
__________

________________________________
______________
__________
__________

________________________________
______________
__________
__________

________________________________
______________
__________
__________

3.
Each
individual
listed
in
number
2
above
certifies
that,
because
of
racial
and/
or
ethnic
prejudice,
and/
or
cultural
bias,
his/
her
ability
to
compete
in
the
free
enterprise
system
has
been
impaired
due
to
diminished
capital
and
credit
opportunities
as
compared
to
others
in
the
same
or
similar
line
of
business
that
are
not
socially
disadvantaged.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
4
SECTION
D
(
All
applicant
firms
must
complete)

Ownership
Corporation:

1.
If
more
than
one
class
of
stock,
provide
information
for
each
class:
Voting
Non
Total
Voting
a)
Total
number
of
shares
authorized:
_____
______
_____
b)
Total
number
of
shares
currently
outstanding:
_____
______
_____

Limited
Liability
Company:

2.
If
more
than
one
class
membership
interest,
provide
information
for
each
class:
Voting
Non
Total
Voting
a)
Total
number
of
memberships
authorized:
_____
______
_____
b)
Total
number
of
memberships
currently
outstanding:
_____
______
_____

Partnership:

3.
Provide
the
name,
title,
and
percentage
of
ownership
for
each
partner
of
the
firm.
Does
the
partnership
agreement
reflect
the
ownership
of
each
partner?
___
Yes
___
No.

Name
Title
Ownership
Percentage
___________________________
____________________
____________________

___________________________
____________________
____________________

___________________________
____________________
____________________

Questions
4
through
8
are
for
Corporations
&
LLCs
ONLY:

4.
List
all
entities,
individuals,
and/
or
trusts
which
have
an
ownership
interest
in
the
applicant
firm.

Name
Title
Ownership
%
Voting
NonVoting
Total
___________________________
____________________
______
_________
_____

___________________________
____________________
______
_________
_____

___________________________
____________________
______
_________
_____

5.
Does
the
private
or
voluntary
organization
or
its
wholly­
owned
subsidiary
receive
at
least
51%
of
the
annual
distributions
of
dividends
paid
on
the
stock
of
a
corporate
applicant
firm?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
D­
1.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
5
6.
Will
the
private
or
voluntary
organization
or
its
wholly­
owned
subsidiary
receive
100%
of
the
unencumbered
value
of
each
share
of
stock
owned
in
the
event
that
the
stock
is
sold?
___
Yes
____
No.
If
no,
please
explain
as
Attachment
D­
2.

7.
If
the
private
or
voluntary
organization
dissolves,
will
the
private
or
voluntary
organization
or
its
wholly­
owned
subsidiary
receive
at
least
51%
of
the
retained
earnings
and
100%
of
the
unencumbered
value
of
each
share
of
stock
owned?
___
Yes
___
No.
If
no,
please
explain
as
Attachment
D­
3.

8.
Is
ownership
by
the
private
or
voluntary
organization
or
its
wholly­
owned
subsidiary
subject
to
conditions
precedent,
conditions
subsequent,
executory
agreements,
voting
trusts,
shareholder
agreements,
or
other
similar
arrangements
which
may
impact
the
unconditional
ownership
of
the
private
or
voluntary
organization?
___
Yes
___
No.
If
yes,
explain
as
Attachment
D­
4.

Corporations,
LLCs
&
Partnerships:

9.
Have
there
been
any
changes
in
ownership
in
the
last
year?
___
Yes
___
No.
If
yes,
did
ownership
affect
the
disadvantaged
status
of
your
firm?
Please
explain
as
Attachment
D­
5.

SECTION
E
(
All
applicant
firms
must
complete)

Control
Corporations
Only:

1.
The
private
or
voluntary
organization
controls
the
board
of
directors
by
virtue
of
the
fact
that:
(
select
only
one
below)

___
a)
The
private
or
voluntary
organization
owns
at
least
100%
of
all
the
voting
stock
of
the
applicant
concern.

___
b)
The
private
or
voluntary
organization
owns
at
least
51%
of
all
voting
stock,
is
on
the
Board
of
Directors,
and
no
super
majority
voting
requirements
exist
for
shareholders
to
approve
corporate
actions.

___
c)
The
private
or
voluntary
organization
owns
at
least
51%
of
all
voting
stock,
is
on
the
Board
of
Directors,
and
owns
at
least
the
percentage
of
voting
stock
needed
to
overcome
the
super
majority
voting
requirements
which
exist
for
shareholders
to
approve
corporate
actions.

___
d)
The
private
or
voluntary
organization
controls
the
Board
of
Directors
through
actual
numbers
of
voting
directors.

___
e)
The
private
or
voluntary
organization
controls
the
Board
of
Directors
through
weighted
voting
and
such
voting
is
permitted
by
applicable
state
law.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
6
Partnerships
Only:

2.
Are
partnership
decisions
determined
by
general
partners?
If
no,
explain
as
Attachment
E­
1.

Corporations,
LLCs
&
Partnerships:

3.
List
the
titles
of
all
officers,
directors,
management
members,
partners
and
key
managers
and
the
hours
devoted,
by
such
individual(
s)
to
the
management
of
the
applicant
firm.

Name
Title
Hours
____________________________
_______________________________
__________

____________________________
_______________________________
__________

____________________________
_______________________________
__________

____________________________
_______________________________
__________

4.
Are
the
CEO,
President,
Managing
Member,
Managing
Partner,
members
of
the
management
team,
business
committee
members,
officers
or
directors
engaged
in
or
plan
to
engage
in
outside
employment?
___
Yes
___
No.
If
yes,
provide
details
as
to
the
extent
of
outside
employment
or
other
business
dealings
to
include
daily
hours
of
employment,
location
and
explanation
as
to
how
this
outside
employment
does
not
conflict
with
the
ability
to
manage
and
control
the
daily
operations
of
the
application
concern.
Provide
as
Attachment
E­
2.

5.
List
the
names
of
all
individuals
who
have
access
to
the
firm's
bank
account.

Name
Title
_______________________________
_______________________________

_______________________________
_______________________________

_______________________________
_______________________________

_______________________________
_______________________________

6.
Are
the
management
and
daily
business
operations
of
the
concern
controlled
by
the
private
or
voluntary
organization
through
one
or
more
disadvantaged
individual
members
who
possess
sufficient
management
experience
of
an
extent
and
complexity
to
run
the
concern?
___
Yes
___
No.
If
yes,
provide
documentation
to
verify
management
competency
as
Attachment
E­
3.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
7
Each
person
signing
below:

1.
Certifies
that
the
information
provided
with
regard
to
my
social
and
economic
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
my
knowledge
and
belief.

2.
Certifies
that
the
information
provided
with
regard
to
my
ownership
and
control
status
is
true,
accurate,
and
complete
to
the
best
of
my
knowledge
and
belief.

3.
Certifies
that
the
information
provided
with
regard
to
my
individual
disadvantaged
status
is
true,
accurate,
and
complete
to
the
best
of
my
knowledge
and
belief.

4.
Certifies
that
the
information
provided,
including
that
shown
on
documents
accompanying
this
application,
is
true,
accurate
and
complete
to
the
best
of
my
knowledge
and
belief.

5.
Acknowledges
that
EPA,
at
its
discretion,
may
give
the
information
submitted
to
Federal,
state,
and
local
agencies
for
determining
violations
of
law.

6.
Acknowledges
that
EPA's
approval
of
an
application
does
not
affect
the
Government's
right
to
pursue
criminal
prosecution
for
incorrect
or
incomplete
information
given
on
the
application
form,
even
if
correct
information
has
been
included
in
other
materials
submitted
to
EPA.

Name
SSN
Date
________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

________________________
_______________________
______________________

The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
three
(
3)
hours.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
8
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.

EPA
DBE
Certification
Application
(
EPA
Form
6100­
1g)
(
Private
and
Voluntary
Organizations
Controlled
by
Individuals
who
are
Socially
and
Economically
Disadvantaged)
9
Disadvantaged
Business
Enterprise
Program
DBE
Subcontractor
Participation
Form
Environmental
Protection
Agency
OMB
Control
No:
________
Approved:
________
Approval
Expires:
________

1Subcontractor
is
defined
as
a
company,
firm,
joint
venture,
or
individual
who
enters
into
an
agreement
with
a
contractor
to
provide
services
pursuant
to
an
EPA
award
of
financial
assistance.

EPA
FORM
6100­
2
(
DBE
Subcontractor
Participation
Form)
NAME
OF
SUBCONTRACTOR1
PROJECT
NAME
ADDRESS
CONTRACT
NO.

TELEPHONE
NO.
E­
MAIL
ADDRESS
PRIME
CONTRACTOR
NAME
Please
use
the
space
below
to
report
any
concerns
regarding
the
above
EPA­
funded
project
(
e.
g.,
reason
for
termination
by
prime
contractor,
late
payment,
etc.).
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

CONTRACT
ITEM
NO.
ITEM
OF
WORK
OR
DESCRIPTION
OF
SERVICES
RECEIVED
FROM
THE
PRIME
CONTRACTOR
AMOUNT
SUBCONTRACTOR
WAS
PAID
BY
PRIME
CONTRACTOR
_________________________________
______________________________________
Subcontractor
Signature
Title/
Date
Disadvantaged
Business
Enterprise
Program
DBE
Subcontractor
Participation
Form
Environmental
Protection
Agency
OMB
Control
No:
________
Approved:
________
Approval
Expires:
________

EPA
FORM
6100­
2
(
DBE
Subcontractor
Participation
Form)
The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
fifteen
(
15)
minutes.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001
,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.
Disadvantaged
Business
Enterprise
Program
DBE
Subcontractor
Performance
Form
Environmental
Protection
Agency
OMB
Control
No:
_________
Approved:
_________
Approval
Expires:
_________

1Subcontractor
is
defined
as
a
company,
firm,
joint
venture,
or
individual
who
enters
into
an
agreement
with
a
contractor
to
provide
services
pursuant
to
an
EPA
award
of
financial
assistance.

EPA
FORM
6100­
3
(
DBE
Subcontractor
Performance
Form)
NAME
OF
SUBCONTRACTOR1
PROJECT
NAME
ADDRESS
BID/
PROPOSAL
NO.

TELEPHONE
NO.
E­
MAIL
ADDRESS
PRIME
CONTRACTOR
NAME
CONTRACT
ITEM
NO.
ITEM
OF
WORK
OR
DESCRIPTION
OF
SERVICES
BID
TO
PRIME
PRICE
OF
WORK
SUBMITTED
TO
PRIME
CONTRACTOR
Currently
certified
as
an
MBE
or
WBE
under
EPA's
DBE
Program?
______
Yes
______
No
Signature
of
Prime
Contractor
Date
Print
Name
Title
___________________________________________
__________________________________________

Signature
of
Subcontractor
Date
___________________________________________
__________________________________________
Print
Name
Title
Disadvantaged
Business
Enterprise
Program
DBE
Subcontractor
Performance
Form
Environmental
Protection
Agency
OMB
Control
No:
_________
Approved:
_________
Approval
Expires:
_________

EPA
FORM
6100­
3
(
DBE
Subcontractor
Performance
Form)
The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
fifteen
(
15)
minutes.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001
,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.
Disadvantaged
Business
Enterprise
Program
DBE
Subcontractor
Utilization
Form
OMB
Control
No:
_________
Approved:
_________
Approval
Expires:
_________

Environmental
Protection
Agency
1Subcontractor
is
defined
as
a
company,
firm,
joint
venture,
or
individual
who
enters
into
an
agreement
with
a
contractor
to
provide
services
pursuant
to
an
EPA
award
of
financial
assistance.

EPA
FORM
6100­
4
(
DBE
Subcontractor
Utilization
Form)
BID/
PROPOSAL
NO.
PROJECT
NAME
NAME
OF
PRIME
BIDDER/
PROPOSER
E­
MAIL
ADDRESS
ADDRESS
TELEPHONE
NO.
FAX
NO.

The
following
subcontractors1
will
be
used
on
this
project:

COMPANY
NAME,
ADDRESS,
PHONE
NUMBER,
AND
E­
MAIL
ADDRESS
TYPE
OF
WORK
TO
BE
PERFORMED
ESTIMATED
DOLLAR
AMOUNT
CURRENTLY
CERTIFIED
AS
AN
MBE
OR
WBE?

I
certify
under
penalty
of
perjury
that
the
forgoing
statements
are
true
and
correct.
In
the
event
of
a
replacement
of
a
subcontractor,
I
will
adhere
to
the
replacement
requirements
set
forth
in
40
CFR
Part
33
Section
33.302(
c).

Signature
Of
Prime
Contractor
Date
Print
Name
Title
Disadvantaged
Business
Enterprise
Program
DBE
Subcontractor
Utilization
Form
OMB
Control
No:
_________
Approved:
_________
Approval
Expires:
_________

Environmental
Protection
Agency
EPA
FORM
6100­
4
(
DBE
Subcontractor
Utilization
Form)
The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
fifteen
(
15)
minutes.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OA­
2002­
0001
,
which
is
available
for
public
viewing
at
the
OEI
Docket
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OEI
Docket
is
(
202)
566­
1752).
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OA­
2002­
0001)
in
any
correspondence.
