OMB
CONTROL
NO.
2090­
0025
APPROVED:
07/
31/
06
APPROVAL
EXPIRES:
07/
31/
09
U.
S.
ENVIRONMENTAL
PROTECTION
AGENCY
MBE/
WBE
UTILIZATION
UNDER
FEDERAL
GRANTS,
COOPERATIVE
AGREEMENTS,
AND
INTERAGENCY
AGREEMENTS
PART
1.
(
Reports
are
required
even
if
no
procurements
are
made
during
the
reporting
period.)

1A.
FEDERAL
FISCAL
YEAR
200_______
1B.
REPORTING
PERIOD
(
Check
ALL
appropriate
boxes)

9
1
st
(
Oct­
Dec)
9
2
nd
(
Jan­
Mar)
9
3
rd
(
Apr­
Jun)
9
4
th
(
Jul­
Sep)
9
Annual
9
Check
if
this
is
the
last
report
for
the
project
(
Project
completed).

1C.
REVISION
OF
A
PRIOR
REPORT?
Y
or
N
Year:
_________
Quarter:
_________
BRIEFLY
DESCRIBE
THE
REVISIONS
YOU
ARE
MAKING:

2A.
EPA
FINANCIAL
ASSISTANCE
OFFICE
ADDRESS
(
ATTN:
DBE
Coordinator)
3A.
RECIPIENT
NAME
AND
ADDRESS
2B.
EPA
DBE
COORDINATOR
Name:

E­
mail:
2C.
PHONE:

Fax:
3B.
RECIPIENT
REPORTING
CONTACT:

Name:

E­
mail:
3C.
PHONE:

Fax:

4A.
FINANCIAL
ASSISTANCE
AGREEMENT
ID
NUMBER
(
SRF
State
Recipients,
refer
to
Instructions
for
Completion
of
blocks
4A,
5A
and
5C.)
4B.
FEDERAL
FINANCIAL
ASSISTANCE
PROGRAM
TITLE
or
CFDA
NUMBER:

5A.
TOTAL
ASSISTANCE
AGREEMENT
AMOUNT
(
SRF
State
Recipients,
refer
to
Instructions
for
Completion
of
blocks
4A,
5A
and
5C.)

EPA
Share:
$_______________________

Recipient
Share:
$_____________________
5B.
If
NO
procurement
and
NO
accomplishments
were
made
this
reporting
period,
check
and
skip
to
Block
No.
7.
(
Procurements
are
all
expenditures
through
contract,
order,
purchase,
lease
or
barter
of
supplies,
equipment,
construction,
or
services
needed
to
complete
Federal
assistance
programs.
Accomplishments,
in
this
context,
are
procurements
made
with
MBEs
and/
or
WBEs.

9
5C.
Total
Procurement
and
MBE/
WBE
Accomplishments
This
Reporting
Period
(
Only
include
amount
not
reported
in
any
prior
reporting
period)

Were
sub­
awards
issued
under
this
assistance
agreement?
Yes___
_
No____
Were
contracts
issued
under
this
assistance
agreement
?
Yes____
No____

Total
Procurement
Amount
$________________________
(
Include
total
dollar
values
awarded
by
recipient,
sub­
recipients
and
SRF
loan
recipients.)

Actual
MBE/
WBE
Procurement
Accomplished:
(
Include
total
dollar
values
awarded
by
recipient,
sub­
recipients,
SRF
loan
recipients
and
Prime
Contractors.)

Construction
Equipment
Services
Supplies
Total
$
MBE:
____________
_____________
_____________
_____________
________________

$
WBE:
____________
______________
______________
_____________
________________

6.
COMMENTS:
(
If
no
MBE/
WBE
procurements
were
accomplished
during
the
reporting
period,
please
explain
what
steps
you
are
taking
to
achieve
the
MBE/
WBE
Program
requirements
specified
in
the
terms
and
conditions
of
the
Assistance
Agreement.)

7.
NAME
OF
RECIPIENT'S
AUTHORIZED
REPRESENTATIVE
TITLE
8.
SIGNATURE
OF
RECIPIENT'S
AUTHORIZED
REPRESENTATIVE
DATE
EPA
FORM
5700­
52A
available
electronically
at
http://
www.
epa.
gov/
osdbu/
5700_
52a.
pdf
MBE/
WBE
PROCUREMENTS
MADE
DURING
REPORTING
PERIOD
EPA
Financial
Assistance
Agreement
Number:
_______________

Type
of
product
or
service
codes:

1
=
Construction
2
=
Supplies
3
=
Services
4
=
Equipment
Note:
Refer
to
Terms
and
conditions
of
your
Assistance
Agreement
to
determine
the
frequency
of
reporting.
Recipients
are
required
to
submit
MBE/
WBE
reports
to
EPA
beginning
with
the
Federal
fiscal
year
quarter
the
recipients
receive
the
award,
continuing
until
the
project
is
completed.

EPA
FORM
5700­
52A
­
(
Approval
Expires
07/
31/
09
1.
Procurement
Made
By
2.
Business
Enterprise
Recipient
Sub­
Recipient
and/
or
SRF
Loan
Recipient
Prime
Minority
Women
3.
$
Value
of
Procurement
4.
Date
of
Award
MM/
DD/
YY
5.
Type
of
Product
or
ServicesA
(
Enter
Code)
6.
Name/
Address/
Phone
Number
of
MBE/
WBE
Contractor
or
Vendor
Instructions:

A.
General
Instructions:

MBE/
WBE
utilization
is
based
on
Executive
Orders
11625,
12138,
12432,
P.
L.
102­
389
and
EPA
Regulations
Part
30
and
31.
EPA
Form
5700­
52A
must
be
completed
by
recipients
of
Federal
grants,
cooperative
agreements,
or
other
Federal
financial
assistance
which
involve
procurement
of
supplies,
equipment,
construction
or
services
to
accomplish
Federal
assistance
programs.

Recipients
are
required
to
report
30
days
after
the
end
of
each
federal
fiscal
quarter
or
annually,
per
the
terms
and
conditions
of
the
financial
assistance
agreement.
Submission
dates
are
January
30,
April
30,
July
30,
and
October
30.
The
submission
date
for
annual
reports
is
October
30.
MBE/
WBE
program
requirements,
including
reporting,
are
material
terms
and
conditions
of
the
financial
assistance
agreement.

B.
Definitions:

Procurement
is
the
acquisition
through
contract,
order,
purchase,
lease
or
barter
of
supplies,
equipment,
construction
or
services
needed
to
accomplish
Federal
assistance
programs.

A
contract
is
a
written
agreement
between
an
EPA
recipient
and
another
party
(
also
considered
"
prime
contracts")
and
any
lower
tier
agreement
(
also
considered
"
subcontracts")
for
equipment,
services,
supplies,
or
construction
necessary
to
complete
the
project.
This
definition
excludes
written
agreements
with
another
public
agency.
This
definition
includes
personal
and
professional
services,
agreements
with
consultants,
and
purchase
orders.

A
minority
business
enterprise
(
MBE)
is
a
business
concern
that
is
(
1)
at
least
51
percent
owned
by
one
or
more
minority
individuals,
or,
in
the
case
of
a
publicly
owned
business,
at
least
51
percent
of
the
stock
is
owned
by
one
or
more
minority
individuals;
and
(
2)
whose
daily
business
operations
are
managed
and
directed
by
one
or
more
of
the
minority
owners.

U.
S.
citizenship
is
required.
Recipients
shall
presume
that
minority
individuals
include
Black
Americans,
Hispanic
Americans,
Native
Americans,
Asian
Pacific
Americans,
or
other
groups
whose
members
are
found
to
be
disadvantaged
by
the
Small
Business
Act
or
by
the
Secretary
of
Commerce
under
section
5
of
Executive
order
11625.
The
reporting
contact
at
EPA
can
provide
additional
information.

A
woman
business
enterprise
(
WBE)
is
a
business
concern
that
is,
(
1)
at
least
51
percent
owned
by
one
or
more
women,
or,
in
the
case
of
a
publicly
owned
business,
at
least
51
percent
of
the
stock
is
owned
by
one
or
more
women
and
(
2)
whose
daily
business
operations
are
managed
and
directed
by
one
or
more
of
the
women
owners.

Business
firms
which
are
51
percent
owned
by
minorities
or
women,
but
are
in
fact
managed
and
operated
by
nonminority
individuals
do
not
qualify
for
meeting
MBE/
WBE
procurement
goals.
U.
S.
Citizenship
is
required.

The
following
affirmative
steps
for
utilizing
MBEs
and
WBEs
must
be
documented.
Such
documentation
is
subject
to
EPA
review
upon
request:

1.
Include
of
MBEs/
WBEs
on
solicitation
lists.

2.
Assure
that
MBEs/
WBEs
are
solicited
once
they
are
identified.

3.
Divide
total
requirements
into
smaller
tasks
to
permit
maximum
MBE/
WBE
participation,
where
feasible.

4.
Establish
delivery
schedules
which
will
encourage
MBE/
WBE
participation,
where
feasible.

5.
Encourage
use
of
the
services
of
the
U.
S.
Department
of
Commerce's
Minority
Business
Development
Agency
(
MBDA)
and
the
U.
S.
Small
Business
Administration
to
identify
MBEs/
WBEs.

6.
Require
that
each
party
to
a
subgrant,
subagreement,
or
contract
award
take
the
affirmative
steps
outlined
here.

C.
Instructions
for
Part
I:

1a.
Specify
Federal
fiscal
year
this
report
covers.
The
Federal
fiscal
year
runs
from
October
1st
through
September
30th
(
e.
g.
November
29,
2005
falls
within
Federal
fiscal
year
2006)

1b.
Check
applicable
reporting
box,
quarterly
or
annually.
Also
indicate
if
this
is
the
last
report
for
the
project.

1c.
Indicate
if
this
is
a
revision
to
a
previous
year
or
quarter,
and
provide
a
brief
description
of
the
revision
you
are
making.

2a­
c.
Please
refer
to
your
financial
assistance
agreement
for
the
mailing
address
of
the
EPA
financial
assistance
office
for
your
agreement.
The
"
EPA
DBE
Reporting
Contact"
is
the
DBE
Coordinator
for
the
EPA
Region
from
which
your
financial
assistance
agreement
was
originated.
For
a
list
of
DBE
Coordinators
please
refer
to
the
EPA
OSDBU
website
at
www.
epa.
gov/
osdbu.
Click
on
"
Regional
Contacts"
for
the
name
of
your
coordinator.

3a­
c.
Identify
the
agency,
state
authority,
university
or
other
organization
which
is
the
recipient
of
the
Federal
financial
assistance
and
the
person
to
contact
concerning
this
report.

4a.
Provide
the
Assistance
Agreement
or
Interagency
Agreement
number
assigned
by
EPA.
A
separate
report
must
be
submitted
for
each
Assistance
Agreement
or
Interagency
Agreement.

*
For
SRF
recipients:
In
box
4a
list
numbers
for
ALL
open
Assistance
Agreements.
SRF
recipients
will
report
activity
for
all
Agreements
on
one
form.

4b.
Refer
back
to
Assistance
Agreement
document
for
this
information.

5a.
Provide
the
total
amount
of
the
Assistance
Agreement
which
includes
Federal
funds
plus
recipient
matching
funds
and
funds
from
other
sources.

*
For
SRF
recipients
only:
SRF
recipients
will
not
enter
an
amount
in
5a.
Please
leave
5a
blank.

5b.
Self­
explanatory.

5c.
State
whether
or
not
sub­
awards
and/
or
subcontracts
have
been
issued
under
the
assistance
agreement
by
indicating
"
yes"
or
"
no".

Provide
the
total
dollar
amount
of
all
contracts/
procurements
awarded
this
reporting
period
by
the
recipient
and
all
sub­
recipients,
and
SRF
loan
recipients.
For
example:
Actual
dollars
for
procurement
from
the
procuring
office;
actual
contracts
let
from
the
contracts
office;
actual
goods,
services,
supplies,
etc.,
from
other
sources
including
the
central
purchasing/
procurement
centers).

Where
requested,
also
provide
the
total
dollar
amount
of
all
MBE/
WBE
procurement
awarded
during
this
reporting
period
by
the
recipient,
subrecipients
SRF
loan
recipients,
and
prime
contractors
in
the
categories
of
construction,
equipment,
services
and
supplies.
These
amounts
include
the
Federal,
State
and
local
shares
in
the
procurement
awards.
*
For
SRF
recipients
only:
In
5c
please
enter
the
total
procurement
amount
for
the
quarter
under
all
of
your
SRF
Assistance
Agreements.
The
figure
reported
in
this
section
is
not
directly
tied
to
an
individual
Assistance
Agreement
identification
number.
(
SRF
state
recipients
report
state
procurements
in
this
section)

6.
If
there
were
no
MBE/
WBE
accomplishments
this
reporting
period,
please
briefly
explain
what
steps
you
are
taking
in
furtherance
of
the
MBE/
WBE
requirements
specified
in
the
terms
and
conditions
of
the
Assistance
Agreement.

7.
Name
and
title
of
official
administrator
or
designated
reporting
official.

8.
Signature
and
month,
day
year
report
submitted.

D.
Instructions
for
Part
II:

For
each
MBE/
WBE
procurement
made
under
this
assistance
agreement
during
the
reporting
period,
provide
the
following
information:

1.
Check
whether
this
procurement
was
made
by
the
recipient,
sub­
recipient/
SRF
loan
recipient,
or
the
prime
contractor.

2.
Check
either
the
MBE
or
WBE
column.
If
a
firm
is
both
an
MBE
and
WBE,
the
recipient
may
choose
to
count
the
entire
procurement
towards
EITHER
its
MBE
or
WBE
accomplishments.
The
recipient
may
also
divide
the
total
amount
of
the
procurement
(
using
any
ratio
it
so
chooses)
and
count
those
divided
amounts
toward
its
MBE
and
WBE
accomplishments.
If
the
recipient
chooses
to
divide
the
procurement
amount
and
count
portions
toward
its
MBE
and
WBE
accomplishments,
please
state
the
appropriate
amounts
under
the
MBE
and
WBE
columns
on
the
form.
The
combined
MBE
and
WBE
amounts
for
that
MBE/
WBE
contractor
must
not
exceed
the
"
Value
of
the
Procurement"
reported
in
column
#
3
3.
Dollar
value
of
procurement.

4.
Date
of
award,
shown
as
month,
day,
year.
Date
of
award
is
defined
as
the
date
the
contract
or
procurement
was
awarded,
not
the
date
the
contractor
received
payment
under
the
awarded
contract
or
procurement,
unless
payment
occurred
on
the
date
of
award.
(
Where
direct
purchasing
is
the
procurement
method,
the
date
of
award
is
the
date
the
purchase
was
made)

5.
Using
codes
at
the
bottom
of
the
form,
identify
type
of
product
or
service
acquired
through
this
procurement
(
eg.,
enter
1
if
construction,
2
if
supplies,
etc).

6.
Name,
address,
and
telephone
number
of
MBE/
WBE
firm.

**
This
data
is
requested
to
comply
with
provisions
mandated
by:
statute
or
regulations
(
40
CFR
Part
30
and
31);
OMB
Circulars;
or
added
by
EPA
to
ensure
sound
and
effective
assistance
management.
Accurate,
complete
data
are
required
to
obtain
funding,
while
no
pledge
of
confidentiality
is
provided.

The
public
reporting
and
recording
burden
for
this
collection
of
information
is
estimated
to
average
l
hour
per
response
annually.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclosure
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.

Send
comments
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
through
the
use
of
automated
collection
techniques
to
the
Director,
OPPE
Regulatory
Information
Division,
U.
S.
Environmental
Protection
Agency
(
2136),
1200
Pennsylvania
Avenue,
NW,
Washington,
D.
C.
20460.
Include
the
OMB
Control
number
in
any
correspondence.
Do
not
send
the
completed
form
to
this
address.
