                                                                EPA FORM 6100-3
                           EPA Disadvantaged Business Enterprise (DBE) Program 
                                             DBE Subcontractor Performance Form

This form is intended to capture the DBE[1] subcontractor's[2] description of work to be performed and the price of the work submitted to the prime contractor.  An EPA Financial Assistance Agreement Recipient must require its prime contractor to have its DBE subcontractors complete this form and include all completed forms in the prime contractors bid or proposal package. 

Subcontractor Name

Project Name
Bid/ Proposal No.
Assistance Agreement ID No. (if known)
Point of Contact

Address

Telephone No.

Email Address
Prime Contractor Name
Issuing/Funding Entity:


                             Contract Item Number
Description of  Work Submitted to the Prime Contractor  Involving Construction,  Services , Equipment or Supplies
                Price of Work Submitted to the Prime Contractor














DBE Certified By: ____DOT              ____SBA     
____Other: ______________________       ____Not certified
Meets/ exceeds EPA certification standards?  
____ YES   ____ NO  ____ Unknown

I certify under penalty of perjury that the forgoing statements are true and correct.  Signing this form does not signify a commitment to utilize the subcontractors above.  I am aware of that  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).  

                          Prime Contractor Signature
                                  Title/ date


                            Subcontractor Signature
                                  Title/ date


      
