OMB Control No: 2090-0030 

Environmental Protection Agency Approval Expires: XX/XX/XX

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) 

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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) 

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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) 

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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) 

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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 1 

hour per response. 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, Collection Strategies Division, U.S. 

Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. 

Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA DBE Certification Application (EPA Form 6100-1b) 

(Limited Liability Company) 

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