OMB Control No: 2090-0030 Approval Expires: XX/XX/XX 

### Environmental Protection Agency
EPA DBE Certification Application For a Minority Business Enterprise (MBE) /Women-owned Busin ess Enterprise (WBE) Under EPA’s Disadvantaged Busi ness Enterprise (DBE) Program **For Limited Liability Company Business Profile**  **:** Name of app licant firm:___________________________________________________________________ Name of Managing Me mbers 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 Amer ican Industrial Classification (NAI C) 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 docu mentation substantiating such disability. Is your firm at least 51% owned by a Disabled American? ___ Yes ___ No. Is your firm certified by the Small Business Ad ministration under its 8(a) Business Development Program? ___ Yes ___ No. If yes, provide PRO-Net number: ___________________________________ Is your firm certified by the Small Business Admini stration under its Small Disadvantaged Business (SDB) Program? ___ Yes ___ No. If ye s, provide PRO- Net number: _________________________________ Is your firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide State(s) an d ID numb er(s): ____________________________________________________________ Is your firm certified by a State government, local governme nt, 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 gove rnment, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide a copy of the prior determination of attemp ts 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, desi g** **nated g**  **roup 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 Am**  **ericans, Asian Pacific Americans, and any other groups designated by the Small Business Administration (SBA). If an individual is claimin**  **g to be a**  **member of a desi g** **nated g**  **roup, complete Section A of this application. If an individual is not claimin g**  **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) 

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# SECTION A **Eligibility Statement - De signated Group Members**  **Social Disadvantage** 1. Li st all individuals claiming disadvantaged status : Nam e 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 intere st 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, pl ease 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 intere st unconditionally owned by one or more disadvantaged individual? ___ Yes ___ No
.

EPA DBE Certification Application (EPA Form 6100-1b) (Limited Liability Company) 

### 32. 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, plea se 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 di sadvantage must provide**  **a separate response for questions 3 through 5.**  

### Social Disadvantage 3. I, ____________________________________ have personally suffered soci al 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 ra ce, ethnic origin, gender, physical handicap, long-term re**  **sidence in an environment isolated from the mainstream of American society, or other similar causes no**  **t common to individuals who are not socially disadvantage**  **d.)** 4. Document how your ability to compete in the fr ee enterprise system has been impaired by such things as inability to obtain adequate bonding, cr edit or financing; inability to obta in licenses or leases; restriction of your market to certain racial, ethnic or social groups; underemployment or unemployment, etc., as compared toothers in the same or similar line of business who are not socia lly disadvantaged. Provide as AttachmentB-2.
5. **Attach a narrative describing how you personally experienced social disadvantage in Amer ican**  **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 docume nts to support any formal action taken by you because of alleged discrimination. You must demonstrate how your identification, as described in the para graph above, has negative ly 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 busine ss 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) 

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# 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 a pplicant firm and equity in the in dividual(s) primary residenc e? ____ Yes ____ No
. 2. For individuals claiming disadvantaged status, list your personal net worth, exclud ing the ownership interest in the applic ant firm and the equityin the individual(s) primary reside nce.
Name Average 2-year Personal Total Income N et Worth Assets

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________ 3. Each individual listed in number 2 above, certifies that because of racial and/or ethnic prejudic e, and/or cultural bias, his/her ability to compete in the free enterprise syst em has been impaired due to diminished capital and cred it 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 eachclass: V oting Non- Total Voting a) Total number of interests authoriz ed:
_____ ______ _____ 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) 

### 53. 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 individu als receive at least 51% of the retained ea rnings 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, di d 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, pl ease complete the chart below, and provide evidence that yo u have a majority interest in the business. Name of Disadvantaged Owne r State of Residence Percent Transferred

__________________________________ _______ _____________

__________________________________ _______ _____________

__________________________________ _______ _____________

__________________________________ _______ _____________ 9. Has any individual(s) listed in number 2 above tr ansferred 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 a ssets 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 ar e**  **consistent with the customary recognition of special occasions, such as birthdays, graduatio ns,**  **anniversaries, and retirements**
. **Individuals may also exclude any transfers to an immediate**  **family if for educational, medica l, 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 fi rm. Name T itle

____________________________ _______________________________

_____________________________ _______________________________

_____________________________ _______________________________

_____________________________ _______________________________ 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 outsid e 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 applicati on 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 pr ior 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) an d 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 th e compensation received by the disadvantaged Management Member? ____ Yes ____ No. If yes, provide the total compensation received by th e 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, cert ifications, 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 T itle

___________________________________ ___________________________________

___________________________________ ___________________________________
EPA DBE Certification Application (EPA Form 6100-1b) (Limited Liability Company) 

### 77. 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 leas ed) ____ Yes ____ No d) Equipment (rent or leas ed) ____ 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 prov ide 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 disadvantage d**  **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 tr**  **ue, 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 tr**  **ue, 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 tr**  **ue, 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 th e Government’s right**  **to pursue criminal prosecution for incorrect or incomplete information given on the applicatio**  **n form, even if correct information has been included in other materials submitted to**  **EPA.** Name S SN D ate

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________ The public reporting a nd recordkeeping burden for this collection of information is estima ted 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 minimiz ing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (282 2T), 12 00 Pennsylvania Ave., NW, Washington, D.C. 20 460. 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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