### 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

**Native Hawaiian Organization Owned Concern**

Name of Parent Native Hawaiian Organization: _________________________________________

Address of Parent Native Hawaiian Organization: _______________________________________

Name of wholly-owned subsid iary (if app licable ): _______________________________________

Address of wholly-ow ned subsid iary : __________________________________________________

**Name of applicant firm** : ______________________________________________________________

Applicant concern is:  C orporat ion  L imited Liability Compan y  Partn ershi p
Name of President/Managing Member/Managing Partner: _______________________________

EIN: _________________________ E-mail Address: _____________________________________

Business Address: _____________________________________________County: _____________

City: _________________________________ St ate: _______________Zip Code: _______________

Phone Numb er: ___________________________ Fax Numb er: _____________________________
Mailing Address (if different than above): ________________________County: _______________

City: _________________________________ St ate: _______________Zip Code: _______________

What is the firm’s (4-digit) primary stan dard industrial cl assificati on code? _________________

Is the firm certified by the Small Business Administ ration 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) an d ID numb er(s) __________________________________________________

Is the firm certified by a State go vernment, 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) OMB C on tr ol No: 2090-0030 Approval Expires: XX/XX/XXHas yo ur firmever been den i ed certificatio n by a F e deral ag en cy , St at e g o ve rnment, loca l government, I n di an t r i b al g o vern m e n t , o r i n depen d en t pri v at e o r g a n i zat i o n ? ___ Y e s ___ N o . I f y e s , pro v i d e expl an at i o n / do cu m e n t at i o n :

_____________________________________________

_________________________________________________________________________________

_________________________________________________________________________________ D o es th e fi rmh a ve an y o t h e r certi f i c ati o n as a di s a dvan tag e d bus i n e s s en ti ty , i

. e., MBE, D BE, WBE, etc? ___Y es ___ N o . I f y e s , pro v i d e t h e St at e(s ) an d I D n u m b er ( s ) :

__________________

__________________________________________________________________________________


# Business Eligibility **SECTION A**

**Social Disadvantage**

1

. A Na tive Ha wa iia n Orga niz a t ion tha t meets th e f o llowing criteria is consid ered socia lly di s a dvan tag e d:

Na tive Ha wa iia n Or ga niz a t ion me a n s a n y c o mmunity se r v ic e or ga niz a t ion se r v ing Na tive Ha wa iia ns in the S t a t e ofHa wa ii, whic h is a not- f o r pr of it or ga niz a t ion, c h a r te r e d by the S t a t e ofHa wa ii. A Na tive Ha wa iia n Orga niz a t ion is controlled by Na tive Ha wa iia ns whose business a c tivities will principa lly benef i t such Na tive Ha wa iia ns.

Provide documenta t ion tha t the a pplica n t enti ty m eets th ese criteria as Attach m e n t A-1.



# SECTION B

**Economic Disadvantage**

1. I s t h e n e t w o rt h o f al l i n di vi du al (s ) cl ai m i n gdi s a dvan t a g e d s t at u s l e s s t h an $750,000, excl u d i n g ownership interest in the a pplic an t fi rm an d eq u i t y i n t h e i n di vi du al (s ) pri m ary res i den c e? ____Y es ____ N o

.

2. F o r i n di vi dual (s ) cl ai m i n gdi s a dvan tag e d s t a t us, list your persona l net worth, exclud ing the ownership interest in the a pplic a n t f i rm a n d the equity in the ind i vid u a l ( s ) prima r y resid e nce.

N a m e Averag e 2-y e ar P e rs o n a l To t a l U.S. Income Net Worth A ssets Citiz e n ( Y /N)

____________________________ ______________ __________ _______ ___________

____________________________ ______________ __________ _______ ___________

____________________________ ______________ __________ _______ ___________

____________________________ ______________ __________ _______ ___________

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1h) ( N ativ e H a w a iian O r g a niz a tio n O w ne d Co nce r n) 

### 23. Eachi n di vi du al l i s t e d i n n u m b er 2 abo v e cert i f i e s t h at , becau s e o f raci al an d/ o r et h n i c prej u d i c e,

a n d / or cultura l bia s , his/her a b ility to compete in the f r ee enterprise syst em ha s been impa ired due to di m i n i s h ed capi tal an d cred it opportunities a s compa r ed to othe r s in the sa me or simila r line of business tha t a r e not socia lly d i sa d v a n ta ged

.

4. P e rs o n a l F i n an ci al St at em en t - Al l i n di vi du al s cl ai m i n gdi s a dvan t a g e d s t at u s an d h i s / h e r s p o u s e , plea se provid e d o cumenta t ion verif ying your a ssets a n d lia bilities ( s plit your a ssets a n d lia bilities, if ma rried ) a s A tta chment B

- 1

.

5. Al l i n di vi du al s cl ai m i n gdi s a dvan t a g e d s t at u s o r i n di vi du al s o w n i n gm o re t h an 10% o f t h e

c onc e r n ple a se pr ovid e the f o llowing d o c u me nta t ion a s A tta c h me nt B

- 2 :

a ) S igned copies of ind i vid u a l Fed e ra l income ta x returns f iled f o r the pa st two yea r s, includ ing al l W

- 2 fo rm s an d al l s c h e du l e s an d at t a ch m e n t s

. b) Si g n ed an d dat e d I R S F o rm4506 (R eq u e s t fo r Co py o r Tran s c ri pt o f Tax F o rm )



# SECTION C

**Owne r**  **ship**

1

. Do Na tive Ha wa iia ns own a ma jor i ty ofboth th e tota l equity of the Na tive Ha wa iia n Orga niz a t ion

an d t h e t o t a l vo t i n g po w e rs t o el ect di rect o r s o ft h e N a t i ve H a w a i i a n O r g a n i zat i o n ? ___ Y e s ___ N o

. If ye s, pr ovid e ve r i f i c a tion ofthe pe r c e n ta ge ofNa tive Ha wa iia n owne r s hip a s a tta c h me nt C

- 1

.

2. I s t h e appl i c an t co n c ern at l e as t 51 percen t o w n e d by a N a t i ve H a w a i i a n O r g a n i zat i o n ? ____ Y e s ____ N o . I f y e s , pl eas e pro v i d e evi d en ce o f o w n e rs h i p as At t a ch m e n t C-2.

**Co r**  **p o**  **r atio**  **ns O n**  **ly :** 

3

. If mor e tha n one c l a ss of stoc k, pr ovid e inf o r m a t ion f o r e a c hc l a ss: Vo tin gNo n To tal Vo tin g a) To t a l n u m b er o fs h ares au t h o r i z ed:

_____ ______ _____ b) To t a l n u m b er o f s h ares cu rren t l y o u t s t a n d i n g :

_____ ______ _____

4

. Ple a se pr ovid e the f o llowing d o c u me nta t ion a s A tta c h me nt C

- 3 :

a ) C o pie s of a ll gove r n ing d o c u me nts, suc ha s the c onc e r n’s c onstitution or busine ss c h a r te r

. b) C o pie s of a ll minute s of sha r e hold e r s me e t ing e l e c ting boa r d of d i r e c t or s a n d minute s of la st sh areh o l ders m eetin g. c) Copies of a ll stock certif ica t es ( f r ont a n d ba ck) a n d stock register. d ) C o py of the c u r r e nt C e r t if ic a t e of Good S t a n d i ng f r om sta t e whe r e c onc e r n is inc o r p or a t e d

. If concern cond ucts business in a st a t e other tha n where it wa s inco rpora t ed , a copy of the f iling

as a F o rei g n Co rpo r at i o n an d a cu rren t Cert i f i c at e o f G o o d St an di n gfro mt h at s t at e are required a s well.

**Limited Liability Co**  **mpanies O n**  **ly :** 

5. If m o re th an o n e clas s m e m b ers h ip in teres t , pro v ide in fo rm atio n fo r eachclas s : Vo tin gNo n To tal Vo tin g a) To t a l n u m b er o f m e m b ers h i p s au t h o r i z ed:

_____ ______ _____ b) To t a l n u m b er o f m e m b ers h i p s cu rren t l y o u t s t a n d i n g :

_____ ______ _____

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1h) ( N ativ e H a w a iian O r g a niz a tio n O w ne d Co nce r n) 

### 36

. Ple a se pr ovid e the f o llowing d o c u me nta t ion a s a tta c h me nt C

- 4 : a) Co py o f O p eratin g Agreem en t b) C o py of A r tic l e s of Or ga niz a t ion a s f ile d with the sta t e

**Par t**  **ner s**  **hips O n**  **ly :** 

7

. Pr ovid e the na me , title
, a n d pe r c e n ta ge of owne r s hip f o r e a c hpa r t ne r of the f i r m

. Doe s the part n e rs h i p ag reem en t refl ect t h e o w n e rs h i p o f eachpart n e r? ___Y es ___N o

.

N a m e T i t l e O w n e r s h i p %

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

8

. Ple a se pr ovid e a c o py of the c onc e r n’s Pa r t ne r s hip A g r e e m e n t a s A tta c h me nt C

- 5

.
**Q u**  **estio ns 9 thr**  **o ug**  **h 13 ar e f**  **o r**  **C o**  **r p**  **o r**  **atio ns &**  **LLC s O**  **N L**  **Y :** 

9. Li s t al l en ti ti es , i n di vi dual s , an d/ o r trus ts w h i c h ha ve a n owne r s hip inte r e st in the a pplic a n t f i r m

.
N a m e T i t l e O w n e r s h i p % V o t i n g N o n V o t i n g T o t a l

___________________________ ____________________ ______ _________ _____

___________________________ ____________________ ______ __________ _____

___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

1 0

. Does the pa rent Na tive Ha wa iia n Orga niz a t ion or its wholly owned subsid ia ry receive a t lea s t 5 1 % of
t h e an n u al di s t ri bu t i o n s o f di vi den d s pai d o n t h e s t o c k o f a co rpo r at e appl i c an t fi rm ? ___Y es ___ N o

. Ifno, ple a se e x pla i n a s A tta c h me nt C

- 6

.

11. Will th e paren t Native Hawaiian O r gan i zatio n o r its wh o lly o w n e d subsidiary receive 100% o f th e

u n en cu m b ered val u e o f eachs h are o fs t o c k o w n e d i n t h e even t t h at t h e s t o c k i s s o l d ? ___Y es ___ N o

. Ifno, ple a se e x pla i n a s A tta c h me nt C

- 7

.

1 2

. Ifthe corpora t ion d i ssolves, will the pa rent Na tive Ha wa iia n Orga niz a t ion or its wholly owned

s u bs i d i a ry recei v e at l e as t 51% o f t h e ret a i n ed earn i n g s an d 100% o f t h e u n en cu m b ered val u e o f each

s h are o f s t o c k o w n e d? ___Y es ___ N o . I f n o , pl eas e expl ai n as At t a ch m e n t C-8.

1 3

. Is ownership by the pa rent Na tive Ha wa iia n Orga niz a t ion or its wholly owned subsid ia ry subject to

c ond itions pr e c e d e n t, c ond itions subse q ue nt, e x e c utor y a g r e e m e n ts, voting tr usts, sha r e hold e r

a g r e e m e n ts or othe r simila r a r r a nge m e n ts whic h ma y impa c t the unc ond itiona l owne r s hip of the N a t i ve H a w a i i a n O r g a n i zat i o n ? ___Y es ___N o

. I f y e s , expl ai n as At t a ch m e n t C-9.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1h) ( N ativ e H a w a iian O r g a niz a tio n O w ne d Co nce r n) 

### 4**Co r**  **p o**  **r atio**  **ns, LLCs & Par**  **t ner**  **s hips:** 

14. H a ve t h ere been an y ch an g e s i n o w n e rs h i p i n t h e l a s t y e ar? ___Y es ___N o

. I f y e s , di d o w n e rs h i p affect t h e di s a dvan t a g e d s t at u s o fy o u r fi rm ? P l eas e expl ai n as At t a ch m e n t C-10.

**F o**  **r All Co**  **ncer ns:** 

15. Please pro v ide co pies o f buy/ sell agreem en ts, co n d itions pr e c e d e n t, c ond itions subse q ue nt, e x e c utor y

a g reements, voting trusts
, sha r e hold e r a g r e e m e n ts or othe r simila r a r r a nge m e n ts, whic h ma y impa c t the unc ond itiona l owne r s hip of the d i sa d v a n ta ge d ind i vid u a l s a s A tta c h me nt C

- 1 1

. 

# SECTION D **Contr o**  **l a nd Ma**  **na ge**  **me nt** 

1

. L i st a ll ind i vid u a l s who ma na ge or cond uct d a ily business opera t ions ofthe a pplica n t concern.

N a m e / T i t l e D a t e

___________________________________________________ _____________

___________________________________________________ _____________

___________________________________________________ _____________

___________________________________________________ _____________

2

. A r e a n y of the ind i vid u a l s listed in question 1 enga ged in or pla n to enga ge in outsid e e m ployme nt? ___ Y e s ___ N o

.

3

. Ifme mbe r s ofthe ma na ge me nt te a m , busine ss c o mmitte e me mbe r s, of f i c e r s , a n d d i r e c t or s a r e

c u r r e ntly e m ploye d outsid e the a pplic a n t c onc e r n, pr ovid e inf o r m a t ion on this e m ployme nt a n d evidence tha t the a c tivity d o e s not c onf lic t with the d a y- to- d a y ma na ge me nt of the a pplic a n t c onc e r n. Ple a se ind i c a te the numbe r ofhour s pe r we e k a n d the nor ma l wor king hour s ofthis outsid e

e m ployme nt a s A tta c h me nt D- 1

.

4

. Ple a se pr ovid e r e sume s ofthe e d uc a t ion, te c hnic a l tr a i ning a n d busine ss a n d e m ployme nt e x pe r i e n c e , inc l ud ing e m ploye r ’s na me s, d a te s ofe m ployme nt, f o r ge ne r a l ma na ge r , of f i c e r s , a n d ke y e m ploye e s (P l e as e acco u n t fo r an y m i s s i n gg a ps i n em pl o y m e n t ) as At t a ch m e n t D

- 2.

5

. L i st the tota l c o mpe n sa tion f r om the a pplic a n t f i r mofa ll owne r s a n d / or ke y ma na ge r s ofthe f i r m

. ( I f

ne c e ssa r y , pr ovid e a d d i tiona l inf o r m a t ion a s A tta c h me nt D- 3 )

.

Na me/Title Compensa tion f r om a pplica n t f i rm ( I n c l u d e s a l a r i e s , b o n u s e s , e t c

. )

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1h) ( N ativ e H a w a iian O r g a niz a tio n O w ne d Co nce r n) 

### 56. D o es t h e appl i c an t fi rmo p erat e i n an i n du s t ry w h i c hreq u i r es bo n d i n g o r pro f es s i o n a l l i c en s e s ?

___ Y e s ___ N o . I f y e s , i d en t i fy t h e q u al i f y i n gi n di vi du al (s ) fo r t h e cri t i c al l i c en s e s , g e n e ral i n dem n i t y

a g reement, permits, certif ica t ions
, a n d bond ing r e quir e d to ope r a t e the a pplic a n t f i r m on A tta c h me nt D- 4

.

7

. L i st the na me s ofa ll ind i vid u a l s who ha ve a c c e ss to the f i r m ’s ba nk a c c o unt.

N a m e T i t l e

___________________________________ __________________________________

**___________________________________ __________________________________** 

___________________________________ __________________________________

___________________________________ __________________________________

8. D o an y i n di vi du al (s ), o r en t i t i es pro v i d e:
a) F i n an ci al s u ppo rt t o t h e appl i c an t fi rm ? ___ Y e s ___ N o b) Su bco n t ract s , Jo i n t V e n t u r es o r Team i n gArran g em en t s ? ___ Y e s ___ N o c) O ffi ce s p ace (ren t o r l e as ed). ___ Y e s ___ N o d) Eq u i pm en t (ren t o r l e as ed). ___ Y e s ___ N o e) Em pl o y ees (o t h er t h an fro mem pl o y m e n t ag en ci es ). ___ Y e s ___ N o

If th e an sw er is yes to an y o fth e abo v e, please pr o v ide s p ecific details (i.e., n a m e s , titles , co pies o f
agreem en ts, leases, etc.) o f s u charran g em en ts as Attach m e n t D

- 5.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1h) ( N ativ e H a w a iian O r g a niz a tio n O w ne d Co nce r n) 

### 6**Each person signing below:**

**1. Certifies that the information provided with regard to the applicant firm’s social and econom**  **ic disadvantaged status is true, accurate, and comple**  **te to the best of his/her knowledge and belief.**

**2. Certifies that the information provided with regard to the applicant firm’s ownership and contro**  **l 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 disadvantage**  **d 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 applicatio n**  **form, even if correct information has been included in other materials submitted to EPA.** 

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

Name SSN Date

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

The public reporting a nd 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), 12 00 Pennsylvania Ave., NW, Wa shington, D. C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this a ddress.

EPA DBE Certification Application (EPA Form 6100-1h) (Native Hawaiian Organization Owned Concern) 

### 7