Environmental Protection Agency

EPA DBE Certification Application 

For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE) 

Under EPA’s Disadvantaged Business Enterprise (DBE) Program 

For Partnerships

Business Profile: 

Name of applicant firm:______________________________________________________________________ 

Name of Managing Partner:__________________________________________________________________ 

EIN:___________________ Social Security Number _________________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: ____________________________________________________________________________________ 

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

(Partnerships)

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OMB Control No: 2090-0030 

Approval Expires: XX/XX/XX
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: ____________________________________ 

_________________________________________________________________________________________ 

_________________________________________________________________________________________ 

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 6100-1c)

(Partnerships)

 

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 SECTION A 

Eligibility Statement - Designated Group Members

Social Disadvantage 

1. Is your firm at least 51% owned by a U.S. citizen? ____ Yes ____ No. If your firm is not at least 51% 

owned by a U.S. Citizen, stop here. You are not eligible to participate as a DBE under EPA’s DBE

Certification Program. 

2. List all individuals claiming disadvantaged status.

 

Name of Individual Group U.S. Citizen Other Last Place of Sex

Membership Y/N Names Used Birth M/F 

__________________________ ___________ ________ ___________ _______ _____ 

 

__________________________ ___________ ________ ___________ _______ _____ 

__________________________ ___________ ________ ___________ _______ _____ 

2a. If you are a naturalized 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

1. List all individuals claiming disadvantaged status:

 

Name of Individual U.S. Citizen Race Sex 

Y/N M/F 

_______________________________ ________ ________ _____ 

_______________________________ ________ ________ _____ 

_______________________________ ________ ________ _____ 

 

1a. If you are a naturalized Citizen, please provide the following as Attachment B-1: 

naturalization number; (b) date of citizenship; and (c) county, state and court.

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

(Partnerships)

 

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For this section, all individuals claiming social disadvantage must provide a separate response for

questions 3 and 4. 

Social Disadvantage 

2. 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.) 

3. 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.

4. 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. 

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

ownership interest in the applicant firm and equity in the individual(s) primary residence? 

 ____ Yes ____ No.

2. For individual(s) 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.

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

(Partnerships)

 

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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, my 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. Provide the name, title, and percentage of ownership (class, if applicable) for each partner of the firm. 

Does the partnership agreement reflect the ownership of each partner? ____ Yes ____ No.

Name Title Ownership Percentage

______________________ ____________________ ___________________________ 

______________________ ____________________ ___________________________ 

______________________ ____________________ ___________________________ 

______________________ ____________________ ___________________________ 

 

2. Has 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-1.

3. 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 as Attachment D-2.

Name of Disadvantaged Partner State Percent Transferred 

 

______________________ ____________________ _____________________ 

______________________ ____________________ _____________________ 

______________________ ____________________ _____________________ 

______________________ ____________________ _____________________ 

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

(Partnerships)

 

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4. Has any individual(s) claiming disadvantaged status 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-3: 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 member if for 

educational, medical or essential support purposes. 

SECTION E 

(All applicant firms must complete) 

Control 

1. List the name(s) of all Partners:

Name Limited/General

 

___________________________________ _____________________________ 

___________________________________ _____________________________ 

___________________________________ _____________________________ 

 

___________________________________ _____________________________ 

2. Are partnership decisions determined by general partners? If no, explain as Attachment E-1.

3. Is a general partner, or any disadvantaged full-time manager engaged in or plan to engage in outside 

employment? ___ Yes ___ No. If yes, explain as Attachment E-2. 

4. Have any of the nondisadvantaged individuals involved in the management of the applicant firm,

partners, or their immediate family members, had a prior business relationship with any individual

claiming disadvantage 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-3.

5. List the total compensation from the applicant firm of all partners and/or key managers of the firm. 

(If necessary, provide additional information as Attachment E-4).

 

Name/Title Compensation from applicant firm 

 (includes salaries, bonuses, etc.)

_________________________________ ___________________________________ 

 

________________________________ ___________________________________ 

________________________________ ___________________________________ 

________________________________ ___________________________________ 

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

(Partnerships)

 

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6. 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 as

Attachment E-5.

7. List the names of all individuals who have access to the firm’s bank account.

Name Title

______________________________ _____________________________ 

______________________________ _____________________________ 

______________________________ _____________________________ 

8. 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) Provide business bank account. ___ Yes ___ No

If you answered yes to any of the above, please provide specific details (i.e., names, titles, copies

of agreements, leases, etc.) of such arrangements as Attachment E-6. 

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

(Partnerships)

 

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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 6100-1c) 

(Partnerships)

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