### 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 Partnerships**

**Business Profile :** 
Name of app licant firm:______________________________________________________________________

Name of Managing Partner:__________________________________________________________________

EIN:___________________ Social Security Number _________________E-mail Address:_______________

Business Address:______________________________________________ County:______________________

City:_________________________________ State:_______________ Zip Code:________________________

Phone Numb er:___________________________ Fax Number :______________________________________

Mailing Address (if different than above): _________________________ County:_____________________

City:_________________________________ State:_______________ Zip Code:________________________

What is the firm’s 4 digit primary North Americ an Industrial Classifi cation (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 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 PR O-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) and ID nu mber(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: ____________________________________________________________________________________

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

### 1 OMB Control No: 2090-0030 Approval Expires: XX/XX/XXHas yo ur firm ever 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 a co py

o f t h e pri o r det e rm i n at i o n o f at t e m p t s t o o b t a i n cert i f i c at i o n :

____________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

D o es y o ur fi rm h 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 e s ___ N o . I f y e s , pro v i d e St at e(s ) an d I D n u m b er(s ): _______________________________________

I n accord an ce w i th 13 C F R §124.103, d e s i gn ated grou p m e m b ers are p res u m ed to b e s o ci al l y d i s a d van taged

. D e s i gn ated grou p m e m b ers are i n d i vi d u a l s w h o h o l d th em s e lves out to be and are iden ti fi ed b y oth ers as Bl ac k Am ericans , Native Am ericans (Am erican I ndians , E s k i m o s , Aleuts , or Native Haw a iians ), His p anic Am ericans , Subco n t i nent Asia n Am erica ns, Asia n P a cif i c Am erica ns , a nd a n y o t her g r o ups desig n a t ed by t h e Sm a l l Bu s i n e s s A d m i n i s t rati on (S BA ). I f an i n d i vi d u a l i s cl ai m i n g to b e a m e m b er of a d e s i gn ated grou p , com p l e te S ecti o n A of th i s ap p l i c ati o n
. I f an i n d i vi d u a l i s n o t cl ai m i n g to b e a m e m b er of a d e s i gn ated grou p , com p l e te Sectio n B o f this a pplica t io n
. A l l a pplica n ts m u st co m p lete Sectio ns C, D, a nd E o f this a pplica t io n
.

E P A D B E Ce r t if icat ion A p p licat ion ( E P A F o r m 6100- 1c) ( P ar t n e r s h ip s ) 

### 2

# SECTION A **Eligibility Statement - De signated Group Members** 

**Social Disadvantage**

1. I s y o u r fi rm at l e as t 51% o w n e d by a U.S. ci t i zen ? ____ Y e s ____ N o . I f y o u r fi rm i s n o t at l e as t 51% owned by a U

. S

. Citiz e n, stop here. You a r e not eligible to pa rticipa t e a s a DB E und e r E P A ’ s DB E Certif ica t ion Progra m.

2. Li s t al l i n di vi dual s cl ai m i n gdi s a dvan tag e d s t atus

.

Na me of Ind i vid u a l Gr oup U

. S

. C i tiz e n Othe r L a st Pla c e of S e x Mem b ers h ip Y / N Nam e s Us ed Birth M/ F

__________________________ ___________ ________ ___________ _______ _____

__________________________ ___________ ________ ___________ _______ _____

__________________________ ___________ ________ ___________ _______ _____

2a. I f y o u are a n a t u ral i z ed Ci t i zen , pl eas e pro v i d e t h e fo l l o w i n gas At t a ch m e n t A-1: ( a ) na tur a liz a t ion numbe r ; ( b ) d a te of c i tiz e nship; a n d ( c ) c o unty, sta t e a n d c o ur t.



# SECTION B **Eligibility Statement – Non Designated Group Members** 

1. Li s t al l i n di vi dual s cl ai m i n gdi s a dvan tag e d s t atus :

Nam e o f In di vi dual U.S. Ci ti zen R a ce Sex Y / N M/ F

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

1a. I f y o u are a n a t u ral i z ed Ci t i zen , pl eas e pro v i d e t h e fo l l o w i n gas At t a ch m e n t B-1:

na tur a liz a t ion numbe r ; ( b ) d a te of c i tiz e nship; a n d ( c ) c o unty, sta t e a n d c o ur t.

E P A D B E Ce r t if icat ion A p p licat ion ( E P A F o r m 6100- 1c) ( P ar t n e r s h ip s ) 

### 3**F o**  **r this sectio**  **n, all indiv i**  **duals claiming so**  **cial disadv**  **antag e**  **must pr o**  **v i**  **de a separ a**  **te r e**  **spo n**  **se f o**  **r questio**  **ns 3 and 4.**


### Social Disadvantage

2. I, ____________________________________ h a ve perso n a lly suffered so cial disadvan tage based
on my id e n tif i c a tion a s **__________________________________. (A claim o**  **f so**  **cial disadv antag**  **e must include at least**  **o n**  **e o**  **b jectiv**  **e f**  **eatur e**  **that has** 

**co ntr**  **i buted to**  **so cial disadv**  **antag e**  **, such as r a**  **ce, ethnic o r**  **ig in, g**  **e nder** 
**, phy**  **sical handicap,**  **lo ng**  **-ter m**  **r e**  **sidence in an env i**  **r o**  **nment iso l**  **ated f r**  **o m the**  **mainstr eam**  **o f**  **Amer ican**  **so ciety** 
**, o**  **r**

**o t**  **her similar**  **causes no t co**  **mmo n to**  **indiv i**  **duals w h**  **o ar**  **e no t so**  **cially disadv**  **antag e**  **d.)**

3

. Document how your a b ility to co mpete in the f r ee enterprise syst em ha s been impa ired by such things a s ina b ility to obta in a d eq ua te bond ing, cred it or f i na ncin g; ina b ility to obta in licenses or le a s e s ; r e str i c t ion of your ma r k e t to c e r t a i n r a c i a l

, e t hnic or soc i a l gr oups; und e r e mployme n t or

une m ployme nt, e t c

. , a s c o mpa r e d to othe r s in the sa me or simila r line of busine ss who a r e not socia lly d i sa d v a n ta ged

. Provid e a s A tta chment B

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.

4. **Attach a nar r**  **a tiv**  **e descr ibing**  **ho w**  **y o**  **u per**  **s o**  **n ally**  **exper ienced**  **so cial**  **disadv antag**  **e in**  **Amer ican so**  **ciety**

**.** When writing your na rra tive, be a s s p e c i f ic an d d e t a i l e d as po ssible. Wh ere

a pplica b le, ea ch sta t ement of a lleged d i scri mina tion should be suppor t e d by d o c u me nte d

e v id e n c e suc h a s a f f i d a vits, d e nia l s of loa n a pplic a t ions, d e nia l s of e m ployme nt oppor t unitie s ( i nc lud i ng non- se le c t ion f o r pa r t ic ula r jobs, d e nia l s of pr omotions, or une q ua l wor k e n vir onme n t
or trea tment) , a n d documents to support a n y f o rma l a c tion ta ken by you beca use of a lleged d i sc r i mina tion. You must d e monstr a t e how your id e n tif i c a tion, a s d e sc r i be d in the pa r a gr a p h

a b ove, ha s nega tively impa cted your entry into or a d va ncement in business. You must a d d r ess d i sa d v a n ta ge in e d uc a t ion, e m ployme nt, a n d busine ss histor y, whe r e a pplic a b le

. E x a m ple s of d i sc r i mina tion inc l ud e , but a r e not limite d to: une q ua l a c c e ss to c o lle ge s or pr of e ssiona l sc hools;

e x c l usion f r om pr of e ssiona l or busine ss a ssoc i a t ions; be ing d e nie d e d uc a t iona l honor s or

r e c o gnition; e x pe r i e n c i ng d i sc r i mina tor y soc i a l pr e ssur e whic h d i sc our a ge d you f r om pur s uing a pr of e ssiona l or highe r e d uc a t ion or f o r c e d you into non- pr of e ssiona l or non- busine ss f i e l d s ; d i sc r i mina tion in e m ployme nt oppor t unitie s or pa y a n d f r inge be ne f i ts; une q ua l a c c e ss to busine ss c r e d it or c a pita l; a n d d i sc r i mina tion in the a w a r d i ng, bid d i ng pr oc e ss, or ne gotia t ing of
gove r n me nt or pr iva t e se c t or c ontr a c t s. Pr ovid e a s A tta c h me nt B

- 3

.



# SECTION C **(All applicant firms must complete)**

**Economic Disadvantage**

1. I s t h e n e t w o rt h o f each 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 e s ____ 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 at us, list your persona l net worth, exclud ing the ownership interest in the a pplic an t fi rm an d t h e eq u i ty in the ind i vid u a l ( s ) prima r y resid e nce.

E P A D B E Ce r t if icat ion A p p licat ion ( E P A F o r m 6100- 1c) ( P ar t n e r s h ip s ) 

### 4N a m e Averag e 2-y e ar P e rs o n a l To t a l I n c o m e N e t W o r t h A s s e t s

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

3. Each i 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 , my a b ility to compete in the f r ee enterprise system ha s been impa ired d u e to d i minished ca pita l a n d cred it opportunities a s comp a r ed to others 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

.


# SECTION D **(All applicant firms must complete)**

**Owne r**  **ship**

1

. Pr ovid e the na me , title

, a n d pe r c e n ta ge of owne r s hip ( c la ss, if a pplic a b le ) f o r e a c h pa r t ne r of the f i r m

. D o es t h e 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 each part n e r? ____ Y e s ____ N o

.

N a m e T i t l e O w n e r s h i p P e r c e n t a g e

______________________ ____________________ ___________________________

______________________ ____________________ ___________________________

______________________ ____________________ ___________________________

______________________ ____________________ ___________________________

2. H a s 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 e s ____ 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 f y o u r fi rm ? P l eas e expl ai n as At t a ch m e n t D

- 1.

3

. For c o mmunity pr ope r ty r e sid e nts only. If you a r e a ma r r i e d d i sa d v a n ta ge d owne r , a n d your spouse is not disa dva n ta ged, plea se complete the cha r t belo w , an d pro v ide eviden ce th at yo u h a ve a m a j o rity interest in the business a s A tta chment D- 2

.

Nam e o f D i sadvan taged Partn e r State Percen t Tran sferred

______________________ ____________________ _____________________

______________________ ____________________ _____________________

______________________ ____________________ _____________________

______________________ ____________________ _____________________

E P A D B E Ce r t if icat ion A p p licat ion ( E P A F o r m 6100- 1c) ( P ar t n e r s h ip s ) 

### 54. H a s an y 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 t r an s f erred an y as s e t s w i t h i n t w o y e ars , i n fu l l

o r i n part , t o a s p o u s e o r an y o t h e r pers o n o r en t i t y , i n cl u d i n ga t r u s t ? ___ Y e s ___ N o . I f y e s , pr ovid e the f o llowing inf o r m a t ion a s A tta c h me nt D- 3 : the da te of tra n sf er; to whom the a ssets were
tra n sf erred; a m ount pa id f o r the a ssets; a n d the ma rk et va lue of the a ssets a t the time of tra n sf er. Ind i vid u a l s ma y exclud e a ssets tra n sf erred to a n immed i a t e f a mily member tha t a r e consistent with the c u stoma r y r e c o gnition of spe c ia l oc c a sions, suc h a s bir t hd a y s, gr a d ua tions, a nnive r s a r ie s a n d retirements. Ind i vid u a l s ma y a l so exclud e a n y tra n sf ers to a n immed i a t e f a mily member if f o r ed uca t iona l, med i ca l or essentia l support purposes.



# SECTION E **(A ll applicant firms must co**  **mplete)**



## Contr **o l** 

1

. L i st the na me ( s ) of a ll Pa r t ne r s :

N a m e L i m i t e d / G e n e r a l

___________________________________ _____________________________

___________________________________ _____________________________

___________________________________ _____________________________

___________________________________ _____________________________

2

. A r e pa r t ne r s hip d e c i sions d e te r m ine d by ge ne r a l pa r t ne r s ? If no, e x pla i n a s A tta c h me nt E

- 1

.

3

. Is a genera l pa rtner, or a n y d i sa d v a n ta ged f u ll- time ma na ger enga ged in or pla n to enga ge in outsid e

em pl o y m e n t ? ___ Y e s ___ N o . I f y e s , expl ai n as At t a ch m e n t E-2.

4

. Ha ve a n y of the nond isa d va nta g e d ind i vid u a l s involve d in the ma na ge me nt of the a pplic a n t f i r m , pa rtners, or their immed i a t e f a mily members, ha d a prior business rela tionship with a n y ind i vid u a l cl ai m i n gdi s a dvan t a g e s t at u s ? Th is includ es such rela tionships a s em plo y er-em p lo yee, superviso r

em pl o y ee, co -w o r k e rs , i n ves t o r -em p l o y ee, et c. ___ Y e s ___ N o . I f y e s , i d en t i fy t h e pers o n ( s ) an d t h e type of busine ss r e la tionship a s A tta c h me nt E

- 3

.

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 m of a ll pa r t ne r s a n d / or ke y ma na ge r s of the 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 E

- 4 )

.

Na me/Title Compensa tion f r om a pplica n t f i rm ( i nclud e s sa la ries, bonuses, etc. )

_________________________________ ___________________________________

________________________________ ___________________________________

________________________________ ___________________________________

________________________________ ___________________________________

E P A D B E Ce r t if icat ion A p p licat ion ( E P A F o r m 6100- 1c) ( P ar t n e r s h ip s ) 

### 66. D o es t h e appl i c an t fi rm o p erat e i n an i n du s t ry which requires bond in g or pr of e ssiona l lic e n se 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 ind e mnity a g reement, permit s, certif ica t ions, a n d bond ing required t o o p erat e t h e appl i c an t fi rm as A tta chment E- 5

.

7

. L i st the na me s of a 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 es an y i n di vi du al (s ), (o t h er t h an t h e 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 en t i t i es provide:

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 m em pl o y m e n t ag en ci es ). ___ Y e s ___ N o f) P r o v i d e bu s i n e s s ban k acco u n t

. ___ Y e s ___ N o
If yo u an sw ered yes to an y o f th 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 ch arran g em en ts as Attach m e n t E-6.

E P A D B E Ce r t if icat ion A p p licat ion ( E P A F o r m 6100- 1c) ( P ar t n e r s h ip s ) 

### 7**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 6100-1c) (Partnerships) 

### 8