### EPA DBE Certification Application Environmental Protection Agency

For a Minority Business Enterprise (MBE) /Women-owned Busin ess Enterprise (WBE) Under EPA’s Disadvantaged Busi ness Enterprise (DBE) Program

**For Corporations**

**Business Profile:**

Name of app licant firm: _____________________________________________________________________

Name of President/Chie f Executive Officer: _____________________________________________________

EIN:_______________________________________ E-mail Address:________________________________

Business Address:________________________________ County:__________________________________

City:_______________________________ State: _________ Zip Code:_______________________________

Phone Numb er:____________________________ Fax Numb er: _________________________

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

City:_________________________________ State:_______________ Zip Code:_______________________

What is the firm’s 4-digit primary North Amer ican Industrial Classi fication (NAI C) code? ______________

Are you claiming disabled status? ___ Yes ___ No. (i.e., a United States citizen who has permanent or temporary physical or me ntal impairment that substantially lim its 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 U.S. 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 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 6100-1d) (Corporations) OMB Control No: 2090-0030 Approval Expires: XX/XX/XXD o y o u 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 es

__

**_** 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**  **acco r**  **d ance w**  **ith 13 C F**  **R §124.103, desi**  **g nated**  **g r**  **o up member**  **s ar e pr**  **esumed to be**  **so cially** 

**disadv antag**  **e d.**  **D e**  **sig n**  **ated g r**  **o up member**  **s ar e indiv**  **i duals w**  **h o**  **ho ld themselv**  **es o u**  **t to be and ar**  **e identif**  **ied by o**  **t her**  **s as B**  **l ack Amer**  **icans, N a**  **tiv e**  **Amer icans**  **(Amer i**  **can I ndians, Eskimo**  **s, Aleuts, o r** 

**N a**  **tiv e H**  **a w**  **a iians), H**  **i spanic Amer**  **icans, Subco**  **n tin**  **ent Asian Amer icans, Asian Pacif**  **i c Amer**  **icans, and any**  **o t**  **her g**  **r o**  **ups desig n**  **ated by the Small B**  **u siness Administr**  **a tio**  **n (SB**  **A ).**  **I f**  **an indiv**  **i dual**  **is**

**claimin g**  **to be a member**  **o f**  **a desi g**  **nated g**  **r o**  **up, co mplete Sectio**  **n A o f**  **this applicatio n.**  **I f**  **an indiv**  **i dual is no**  **t claimin g**  **to be a member**  **o f**  **a desi g**  **nated g**  **r o**  **up, co mplete Sectio**  **n B o**  **f this**  **applicatio n** 

**. A**  **l l**  **a p**  **p l**  **i c**  **a n**  **t s**  **m u**  **s t**  **c o**  **mplete Sectio**  **ns C, D**

**, and E o**  **f this applicatio**  **n**

**.**

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1d) ( C o r po r a tio ns ) 

### 2

## SECTI **ON 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 g di s a dvan tag e d s t atus :

Nam e o f In dividual O t h e r la st U

. S

. C i tiz e n Pla c e of Gr oup S e x

Nam e s Us ed Y / N Birth Mem b ers h ip M/ F

___________________ ___________ ________ ___________ _______ _____

___________________ ___________ ________ ___________ _______ _____

___________________ ___________ ________ ___________ _______ _____

a) If y o u are a n a tu ralized citizen , pleas e prov ide th e f o llo w i n g as A ttach m e n t A

- 1

, (a) n a tu ralizatio n

n

u m ber; (b) date of citizen s h ip; an d (c) cou n t y
, s t ate an d cou r t.



## SECTI **ON B Eligibility Statement - Non**  **Designated Group Members**

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

Nam e o f In di vi dual U.S. Ci tizen R a ce Sex

Y / N M/ F

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

a) 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 g as At t a ch m e n t B-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.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1d) ( C o r po r a tio ns ) 

### 3**F o**  **r this sectio**  **n, any indiv**  **i dual claiming**  **so cial di**  **sadv antag**  **e must pr**  **o v**  **i de**  **a s**  **e p**  **a ra**  **t e**  **re s**  **p on**  **s e**  **for 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 compete in the f r ee enterprise system ha s b een impa ired by such things a s ina b ility to obta in a d equa te bond ing, cr ed it or f i na ncing; ina b ilit y 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

- 2

.

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

.



## SECTI **ON 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 g di 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

owne r s hip inte r e st in the a pplic a n t c o r p or a t ion a n d equity in the ind i vid u a l ( s ) prima r y

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 g di s a dvan tag e d s t a t us, list your persona l net worth, exclud ing the

owne r s hip inte r e st in the a pplic a n t c o r p or a t i on a n d the equity in the ind i vid u a l ( s ) prima r y residen c e.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1d) ( C o r po r a tio ns ) 

### 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. H a ve an y i n di vi du al (s ) l i s t e d i n n u m b er 2 abo v e t r an s f erred an y as s e t s w i thin two yea r s, in f u ll

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 g a 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 C

- 1 : the da te of tra n sf er; to whom the a ssets

w e re tran sferred; am o u n t paid fo r th e assets; an d th e m a rket value o f th e assets at th e tim e o f

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

c onsiste nt 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,

an n i vers ari e s an d ret i rem e n t s

. I n di vi du al (s ) m a y al s o excl u d e an y t r an s f ers t o an i m m e di at e
f a mily member if f o r ed uca t iona l, me d i ca l or essentia l support purposes.

4. 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 , 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

.



## SECTI **ON D (All applicant firms must complete)** 

**Ownership**

1

. 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 h c l a ss:

V o t i n g N o n T o t a l Voting a) To t a l n u m b er o f s 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 :

_____ ______ _____

2. Li s t al l i n di vi dual s , en ti ti es , 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

.

Nam e Title Vo tin g O w n e rs h i p Percen tage

No n

- Vo tin g To tal

________________ ______ _____ ____________ __________

3. D o di s a dvan t a g e d i n di vi du al s recei v e at l e as t 51% o f 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 e s ___ N o . I f n o , pl eas e expl ai n an d pro v i d e as

A tta chment D- 1

.

4

. Do d i sa d v a n ta ge d ind i vid u a l s own 5 1 % or mor e of e a c h c l a ss of voting stoc k outsta nd ing a n d 5 1 % of

t h e ag g r eg at e o f al l s t o c k o u t s t a n d i n g ? ___ Y e s ___ N o

.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1d) ( C o r po r a tio ns ) 

### 55. Will disadvan taged in dividuals receive 100% o f th e un en cum b ered value o f each sh are o f sto 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 . I f n o , pl eas e expl ai n an d pro v i d e as

A tta chment D- 2

.

6

. If the corpora t ion d i ssolves, will d i sa d v a n ta ged ind i vid u a l s receive a t lea s t 5 1 % of the reta ined

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 h e o r s h e o w n s ?

___ Y e s ___ N o . I f n o , pl eas e expl ai n an d pro v i d e as At t a ch m e n t D

- 3.

7

. Is owne r s hip by a n y ind i vid u a l c l a i ming d i sa d v a n ta ge d sta t us subje c t 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

arran g em en t s , w h i c h m a y i m pact t h e u n co n d i t i o n a l o w n e rs h i p o f s u ch i n di vi du al s ? ___ Y e s ___ N o

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

- 4.

8. 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 e s ___ N o . I f y e s , di d t h e ch an g e i n

owne r s hip a f f e c t the d i sa d v a n ta ge d sta t us of your f i r m ? Ple a se e x pla i n a s A tta c h me nt D- 5

.

**F o**  **r co**  **mmunity pr**  **o p**  **er ty**  **r e**  **sidents o n**  **ly**

**.** I f y o u are a m a rri ed di s a dvan t a g e d o w n e r, an d y o u r spouse is not d i sa d v a n ta ged

, plea se complete the cha r t below, a n d provid e evid ence tha t you ha ve a

ma jority interest in the business.

Na me of Disa d v a n ta ge d Owne r S t a t e of Re sid e nc e Pe r c e n t T r a n sf e r r e d

____________________________ _______ __________________

____________________________ _______ __________________

____________________________ _______ __________________

____________________________ _______ __________________



## SECTI **ON E (All applicant firms must complete)** 

**Co ntro**  **l**

1. D i s a dvan tag e d i n di vi dual s co n t ro l th e bo ard o f di recto r s by vi rtue o f th e fact th at **(select o n**  **ly o**  **n e**  **belo w**  **) :** 

____ a) A s i n g l e di s a dvan t a g e d i n di vi du al o w n s 100% o f al l t h e **v o**  **ting** stoc k of the

a pplica n t business.

____ b) A s i n g l e di s a dvan t a g e d i n di vi du al o w n s at l e as t 51% o f al l **v o**  **ting** stoc k, is on the

B o a r d of Dir e c t or s, a n d no supe r ma jor i ty voting r e quir e m e n ts e x ist f o r sha r e hold e r s to

a ppr ove c o r p or a t e a c tions.

____ c) A s i n g l e di s a dvan t a g e d i n di vi du al o w n s at l e as t 51% o f al l **v o**  **ting** stoc k, is on the

B o a r d of Dir e c t or s, a n d owns a t le a s t the pe r c e n ta ge of voting stoc k ne e d e d to ove r c o me the super ma jority voting requ irem en ts w h ich exist fo r sh areh o l ders to appro v e co rpo r ate

a c tions.

____ d) Mo re t h an o n e di s a dvan t a g e d i n di vi du al o w n s at l e as t 51% o f al l **v o**  **ting** stock, a ll

suc h ind i vid u a l s se r v e on the B o a r d of Dir e c t or s, no supe r ma jor i ty voting r e quir e m e n ts

e x ist f o r sha r e hold e r s to a ppr ove c o r p or a t ion a c tions, a n d the d i sa d v a n ta ge d

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1d) ( C o r po r a tio ns ) 

### 6sha r e hold e r s c a n d e monstr a t e the y ha ve ma d e e n f o r c e a ble a r r a nge m e n ts to pe r m it one of

the m to vote the stoc k of a ll a s a bloc k without hold i ng a sha r e hold e r me e t ing.

____ e) Mo re t h an o n e di s a dvan t a g e d i n di vi du al o w n s at l e as t 51% o f al l **v o**  **ting** stock, a ll

suc h ind i vid u a l s se r v e on the B o a r d of Dir e c t or s, in tota l a ll own a t le a s t the pe r c e n ta ge of voting stoc k

n eeded to o v erco m e th e existin g super m a j o rity vo tin g req u irem en ts w h ich ex ist fo r sh areh o l ders to

appro v e co rpo r ate acti o n s , an d th e di s a dvan tag e d i n di vi dual s can dem o n s trate th ey h a ve m a de

e n f o r c e a ble a r r a nge m e n ts to pe r m it one of the m to vote the stoc k of a ll a s a bloc k without hold i ng a
sh areh o l der m eetin g.

OR

____ f) Th e di s a dvan t a g e d i n di vi du al (s ) co n t ro l t h e Bo ard o f D i rect o r s t h ro u g h act u al

numbe r s of voting d i r e c t or s.

____ g ) Th e di s a dvan t a g e d i n di vi du al (s ) co n t ro l t h e Bo ard o f D i rect o r s t h ro u g h w e i g h t e d voting and such voti ng is permitted by a pplica b le sta t e la w.

2. Li s t th e ti tl es o f al l o ffi cers , di recto r s , an d k e y m a n a g e rs an d th e h o u rs devo ted by s u ch i n di vi dual s to

the ma na ge me nt of the a pplic a n t busine ss.

Nam e Title Ho urs

_____________________ __________ _______

_____________________ __________ _______

_____________________ __________ _______

_____________________ __________ _______

3

. Is the CE O, Presid ent or a n y d i sa d v a n ta ged f u ll- ti me ma na ger enga ged in or pla nning to enga ge in

o u t s i d e em pl o y m e n t ? ___ Y e s ___ N o . I f y e s , pro v i d e det a i l s as t o t h e ext e n t o f o u t s i d e em pl o y m e n t

or other business d e a lings includ ing d a ily hours of employment, loca tion a n d expla n a t ion a s to how

this outsid e employment d o es not conf lict with th e a b ility to ma na ge a n d control the d a ily opera t ions

of the a pplic a n t c onc e r n, pr ovid e a s A tta c h me nt E

- 1

.

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 ,

a n d / or stockhold e rs, of f i cers, d i rectors or thei r immed i a t e f a mily member s, ha d a prior business

rel a ti o n s h i p w i th an y i n di vi dual cl ai m i n g di s a dvan ta ged sta t us? This includ es such rela tionships a s

em pl o y er-em p l o y ee, s u pervi s o r -em p l 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

ye s, id e n tif y the pe r s on( s) a n d the type of busine ss r e la tionship, pr ovid e a s A tta c h me nt E

- 2

.

5

. Doe s a n y nond isa d va nta g e d ind i vid u a l r e c e ive c o mpe n sa tion in a n y f o r m , inc l ud ing d i vid e nd s, a s a
directo r , o fficer, o r em plo y ee th at exceeds th e co m p en satio n received by th e di s a dvan tag e d P r es i d en t

o r CEO ? ____ Y e s ____ N o . I f y e s , pro v i d e t h e t o t a l co m p en s a t i o n recei v ed by t h e P r es i d en t o r CEO

,

a n d the na me ( s ) a n d the a m ount of the tota l c o mpe n sa tion pa id to the nond isa d va nta g e d

ind i vid u a l ( s )

. If a n y nond isa d va nta g e d ind i vid u a l is mor e highly c o mpe n sa te d

, pr ovid e a sta t e m e n t

tha t justif ie s the ne e d f o r the nond isa d va nta g e d ind i vid u a l ( s ) to r e c e ive a highe r c o mpe n sa tion,

pr ovid e a s A tta c h me nt E

- 3

.

6. 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 tha t requires bond ing 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 g i 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, permits, ce rtif ica t ions, a n d bond ing required to opera t e the a pplica n t f i rm,

pr ovid e a s A tta c h me nt E

- 4

.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1d) ( C o r po r a tio ns ) 

### 77. Li s t th e n a m e s an d ti tl es o f al l i n di vi dual s who ha ve a c c e ss to the f i r m ’s ba nk a c c o unt.

Nam e Title

________________________ _______________________

________________________ _______________________

________________________

_______________________

________________________

_______________________

________________________

_______________________

8. D o an y i n di vi du al , (o t h er t h an t h e i n di vi du al (s ) cl ai m i n g di s a dvan t a g e d s t at u 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 g Arran 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

If yo u an sw ered yes to an y o f th e abo v e, please pro v id e specif ic d e ta ils ( i .e., na mes, titles, copies of

agreem en ts, leases, etc.) o f s u ch arran g em en ts , pro v ide as Attach m e n t E-5.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1d) ( C o r po r a tio ns ) 

### 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 to determine 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 SSN Date

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

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 6100-1d) (Corporations) 

### 9