### 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 Sole Proprietorships**

**Business Profile :** 

Name of app licant firm:____________________________________________________________________

Name of Sole Prop rietor an d Title:____________________________________________________________

SSN of Sole Proprietor:_________________________ 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 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 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.

Are you certified by the Small Business Administrati on under its 8(a) Business Development Program? ___ Yes ___ No. If yes, provide PRO-Net number ______________________________________________

Are you certified by the Small Business Administration under its Small Disadvantaged Business (SDB) Program? ___ Yes ___ No. If ye s, provide PRO- Net number ____________________________________

Are you certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide State(s) and ID number(s) ___________________________________________________________________

Are you certified by a State govern ment, 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 (Form 6100-1a) (Sole Proprietorship) OMB Control No: 2090-0030 Approval Expires: XX/XX/XXHave yo u ever been den i ed certificatio n by a Federa l ag en cy , St at e g o vern m e n t , loca l government, Ind i a n 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 fy e s , pro v i d e a co py o ft h e prior determina t ion ofa ttempts to obta in certif ica t ion:

_________________________________________________________________________________________

_________________________________________________________________________________________

D 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 e s ___ N o . I fy 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 ionA p p licat ion( F or m6100- 1a) (So l e Pro pri e t o rsh i p) 

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

**Social Disadvantage**

1. As t h e pro p ri et o r cl ai m i n gdi s a dvan t a g e d s t at u s , co m p l e t e t h e fo l l o w i n g :

Na me ofInd i vid u a l Othe r L a st C i tiz e n Pla c e of Gr oup S e x Na mes Used Y/N Birth M e mbership

_________________ ___________ ________ ___________ _______ _____

If you a r e not 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.

1a. I fy o u are a n a t u ral i z ed Un i t ed St at es 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 ofc 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. As th e pro p rieto r claim i n gdi sa d v a n ta ged sta t us, complete the f o llowing:

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

_______________________________ ________ ________ _____

1a. I fy 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: ( a ) na tur a liz a t ion numbe r ; ( b ) d a te ofc i tiz e nship; a n d ( c ) c o unty, sta t e a n d c o ur t.

**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 been 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

E P A D B E Ce r t if icat ionA p p licat ion( F or m6100- 1a) (So l e Pro pri e t o rsh i p) 

### 3une 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 ha 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 **(A ll applicant firms must co**  **mplete)**


## Economic Disadvantage

1. I s y o u r n e t w o rt hl e s s t h an $750,000, excl u d i n g y o u r o w n e rs h i p in teres t in th e applican t fi rman d y o u r eq u i t y i n y o u r pri m ary res i den c e? ____ Y e s ____ N o

.

2. As th e i n di vi dual 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

owne r s hip inte r e st in the a pplica n t f i rm a n d the equity in the 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 I n c o m e N e t W o r t h A s s e t s

________________________________ ______________ __________ __________

3. I
, ___________________________, cert i f y t h at becau s e o fraci al an d/ o r et h n i c prej u d i c e, an d/ o r 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

.

E P A D B E Ce r t if icat ionA p p licat ion( F or m6100- 1a) (So l e Pro pri e t o rsh i p) 

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



## Owne **r ship** 

1. H a ve y o u , t h e i n di vi du al cl ai m i n g di 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

. If yes, provid e the f o llowing inf o rma t ion a s A tta ch ment D- 1 : the da te oftra n sf er; to whom the

a ssets were tra n sf erred ; a m ount pa id f o r the a ssets ; an d th e m a rket value o fth e assets at th e tim e oftra 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 ofspe c ia l oc c a sions, suc ha 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 iff o r ed uca t iona l, me d i ca l or essentia l support purposes.

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

**.** I fy 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
, pl ease co m p lete th e ch art belo w , an d pro v ide eviden ce th at yo u ha ve a ma jority interest in the business.

Nam e o f D i sadvan taged O w n e r State Percen t Tran sferred

____________________________ _______ __________________

2. 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 fy e s , di d

owne r s hip a f f e c t the d i sa d v a n ta ge d sta t us ofyour f i r m ? Ple a se e x pla i n a s A tta c h me nt D- 2

.



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



## Contr **o l** 

1

. Does a n y ind i vid u a l other tha n the S o le Prop rietor ma na ge or cond uc t d a ily business opera t ions ofthe a pplic a n t c onc e r n? If ye s, pr ovid e na me , title a n d d a te s.

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

___________________________________________________ __________________________

___________________________________________________ __________________________

2. Are y o u en g a g e d i n o r pl an t o en g a g e i n o u t s i d e em pl o y m e n t ? ___ Y e s ___ N o . I f y es , explain

as At t a ch m e n t E-1.

E P A D B E Ce r t if icat ionA p p licat ion( F or m6100- 1a) (So l e Pro pri e t o rsh i p) 

### 53. If the answer to question 2 is yes, have any of the nondisadvantaged individuals involved in the management of the applicant firm, or their immediate family members, had a prior business relationship with you? This in cludes such relationships as employer-employee, supervisoremployee, co-workers, investor-employee, etc. ___ Yes ___ No ___ N/A. If yes, identify th e person(s) and the type of business relationship as Attachment E-2.

4. List the total compensation from the applicant firm of all owners and/or key managers of the firm. (If necessary, provide additional information as Attachment E-3).

Na me/Title Compensa tion from applicant firm ( Include salaries, bonuses, etc.)

_____________________________________ __________________________________

_____________________________________ __________________________________

5. Does the applicant firm operate in an industry which requires bonding or professiona l 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 fi rm on Attachment E-4.

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

Name T itle

____________________________________ _________________________________

**____________________________________ _________________________________** 

7. Does any individual(s), (other than th e Sole Proprietor) or entities prov ide:

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

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-5.

EPA DBE Certification Application (Form 6100-1a) (Sole Proprietorship) 

### 6**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. Acknowled**  **g es that EPA’s approval of an application does not affect the Government’s ri**  **g ht**  **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 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 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 (Form 6100-1a) (Sole Proprietorship) 

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