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 Sole Proprietorships 

Business Profile: 

Name of applicant firm:____________________________________________________________________ 

Name of Sole Proprietor and Title:____________________________________________________________ 

SSN of Sole Proprietor:_________________________ 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. 

Are you certified by the Small Business Administration 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 yes, 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 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 (Form 6100-1a) 

(Sole Proprietorship) 

OMB Control No: 2090-0030 

Approval Expires: XX/XX/XX
Have you 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: 

_________________________________________________________________________________________ 

_________________________________________________________________________________________ 

Do you 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 (Form 6100-1a)

(Sole Proprietorship) 2
SECTION A 

Eligibility Statement - Designated Group Members

Social Disadvantage

1. As the proprietor claiming disadvantaged status, complete the following:

 

Name of Individual Other Last Citizen Place of Group Sex

Names Used Y/N Birth Membership 

_________________ ___________ ________ ___________ _______ _____ 

If you are not a U.S. citizen, stop here. You are not eligible to participate as a DBE under EPA’s 

DBE Certification Program. 

1a. If you are a naturalized United States 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. As the proprietor claiming disadvantaged status, complete the following:

 

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: 

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

For this section, any individual 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

EPA DBE Certification Application (Form 6100-1a)

(Sole Proprietorship) 3
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 your net worth less than $750,000, excluding your ownership interest in the applicant 

firm and your equity in your primary residence? ____ Yes ____ No. 

2. As the individual claiming disadvantaged status, list your personal net worth, excluding the 

ownership interest in the applicant firm and the equity in the primary residence. 

Name Average 2-year Personal Total 

 Income Net Worth Assets

________________________________ ______________ __________ __________ 

3. I, ___________________________, certify 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. 

EPA DBE Certification Application (Form 6100-1a)

(Sole Proprietorship) 4
SECTION D 

(All applicant firms must complete) 

Ownership

1. Have you, the individual 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-1: 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. 

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. 

Name of Disadvantaged Owner State Percent Transferred 

____________________________ _______ __________________ 

2. Have 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-2.

SECTION E 

(All applicant firms must complete) 

Control 

1. Does any individual other than the Sole Proprietor manage or conduct daily business operations 

of the applicant concern? If yes, provide name, title and dates.

Name/Title Date

___________________________________________________ __________________________ 

___________________________________________________ __________________________ 

2. Are you engaged in or plan to engage in outside employment? ___ Yes ___ No. If yes, explain 

as Attachment E-1. 

EPA DBE Certification Application (Form 6100-1a)

(Sole Proprietorship) 5
3. 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 includes such relationships as employer-employee, supervisoremployee, co-workers, investor-employee, etc. ___ Yes ___ No ___ N/A. If yes, identify the

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).

Name/Title Compensation from applicant firm 

(Include salaries, bonuses, etc.) 

_____________________________________ __________________________________ 

_____________________________________ __________________________________ 

5. 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

on Attachment E-4.

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

Name Title 

____________________________________ _________________________________ 

____________________________________ _________________________________ 

7. Does any individual(s), (other than the Sole Proprietor) 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 

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 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 (Form 6100-1a) 

(Sole Proprietorship) 7