On September 6, 2012, the U.S. Department of Transportation published the Notice of Proposed 

Rulemaking (NPRM) entitled, “Disadvantaged Business Enterprise: Program Implementation 

Modifications.” See 77 Fed. Reg. 54952 (Sept. 6, 2012). Included in this NPRM are proposed 

revisions to Appendix F, the Uniform Certification Application Form, id. at 54981-5016, and a 

proposed new Appendix G, the Personal Net Worth Statement, id. at 55017-25. However, 

subsequent to publication, the Department noticed that the format of these proposed forms was 

altered during the printing process, leading to potential confusion as to what the Department 

proposed. The Department notes, though, that the forms published in the Federal Register 

contain the correct information. 

The Department is now making available in the docket for this rulemaking the attached 

document, which contains a version of both the Uniform Certification Application Form 

(Appendix F) and the Personal Net Worth Statement (Appendix G) in the correct format. These 

versions are identical in content to the forms published in the Federal Register on September 6, 

2012, but more clearly show the correct format of the proposed forms. 
 Appendix F 

U.S. DEPARTMENT OF 

TRANSPORTATION 

UNIFORM CERTIFICATION APPLICATION 

DISADVANTAGED BUSINESS ENTERPRISE / 

AIRPORT CONCESSION DISADVANTAGED 

BUSINESS ENTERPRISE 

49 C.F.R. PARTS 23 and 26 

Send Application To: 

[UCP PARTICIPATING MEMBER] 

[Address] 

[Phone:] [Fax] 

A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS 

SUFFICIENT CAUSE FOR DENIAL OF CERTIFICATION, REVOCATION OF A PRIOR APPROVAL, INITIATION 

OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR ENTITY 

MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES AVAILABLE 

PURSUANT TO APPLICABLE FEDERAL AND STATE LAW. 

____________________________________________________________________________________________________ 

In collecting the information requested by this form, the Department of Transportation (Department) complies with the provisions of the Federal 

Freedom of Information and Privacy Acts (5 U.S.C. 552 and 552a). The Privacy Act provides comprehensive protections for your personal information. 

This includes how information is collected, used, disclosed, stored, and discarded. Your information will not be disclosed to third parties without your 

consent. The information collected will be used solely to determine your firm's eligibility to participate in the Department's Disadvantaged Business 

Enterprise Program as defined in 49 CFR section 26.5 and the Airport Concession Disadvantaged Business Enterprise Program as defined in 49 CFR 

section 23.3. You may review DOT’s complete Privacy Act Statement in the Federal Register published on April 11, 2000 (65 FR 19477). 
Roadmap for Applicants 

1. Should I apply?

You may be eligible to participate in the DBE/ACDBE program if you answer "Yes" to the following:

 Is your firm organized as a for-profit business that performs or seeks to perform transportation related 

work for a recipient of Federal Transit Administration, Federal Highway Administration, or Federal 

Aviation Administration funds? 

 Is your firm at least 51% owned by a socially and economically disadvantaged individual(s) who also 

controls the firm? 

 Is the disadvantaged owner a U.S. citizen or lawfully admitted permanent resident of the U.S.? 

 Is your firm a small business that meets the Small Business Administration's (SBA's) size standard and 

does not exceed $22.41 million in gross annual receipts for DBE ($52.47 million for ACDBEs)? (Note, 

other size standards apply ACDBE applications from banks/financial institutions, car rental companies, 

pay telephone firms, and automobile dealers.) 

2. How do I apply? 

You must complete and submit this certification application and related material to an agency in your 

home state; and second participate in an on-site interview conducted by that agency. The attached 

document checklist can help you locate the items you need to submit to the agency with your completed 

application. If you fail to submit the required documents, your application may be delayed and/or denied. 

3. Who will contact me about my application and what are the eligibility standards? 

The DBE and ACDBE Programs require that all U.S. DOT recipients of federal assistance must 

participate in a statewide Unified Certification Program (UCP). The UCP is a one-stop certification 

procedure that eliminates the need for your firm to obtain certification from multiple agencies within the 

state. The UCP is responsible for certifying firms and maintaining a database of certified DBEs and 

ACDBEs for DOT grantees, pursuant to the eligibility standards found in 49 CFR Parts 23 and 26. 

4. Where can I find more information? 

U.S. DOT—http://www.osdbu.dot.gov/DBEProgram/index.cfm (This site provides useful links to the 

rules and regulations governing the DBE/ACDBE programs, questions and answers, and other pertinent 

information) 

http://www.census.gov/eos/www/naics/ (provides a listing of NAICS codes) and 

http://www.sba.gov/content/table-small-business-size-standards (SBA has established a Table of Small

Business Size Standards that is matched to the North American Industry Classification System (NAICS)

for industriesprovides a listing of NAICS codes and size standards) 

Under 49 CFR §26.107, dated February 2, 1999, if at any time, the Department or a recipient has reason to believe that any 

person or firm has willfully and knowingly provided incorrect information or made false statements, the Department may 

initiate suspension or debarment proceedings against the person or firm under 49 CFR Part 29, Governmentwide Debarment 

and Suspension (nonprocurement) and Governmentwide Requirements for Drug-free Workplace (grants), take enforcement 

action under 49 CFR Part 31, Program Fraud and Civil Remedies, and/or refer the matter to the Department of Justice for 

criminal prosecution under 18 U.S.C. 1001, which prohibits false statements in Federal programs.
 INSTRUCTIONS FOR COMPLETING THE 

DISADVANTAGED BUSINESS ENTERPRISE 

AIRPORT CONCESSIONS DISADVANTAGED BUSINESS ENTERPRISE 

UNIFORM CERTIFICATION APPLICATION 

 NOTE: If you require additional space for any question in this application, please attach additional sheets or copies as needed, 

taking care to indicate on each attached sheet/copy the section and number of this application to which it refers. 

Section 1: CERTIFICATION INFORMATION 

A. Basic Contact Information 

(1) State the contact person and title of the person 

completing this application and the person who will 

serve as your firm's primary contact for this 

application. 

(2) State the legal name of your firm, as indicated in 

your firm's Articles of Incorporation or charter. 

(3) State the primary phone number of your firm. 

(4) State a secondary phone number, if any. 

(5) State your firm's fax number, if any. 

(6) State the contact person's email address. 

(7) State your firm's website address, if any. 

(8) State the street address of your firm (i.e. the 

physical location of its offices—not a post office box 

address). 

(9) State the mailing address of your firm, if it is 

different from your firm’s street address. Check the 

box if this is homes based business and identify who 

holds title to the property. 

B. Prior/Other Certifications and Applications 

(10) Check the appropriate box indicating for which 

program your firm is currently certified. If you are 

already certified as a DBE/ACDBE, indicate in the 

appropriate box the name of the certifying agency that 

certified your firm, and also indicate whether your 

firm has undergone an onsite visit. If your firm has 

already undergone an onsite visit/review, indicate the 

dates of the review(s) and the state UCP(s) that 

conducted the review. 

(11) Indicate whether your firm or any of the persons 

listed has ever been denied certification as a DBE, 

8(a), or SDB firm, or state and local MBE/WBE firm. 

Indicate if the firm has ever been decertified from one 

of these programs. Indicate if the application was 

withdrawn or whether the firm was debarred, 

suspended, or otherwise had its bidding privileges 

denied or restricted by any state or local agency, or 

Federal entity. If your answer is yes, identify the name 

of the agency, and explain fully the nature of the 

action in the space provided. Indicate if you have ever 

appealed this decision to the Department and if so, 

attach a copy of USDOT’s final agency decision(s). 

Section 2: GENERAL INFORMATION 

A. Business profile: 

 

(1) Give a concise description of the firm’s primary 

activities, the product(s) or services the company 

provides, or type of construction. If your company 

offers more than one product/service, list primary 

product or service first. Use additional paper if 

necessary. This description may be used in our 

database and the UCP online directory if you are 

certified as a DBE. 

(2) Identify the appropriate NAICS Code for the 

line(s) of work you identified in your business profile. 

(3) State the date on which your firm was officially 

established as stated in your firm’s Articles of 

Incorporation or charter. 

(4) State the date on which you and/or each other 

owner took ownership of the firm. 

(5) Check the appropriate box that describes the 

manner in which you and each other owner acquired 

ownership of your firm. If you checked “Other,” 

explain in the space provided. 

(6) Check the appropriate box that indicates whether 

your firm is “for profit.” NOTE: If you checked “No,” 

then you do NOT qualify for the DBE/ACDBE 

program and should not complete the rest of this 

application. All participating firms must be for-profit 

enterprises. If the firm is a for profit enterprise, 

provide the Federal Tax ID number as stated on your 

firm’s filed tax returns, if you have one. This could 

also be the Social Security number of the owner of 

your firm. 

(7) Check the appropriate box that describes the legal 

form of ownership of your firm, as indicated in your 

firm’s Articles of Incorporation or similar document. 

If you checked “Other,” briefly explain in the space 

provided. 

(8) Check the appropriate box that indicates whether 

your firm has ever existed under different ownership, 

a different type of ownership, or a different name. If 

you checked “Yes,” explain the circumstances in the 

space provided. 

(9) Indicate in the spaces provided how many 

employees your firm has, specifying the number of 

employees who work on a full-time, part-time, and 

seasonal basis. Attach a list of employees, their job 

titles, and dates of employment, to your application. 

(10) Specify the total gross receipts of your firm for 

each of the past three years, as declared in your firm’s 

filed tax returns. You must submit complete copies of 

the firm’s State and Federal tax returns for each year 
and audited financial statements (if available). If there 

are any affiliates or subsidiaries of the applicant firm 

or owners, you must submit complete copies of these 

firm(s) state and federal tax returns. Affiliation is 

defined in 49 CFR §26.5 and 13 CFR part 121.

B. Relationships and Dealings with Other 

Businesses 

(1) Check the appropriate box that indicates whether 

your firm is co-located at any of its business locations, 

or whether your firm shares a telephone number(s), a 

post office box, any office space, a yard, warehouse, 

other facilities, any equipment, financing, or any 

office staff and/or employees with any other business, 

organization or entity of any kind. If you answered 

“Yes,” then specify the name of the other firm(s) and 

fully explain the nature of your relationship with these 

other businesses by identifying the business or person 

with whom you have any formal, informal, written, or 

oral agreement. Provide an explanation of any items 

shared with other firms in the space provided. 

(2) Check the appropriate box indicating whether any 

other firm currently has or had an ownership interest 

in your firm at present or at any time in the past. 

(3) Check the appropriate box that indicates whether 

at present or at any time in the past your firm: 

(a) has been a subsidiary of any other firm; 

(b) existed as a partnership in which one or more of 

the partners are/were other firms; 

(c) has owned any percentage of any other firm; and 

(d) has had any subsidiaries of its own. 

(e) has served as a subcontractor with another firm 

constituting more than 25% of your firm’s receipts? 

If you answered “Yes” to any of the questions in (3)(ae), describe the subsidiaries, partnership interests or 

other arrangements. In addition, explain whether these 

relationships are continuing today, or if not, when they 

ended. 

C. Immediate Family Member, Manager, or 

Employee Businesses 

Check the appropriate to indicate whether any of your 

immediate family members, managers, or employees, 

own, manage, or are associated with another company. 

An “immediate family member” is any person who is 

your father, mother, husband, wife, son, daughter, 

brother, sister, grandmother, grandfather, grandson, 

granddaughter, mother-in-law, or father-in-law. If you 

answered “Yes,” provide the name of each person, 

your relationship to them, the name of the company 

they own or manage the type of business, and whether 

they own or manage the company. 

Section 3: OWNER INFORMATION 

Identify all individuals or holding companies with any 

ownership interest in your firm, providing the information 

requested below (if your firm has more than one owner, 

provide completed copies of this section for each additional 

owner): 

A. Background Information 

(1) Give the name of the owner. 

(2) State his/her title or position within your firm. 

(3) Give his/her home phone number. 

(4) State his/her home (street) address. 

(5) Indicate this owner’s gender. 

(6) Identify the owner’s ethnic group membership. If 

you checked “Other,” specify this owner’s ethnic 

group/identity not otherwise listed. 

(7) Check the appropriate box to indicate whether 

this owner is a U.S. citizen. If this owner is not a U.S. 

citizen, check the appropriate box that indicates 

whether this owner is a lawfully admitted permanent 

resident. If this owner is neither a U.S. citizen nor a 

lawfully admitted permanent resident of the U.S., then 

this owner is NOT eligible for certification as a DBE 

owner. This, however, does not necessarily disqualify 

your firm altogether from the DBE program if another 

owner is a U.S. citizen or lawfully admitted permanent 

resident and meets the program’s other qualifying 

requirements. 

(8) (a)(i) State the personal net worth of each owner 

claiming to be socially and economically 

disadvantaged applying for DBE qualification. (Each 

owner claiming disadvantaged status must submit a 

separate statement. (ii) State whether a trust has been 

created for the benefit of this owner. If you answered 

“Yes,” briefly explain the nature, history, purpose, and 

current value of the trust(s). NOTE: You only need to 

complete this section for each owner that is 

applying for DBE qualification (i.e., for each owner 

who is claiming to be “socially and economically 

disadvantaged” and whose ownership interest is to 

be counted toward the control and 51% ownership 

requirements of the DBE program) Use the PNW 

form at the end of this application to compute each 

disadvantaged owner’s PNW. 

B. Ownership Interest 

(1) State the number of years during which this 

owner has been an owner of your firm. 

(2) Indicate the dollar value of this owner’s initial 

investment to acquire an ownership interest in your 

firm, broken down by cash, real estate, equipment, 

and/or other investment. Describe how you acquired 

the shares. Attach documentation substantiating this 

investment. 

(3) Indicate the number, percentage of the total, 

class, date acquired, of stock acquired by the owner. 

(4) Describe the familial relationship of this owner to 

each other owner of your firm and employees. 

(5) Check the appropriate box that indicates whether 

this owner performs a management or supervisory 

function for any other business. If you checked “Yes,” 

state the name of the other business and this owner’s 

title or function held in that business. 
(6) (a) Check the appropriate box that indicates 

whether this owner owns or works for any other 

firm(s) that has any relationship with your firm. If you 

checked “Yes,” identify the name of the other 

business, the nature of the business relationship, and 

the function at the firm. 

(b) If the owner works for any other firm, non-profit 

organization, or is engaged in any other activity more 

than 10 hours per week, please identify this activity. 

Section 4: CONTROL 

A. Identify the firm’s Officers and Board of Directors 

(1) In the space provided, state the name, title, date 

of appointment, ethnicity, and gender of each officer 

of your firm. 

(2) In the space provided, state the name, title, date 

of appointment, ethnicity, and gender of each 

individual serving on your firm’s Board of Directors. 

(3) Check the appropriate box to indicate whether 

any of your firm’s officers and/or directors listed 

above performs a management or supervisory function 

for any other business. If you answered “Yes,” 

identify each person by name, his/her title, the name 

of the other business in which s/he is involved, and 

his/her function performed in that other business. 

(4) Check the appropriate box that indicates whether 

any of your firm’s officers and/or directors listed 

above own or work for any other firm(s) that has a 

relationship with your firm. If you answered “Yes,” 

identify the name of the firm, the individual’s name, 

and the nature of his/her business relationship with 

that other firm. 

(5) Check the appropriate box to that indicates 

whether the applicant business and/or owner is 

involved in any present or pending litigation or 

administrative proceedings. If you answered “Yes,” 

provide details of the litigation or administrative 

proceedings. 

B. Duties of Owners, Officers, Directors, Managers, 

and Key Personnel 

In the chart provided, specify the roles of the majority 

and minority owners, directors, officers, and 

managers, and key personnel who perform significant 

functions for the business. Make enough copies of this 

form to provide information on each and every person. 

Submit résumés for each owner and non-owner 

identified below. State the name of the individual, 

title, race, percentage of the firm that they own, 

gender, salary and benefits. 

Circle the frequency of each person’s involvement as 

follows: “always, frequently, seldom, or never” 

(1) Setting policy for company direction/scope, or 

financial decisions. 

(2) Bidding and estimating including calculation of 

cost estimates, bid preparation and submission; 

(3) Making purchasing decisions 

(4) Marketing and sales 

(5) Supervising field operations 

(6) Attending bid openings and lettings 

(7) Perform office management, such as billing, 

accounts receivable, and accounts payable 

(8) Hires and fires management staff 

(9) Hire and fire field staff or crew 

(10) Designates profit spending or investment 

(11) Obligates the business by 

contract/credit/bond/insurance 

(12) Purchase equipment 

(13) Signs business checks 

Check the appropriate box that indicates whether any 

of the persons listed in (1) through (13) above perform 

a management or supervisory function for any other 

business. If yes identify the person, business, and their 

title/function. Identify if any of the persons listed 

above own or work for any other firm(s) that has a 

relationship with this firm (e.g. ownership interest, 

shared office space, financial investment, equipment, 

leases, personnel sharing, etc.) If you answered “Yes,” 

describe the nature of his/her business relationship 

with that other firm. 

C. Indicate firm inventory in the following categories: 

(1) Equipment and Vehicles 

State the type, make and model, and current dollar 

value of each piece of equipment and motor vehicle 

held and/or used by your firm. Indicate whether each 

piece is either owned or leased by your firm and where 

this item is stored. 

(2) Office Space 

State the street address of each office space held 

and/or used by your firm. Indicate whether your firm 

or owner owns or leases the office space and the 

current dollar value of that property or its lease. 

(3) Storage Space 

State the street address of each storage space held 

and/or used by your firm. Indicate whether your firm 

or owner owns or leases the storage space and the 

current dollar value of that property or its lease. 

D. Does your firm rely on any other firm for 

management functions or employee payroll? 

Check the appropriate box that indicates whether your 

firm relies on any other firm for management 

functions or for employee payroll. If you answered 

“Yes,” briefly explain the nature of that reliance and 

the extent to which the other firm carries out such 

functions. 

E. Financial / Banking Information 

Banking Information. State the name and address of 

your firm’s bank. In the space provided, identify the 

individuals able to sign checks on this account. 
Bonding Information. State your firm’s Binder 

Number. State the name of your firm’s bond agent 

and/or broker. Give your agent’s/broker’s phone 

number. Give your agent’s/broker’s address. State 

your firm’s bonding limits (in dollars), specifying both 

the aggregate and project limits. 

F. Identify all sources, amounts, and purposes of 

money loaned to your firm, including the names of 

persons or firms securing the loan. 

State the name and address of each source, the name 

of person securing the loan, original dollar amount and 

the current balance of each loan, and the purpose for 

which each loan was made to your firm. 

G. List all contributions or transfers of assets to/from 

your firm and to/from any of its owners or another 

individual over the past two years: 

Indicate in the spaces provided, the type of 

contribution or asset that was transferred, its current 

dollar value, the person or firm from whom it was 

transferred, the person or firm to whom it was 

transferred, the relationship between the two persons 

and/or firms, and the date of the transfer. 

H. List current licenses/permits held by any owner or 

employee of your firm. 

List the name of each person in your firm who holds a 

professional license or permit, the type of permit or 

license, the expiration date of the permit or license, 

and the license/permit number and issuing State of the 

license or permit. 

I. List the three largest contracts completed by your 

firm in the past three years, if any. 

List the name of each owner or contractor for each 

contract, the name and location of the projects under 

each contract, the type of work performed on each 

contract, and the dollar value of each contract. 

J. List the three largest active jobs on which your 

firm is currently working. 

For each active job listed, state the name of the prime 

contractor and the project number, the location, the 

type of work performed, the project start date, the 

anticipated completion date, and the dollar value of 

the contract. 

AIRPORT CONCESSION (ACDBE) APPLICANTS 

Identify the concession space, address and location at the 

airport, the value of the property or lease, and fees/lease 

payments paid to the airport. Provide information 

concerning any other airport concession businesses the 

applicant firm or any affiliate owns and/or operates, 

including name, location, type of concession, and start date 

of the concession enterprise. 

AFFIDAVIT & SIGNATURE 

The Affidavit of Certification must accompany your 

application for DBE/ACDBE certification. Carefully read 

the attached affidavit in its entirety. Fill in the required 

information for each blank space, and sign and date the 

affidavit in the presence of a Notary Public, who must then 

notarize the form. 
 UNIFORM DBE/ACDBE CERTIFICATION APPLICATION Date________ 

U.S. DOT Uniform DBE / ACDBE Certification Application  Page 1 of 14 

Section 1: CERTIFICATION INFORMATION 

A. Basic Contact Information 

(1) Contact person and Title: ____________________ 

 _____________________ 

(2) Legal name of firm: _________________________ 

_____________________________________________ 

(3) Phone #: (___) _____ - _______ (4) Other Phone #: (____) _____ - _____ (5) Fax #: (____) ______ - _____ 

(6) E-mail: _________________________________ (7) Firm Websites: ________________________________ 

(8) Street address of firm (No P.O. Box): 

________________________________________

City: 

________________ 

County/Parish: 

___________________ 

State: 

______ 

Zip: 

________ - ____ 

(9) Mailing address of firm (if different): 

___________________________________ 

City: 

________________

County/Parish: 

___________________ 

State: 

______ 

Zip: 

________ - ____ 

Home Based Business?  Yes No If Yes, who holds the title to the property? ______________________ 

B. Prior/Other Certifications and Applications 

(10) Is your firm currently certified for any of the following programs? (If Yes, check appropriate box(es)) 

 DBE  ACDBE Names of certifying agencies: ______________________________________________ 

List the dates of any site visits conducted by your home state and any other states or UCP members: 

Date ____/ ____/____ State/UCP Member: ___________________________ 

Date ____/ ____/____ State/UCP Member: ___________________________ 

Date ____/ ____/____ State/UCP Member: ___________________________ 

You will be required to provide a copy of the above on-site reports as part of this application process. 

Already certified in your home state?  STOP! You may not have to complete this application. Ask your 

state UCP about the streamlined application process.

(11) Has your firm (under any name) or any firm owned or controlled by your firm’s owners, Board of 

Directors, officers or management personnel, ever been: 

 (a) Denied certification as a DBE, ACDBE, 8(a), SDB, MBE/WBE firm?  Yes No 

 (b) Decertified from these programs?  Yes No 

(c) Withdrawn an application for these programs, or debarred or suspended or otherwise had bidding privileges 

denied or restricted by any state or local agency, or Federal entity?  Yes No 

If yes to any of the above, identify all state, local, or Federal agencies and explain the nature of the action(s): 

___________________________________________________________________________________________ 

If you appealed this decision to USDOT, what was the result? Please attach a copy of USDOT’s decision(s). 

___________________________________________________________________________________________ 

_____________________________________________________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 2 of 15 

Section 2: GENERAL INFORMATION 

A. Business Profile: (1) Give a concise description of the firm’s primary activities, the product(s) or services the 

company provides, or type of construction. If your company offers more than one product/service, list the primary 

product or service first. Please use additional paper if necessary. This description may be used in our database and 

the UCP online directory if you are certified as a DBE or ACDBE. 

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

____________________________________________________________________________________________ 

____________________________________________________________________________________________ 

(2) Applicable NAICS Codes for this line of work include: ______ ______ _______ _______ ________ ______ 

(3) This firm was established on ____/____/____ (4) I/We have owned this firm since: ____/____/____ 

(5) Method of acquisition (Check all that apply): 

  Started new business  Bought existing business  Inherited business  Secured concession 

  Merger or consolidation  Other (explain) _____________________________ 

(6) Is your firm “for profit”?  Yes No→ 

Employer’s ID # ________________________ 

Federal Tax ID# ________________________ 

 

 STOP! If your firm is NOT for-profit, then you do NOT 

qualify for this program and should not fill out this application. 

(7) Type of Legal Business Structure: (check all that apply): 

 Sole Proprietorship  Limited Liability Partnership 

 Partnership Corporation 

 Limited Liability Corporation  Joint Venture (Identify all JV partners __________________________) 

 Applying as an ACDBE 

 Other, Describe: _______________________________________________ 

(8) Has your firm ever existed under different ownership, a different type of ownership, or a different name? 

  Yes  No If Yes, explain: _______________________________________________________________ 

____________________________________________________________________________________________

____________________________________________________________________________________________ 

(9) Number of employees: Full-time ________ Part-time ________ Seasonal ________Total _________ 

 

 (Please attach a list of employees, their job titles, and dates of employment, to your application). 

(10) Specify the firm’s gross receipts for the last 3 years.

You must submit complete copies of the firm’s State and 

Federal tax returns for each year, and audited financial 

statements (if available). If there are any affiliates or 

subsidiaries of the applicant firm or owners, you must submit 

complete copies of these firms’ State and Federal tax returns. 

Year _______ Total receipts $ _________________ 

 

Year _______ Total receipts $ _________________ 

 

Year _______ Total receipts $ _________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 3 of 15 

B. Relationships and Dealings with Other Businesses 

(1) Is your firm co-located at any of its business locations, or does it share a telephone number, P.O. Box, 

office or storage space, yard, warehouse, facilities, equipment, inventory, financing, office staff, and/or 

employees with any other business, organization, or entity?  Yes  No If Yes, explain fully the nature of 

your relationship with these other businesses by identifying the business or person with whom you have any formal, 

informal, written, or oral agreement. Also detail the items shared. 

____________________________________________________________________________________________ 

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________ 

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________ 

(2) Has any other firm had an ownership interest in your firm at present or at any time in the past? 

 Yes  No If Yes, explain____________________________________________________________________ 

(3) At present, or at any time in the past, has your firm:

 (a) been a subsidiary of any other firm?  Yes  No 

 (b) existed as a partnership in which one or more of the partners are/were other firms?  Yes  No 

 (c) owned any percentage of any other firm?  Yes  No 

 (d) had any subsidiaries?  Yes  No 

 (e) been a subcontractor with another firm constituting more than 25% of your firm’s receipts?  Yes  No 

If you answered “Yes” to any of the questions in (2) and/or (3)(a)-(e), describe the subsidiaries, partnership interests, 

or other arrangements and whether this continues. Please attach a separate sheet if necessary. 

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________ 

C. Immediate Family Member, Manager, or Employee Businesses 

Do any of your immediate family members, managers, or employees own, manage, or are associated with another 

company?  Yes  No If Yes, then list: (Please attach extra sheets, if needed): 

 Name Relationship Company Type of Business Own/Manage/Associated with 

1. __________________________________________________________________________________________ 

2. _________________________________________________________________________________________ 

3. _________________________________________________________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 4 of 15 

Section 3: MAJORIY OWNER INFORMATION

A. In this section, specify the majority owner of the firm holding 51% or more ownership interest. 

 (1) Full Name: 

____________________________ 

(2) Title: 

_________________________ 

(3) Home Phone #: 

( ) _____ - _______ 

(4) Home Address (Street and Number): 

____________________________________________________ 

City: 

____________________ 

State: 

________ 

Zip: 

_________ - ______ 

(5) Gender:  Male  Female 

(6) Ethnic group membership 

(Check all that apply): 

 Black  Hispanic 

 Asian Pacific  Native American 

 Subcontinent Asian 

 Other (specify) ___________________ 

(7) U.S. Citizenship: 

Birth Naturalized 

Lawfully Admitted Permanent Resident

(8)(a) Economic Disadvantaged Status: Complete this 

section only for each owner claiming to be socially and 

economically disadvantaged applying for DBE qualification. 

(i) What is the Personal Net Worth of the owner applying for 

DBE/ACDBE qualification? $______________ 

(Use and attach the Personal Financial Statement form attached to 

this application. Each owner must submit a separate statement). 

(ii) Has any trust been created for the benefit of this 

disadvantaged owner(s)?  Yes  No 

If Yes, provide a copy (Attach additional sheets if needed):

B. Ownership Interest 

(1) Number of years as owner: _______ (2) Initial investment to Type Dollar Value 

acquire ownership Cash $ 

interest in firm: Real Estate $ 

 Equipment $ 

 Other $ 

Describe how you acquired your business 

Started business myself 

It was a gift from: ______________________ 

I bought it from: _______________________ 

 I inherited it from: _____________________ 

Other 

(Attach documentation substantiating your investment)

(3) Percentage owned: ________ % 

 Class of stock owned: ______ 

 Date acquired ______ 

(4) Describe familial relationship to other owners and 

employees:_____________________________________

_______________________________________________

_______________________________________________

_______________________________________________ 

_______________________________________________ 

_______________________________________________ 

(5) Does this owner perform a management or supervisory function for any other business?  Yes  No 

If Yes, identify: Name of Business: __________________________________ Function/Title: _______________________________

(6)(a) Does this owner own or work for any other firm(s) that has a relationship with this firm? (e.g., ownership 

interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)  Yes  No 

Identify than name of the business, and the nature of the relationship, and the owner’s function at the firm: 

___________________________________________________________________________________________ 

(b) Does this owner work for any other firm, non-profit organization, or is engaged in any other activity 

more than 10 hours per week? If yes, identify this activity: __________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 5 of 15 

Section 3: OWNER INFORMATION, Cont’d. 

A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in 

your firm (If more than one owner holding less than 51%, attach separate sheets for each additional owner)

 (1) Full Name: 

____________________________ 

(2) Title: 

_________________________ 

(3) Home Phone #: 

( ) _____ - _______ 

(4) Home Address (street and number): 

____________________________________________________ 

City: 

____________________ 

State: 

________ 

Zip: 

_________ - ______ 

(5) Gender:  Male  Female 

(6) Ethnic group membership 

(Check all that apply): 

 Black  Hispanic 

 Asian Pacific  Native American 

 Subcontinent Asian 

 Other (specify) ___________________ 

(7) U.S. Citizenship: 

Birth Naturalized 

Lawfully Admitted Permanent Resident:

(8)(a) Economic Disadvantaged Status: Complete this 

section only for each owner claiming to be socially and 

economically disadvantaged applying for DBE qualification 

(i) What is the Personal Net Worth of the owner applying for 

DBE/ACDBE qualification? $_______________ 

(Use and attach the Personal Financial Statement form attached to 

this application. Each owner must submit a separate statement). 

(ii) Has any trust been created for the benefit of this 

disadvantaged owner(s)?  Yes  No 

If Yes, please explain (attach additional sheets if needed): 

B. Ownership Interest 

(1) Number of years as owner: _______ (2) Initial investment to Type Dollar Value 

acquire ownership Cash $ 

interest in firm: Real Estate $ 

 Equipment $ 

 Other $ 

Describe how you acquired your business 

Started business myself 

It was a gift from: ______________________ 

I bought it from: _______________________ 

 I inherited it from: _____________________ 

Other 

Attach documentation substantiating your investment 

(3) Percentage owned: ________ % 

 Class of stock owned: ______ 

 Date acquired ______ 

(4) Describe familial relationship to other owners and 

employees:_____________________________________

______________________________________________

______________________________________________

______________________________________________ 

______________________________________________ 

______________________________________________ 

(5) Does this owner perform a management or supervisory function for any other business?  Yes  No 

If Yes, identify: Name of Business: __________________________________ Function/Title: _______________________________ 

(6)(a) Does this owner own or work for any other firm(s) that has a relationship with this firm? (e.g., ownership 

interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)  Yes  No 

Identify than name of the business, and the nature of the relationship, and the owner’s function at the firm: 

___________________________________________________________________________________________ 

(b) Does this owner work for any other firm, non-profit organization, or is engaged in any other activity 

more than 10 hours per week? If yes, identify this activity: ___________________________________________ 

____________________________________________________________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 6 of 15 

Section 4: CONTROL 

 A. Identify your firm’s Officers and Board of Directors 

 (If additional space is required, attach a separate sheet): 

Name Title 

Date 

Appointed Ethnicity Gender 

(1) Officers 

of the 

Company 

(a) 

(b) 

(c) 

(d) 

(e) 

(2) Board of 

Directors 

(a) 

(b) 

(c) 

(d) 

(e) 

(3) Do any of the persons listed above perform a management or supervisory function for any other 

business?  Yes  No If Yes, identify for each: 

Person: __________________________________ Title: _________________________________________________ 

Business: ________________________________ Function: ______________________________________________ 

Person: __________________________________ Title: _________________________________________________ 

Business: ________________________________ Function: ______________________________________________ 

(4) Do any of the persons listed (1) and/or (2) above own or work for any other firm(s) that has a relationship 

with this firm (e.g., ownership interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)? 

 Yes  No If Yes, identify for each: 

Firm Name: _______________________________ Person: _____________________________ 

Nature of Business Relationship: __________________________________________________________________________ 

(5) Is the applicant business and/or owner involved in any present or pending lawsuits? 

 Yes  No If Yes, provide details: 

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 7 of 15 

B. Duties of Owners, Officers, Directors, Managers, and Key Personnel 

 

Complete for all owners and non-owners who perform significant functions for the business. Make enough copies 

of this form to provide information on each and every person. Submit résumés for each person identified below. 

Circle the frequency of each person’s involvement as follows: 

 Majority Owner (51% or more) Minority Owner (49% or less) 

A= Always 

F = Frequently 

S = Seldom 

N = Never

Name: _______________________ 

Title: ________________________ 

Race:________________________ 

Percent Owned:________________ 

Gender: _____Male _____Female 

Salary: $______________________ 

Other Benefits $________________ 

Name: _______________________ 

Title: ________________________ 

Race:________________________ 

Percent Owned:________________ 

Gender: _____Male _____Female 

Salary: $______________________ 

Other Benefits $______________ 

Sets policy for company 

direction/scope/ of operations 

A F S N A F S N 

Bidding and estimating A F S N A F S N 

Major purchasing decisions A F S N A F S N 

Marketing and sales A F S N A F S N 

Supervises field operations A F S N A F S N 

Attend bid opening and lettings A F S N A F S N 

Perform office management, such as 

billing, accounts receivable and 

accounts payable, etc. 

A F S N A F S N 

Hires and fires management staff A F S N A F S N 

Hire and fire field staff or crew A F S N A F S N 

Designates profits spending or 

investment 

A F S N A F S N 

Obligates business by 

contract/credit/bond/insurance 

A F S N A F S N 

Purchase equipment A F S N A F S N 

Signs business checks A F S N A F S N 

Do any of the persons listed above perform a management or supervisory function for any other business? If Yes, 

identify the person, the business, and their title/function: 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

Do any of the persons listed above own or work for any other firm(s) that has a relationship with this firm? (e.g.,

ownership interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)  Yes  No 

If Yes, describe the nature of the business relationship: ______________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 8 of 15 

B. Duties of Owners, Officers, Directors, Managers, and Key Personnel, continued. 

 

Complete for all owners and non-owners who do anything listed below for the business. Make enough copies of 

this form to provide information on each and every person. Submit résumés for each person identified below. 

Circle the frequency of each person’s involvement as follows: 

 Person 3 Person 4 

A= Always 

F = Frequently 

S = Seldom 

N = Never

Name: _______________________ 

Title: ________________________ 

Race:________________________ 

Percent Owned:________________ 

Gender: _____Male ____Female 

Salary: $______________________ 

Other Benefits $________________ 

Name: _______________________ 

Title: ________________________ 

Race:________________________ 

Percent Owned:________________ 

Gender: _____Male ____Female 

Salary: $______________________ 

Other Benefits $______________ 

Sets policy for company 

direction/scope/ of operations 

A F S N A F S N 

Bidding and estimating A F S N A F S N 

Major purchasing decisions A F S N A F S N 

Marketing and sales A F S N A F S N 

Supervises field operations A F S N A F S N 

Attend bid opening and lettings A F S N A F S N 

Perform office management, such 

as billing, accounts receivable and 

accounts payable, etc. 

A F S N A F S N 

Hires and fires management staff A F S N A F S N 

Hire and fire field staff or crew A F S N A F S N 

Designates profits spending or 

investment 

A F S N A F S N 

Obligates business by 

contract/credit/bond/insurance 

A F S N A F S N 

Purchase equipment A F S N A F S N 

Signs business checks A F S N A F S N 

Do any of the persons listed above perform a management or supervisory function for any other business? If Yes, 

identify the person, the business, and their title/function: 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

Do any of the persons listed above own or work for any other firm(s) that has a relationship with this firm? (e.g.,

ownership interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)  Yes  No 

If Yes, describe the nature of the business relationship: _______________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 9 of 15 

C. Inventory: 

Indicate your firm’s inventory in the following categories (Please attach additional sheets if needed):

Equipment and Vehicles (Provide titles, proof of ownership, or signed lease agreements for the items listed)

Type of Equipment or Vehicle 

(Make and Model) Current Value 

Owned or Leased by 

Firm or Owner? Where is this item stored? 

1. __________________________________________________________________________________________ 

2. __________________________________________________________________________________________ 

3. __________________________________________________________________________________________ 

4. __________________________________________________________________________________________ 

5. __________________________________________________________________________________________ 

6. __________________________________________________________________________________________ 

7. __________________________________________________________________________________________ 

8. __________________________________________________________________________________________ 

9. __________________________________________________________________________________________ 

10. _________________________________________________________________________________________ 

11. _________________________________________________________________________________________ 

12. _________________________________________________________________________________________ 

13. _________________________________________________________________________________________ 

14. _________________________________________________________________________________________ 

15. _________________________________________________________________________________________ 

16. _________________________________________________________________________________________ 

Office Space (Provide signed lease agreements for the properties listed)

Street Address Owned or Leased 

by Firm or 

Owner? 

Current Value of Property or Lease 

1.__________________________________________________________________________________________ 

2. _________________________________________________________________________________________ 

Storage Space (Provide signed lease agreements for the properties listed)

Street Address Owned or Leased by 

Firm or Owner? 

Current Value of Property or Lease 

1.___________________________________________________________________________________________ 

2. __________________________________________________________________________________________ 

D. Does your firm rely on any other firm for management functions or employee payroll?  Yes  No 

If Yes, explain: 

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 10 of 15 

 

E. Financial / Banking Information (Provide bank authorization and signature cards)

Name of bank: _________________________________ 

Address of bank: _______________________________ City: ______________ State: _____ Zip: __________ 

The following individuals are able to sign checks on this account: ______________________________________ 

Name of bank: _________________________________ 

Address of bank: _______________________________ City: ______________ State: _____ Zip: __________ 

The following individuals are able to sign checks on this account: ______________________________________ 

Bonding Information: If you have bonding capacity, identify: (a) Binder No: _________________________ 

(b) Name of agent/broker ______________________________ (c) Phone No: ( ) ______________________ 

(d) Address of agent/broker: ____________________________ __________________________________________

(e) Bonding limit: Aggregate limit $ ______________________ Project limit $ _____________________ 

F. Identify all sources, amounts, and purposes of money loaned to your firm including from financial 

institutions. Identify whether you the owner and any other person or firm loaned money to the applicant 

DBE/ACDBE. Include the names of any persons or firms securing the loan, if other than the listed owner. 

(Provide copies of signed loan agreements and security agreements).

Name of Source Address of Source Name of Person 

Securing the Loan 

Original 

Amount 

Current 

Balance 

Purpose of Loan 

1. ___________________________________________________________________________________________ 

2. __________________________________________________________________________________________ 

3.___________________________________________________________________________________________ 

G. List all contributions or transfers of assets to/from your firm and to/from any of its owners or another 

individual over the past two years (attach additional sheets if needed): 

Contribution/Asset Dollar Value From Whom 

Transferred 

To Whom 

Transferred 

Relationship Date of 

Transfer 

1. __________________________________________________________________________________________ 

2.__________________________________________________________________________________________ 

3.__________________________________________________________________________________________ 

H. List current licenses/permits held by any owner and/or employee of your firm 

(e.g. contractor, engineer, architect, etc.)(Provide copies of the licenses and attach additional sheets if 

needed): 

Name of License/Permit Holder Type of License/Permit Expiration 

Date 

License Number 

and State 

1.___________________________________________________________________________________________ 

2.___________________________________________________________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 11 of 15 

 I. List the three largest contracts completed by your firm in the past three years, if any: 

 Name of 

Owner/Contractor 

Name/Location of 

Project 

Type of Work Performed Dollar Value of 

Contract 

1.___________________________________________________________________________________________ 

2. __________________________________________________________________________________________ 

3. __________________________________________________________________________________________ 

J. List the three largest active jobs on which your firm is currently working: 

Name of Prime 

Contractor and Project 

Number 

Location of 

Project 

Type of Work Project 

Start Date 

Anticipated 

Completion 

Date 

Dollar 

Value of 

Contract 

1.

_____________________________________________________________________________________

____________________________________________________________________________________________ 

2.

_____________________________________________________________________________________

____________________________________________________________________________________________ 

3.

_____________________________________________________________________________________

_____________________________________________________________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 12 of 15 

 AIRPORT CONCESSION (ACDBE) APPLICANTS MUST COMPLETE THIS PAGE 

Concession Space Address / Location at 

Airport 

Value of Property or 

Lease 

Fees/Lease Payments 

Paid to the Airport 

 

 

 

 

Provide information concerning any other airport concession businesses the applicant firm or any affiliate owns and/or 

operates, including name, location, type of concession, and start date of concession 

Name of Concession Location Type of Concession Start Date of Concession 

 

 

 

 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 13 of 15 

AFFIDAVIT OF CERTIFICATION 

This form must be signed and notarized for each owner upon which disadvantaged status is relied.

A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS SUFFICIENT 

CAUSE FOR DENIAL OF CERTIFICATION, REVOCATION OF A PRIOR APPROVAL, INITIATION OF SUSPENSION OR 

DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR ENTITY MAKING THE FALSE STATEMENT TO 

ANY AND ALL CIVIL AND CRIMINAL PENALTIES AVAILABLE PURSUANT TO APPLICABLE FEDERAL AND STATE LAW. 

I _________________________ (full name printed), swear or affirm under penalty of law that I am _______________ 

_________________(title) of the applicant firm __________________________ (firm name) and that I have read and 

understood all of the questions in this application and that all of the foregoing information and statements submitted in 

this application and its attachments and supporting documents are true and correct to the best of my knowledge, and 

that all responses to the questions are full and complete, omitting no material information. The responses include all 

material information necessary to fully and accurately identify and explain the operations, capabilities and pertinent 

history of the named firm as well as the ownership, control, and affiliations thereof. 

I recognize that the information submitted in this application is for the purpose of inducing certification approval by a 

government agency. I understand that a government agency may, by means it deems appropriate, determine the 

accuracy and truth of the statements in the application, and I authorize such agency to contact any entity named in the 

application, and the named firm’s bonding companies, banking institutions, credit agencies, contractors, clients, and 

other certifying agencies for the purpose of verifying the information supplied and determining the named firm’s 

eligibility. 

I agree to submit to government audit, examination and review of books, records, documents and files, in whatever 

form they exist, of the named firm and its affiliates, inspection of its places(s) of business and equipment, and to 

permit interviews of its principals, agents, and employees. I understand that refusal to permit such inquiries shall be 

grounds for denial of certification. 

If awarded a contract, subcontract, concession lease or sublease, I agree to promptly and directly provide the prime 

contractor, if any, and the Department, recipient agency, or federal funding agency on an ongoing basis, current, 

complete and accurate information regarding (1) work performed on the project; (2) payments; and (3) proposed 

changes, if any, to the foregoing arrangements. 

I agree to provide written notice to the recipient agency or Unified Certification Program (UCP) of any material 

change in the information contained in the original application within 30 calendar days of such change (e.g., 

ownership, address, telephone number, etc.). 

I acknowledge and agree that any misrepresentations in this application or in records pertaining to a contract or 

subcontract will be grounds for terminating any contract or subcontract which may be awarded; denial or revocation of 

certification; suspension and debarment; and for initiating action under federal and/or state law concerning false 

statement, fraud or other applicable offenses. 

I certify that I am a socially and economically disadvantaged individual who is an owner of the above-referenced firm 

seeking certification as a Disadvantaged Business Enterprise (DBE) or Airport Concession Disadvantaged Business 

Enterprise (ACDBE). In support of my application, I certify that I am a member of one or more of the following 

groups, and that I have held myself out as a member of the group(s): (Check all that apply): 

 

 Female  Black American  Hispanic American  Native American  Asian- Pacific American 

 Subcontinent Asian American Other (specify) ____________________________________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 14 of 15 

I certify that I am socially disadvantaged because I have been subjected to racial or ethnic prejudice or cultural bias, or 

have suffered the effects of discrimination, because of my identity as a member of one or more of the groups identified 

above, without regard to my individual qualities. 

I further certify that my personal net worth does not exceed $1.32 million, and that I am economically disadvantaged 

because 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 who are not socially and economically 

disadvantaged. 

I declare under penalty of perjury that the information provided in this application and supporting documents is true 

and correct. 

Signature _________________________________ Executed on ___________(Date) 

 (DBE/ACDBE Applicant) 

 

NOTARY CERTIFICATE 

 Subscribed and sworn to before me this ___day of __________, 20___. 

 

 ________________________________________ 

 Notary Public in and for the State of: 

 Residing at:_______________________________ 

 

 ________________________________________ 

 

 My Commission Expires:_____________________ 
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 15 of 15 

UNIFORM CERTIFICATION APPLICATION 

SUPPORTING DOCUMENTS CHECKLIST 

In order to complete your application for DBE or ACDBE certification, you must attach copies of all of the following 

documents. The UCP to which you are applying may have additional required documents that you must also supply with 

your application. Contact the appropriate certifying agency to which you are applying to find out if more is required. A 

failure to supply any information requested by the UCP may result in a determination that you failed to cooperate. 

All Applicants 

 Résumés (that include places of ownership/employment with corresponding dates), for all owners, officers, and key 

personnel of the applicant firm 

 Personal Net Worth Statement for socially and economically disadvantaged owners (form available with this 

application) 

 Personal Federal and State tax returns for the past 3 years, if applicable, for each disadvantaged owner 

 Federal and state tax returns (and requests for extensions) filed by the firm and its affiliates including all related 

schedules, and firm audited financial statements (if available) for the past 3 years. 

 Documented proof of contributions used to acquire ownership for each owner (e.g. both sides of cancelled checks) 

 Your firm’s signed loan agreements, security agreements, and bonding forms 

 Descriptions of all real estate (including office/storage space, etc.) owned/leased by your firm and documented proof 

of ownership/signed leases 

 List of equipment and/or vehicles owned and leased. Signed lease agreements and titles/proof of ownership 

 Property leases 

 Documented proof of any transfers of assets to/from your firm and/or to/from any of its owners over the past 2 years 

 Year-end balance sheets and income statements for the past three years (or life of firm, if less than three years); a 

new business must provide a current balance sheet 

 All relevant licenses, license renewal forms, permits, and haul authority forms 

 DBE, ACDBE and SBA 8(a), SDB, MBE/WBE certifications, denials, and/or decertifications, if applicable; and 

U.S. DOT appeal decisions (if any) on these actions. 

 Bank authorization and signatory cards 

 Schedule of salaries (or other remuneration) paid to all officers, managers, owners, and/or directors of the firm 

 List of all employees, job titles, and dates of employment. 

 Trust agreements held by any owner claiming disadvantaged status, if any 

Partnership or Joint Venture 

 Original and any amended Partnership or Joint Venture Agreements 

Corporation or LLC 

 Official Articles of Incorporation (signed by the state official) 

 Both sides of all corporate stock certificates and your firm’s stock transfer ledger 

 Shareholders’ Agreement 

 Minutes of all stockholders and board of directors meetings 

 Corporate by-laws and any amendments 

 Corporate bank resolution and bank signature cards 

 Official Certificate of Formation and Operating Agreement with any amendments (for LLCs) 

Trucking Company 

 Documented proof of ownership of the company 

 Insurance agreements for each truck owned or operated by your firm 

 Title(s), registration certificate(s), and U.S. DOT numbers for each truck owned or operated by your firm 

Suppliers 

 Proof of warehouse/storage facility ownership or lease arrangements 

 List of product lines carried and list of distribution equipment owned and/or leased 
 

U.S. Department of 

Transportation 

 Appendix G 

Personal Net Worth Statement OMB APPROVAL NO:

For DBE/ACDBE Program Eligibility EXPIRATION DATE: 

As of __________________

This form is used by all participants in the U.S. Department of Transportation’s Disadvantaged Business Enterprise 

Programs as set forth in 49 CFR Parts 23 and 26 and must be submitted to determine whether an owner is economically 

disadvantaged. Complete this form separately for: (1) each disadvantaged proprietor, (2) each limited partner who owns 

51% or more interest and each general partner, and (3) each stockholder owning 51% or more of voting stock. 

Do not make adjustments to your figures pursuant to the DBE Program Regulation. The agency you apply to will use the 

information provided on this statement to determine your personal net worth. Please send form to appropriate Unified 

Certification Program member, not U.S. DOT.

Full Name Business Name of Applicant Firm 

Residence Address (As 

reported to the IRS)

 Business Address 

City, State and Zip Code City, State and Zip Code 

Residence Phone Business Phone 

Marital Status: Married, Divorced, Never 

Married, Widowed 

 Spouse’s Full Name 

ASSETS (Omit Cents) LIABILITIES (Omit Cents)

Joint 

Asset? 

Cash and Cash Equivalents 

(Complete Section 1A) 

 $ Mortgages on Real Estate 

Excluding Primary Residence 

(Complete Section 2 

 $ 

Retirement Accounts (IRA, 401Ks, 403Bs, 

Pensions, etc) (Report Full Value and 

Complete Section 1B) 

 $ Loan on Life Insurance 

(Complete Section 3) 

 $ 

Brokerage, Investment Accounts 

(Complete Section 1C) 

 $ Notes, Obligations on Personal 

Property (Complete Section 4) 

 $ 

Assets Held in Trust 

(Complete Section 1D) 

 $ Notes & Accounts Payable to Banks 

and Others (Complete Section 6) 

 $ 

Shareholder Loans & Other Receivables 

(Complete section 1E) 

 $ Other Liabilities 

(Complete Section 7) 

 $ 

Real Estate Excluding Primary Residence 

(Complete Section 2) 

 $ Unpaid Taxes 

(Complete Section 8) 

 $ 

Life Insurance (Cash Surrender Value Only) 

(Complete Section 3 

 $ 

Other Personal Property and Assets 

(Complete Section 4) 

 $ 

Other Business Interests 

(Complete Section 5 ) 

 $ 

Total Assets $ Total Liabilities $ 
ASSETS (Provide Current Account Statements)

SECTION 1A: Cash on Hand, Checking, Savings, Money Market, Certificates of Deposit 

Name on Account 

(including co-owners) 

Type of Account 

(checking, 

savings, revolving 

credit, IRA, other, 

(explain) 

Bank Name and 

Address 

Account 

number 

Account 

Status 

 (joint, single, 

trust) 

Current Balance 

Total 

Section 1B: Retirement Accounts, IRA, 401Ks, 403Bs, Pensions 

Name on Account 

(including co-owners) 

Type of 

Account 

Bank Name and Address Account number Current 

Balance 

Total 

SECTION 1C: Brokerage/Investment Accounts 

Name of Brokerage Firm And account number) Type of Account Market value 

as of date of 

form 

Total 

SECTION 1D: Assets Held in Trust: (Submit trust agreements and amendments, and document the valuation of assets) 

Name of Settlor Type of trust 

(revocable, 

irrevocable, 

etc.) 

Date Trust 

established 

Specific Assets held 

and Value 

Date and 

Method of 

Valuation 

Trustee Names of 

Beneficiaries 

Section 1E: Securities Not reported in Section 1C and Shareholder Loans, Promissory Notes and Other Receivables Not 

Listed Above: Provide amount and describe: 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________ 

_________________________________________________________________________________________________________ 
SECTION 2: Real Estate Owned (Including Personal Residence, Investment Properties, Personal Property 

Leased or Rented for Business Purposes, Farm Properties, or any Other Income Producing property. 

(List each parcel separately. Submit copies of deeds for each parcel, mortgage note, instrument of conveyance) Add 

additional sheets if necessary. 

Primary Residence Property B Property C 

Type of Property 

Address 

Date Acquired and 

Method of Acquisition 

(purchase, inherit, divorce, 

gift, etc.) 

Names on Deed 

Purchase Price 

Present Market Value 

Source of Market 

Valuation 

Name & Address of all 

Mortgage Holders, 

including 

Mortgage Account 

Number 

Mortgage Balance As of 

Date of Form: 

Equity line of credit 

Balance 

Amount of Payment Per 

Month/Year (Specify) 

SECTION 3: Life Insurance Held 

(Submit policies and most recent statement) 

(Give face amount and cash surrender value of policies, name of insurance company and beneficiaries).

Insurance Company Face 

Value 

Amount 

Cash Surrender Amount Beneficiaries Loan on Policy Information
SECTION 4: Other Personal Property and Assets 

(Other documentation may be required upon request, such as invoices, bill of sale, valuation documents, insurance 

policies) 

Type of Property or Asset 

Total 

Present 

Value 

Amount of 

Liability 

(Balance) 

Is this asset 

insured? 

(If so, attach a 

copy of the 

policy) 

Lien or Note 

amount and Terms 

of Payment 

(Attach a copy of 

the instrument) 

Automobiles and Vehicles (including recreation vehicles, 

motorcycles, boats, etc.) Include personally owned vehicles 

that are leased or rented to businesses or other individuals. 

Household Goods 

Jewelry 

Other (List) 

Accounts and Notes Receivables 

Total Present Value: $ ____________ 

Total Liability: $ ____________ 

Total Personal Property $ ____________ 
SECTION 5: Other Business Investments, Other Businesses Owned (excluding applicant firm) 

Sole Proprietorships, General Partners, Joint Ventures, Limited Liability Companies, Closely-held and Public Traded Corporations 

(Provide the information below and submit business financial statements, balance sheets including net worth, Federal tax returns) 

Name of Sole 

Proprietorship, 

partnership, Joint 

Venture 

(Indicate % of 

ownership) 

Address Business 

Value 

in $ 

Date 

Acquired 

Names of Partners, Unit 

holders, % of Ownership, 

and Date Acquired 

Primary scope of 

Operations 

Name of Corporation 

or LLC 

Address Business 

Value 

in $ 

Date 

Acquired 

Name of Stockholders on 

Certificates, Date Stock 

Acquired, Total Outstanding 

Shares of Stock or Units, 

Market Value and Date of 

Quotation/Exchange, 

Primary scope of 

Operations 

LIABILITIES 

SECTION 6: Notes and Accounts Payable to Bank and Others (Including Installment accounts) 

(Submit copy of note/security agreement, and most recent account statement) 

Name of 

Borrower(s) 

Name of 

Noteholder(s) 

Date of 

Instrument 

Original 

Balance 

Current 

Balance 

Payment 

Amount and 

Terms 

How Secure/By Whom 

Guaranteed, Collateral 

 

SECTION 7: Other Liabilities 

(Submit copy of most recent statement, or any other debt instrument) 

Name of Individual 

Obligated 

Name of 

Co-signer(s) 

Description Name and Address 

of Entity Owed 

Date of 

Obligation 

Amount Payment Amount and 

Terms (frequency) 

 

 
 

 

SECTION 8: Unpaid Taxes 

(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches). 

Name of Individual 

Obligated 

Name of Cosigner(s) Type of 

Unpaid 

Tax 

Payable to Whom Date Due Amount Property Attached with Tax 

Lien (if any) 

 

 

SECTION 9: Transfer of Assets: Have you transferred, within 2 years of this personal net worth statement, transferred 

assets to a spouse, domestic partner, relative, or entity in which you have an ownership or beneficial interest including a 

trust? Yes  No 

(Provide a brief description of all transfers of assets within 2 years from date of application. List the names of individuals on deed, 

title, note or other instrument receiving assets and relation to transferor.(Submit Bill of Sale or Invoice, transfer document (title, 

deed, etc., date of transfer, estimate or valuation of the consideration received)) 

_________________________________________________________________________________________________________ 

AFFIDAVIT

I declare under penalty of perjury that the information provided in this application and supporting documents is complete, true and 

correct. I certify that no assets have been transferred to any beneficiary for less than fair market value in the last two years. I 

recognize that the information submitted in this application is for the purpose of inducing certification approval by a government 

agency. I understand that a government agency may, by means it deems appropriate, determine the accuracy and truth of the 

statements in the application, and I authorize such agency to contact any entity named in the application or this personal financial 

statement, including the names banking institutions, credit agencies, contractors, clients, and other certifying agencies for the 

purpose of verifying the information supplied and determining the named firm’s eligibility. I acknowledge and agree that any 

misrepresentations in this application or in records pertaining to a contract or subcontract will be grounds for terminating any 

contract or subcontract which may be awarded; denial or revocation of certification; suspension and debarment; and for initiating 

action under federal and/or state law concerning false statement, fraud or other applicable offenses. 

 

 ___________________________________ __________________ 

 Signature (DBE/ACDBE Applicant) Date

NOTARY CERTIFICATE: (Insert applicable state acknowledgment, affirmation, or oath) 

In collecting the information requested by this form, the Department of Transportation (Department) complies with the provisions of the Federal Freedom of Information 

and Privacy Acts (5 U.S.C. 552 and 552a). The Privacy Act provides comprehensive protections for your personal information. This includes how information is collected, 

used, disclosed, stored, and discarded. Your information will not be disclosed to third parties without your consent. The information collected will be used solely to 

determine your firm's eligibility to participate in the Department's Disadvantaged Business Enterprise Program as defined in 49 CFR section 26.5 and the Airport 

Concession Disadvantaged Business Enterprise Program as defined in 49 CFR section 23.3. You may review DOT’s complete Privacy Act Statement in the Federal 

Register published on April 11, 2000 (65 FR 19477). 
General Instructions for Completing the 

Personal Net Worth Statement 

for DBE/ACDBE Program Eligibility 

Please do not make adjustments to your figures pursuant to 

U.S. DOT regulations 49 CFR Parts 23 and 26. The agency 

that you apply to will use the information provided on your 

completed Personal Net Worth Statement to determine 

whether you meet the economic disadvantage requirements 

of 49 CFR Part 26. If there are discrepancies or questions 

regarding your form, it may be returned to you to correct and 

complete again. 

An individual's Personal Net Worth according to 49 CFR 

Part 26 includes only his or her own share of assets held 

separately, jointly, or as community property with the 

individual’s spouse and excludes the following: 

 Individual's ownership interest in the applicant firm; 

 Individual's equity in his or her primary residence; 

 Tax and interest penalties that would accrue if retirement 

savings or investments (e.g., pension plans, Individual 

Retirement Accounts, 401(k) accounts, etc.) were 

distributed at the present time. 

Be sure to indicate whether the figures reported are jointly 

held. 

If your personal net worth according to 49 CFR Parts 23 and 

26 exceeds the $1.32 million cap and you, individually, or 

you and other individuals are the majority owners of an 

applicant firm, the firm is not eligible for DBE or ACDBE 

certification. If the personal net worth of the majority 

owner(s) exceeds the $1.32 million cap at any time after 

your firm is certified, the firm is no longer eligible for 

certification. Should that occur, it is your responsibility to 

contact your certifying agency in writing to advise that your 

firm no longer qualifies as a DBE or ACDBE. You must fill 

out all line items on the Personal Net Worth Statement. If 

necessary, use additional sheets of paper to report all 

information and details. If you have any questions about 

completing this form, please contact one of the UCP 

certifying agencies. 

Assets 

All assets must be reported at their current fair market values 

as of the date of your statement. Assessor’s assessed value 

for real estate, for example, is not acceptable. Assets held 

in a trust generally should be included. 

Cash and Cash Equivalents: In Section 1A Enter the total 

amount of cash or cash equivalents in bank accounts, 

including checking, savings, money market, certificates of 

deposit held domestic or foreign. Provide copies of the bank 

statement. 

Retirement Accounts, IRA, 401Ks, 403Bs, Pensions: 

Enter the total present value of all accounts (including Roth 

IRAs) and other retirement accounts, including any deferred 

compensation and pension plans in Section 1B. 

Brokerage/Investment Accounts: Enter the name of 

brokerage firm and account number; type of account and 

current market value of the account as of the date of the 

PNW statement. 

Assets Held in Trust: Enter the specific assets held in trust, 

the names of beneficiaries and trustees, and other 

information. Complete Section 1D.

Securities Not Reported Above, including Shareholder 

Loans, Promissory Notes, and Other Receivables not 

listed: Enter amounts loaned to you from your firm, from or 

any other business entity in which you hold an ownership 

interest, and other receivables not listed above . Complete 

Section 1E.

Real Estate: Complete Section 2, beginning with your 

primary residence (be sure to identify it as your primary 

residence); enter the type of property, address, method of 

acquisition, date of acquired, names of deed, purchase price, 

present fair market value, source of market valuation, name 

and address of all mortgage holders, mortgage account 

number, mortgage balance, equity line of credit balance, and 

amount of payment, for all real estate held. Please ensure 

that this section contains all real estate owned, including 

rental properties, vacation properties, commercial properties, 

personal property leased or rented for business purposes, 

farm properties and any other income producing properties, 

etc. Attach additional sheets if needed. 

Life Insurance: Enter the name of the insurance company, 

the face value of the policy, cash surrender value, 

beneficiary names, and any loans on the policy in Section 3. 

Other Personal Property and Assets: Enter personal 

property and other assets owned in Section 4. Personal 

property includes motor vehicles, boats, trailers, jewelry, 

furniture, household goods, collectibles, clothing, and 

personally owned vehicles that are leased or rented to 

businesses or other individuals. Enter the present value of 

the personal property owned, amount of liabilities, and 

whether the asset is insured. For accounts and notes 

receivable, enter the total value of all monies owed to you 

personally, if any. This should include shareholder loans to 

the applicant firm, if any. If the asset is insured, please 

attach a copy of the policy. Also attach a copy of any liens 

or notes on the property and indicate in the space provided 

the terms of payment. Total the present value and liabilities 

at the bottom of the form. 

Other Business Investments/Other Businesses Owned 

Interests: Enter information concerning any businesses you 
hold an ownership interest in, such as sole proprietorships, 

partnerships, joint ventures, corporations, or limited liability 

corporations (other than the applicant firm) in Section 5. Do 

not reduce the value of these entries by any loans from the 

outside firm to the DBE/ACDBE applicant business. 

Liabilities 

Mortgages on Real Estate: Enter the total balance on all 

mortgages payable on real estate in section 2. 

Loans on Life Insurance: Enter the total value of all loans 

due on life insurance policies in Section 3.

Notes & Accounts Payable to Bank and Others: Enter the 

name of borrowers, noteholders, date of note, original and 

current balances, payment terms, and security/collateral 

information in Section 6. The entries should include 

automobile installment accounts. This should not, however, 

include any mortgage balances as this information is 

captured in section 2. Do not include loans for your business 

or mortgages for your properties in Section 6. Submit copy 

of note/security agreement, and the most recent account 

statement)

Other Liabilities: Enter the total value due on all other 

liabilities not classified in the previous entries. Report the 

name of the individual obligated, names of co-signers, a 

description of the liability, the name and address of the 

entity owed, the date of the obligation, payment amounts and 

terms. Note: Do not include contingent liabilities in this 

section. Contingent liabilities are liabilities that belong to 

you only if an event(s) should occur. For example, if you 

have co-signed on a relative’s loan, but you are not 

responsible for the debt until your relative defaults, that is a 

contingent liability. Contingent liabilities do not count 

toward your net worth until they become actual liabilities. 

Unpaid Taxes: Enter the total amount of all taxes that are 

currently due, but are unpaid in Section 8. Contingent tax 

liabilities or anticipated taxes for current year should not be 

included. Describe in detail the name of the individual 

obligated, names of co-signers, the type of unpaid tax, to 

whom the tax is payable, due date, amount, and to what 

property, if any, the tax lien attaches. If none, state “NONE.” 

You must include documentation, such as tax liens, to 

support the amounts. 

Transfers of Assets: 

Transfers of Assets: Detail all asset transfers (within 2 

years of the date of this personal net worth statement) to a 

spouse, domestic partner, relative, or entity in which you have an 

ownership or beneficial interest including a trust. Include a 

description of the asset; names of individuals on the deed, 

title, note or other instrument indicating ownership rights; 

the names of individuals receiving the assets and their 

relation to the transferor; the date of the transfer; and the 

value or consideration received. Submit documentation 

requested on the form related to the transfer. 

Affidavit 

Be sure to sign and date at the statement. The Personal Net 

Worth Statement must be notarized.