### On September 6, 2012, the U.S. Department of Tr ansportation published the Notice of Proposed Rulemaking (NPRM) entitled, “D isadvantaged Business Enterprise: Program Implementation

Modifications.” See 77 Fed. Reg. 54952 (Sept. 6, 2012). In cluded in this NPRM are proposed revisions to Appendix F, the Unifor m 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 conf usion as to what the Department proposed. The Department notes, though, that th e 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 CONNECTIO N 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 Depar tment of Transportation (Department ) complies with the provision s of the Federal Freedom of Information and Privacy Acts (5 U.S.C. 552 and 552a). The Privacy Act prov ides comprehensive protections for your pe rsonal information.
This includes how information is collected, used, disclosed, st ored, and discarded. Your information will not be disclosed to t hird parties without your consent. The information collected will be used solely to determi ne 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 de fined in 49 CFR section 23.3. You may review DOT’s complete Privacy Act Statemen t in the Federal Register published on April 11, 2000 (65 FR 19 477).

## 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 Administra tion, 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 la wfully admitted permanent resident of the U.S.?

 Is your firm a small business that meets the Sma ll Business Administration's (SBA's) size standard and does not exceed $22.41 million in gross annual receipt s for DBE ($52.47 million for ACDBEs)? (Note, other size standards apply ACDBE applications from ba nks/financial institutions, car rental companies, pay telephone firms, and automobile dealers.)

2. How do I apply?

You must complete and submit this certification appli cation and related material to an agency in your home state; and second participate in an on-site in terview 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 documen ts, 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 mu ltiple 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 eligibilit y 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.cf m (This site provides useful links to the rules and regulations governing the DBE/ACDBE progr ams, 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-sta ndards (SBA has established a Table of Small

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

for industries provides a listing of NAICS codes and size standards)

Under 49 CFR §26.107, dated February 2, 1999, if at any time, th e 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 Requir ements 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 pr ohibits false statements in Federal programs.

### INSTRUCTIONS FOR COMPLETING THE

DISADVANTAGED BUSINESS ENTERPRISE

AIRPORT CONCESSIONS DISADVANT AGED BUSINESS ENTERPRISE

UNIFORM CERTIFICATION APPLICATION

NOTE: If you require additional space for an y question in this application, please atta ch additional sheets or copies as needed

, taking care to indicate on ea ch attached sheet/copy the section and numb er 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 pr imary 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 fi rm 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 descripti on 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 pr oduct/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 participati ng 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 existe d 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 yearand audited financia l 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 ta x 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 form al, 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 subcontra ctor 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, grandmothe r, 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 pos ition 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 appropr iate box that indicates whether this owner is a lawfully admitted permanent

resident. If this owner is ne ither 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 socia lly and economically disadvantaged applying for DBE qualification. (Each owner claiming disadvantaged status must submit a separate statement. (ii) St ate whether a trust has been created for the benefit of this owner. If you answered “Yes,” briefly explain the na ture, 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 ow nership interest in your firm, broken down by cash, real estate, equipment,

and/or other investment. De scribe 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 relations hip with your firm. If you checked “Yes,” identify the name of the other business, the nature of th e 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, pleas e identify this activity.

Section 4: CONTROL

A. Identify the firm’s Offic ers and Board of Directors

(1) In the space provided, state the name, title, date of appointment, ethnicity, a nd 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 wh ich 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 spe nding 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, et c.) If you answered “Yes,”

describe the nature of hi s/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 eq uipment 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 na ture 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 ch ecks 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 wa s transferred, its current dollar value, the person or firm from whom it was transferred, the person or firm to whom it was transferred, the relationshi p 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 affili ate 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 you r 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 owne d 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 debarre d 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 compan y offers more than one product/service, list the primary product or service first. Please use additional paper if necess ary. 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 recei pts $ _________________

Year _______ Total receipt s $ _________________

Year _______ Total recei pts $ _________________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 locati ons, or does it share a telephone number, P.O. Box, office or storage space, yard, warehouse, facilities, equi pment, 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 identifyi ng 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 conti nues. Please attach a separ ate sheet if necessary.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

C. Immediate Family Member, Ma nager, 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 wit h

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 (S treet 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 appl ying 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 (A ttach 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 s pace, financial investments, equipm ent, 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 othe r 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 comp anies that hold LESS THAN 51% ownership interest in your firm ( I f 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 appl ying 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 substa ntiating 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 s pace, financial investments, equipm ent, 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 othe r 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 ma nagement 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 ow n or work for any other firm(s) that has a relationship

with this firm ( e.g., ownership interest, shared office s pace, financial investments, equipmen t, leases, personne l 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, Direc tors, Managers, and Key Personnel

Complete for all owners and non-ow ners 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 s pace, financial investmen ts, equipment, leases, personnel sharing, etc. 

### ) 

###  Yes 

###  No

If Yes, describe the n ature of the business relationship: ______________________________________________U.S. DOT Uniform DBE/ACDBE Certification Application  Page 8 of 15 

### B. Duties of Owners, Officers, Directors, Ma nagers, and Key Personnel, continued.

Complete for all owners and non-ow ners 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 pers on’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 s pace, financial investmen ts, 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 si gned 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/broke r: _____________

_______________

__________________________________________ 

### (e) Bonding limit: Aggregate limit $ ___________ ___________ Project lim it $ _____________________

F. Identify all sources, amounts, and purposes of mo ney 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/f rom 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 ConcessionU.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 OM ISSION 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 a pplication 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 id entify and explain the operations, capabilities and pertinent history of the named firm as well as the owne rship, control, and affiliations thereof.

I recognize that the information submitted in this applicati on 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 c ontact 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 pe rformed 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 ap plication 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 terminati ng any contract or subcontract which may be awarded; denial or revocation of certification; suspension and debarment; and for initiati ng 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 Enterpri se (DBE) or Airport Concession Disadvantaged Business Enterprise (ACDBE). In support of my application, I certif y 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 iden tity 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 impa ired due to diminished capital and credit opportunities as compared to others in the same or simila r line of business who are not socially and economically disadvantaged.

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

and correct.

Signature _________________________________ Executed on ___________(Date) (DBE/ACDBE Applicant)



### NOTARY CERTIFICATE

Subscribed and sworn to be fore 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 certif ication, you must attach copi es of all of the following documents. The UCP to which you are applying may have addi tional required docu ments 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 th at you failed to cooperate.



### All Applicants  Résumés (that include places of ownership/employment w ith corresponding dates), for all owners, officers, and key personnel of the applicant firm  Personal Net Worth Statement for socially and economica lly 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 fi rm and/or to/from any of its owners over the past 2 years

 Year-end balance sheets and income st atements 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 form s, 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 Partners hip 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 num bers 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 leasedU.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. Depart ment 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

A sset?

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 trus t agreements and amendm ents, 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 Shar eholder 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 fo r 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 polic ies, name of insurance company and beneficiaries).

Insurance Company Face

Value

Amount Cash Surrender Amount Beneficiaries Loan on Policy InformationSECTION 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 bu sinesses 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 Corporation s (Provide the information below and submit business financial stat ements, balance sheets including net worth, Federal tax return s)

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 (Includi ng Installment accounts)
(Submit copy of note/security agreemen t, 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 stat ement, 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, with in 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 benef iciary for less than fair market value in the last two year s. I recognize that the information submitted in this application is for the purpose of inducing certif ication approval by a governm ent agency. I understand that a government agency may, by means it deems appropriate, determine t he accuracy and truth of the statements in the applicat ion, and I authorize such agency to contact any enti ty named in the application or this personal fina ncial statement, including the names banking institut ions, credit agencies, contractors, cli ents, and other certifying agencies for t he 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 an y contract or subcontract which may be awarded; denial or revoca tion of certification; suspension and debarment; and for initiati ng action under federal and/or state law concerning fals e 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 Depar tment of Transportation (Department ) complies with the provision s 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. Thi s includes how information is collected,
used, disclosed, stored, and disc arded. Your information will not be disclosed to third parties without y our consent. The infor mation 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 A ct 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 th e 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 accoun ts, 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 Ab ove, 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, sour ce 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 prop erties, 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. Al so 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 youhold 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 accoun ts. 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 a ttaches. 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 in terest 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 recei ving 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 th e statement. The Personal Net

Worth Statement must be notarized.