Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices 40117 

Federal Register by the Paperwork 

Reduction Act of 1995. 

DATES: Please submit comments by 

October 12, 2018. 

ADDRESSES: You may submit comments 

identified by DOT Docket ID 2018–0041 

by any of the following methods: 

Website: For access to the docket to 

read background documents or 

comments received go to the Federal 

eRulemaking Portal: Go to http://

www.regulations.gov. Follow the online 

instructions for submitting comments. 

Fax: 1–202–493–2251. 

Mail: Docket Management Facility, 

U.S. Department of Transportation, 

West Building Ground Floor, Room 

W12–140, 1200 New Jersey Avenue SE, 

Washington, DC 20590–0001. 

Hand Delivery or Courier: U.S. 

Department of Transportation, West 

Building Ground Floor, Room W12–140, 

1200 New Jersey Avenue SE, 

Washington, DC 20590, between 9 a.m. 

and 5 p.m. ET, Monday through Friday, 

except Federal holidays. 

FOR FURTHER INFORMATION CONTACT: 

Melissa Corder, 202–366–5853, 

melissa.corder@dot.gov; Office of Real 

Estate Services, Federal Highway 

Administration, Department of 

Transportation, New Jersey Avenue SE., 

Washington, DC 20590–0001. Office 

hours are from 6:15 a.m. to 3:45 p.m., 

Monday through Friday, except Federal 

holidays. 

SUPPLEMENTARY INFORMATION: 

Title: Fixed Residential Moving Cost 

Schedule. 

Background: Relocation assistance 

payments to owners and tenants who 

move personal property for a Federal or 

federally-assisted program or project are 

governed by the Uniform Relocation 

Assistance and Real Property 

Acquisition Policies Act of 1970, as 

amended (Uniform Act). 49 Code of 

Federal Regulations (CFR), part 24, is 

the implementing regulation for the 

Uniform Act. 49 CFR 24.301 addresses 

payments for actual and reasonable 

moving and related expenses. The fixed 

residential moving cost schedule is an 

administrative alternative to 

reimbursement of actual moving costs. 

This option provides flexibility for the 

agency and affected property owners 

and tenants. The FHWA requests the 

State Departments of Transportation 

(State DOTs) to analyze moving cost 

data periodically to assure that the fixed 

residential moving cost schedules 

accurately reflect reasonable moving 

and related expenses. The regulation 

allows State DOTs flexibility in 

determining how to collect the cost data 

in order to reduce the burden of 

government regulation. Updated State 

fixed residential moving costs are 

submitted to the FHWA electronically. 

Respondents: State Departments of 

Transportation (52, including the 

District of Columbia and Puerto Rico). 

Frequency: Once every 3 years. 

Estimated Average Burden per 

Response: 24 hours per respondent. 

Estimated Total Annual Burden 

Hours: 24 hours for each of the 52 State 

Departments of Transportation. The 

total is 1,248 burden hours, once every 

3 years, or 416 hours annually. 

Public Comments Invited: You are 

asked to comment on any aspect of this 

information collection, including: (1) 

Whether the proposed collection is 

necessary for the FHWA’s performance; 

(2) the accuracy of the estimated 

burdens; (3) ways for the FHWA to 

enhance the quality, usefulness, and 

clarity of the collected information; and 

(4) ways that the burden could be 

minimized, including the use of 

electronic technology, without reducing 

the quality of the collected information. 

The agency will summarize and/or 

include your comments in the request 

for OMB’s clearance of this information 

collection. 

Authority: The Paperwork Reduction Act 

of 1995; 44 U.S.C. Chapter 35, as amended; 

and 49 CFR 1.48. 

Issued On: August 7, 2018. 

Michael Howell, 

Information Collection Officer. 

[FR Doc. 2018–17314 Filed 8–10–18; 8:45 am] 

BILLING CODE 4910–22–P 

DEPARTMENT OF TRANSPORTATION 

[Docket No. DOT–OST–2018–0075] 

Request for Comments of a Previously 

Approved Information Collection(s) 

AGENCY: Office of the Secretary, DOT. 

ACTION: Notice and request for 

comments. 

SUMMARY: In accordance with the 

Paperwork Reduction Act of 1995, this 

notice announces that the Information 

Collection Request (ICR) abstracted 

below is being forwarded to the Office 

of Management and Budget (OMB) for 

review and comment. A Federal 

Register Notice with a 60-day comment 

period soliciting comments on the 

information collection was published on 

June 4, 2018. One comment was 

received that does not warrant any 

adjustments to the forms. 

DATES: Comments must be submitted on 

or before September 12, 2018. 

ADDRESSES: Send comments regarding 

the burden estimate, including 

suggestions for reducing the burden, to 

the Office of Management and Budget, 

Attention: Desk Officer for the Office of 

the Secretary of Transportation, 725 

17th Street NW, Washington, DC 20503. 

Comments are invited on: Whether 

the proposed collection of information 

is necessary for the proper performance 

of the functions of the Department, 

including whether the information will 

have practical utility; the accuracy of 

the Department’s estimate of the burden 

of the proposed information collection; 

ways to enhance the quality, utility and 

clarity of the information to be 

collected; and ways to minimize the 

burden of the collection of information 

on respondents, including the use of 

automated collection techniques or 

other forms of information technology. 

FOR FURTHER INFORMATION CONTACT: Mr. 

Marc Pentino, Departmental Office of 

Civil Rights, Office of the Secretary, U.S. 

Department of Transportation, 1200 

New Jersey Avenue SE, Washington, DC 

20590, (202) 366–6968, or at 

marc.pentino@dot.gov. 

SUPPLEMENTARY INFORMATION: 

Title: Disadvantaged Business 

Enterprise Program Collections. 

OMB Control Number: 2105–0510. 

Type of Request: Renewal of a 

Previously Approved Information 

Collection. 

Abstract: The following information 

collections are associated with the U.S. 

Department of Transportation’s (DOT) 

Disadvantaged Business Enterprise 

(DBE) program: Uniform Report of DBE 

Awards or Commitments and Payments, 

Uniform Certification Application Form, 

Annual Affidavit of No Change, DOT 

Personal Net Worth Form, and 

Reporting Requirements for Percentages 

of DBEs in Various Categories. All five 

collections were previously approved 

under one OMB Control Number (2105– 

0510) to allow DOT to more efficiently 

administer the DBE program. The DBE 

program is mandated by statute, 

including Section 1101(b) of the Fixing 

America’s Surface Transportation Act 

(FAST Act) (Pub. L. 114–94) and 49 

U.S.C. 47113. DOT’s final regulations 

implementing these statutes are 49 CFR 

parts 23 and 26. The information to be 

collected is necessary because it helps 

to ensure that State and local recipients 

that let federally-funded contracts carry 

out their mandated responsibility to 

provide a level playing field for small 

businesses owned and controlled by 

socially and economically 

disadvantaged individuals. 

Uniform Report of DBE Awards/ 

Commitments and Payments 

Affected Public: DOT financiallyassisted State and local transportation 

agencies. 


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40118 Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices 

Number of Respondents: 1,250. 

Frequency: Once/twice per year. 

Number of Responses: One/two. 

Total Annual Burden: 9,000 hours. 

Uniform Certification Application Form 

Affected Public: Firms applying to be 

certified as DBEs. 

Number of Respondents: 9,500. 

Frequency: Once during initial 

certification. 

Number of Responses: One. 

Total Annual Burden: 76,000 hours. 

Annual Affidavit of No Change 

Affected Public: Certified DBEs. 

Number of Respondents: 

Approximately 38,465 certified DBE 

firms. 

Frequency: Once per year. 

Number of Responses: One. 

Total Annual Burden: 57,698 hours. 

Personal Net Worth Form 

Affected Public: Firms applying to be 

DBEs. 

Number of Respondents: 9,500. 

Frequency: Once. 

Number of Responses: One. 

Total Annual Burden: 19,000 hours. 

Percentage of DBEs in Various 

Categories 

Affected Public: States (through their 

Unified Certification Programs). 

Number of Respondents: 53 (50 states, 

plus the District of Columbia, Puerto 

Rico, and the Virgin Islands). 

Frequency: Once per year. 

Number of Responses: One. 

Total Annual Burden: 161.6 hours. 

Authority: The Paperwork Reduction Act 

of 1995; 44 U.S.C. Chapter 35, as amended; 

and 49 CFR 1:48. 

Issued in Washington, DC. 

Charles E. James, Sr., 

Director, Departmental Office of Civil Rights, 

U.S. Department of Transportation. 

BILLING CODE 4910–9X–P 


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0 Personal Net Worth Statement OMB APPROVAL NO: £105-0510 

U.S. Department of For DBE/ACDBE Program Eligibility EXPIRATION DATE: 8/31/2018 

Transportation As of 

This form is used by all participants in the U.S. Department of Transportation's Disadvantaged Business Enterprise (DBE) and Airport Concession DBE 

(ACDBE) Programs. Each individual owner of a firm applying to participate as a DBE or ACDBE, whose ownership and control are relied upon for DBE 

certification must complete this form. Each person signing this form authorizes the certifying agency to make inquiries as necessary to verify the 

accuracy of the statements made. The agency you apply to will use the information provided to determine whether an owner is economically 

disadvantaged as defined in the DBE program regulations 49 C.F.R. Parts 23 and 26. Return form to appropriate certifying agency, not U.S. DOT. 

Applicant Name: 

Residence: (As reported to the IRS) Residence Phone 

Address, City, State and Zip Code 

Business Name of Applicant Firm Business Phone 

Marital Status: D Single, D Married, D Divorced, D Union Spouse's Full Name: 

ASSETS (Omit Cents) LIABILITIES (Omit 

Cents) 

Cash and Cash Equivalents $ Loan on Life Insurance $ 

(Complete Section 5) 

Retirement Accounts (IRAs, 401 Ks, 403Bs. Pensions. $ Mortgages on Real Estate $ 

etc.) (Report full value minus Federal taxes and Excluding Primary Residence Debt 

penalties if applicable if assets were distributed today) (Complete Section 4) 

(Complete Section 3) 

Brokerage, Investment Accounts $ Notes, Obligations on Personal $ 

Property (Complete Section 6) 

Assets Held in Trust $ Noles & Accounts Payable to $ 

Banks and others 

(Complete Section 2) 

Loans from You to the Firm, Other Entities, Individuals, $ Other Liabilities $ 

& Other Receivables (Complete Section 6) (Complete Section 8) 

Real Estate Excluding Primary Residence $ Unpaid Taxes $ 

(Complete Section 4) (Complete Section 8) 

Life Insurance (Cash Surrender Value Only) $ 

(Complete Section 5) 

Other Personal Property and Assets $ 

(Complete Section 6) 

Business Interests Other Than the Applicant Firm $ 

(Complete Section 7) 

Total Assets $ Total Liabilities $ 

NET WORTH 

Section 2. Notes Payable to Banks and Others 

Name of Noteholder(s) Original Current Payment Frequency How Secured or Endorsed Type of Collateral 

Balance Balance Amount (monthly, etc.) 

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Section 3. Brokerage and custodial accounts, stocks, bonds, retirement accounts. (Full Value) (Use attachments if necessary). 

Name of Security I Brokerage Account I Retirement Cost Markel Value Dale of Total Value Account Quotation/Exchange Quotation/Exchange 

Section 4. Real Estate Owned (Including Primary Residence, Investment Properties, Personal Property Leased or Rented for Business 

Purposes, Farm Properties, or any Other Income Producing property), (List each parcel separately. 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 Markel Valuation 

Name of all Mortgage 

Holders 

Mortgage Ace. # and 

balance (as of date of form) 

Equity line of credit balance 

Amount of Payment Per 

Month/Year (Specify) 

Section 5. Life Insurance Held (Give face amount and cash surrender value of policies, name of insurance company and beneficiaries). 

Insurance Company Face Value Cash Surrender Amount Beneficiaries Loan on Policy Information 

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Section 6. Other Personal Property and Assets (Use attachments as necessary) 

Total Present Amount of Is this Lien or Note amount 

Value Liability asset and Terms of 

Type of Property or Asset (Balance) insured? Payment 

Automooiles and Vehicles (including recreation vehicles, motorcycles, 

ooats, etc.) Include personally owned vehicles that are leased or rented 

to ousinesses or other individuals. 

Household Goods I Jewelry 

Loans from owner to Firm, Other Entities, Individuals 

Other (List) 

Accounts and Notes Receivables 

Section 7. Value of Other Business Investments, Other Businesses Owned (excluding applicant firm) 

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

Section 8. Other Liabilities and Unpaid Taxes (Describe) 

Section 9. Transfer of Assets: Have you within 2 years of this personal net worth statement, transferred assets to a spouse, domestic 

Partner, relative, or entity in which vou have an ownership or beneficial interest includinq a trust? Yes o No o If ves, describe. 

I declare under penalty of perjury that the information provided in this personal net worth statement and supporting documents is complete, true 

and correct. I certify that no assets have oeen transferred to any oeneficiary 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 this personal 

net worth statement, 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. 

NOTARY CERTIFICATE: 

(Insert applicable state acknowledgment, affirmation, or oath) 

Signature (DBE/ACDBE 01tv11er) Date 

In co!!ecting the information requested by this form, the Department of Transportation complies with Federal Freedom of Information Privacy Act U.S C. 552 and 

~~~~a) how 15 used 

Information The used so!e!y to 

Ito in ~,- (DBE) Program '<.,;on~~~'u"ct"c DBE Programs as defined 49 C.F .R. Parts 

I review DOT's Fed era! FR 19477). 

U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility • Page 1005 of 5 
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General Instructions fot· 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 C.F.R. Parts 23 and 26. The 

agency that you apply to will use the infom1ation provided 

on your completed Personal Net Worth (PNW) Statement to 

detennine whether you meet the economic disadvantage 

requirements of 4 9 C.F .R. Parts 23 and 26. If there are 

discrepancies or questions regarding your form, it may be 

ret11med to you to correct and complete again. 

An individual's personal net worth according to 49 C.F.R. 

Parts 23 and 2o includes only his or her own share of assets 

held separately, jointly, or as conununity property with the 

individual's spouse and excludes the following 

• Individual's ownership interest in the applicant finn; 

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

• Federal Tax and penalties, if applicable, that would 

accrue if retirement savings or investments (e.g., pension 

plans, Individual Retirement Accounts, 40l(k) accounts, 

etc.) were distributed at the present time. 

Indicate on the form if any items are jointly owned. If the 

personal net worth of the majority owner(s) of the firm 

exceeds $1.32 million, as defined by 49 C.F.R. Parts 23 and 

26, tl1e firm is not eligible for DEE or ACDEE certification. 

If the personal net worth of the majority owncr(s) exceeds 

the $1.32 million cap specified in §26.67(a)(2)(i) at any time 

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

certification. Should iliat occur. it is your responsibility to 

contact your certifying agency in writing to advise tllat your 

firm no longer qualifies as a DEE or A CD BE. Yon must fill 

out all line items on the Personal Net Worth Statement. 

If necessary, usc additional sheets of paper to report all 

information and details. If you have any questions about 

completing this form, please contact ilie certifying agency. 

All assets must be reported at ilieir 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 should be included. 

Cash and Cash Equivalents: On page 1, 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, 401K~, 403Bs, Pensions: On 

page l, enter ilie full value minus Federal ta" and penalties 

Brokerage and Custodial Accounts, Stocks, Bonds, 

Retirement Accounts: Report total value on page 1, and on 

page 2, section 3, enter the name of the security, brokerage 

account, retirement account, etc.; the cost; market value of 

the asset; the date of quotation; and total value as of the date 

of the PNW statement. 

Assets Held in Trust: Enter the total value of the assets held 

in tmst on page 1, and provide the names of beneficiaries 

and tmstees, and other infonnation in Section o on page 3. 

Loans fmm you to the firm, other Entities, Individuals, 

and Other Receivables not listed: Enter current balances of 

loans you have extended to tllis finn and to other entities or 

individuals, plus interest payable on those loans; and other 

receivables not listed above. Complete Section 6 on page 3. 

Real Estate: The total value of real estate excluding your 

primary residence should be listed on page I. In section 4 on 

page 2, please list your primary residence in column I, 

including the address. meU10d of acquisition, date of 

acquired, names of deed, purchase price, present fair market 

value, source of market valuation, names of all mortgage 

holders. mortgage account number and balance, equity line 

of credit balance, and amount of payment. List this 

infonnation for all real estate held. Please ensure that this 

section contains all real estate owned, including rental 

properties, vacation properties, connnercial properties. 

personal property leased or rented for business purposes, 

farm properties and any oilier income producing properties, 

etc. Attach additional sheets if needed. 

Life Insurance: On page l, enter ilie cash surrender value of 

this asset. In section 5 on page 2, enter ilic name ofilic 

insurance company, ilic face value ofilic policy, cash 

surrender value, names of beneficiaries, and loans on ilic 

policy. 

Other Personal Pmperty and Assets: Enter the total value 

of personal property and assets you own on page I. Personal 

property includes motor vehicles, boats, trailers, jewelry, 

funliturc, household goods, collectibles, clotlling, and 

personally owned vehicles tllat are leased or rented to 

businesses or other individuals. In section 6 on page 3, list 

these assets and enter the present value, the balance of anv 

liabilities, whether ilie asset is insured, and lien or note · 

information and terms of payments. For accounts and notes 

receivable, enter the total value of alimonies owed to you 

personally, if any. Yon may also be asked to provide a copy 

of any liens or notes on ilie property. 

that would apply if assets were distributed as of the date of Other Business Interests Other than Applicant Firm: On 

the fom1. Describe the number of shares, name of securities, page 1, enter ilie total value of your oilier business 

cost market value, date of quotation, and total value in investments (excluding the applicant firm). In section 7 on 

section 3 on page 2. page 3, enter information concenling the businesses you 

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hold an ownership interest in, such as sole proprietorships, 

partnerships, joint ventures, corporations, or limited liability 

corporations (other than the applicant finn). 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 on page 1. 

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

due on life insurance policies on page 1, and complete 

section 5 on page 2. 

Notes & Accounts Payable to Bank and Others: On page 

1, section 2, enter details concerning any liability, including 

name of notcholdcrs, original and current balances, payment 

terms, and security/collateral information. The entries should 

include automobile installment accounts. This should not, 

however, include any mortgage balances as this information 

is captured in section 4. Do not include loans for your 

business or mortgages for your properties in this section. 

You may be asked to submit copy of note/security 

agreement, and the most recent account statement. 

Other Liabilities: On page I, enter the total value due on all 

other liabilities not listed in the previous entries. In section 

8, page 3, report the name of the individual obligated, names 

of co-signers, description of the liability, the name of the 

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

tenus. Note: Do not include contingent liabilities in Uris 

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 on page 1, and complete 

section 8 on page 3. Contingent tax liabilities or anticipated 

taxes for current year should not be included. Describe in 

detail the name of the individual obligated, names of cosigners, tlte 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: If you checked the box indicating yes 

on page 3 in this category, provide details on all asset 

transfers (within 2 years of the date of tlris 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 otl1er 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. 

Subnrit documentation requested on tl1e fom1 related to the 

transfer. 

Affidavit 

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

Worth Statement must be notarized. 

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UNIFORM CERTIFICATION APPLICATION 

DISADVANTAGED BUSINESS ENTERPRISE (DBE) I 

Appendix F 

AIRPORT CONCESSION DISADVANTAGED BUSINESS ENTERPRISE (ACDBE) 

49 C.F.R. Parts 23 and 26 

Roadmap for Applicants 

1. Should I apply? 

You may be eligible to participate in the DEE/ A CD BE program if: 

• The firm is a for-profit business that performs or seeks to perform transportation related work (or a concession 

activity) for a recipient of Federal Transit Administration, Federal Highway Administration, or Federal Aviation 

Administration funds. 

• The finn is at least 51% owned by a socially and economically disadvantaged individual(s) who also controls it. 

• The firm's disadvantaged owners are U.S. citizens or lawfully admitted permanent residents of the U.S. 

• The firm meets the Small Business Administration's size standard and docs not exceed $23.9R million in gross 

annual receipts for DBE ($56.42 million for ACDBEs). (Other size standards apply for A CD BE that arc 

banks/financial institutions, car rental companies, pay telephone finns, and automobile dealers.) 

2. How do I apply? 

First time applicants for DBE certification must complete and submit this certification application and related 

material to the certifying agency in your home state and 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. lfyou fail to submit the required documents, your application may be delayed and/or denied. 

Firms already certified as a DEE do not have to complete this form, but may be asked by certifying agencies outside 

of your home state to provide a copy of your initial application form, supporting documents, and any other 

information you submitted to your home state to obtain certification or to any other state related to your 

certification. 

3. Where can I send my application? [INSERT UCP PARTICIPATING MEJ\1BER CONTACT INFORMATION] 

4. Who will contact me about my a1>plication and what are the eligibility standards? A transportation agency in 

your state that performs certification functions will contact you. The agency is a member of a statewide Unified 

Certification Program (UCP), which is required by the U.S. Department of Transportation. The UCP is a one-stop 

certification program that eliminates the need for your finn to obtain certification from multiple certifying agencies 

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

ACDBEs, pursuant to the eligibility standards found in 49 C.F.R. Parts 23 and 26. 

5. Where can I find more information? 

U.S. DOT -https://www.transportation.gov/civil-rights (This site provides useful links to the rules and regulations 

governing the DEE/ A CD BE program, questions and answers, and other pertinent information) 

SEA-Small Business Size Standards matched to the North American Industry Classification System (NAICS): 

http :1 /www. census. gov /eos/www /naics/ and http://www. sba. gov /content/table-small-business-size-standards. 

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

Freedom oflnformation 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. 1l1e information collected will be used solely to determine your tim1's eligibility to participate in the Department's 

Disadvantaged Business Enterprise Program as defined in 49 C.F.R. §26.5 and the Airport Concession Disadvantaged Business Enterprise 

Program as defined in 49 C.F.R. §23.3. You may review DOT's complete Privacy Act Statement in the Federal Register published on Aprilll, 

2000 (65 FR 19477). 

Under 49 C.F.R. §26.107, dated Febmary 2, 1999 and January 28, 2011, 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 fim1under 2 C.F.R. Parts 180 and 1200, Konprocurement Suspension and Department, take 

enforcement action under 49 C.F.R. 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. 

U.S. DOT Uniform DBE/ACDBE Certification Application • Page 1008 of 15 
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INSTRUCTIONS FOR COMPLETING THE 

DISADVANTAGED BUSINESS ENTERPRISE (DBE) 

AIRPORT CONCESSIONS DISADVANTAGED BUSINESS ENTERPRISE (ACDBE) 

UNIFORM CERTIFICATION APPLICATION 

NOTE: All participating firms must be for-profit enterprises. If your firm is not for profit, then you do NOT qualify for 

the DBE/ACDBE program and should not complete this application. 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 

(I) Enter the contact name and title of the person 

completing this application and the person who will 

serve as your finn's contact for this application. 

(2) Enter lhe legal name or your finn, as inclicalecl in your 

finn's Articles ofincorporation or charter. 

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

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

(5) Enter your fim1's fax number, if any. 

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

(7) Enter your linn's website acldresses, if any. 

(8) Enter the street address of the fnm where its offices 

are physically located (not a P.O. Box). 

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

from your fm11' s street address. 

B. Prior/Other Certifications and Applications 

(10) Check the appropriate box indicating whether your 

firm is currently certified in the DBE/ACDBE 

programs, and provide the name of the certifying 

agency that certified your finn. List the dates of any 

site visits conducted by your home state and any other 

slates or lJCP members. Also provide lhe names or 

state/UCP members that conducted the review. 

(II) Indicate whether your firm or any films owned by the 

persons listed has ever been denied certification as a 

DBE/ACDBE, 8(a), or Small Disadvantaged Business 

(SDB) finn, or state and local MBE/WBE finn. 

lnclicale ir lhe finn has ever been clecerlifiecllrom one 

of these programs. Indicate if the application was 

withdrawn or whether the firm was debarred, 

suspended, or otherwise had its biddi11g privileges 

denied or restricted by any state or local agency, or 

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

of the agency, am! 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 ofUSDOT's final agency decision(s). 

Section 2: GENERAL INFORMATION 

A. Business profile: 

(I) Give a concise description of the fnm's prinlary 

activities, the product( s) or services the company 

provides, or type of construction. If your company 

otTers more than one product/service, list primmy 

proclucl or service first ( allach additional sheets i r 

necessary). This description may be used in our UCP 

online directory if you arc certified as a DBE. 

(2) 1r you know lhe appropriate NAICS Code f(JT lhe 

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

enter the codes in the space provided. 

(3) State the date on which your fmn was established as 

stated in your finn's Articles of Incorporation or 

charter. 

(4) Slate lhe elate each person became a rinn o\Vner. 

( 5) Check the appropriate box describing 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 

linn is "for profit." If you checked "No," then you 

do NOT quality for the DBE/ACDBE program and 

should not complete this application. All participating 

finns must be for-profit enterprises. Provide the 

Federal Tax ID number as stated on your fm11's 

Federal l<L"X retum. 

(7) Check the appropriate box that describes the type of 

legal busi11css stmcturc of your firm, as indicated in 

your firm's Articles of Incorporation or sinlilar 

document. If you checked "Other," briet1y explain in 

the space provided. 

(8) Indicate in the spaces provided how many employees 

your !Inn has, specifying the number or employees 

who work on a full-time, part-time, and seasonal basis. 

Attach a list of employees. their job titles, m1d dates of 

employment, to your application. 

(9) Specify the finn's gross receipts for each of the past 

tlu·ee years, as stated in your finn's filed Federal tax 

returns. You must submit complete copies or lhe 

finn's Federal tax retums for each year. If there are 

any affiliates or subsidiaries of the applicant firm or 

owners, you must provide these firms' gross receipts 

and submit complete copies of tl1ese tlrm(s) Federal 

tax retums. Affiliation is defined in 49 C.F.R. §26.5 

and 13 C.F.R. Part 121. 

B. Relationships and Dealings with Other Businesses 

( 1) Check the appropriate box that indicates whether your 

finn is co-located at any of its busi11ess locations, or 

whether your finn shares a telephone numher(s), a 

post otlice box, any otlice space, a yar~ warehouse, 

other facilities, any equipment, financing, or any 

otiice staff and/or employees with m1y other busi11ess, 

organization or entity of any kind. If you answered 

"Yes," then specify tl1e name of tl1e other finn( s) and 

fully explain the nature of your relationship witl1 tl1ese 

other businesses by identirying lhe business or person 

with whom you have any tormal, intormal, written, or 

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oral agreement. Provide an explanation of any items 

shared with other finns in the space provided. 

(2) Check the appropriate box indicating whether any 

other finn currently has or had an ownership interest 

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

checked yes, please explain. 

(3) Check the appropriate box tlmt indicates whether at 

present or at any time in the past your finn: 

(a) ever existed under ditTerent mvnership, a ditlerent 

type of ow1rership, or a different name; 

(b) existed as a subsidiary of any other firm; 

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

partners are/were other finns; 

(d) ow11ed any percentage of any other tinn; and 

(e) had any subsidiaries of its own. 

(f) served as a subcontractor with another firm 

constituting more tlmn 25% of your tum's receipts. 

If you answered "Yes" to any of the questions in (3)(a-f), 

you may he asked to explain the arrangement in detail. 

Section 3: MAJORITY OWNER INFORM A TTON 

Tdentity all individuals or holding companies with any 

ov.nership interest in your finn, providing tlre infonnation 

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

provide completed copies of this section for each ow1rer ): 

A. Identify the majority owner of the firm holding 51% 

or more ownership interest 

( l) Enter the full name of the owner. 

(2) Enter his/her title or position within your finn. 

(3) Give his/her home phone number. 

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

(5) Indicate this owner's gender. 

(6) Iclenlify the owner's elhnic 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 

ow1rer is a U.S. citizen or a lawfully admitted 

permanent resident. If this owner is neither a U.S. 

cilizen nor a lawfully aclmillecl pennanenl resiclenl of 

the U.S., then this owner is NOT eligible for 

cerli1icalion as a DEE owner. 

(8) Enter the number of years during which this owner has 

been an owner of your fmn. 

(9) Indicate the percentage of the total ownership this 

person holcls ancl the clale acquirecl, inclucling (if 

appropriate), the class of stock owned. 

(10) Indicate the dollar value of tlris owner's initial 

investment to acquire an ownership interest in your 

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

and/or other investment. Describe how you acquired 

your business ancl allach clocumenlalion subslanlialing 

this investment. 

B. Additional Owner Information 

( l) Describe tire familial relationship of tlris mv1rer to each 

other ow1rer of your firm and employees. 

(2) Indicate whether tlris owner perfonns a management 

or supervisory function for any other business. If you 

checked "Yes," state the name of tire other business 

and this owner's fi.mctionltitlc held in that business. 

(3) (a) Check the appropriate box tlrat indicates whether 

this owner owns or works for any other firm( s) that 

has l!!.!Y relationship witlr your finn. lf you checked 

"Yes," identify the name of the other business, the 

nature of tire business relationslrip, and tire owner's 

function at the finn. 

(b) lf the owner works for any other finn, non-profit 

organization, or is engaged in any other activity more 

tlran l 0 hours per week, please identity tlris activity. 

(4) (a) Provide the personal net worth of the owner 

applying for certification in tire space provided. 

Complete and attach the accompanying "Personal Net 

Worth Statement for DEE/ACDEE Program 

Eligibility" with your application. Note, complete this 

section and accompanying statement only for each 

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

owner clainring to be socially and economically 

disadvantaged). 

(b) Check tire appropriate box that indicates whetlrer any 

trust has heen created for the benefit of the 

disadvantaged owner(s). If you answered "Yes," you 

may be asked to provide a copy of the trust 

instrument. 

(5) Check the appropriate to indicate whether any of your 

immediate family members, managers, or employees, 

own, manage, or are associated with another company. 

Immediate family member is defined in 49 C.F.R. 

§26.5. If you answered "Yes," provide the name of 

each person, your relationship to tlrem, the name of 

the company, the type of business, and whether they 

own or manage tire company. 

Section 4: CONTROL 

A Identity the firm's Officers and Board of 

Directors 

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

appoinlmenl, elhuicily, ancl gencler of each officer. 

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

appointment, etlmicity, and gender of each individual 

serving on your finn's Doard of Directors. 

(3) Check the appropriate box lo inclicale whether any of 

your firm's ofticers and/or directors listed above 

per1onns a managemenl or supervisory runclion ror 

any other business. If you answered "Yes," identifv 

each person by name, Iris/her title, tire name of tire 

other business in which s/he is involved, and his/her 

funclion perfonnecl in thal other business. 

( 4) Check the appropriate box that indicates whether any 

of your finn's otlicers and/or directors listed above 

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

relationship witlr your finn. (e.g., ownership interest, 

shared office space, financial investments, equipment 

leases, personnel sharing, elc.) If you answerecl "Yes," 

identify the name of the firm, tire individual's name, 

and the nature of his/her business relationslrip with 

that other firm. 

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

Key Personnel 

(1 ), (2) Specify the roles of the majority and minority 

owners, directors, otlicers, and managers, and key 

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persmmel who are responsible for the functions listed for 

the finn. Submit resumes for each owner aud non-owner 

identified belov.. Slate lhe mune of lhe individmtl, lille, race 

and gender and pencentage ov.11ership if any. Circle the 

frequency of each person's involvement as follows: 

"always, frequently, seldom, or never" in each area. 

Indicate whether any of the persons listed in this section 

perfonn a management or supervisory function for any 

other business. Identify the person, business, aud their 

title/function Identify if any of the persons listed above 

own or work for any otlrer finn(s) tlmt has a relationship 

with this finn (e.g. ownership interest, shared office space, 

financial investment, equipment, leases, personnel sharing. 

etc.) If you answered ·'Yes," describe the natme of his/her 

business relationship with that otlrer finn. 

C. Inventory: Indicate finn inventory in these categories: 

(1) Equipment and Vehicles 

State the make and model, and current dollar value of 

each piece of equipment and motor vehicle held and/or 

used hy your tlnn. Indicate whether each piece is 

either ov.ned or leased by your tlnn or ov.ner, whetlrer 

it is used as collateral, and where this item is stored. 

(2) Office Space 

State tire street address of each office space held 

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

or mvner owns or leases the office space and the 

current dollar value of that property or its lease. 

(3) Storage Space 

State the str·eet adch·ess of each storage space held 

and/or used by your finn. Indicate whether your fmn 

or ov.ner owns or leases the storage space and the 

current dollar value of llial properly or ils lease. 

Provide a signed lease agreement for each property. 

D. Does your firm rely on any other firm for 

management functions or employee payroll'! 

Check the appropriate box that indicates whether your fum 

relics on auy other tirm for management fimctions or for 

employee payroll. If you answered "Yes," you may be 

asked to explain the narure of that reliance and the extent to 

which the other tlnn carries out such functions. 

E. Financial/ Banking Information 

State the name, City and State of your firm's bank. Identify 

llie persons able lo sign checks on lliis account. Provide 

hank authorization and signature cards. 

Bonding Information. State your finn's bonding linlits both 

aggregate and projecllimils. 

F. Sources, amounts, and purposes of money loaned to 

your firm, including the names of persons or firms 

guaranteeing the loan. 

State the name aud address of each source, the name of 

person securing the loan, original dollar amount aud the 

cunent balance of each loan, and tire pwpose for which 

each loau was made to your finn. Provide copies of signed 

loan agreements and security agreements 

G. 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 

finn to whom it was tmnsfenec"'" the relationship between 

tire two persons and/or finns, and tire date of tire transfer. 

H 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 penni!, the type of permit or license, 

the expiration date of the permit or license, and issuing 

State of the license or pennit. Attach copies of licenses, 

license renewal forms, pennits, and haul authority forms. 

l Largest contracts completed by your firm in the past 

three years, if any. 

List llie name of each owner or contractor for each contract, 

tire name and location of tire projects wrder each contract, 

the type of work perfonned on each contract, and the dollar 

value of each contract. 

J. Largest active _jobs on which your firm is currently 

working. 

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

contractor and tire project nurnber, tire location, the type of 

work perfonned, the project start date, the anticipated 

completion date, mrd the dollar value ofthe contract. 

Section 5: AIRPORT CONCESSION (A CD BE) 

APPLICANTS 

C ornplele llie entries in lliis sec lion if you are applying for 

ACDRR certification. Indicate in Section A if you operate a 

concession at the airport, aud/or supply a good or service to 

an airport concessionaire. Indicate in Section B whether the 

applicant finn owns or operates any off.ai:tpori locations, 

providi:trg tire type of busi:tress, lease i:trfonnation, 

address/location, mrd mrnual gross receipts generated. 

Provide similar information in section C for any airport 

concession locations the finn cunently owns or operates. If 

tire applicmrt tlnn has mry affiliates, provide the requested 

infonnation in Section D. Indicate whetlrer the ACDBE 

linn is participating i:tr tmy joint venlttres, tmd if so, include 

the original and any amended joint venture agreements. 

AFFIDAVIT & SIGNATURE 

The Affidavit of Certification must accompany your 

application. Carefully read the attached affidavit in its 

entirety. Fill in the required infomration tor each blmlk 

space, and sign and date the affidavit i:tt tire presence of a 

Notary Public, who must tlren notarize tire fonn. 

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Section 1: CERTIFICATION INFORMATION 

A. Basic Contact Information I am applying for certification as 0 DBE DACDBE 

(1) Contact person and Title: ________ _ (2) Legal name offirm: __________ _ 

(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 (ifdifferenl) City: County/Parish: State: Zip: 

B. Prior/Other Certifications and Applications 

(10) Is your firm currently certified for any ofthe following U.S. DOT programs? 

D DBE D A CD BE Names of certifying agencies: _____________________ _ 

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

Date ___ Statc/UCP Member: _____ Date ___ Statc/UCP Member: ______ _ 

(11) Indicate whether the firm or any persons listed in this application have ever been: 

(a) Denied certification or decertified as a DBE, A CD BE, 8(a), SDB, MBE/WBE firm? D Y cs DNo 

(b) 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? D Yes D No 

If yes, explain the nature of the action. (l{}'OU appealed the decision to DOT or another agency, attach a copy of the decision) 

Section 2: GENERAL INFORMATION 

A. Business Profile: (1) Give a concise description of the tlm1' s primary activities and the product(s) or service(s) 

it provides. 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 I I I (4) J/We have owned this firm since: __ / __ / __ 

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

D Started new business D Bought existing business D Inherited business D Gifted 

D Merger or consolidation D Other (explain! ________________________ _ 

(6) Is your firm "for profit"? DYes DNo----> 

Federal Ta" ID# __________ _ 

®STOP! If your finn is NOT for-profit, then you do NOT 

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

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

D Sole Proprietorship D Limited Liability Partnership 

D Partnership DCorporation 

D Limited Liability Company D Other, Describe __________________ _ 

(8) Number of employees: Full-time Part-time Seasonal Tot..1.l ___ _ 

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

(9) Specify the firm's gross receipts for the last 3 years. (Sub mil complete copies ofthejirm 's Federal fax returnsfor 

each year. If /here are affiliates or subsidiaries of the applicanl firm or owners, you must submit complete copies of these 

firms' Federal tax returns). 

Year ___ Gross Receipts of Applicant Firm $ ______ Gross Receipts of Affiliate Firms $ ____ _ 

Year Gross Receipts of Applicant Firm $ Gross Receipts of Affiliate Firms $ ___ _ 

Y car Gross Receipts of Applicant Firm $ Gross Receipts of Affiliate Firms $ ____ _ 

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? 0 Y cs 0 No 

If Yes, explain the nature ofyour 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? 

DYes D No lfYes, explain _____________________________ _ 

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

(a) Ever existed under different ownership, a different type of ownership, or a different name? 0 Yes 0 No 

(b) Existed as a subsidiary of any other firm? 0 Yes 0 No 

(c) Existed as a partnership in \vhich one or more of the partners are/were other finns? 0 Yes 0 No 

(d) Owned any percentage of any other finn? 0 Yes 0 No 

(e) Had any subsidiaries? DYes D No 

(t) Served as a subcontractor with another finn constituting more than 25% of your finn's receipts? DYes D No 

({(you answered "Yes" to any of the questions in (2) and/or (3)(a)-(f}, you may be asked to provide further details and explain 

whether the arrangement continues). 

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Section 3: MAJORITY OWNER INFORMATION 

A. Identify the majority owner of the firm holding 51% or more ownership interest. 

(1) Full Name: I (2) Title: 

(4) Home Address (Street and Number): 

(5) Gender: 0 Male 0 Female 

(6) Ethnic group membership (Check all that appZr): 

0 Black 0 Hispanic 

0 Asian Pacific 0 Native American 

0 Subcontinent Asian 

0 Other (specifY) ---------

(7) U.S. Citizenship: 

0 U.S. Citizen 

0 Lawfully Admitted Permanent Resident 

B. Additional Owner Information 

I 

(3) Home Phone #: 

( ) ----------

City: State: Zip: 

(8) Number of years as owner: __ _ 

(9) Percentage owned: _____ % 

Class of stock owned: ___ _ 

Date acquired _______ _ 

(10) Initial investment to Type 

acquire ownership Cash 

Dollar Value 

$ 

interest in firm: Real Estate 

Equipment 

Other 

$ 

$ 

$ 

Describe how you acquired your business: 

0 Started business myself 

0 It was a gift from: ____________ _ 

0 1 bought it from: ____________ _ 

0 1 inherited it from: ------------- 0 Other ------------------ (Attach documentation substantiating your investment) 

(1) Describe familial relationship to other owners and employees: 

(2) Does this owner perform a management or supervisory function for any other business? 0 Yes 0 No 

If Yes, identifY: Name of Business _____________ Function!Iitle: ___________ _ 

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

inleresl, shared office space, financial inves/menls, equipmenl, leases, personnel shan·ng, e/c.) 0 Yes 0 No 

IdentifY the 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 engage in any other activity more 

than 10 hours per week? 1fyes, identifY this activity: ___________________ _ 

(4)(a) What is the personal net worth of this disadvantaged owner applying for certification?$. ____ _ 

(b )Has any trust been created for the benefit of this disadvantaged owner(s)? 0 Yes 0 No 

(I,[ Yes, you may be asked fo provide a copy of the trust instrument). 

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

another company? 0 Y cs 0 No IfY cs, provide their name, relationship, company, type of business, and 

indicate whether they own or manage the company: (Please attach exira sheets, if needed): _________ _ 

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Section 3: OWNER INFORMATION, Cont'd. 

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

firm (Attach separate sheets for each additional owner) 

I (2) Title: (1) Full Name: 

I 

(3) Home Phone#: 

( ) ----------

(4) Home Address (Street and Number): City: State: Zip: 

(5) Gender: 0 Male 0 Female (8) Number of years as owner: __ _ 

(9) Percentage owned: % 

(6) Ethnic group membership (Check all that app~v) Class of stock owned: ___ _ 

0 Black 0 Hispanic 

0 Asian Pacific 0 Native American 

0 Subcontinent Asian 

0 Other (specifY) ---------

(7) U.S. Citizenship: 

0 U.S. Citizen 

0 Lawfully Admitted Permanent Resident 

B. Additional Owner Information 

Date acquired ______ _ 

(10) Initial investment to 

acquire ownership 

interest in firm: 

Type 

Cash 

Real Estate 

Equipment 

Other 

Dollar Value 

$ 

$ 

$ 

$ 

Describe how you acquired your business: 

0 Started business myself. 

0 It \vas a gift from: ____________ _ 

0 I bought it from: ____________ _ 

0 I inherited it from: -------------

0 Other -------------------

~4ttach documentation substantiating your investment) 

(1) Describe familial relationship to other owners and employees: 

(2) Does this owner perform a management or supervisory function for any other business? 0 Yes 0 No 

If Yes, identifY: Name of Business: _____________ Funclion/TiUe: ___________ _ 

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

interest, shared office space .financial investments, equipment, leases, personnel sharing, etc.) 0 Yes 0 No 

IdentifY the 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: ___________________ _ 

(4)(a) What is the personal net worth of this disadvantaged owner applying for certification?$ ____ _ 

(b) Has any trust been created for the benefit of this disadvantaged owner(s)? 0 Yes 0 No 

(If Yes, you may be asked to provide a copy of the trust instrument). 

(5) Do any of your immediate family members, managers, or employees own, manage, or are associated 

with another company? 0 Yes 0 No IfYes, provide their name, relationship, company, type of 

business, and indicate whether they own or manage: (Please attach extra sheets, if needed): _______ _ 

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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 Ethnicitv Gender 

(1) Officers of the Company (a) 

(b) 

(c) 

(d) 

(2) Board of Directors (a) 

(b) 

(c) 

(d) 

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

D Yes D No lfYes, identity for each: 

Person: _______________ Title: _____________________ _ 

Business: Function: ____________________ _ 

Person: _______________ Title:,-----------------------

Business: Function: ____________________ _ 

(4) Do any ofthe persons listed in section A 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.) 

D Yes D No lf Yes, identity for each: 

FirmName: ______________ Person: ______________________ _ 

Nature of Business Relationship:---------------------------------

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

1. Complete for all Owners who are responsible for the following functions of the firm (Atrach separate sheets as 

needed) 

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

A= Always S =Seldom Name: Name: 

F = Frequently N =Never Title: Title: 

Percent Owned: Percent Owned: 

Sets policy for company direction/scope A F s N A F s N 

of operations 

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 (billing, A F s N A F s N 

accounts receivable/payable, etc ) 

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 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 

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2. Complete for all Officers, Directors, Managers, and Key Personnel who are responsible for the following 

functions of the firm (Artach separate sheets as needed) 

Officer/Director/Manager/Key Pers01mel Officer/Director/Manager/ Key Pers01mel 

A= Always S =Seldom Name: Name: 

F = Frequently N =Never Title: Title: 

Race and Gender: Race and Gender: 

Percent Owned: Percent Owned: 

Sets policy for company direction/scope A F s N A F s N 

of operations 

Bidding and c stimating A F s N A F s N 

Maior purchasing decisions A F s N A F s N 

Marketing and sales A F s N A F s N 

Supervises field opemtions A F s N A F s N 

Attend bid opening and lcttings A F s N A F s N 

Perform office management (billing, A F s N A F s N 

accounts receivable/pavable, etc.) 

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 bv contmct/crcdit 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 in B 1 or B2 perform a management or supervisory function for any other business? TfY cs, 

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 inleres/, shared office space, financial inves/menls, equipment, leases, personnel sharing, etc.) If Yes, describe tl1e nature of 

the business relationship: ___________________________________ _ 

C. Inventory: Indicate your firm's inventory in the following categories (Please artach additional sheets if needed): 

1. Equipment and Vehicles 

Make and Model 

l. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

2. Office Space 

Street Address 

Current 

Value 

Owned or Leased Used as collateral? Where is item stored? 

by Firm or Owner? 

Owned or Leased by Firm or Owner? Current Value of Property or Lease 

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3. 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 

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

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

Name of bank: City and State: _____________ _ 

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

Name of bank: City and State: ______________ _ 

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

Bonding Information: If you have bonding capacity, identify the firm's bonding aggregate and project limits: 

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 guaranteeing the loan, if other than the listed owner. 

(l'rovide copies ofsigned loan agreements and security agreements). 

N arne of Source Address of Source N arne of Person 

Guaranteeing the 

Loan 

Original 

Amount 

Current 

Balance 

Purpose of Loan 

!. ______________________________________ _ 

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 (Ailach additional sheets if needed): 

Contribution/ Asset Dollar Value From Whom 

Transferred 

To Whom 

Transferred 

Relationship Date of 

Transfer 

l. _____________________________________ ___ 

2. __________________________________ ___ 

3. _____________________________________ ___ 

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

(e.g. contractor, engineer, architect, etc.)(Attach additional sheets if needed): 

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

l. ______________________________________ _ 

2. ___________________________________ _ 

3. _____________________________________ ___ 

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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·--------------------------------------------------------------------------------

Additional Information: 

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SECTION 5- AIRPORT CONCESSION 

(A CD BE APPLICANTS ONLY) 

A. I am applying for A CD BE certification to: (check all that apply) 

D Operate a concession at an airport D Supply a good or service to an airport concessionaire 

B. Does the applicant firm own/operate any off-airport locations? DYes D No If"Yes, identify thefollowing 

Type of Business Lease Lease Address I Location Annual Gross 

(e.g., F&B, News & Gift Retail, Duty Term Start Date Receipts Generated 

Free, Advertising. etc.) (years) 

c. Does the applicant firm currently own/operate any airport concession locations? DYes D No !{Yes, supply 

the following information. 

Airport Name Concession Type Number of Number of Annual Gross Lease Type 

(e.g., F &B, News & Leases Locations Receipts (e.g. Direct Lease, Subcontract 

Gift, Retail, Duty Free, Generated Afanagement Agreement, etc. enter 

Advertising, etc.) all that apply to the leases listed) 

D. Does the applicant firm have any affiliates? DYes D No !{Yes, provide the following information concerning 

any locations owned1operated by affiliate firms. 

Airport Name Concession Type Number of Number of Annual Gross Lease Type 

(e.g., F &B, News & Leases Locations Receipts (e.g. Direct Lease, Subcontract 

Gift, Retail, Duty Free, Generated A1anagement Agreement, etc. enter 

Advertising, elc.) all that app~v to the leases listed) 

E. Is the ACDBE applicant firm a participant in any joint ventures? DYes D No !{Yes, attach all original and 

any amended Joint Venture Agreements and any amendments to the agreements. 

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AFFIDAVIT OF CERTIFICATION 

1his 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. 

______________ (full name printed), 

swear or affinn under penalty of law that Jam 

____________ (title) of the applicant firm 

__________________ and that 1 

have read and understood all of the questions in this 

application and that all of the foregoing infonnation and 

statements submitted in this application and its attachments 

and supporting documents are true and correct to U1e best of 

my knowledge, and Uml all responses to U1e 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 

J recognize that the infonnation submitted in this application is 

for the purpose of inducing certification approval by a 

government agency. 1 understand tlmt 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 oU1er certifying 

agencies for the purpose of verifying tl1e information supplied 

and detennining tl1e named finn's eligibility. 

I agree to submit to govemment audit, examination and review 

of books, records, documents and files, in wlmtever 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. J understand that 

refusal to permit such inquiries slmll be grounds for denial of 

certification. 

If awarded a contract, subcontract, concession lease or 

sublease, I agree to prompUy and direcUy provide U1e prime 

contractor, if any, and U1e Department, recipient agency, or 

federal funding agency on an ongoing basis, current, complete 

and accurate information regarding (1) work performed on tl1e 

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 of any 111aterial clmnge in the 

infommtion contained in the original application within 30 

calendar days of such change (e.g., ownership changes, 

address/telephone number, personal net worth exceeding $1.32 

million, etc.). 

J 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 111ay be awarded; denial or revocation of certification; 

suspension and debarment; and for initiating action under 

federal and/or state law conccming false statement, fraud or 

other applicable offenses. 

I certify that I am a socially and economically disadvantaged 

individual who is an owner of tl1e above-referenced firm seeking 

certification as a Disadvantaged Business Enterprise or Airport 

Concession Disadvantaged Business Enterprise. In support of my 

application, I certify tlmt I am a member of one or more of the 

following groups, and tlmt I lmve held myself out as a member of 

the group(s): (Check all tlmt apply): 

0 Female 0 Black American 0 Hispanic American 

0 Native American 0 Asian-Pacific American 

0 Subcontinent Asian American 0 Other (specify) 

I certify that I am socially disadvantaged because I have been 

subjected to racial or eUnric prejudice or cultural bias, or have 

suffered the effects of discrimination, because of my identity 

as a member of one or more of tl1e groups identified above, 

without regard to my individual qualities. 

I further certify tlmt my personal net worth does not exceed 

$1.32 million, and tlmt I am economically disadvantaged 

because my ability to compete in the free enterprise system lms 

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 penally of peij ury Uml U1e infonnation 

provided in tlris application and supporting documents is true 

and correct. 

Signature----.,----------

(DBE/ACDBE Applicant) 

NOTARY CERTIFICATE 

(Date) 

U.S. DOT Uniform DEE/ A CD BE Certification Application • Page 1021 of 15 
40138 Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices 

BILLING CODE 4910–9X–C 


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UNIFORM CERTIFICATION APPLICATION 

SUPPORTING DOCUMENTS CHECKLIST 

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

REQUIRED documents. A failure to supply any information requested by the UCP may result in your firm denied 

DBE/ACDBE certification. 

Required Documents (or All Applicants 

l Resumes (that include places of employment with 

corresponding dates), for all owners, officers, and key 

personnel of the applicant firm 

J Personal Net Worth Statement for each socially and 

economically disadvantaged owners who the applicant firm 

relics upon to satisfy the Regulation's 51% ownership 

requirement. 

J Personal Federal tax returns for the past3 years, if 

applicable, for each disadvantaged owner 

J Federal tax returns (and requests for extensions) filed by 

the finn and its affiliates with related schedules, for the past 3 

years. 

J Documented proof of contributions used to acquire 

ownership for each owner (e.g., both sides ofcancelled 

checks) 

l Signed loan and security agreements, and bonding forms 

L List of equipment and/or vehicles owned and leased 

including YIN numbers, copy of titles, proof of ownership, 

insurance cards for each vehicle. 

J Titlc(s), registration certificatc(s), and U.S. DOT numbers 

for each truck owned or operated by your finn 

J Licenses, license renewal fonns, pennils, and haul 

authority forms 

J Descriptions of all real estate (including office/storage 

space, etc.) owned/leased by your finn and documented proof 

of ownership/signed leases 

J Documented proof of any transfers of assets to/from your 

firm and/or to/from any of its owners over the past 2 years 

J DBE/ACDBE and SEA 8(a). SDB, MBE/WBE 

certifications, denials, and/or decertifications, if applicable; 

and any U.S. DOT appeal decisions on these actions. 

J Bank authorization and signatory cards 

J Schedule of salaries (or other remuneration) paid to all 

officers, managers, owners, and/or directors of the finn 

J List of all employees, job titles, and dales of employment. 

J Proof of warehouse/storage facility ownership or lease 

arrangements 

Partnership or Joint Venture 

J Original and any amended Partnership or Joint Venture 

Agreements 

Corporation or LLC 

J Official Articles of Incorporation (5igned by the srate 

ojjicial) 

J Both sides of all corporate stock certificates and your 

firm's stock tnmsfcr ledger 

J Shareholders· Agrecment(s) 

= 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) 

Optional Documents to Be Provided on Request 

The certi[ving agency fo which you are appZving may require 

the submission of the following documents. If requested to 

provide these document, you must suppZv them with your 

application or at the on-site visit. 

L Proof of citizenship 

= Insurance agreements for each tmck owned or operated by 

your firm 

- Audited financial statements (if available) 

- Tmst agreements held by any owner claiming 

disadvantaged status 

= Year-end balance sheets and income statements for the 

past 3 years (or life affirm, !{less than three years) 

Suppliers 

= List of product lines carried and list of distribution 

equipment owned and/or leased 

U.S. DOT Uniform DEE/ A CD BE Certification Application • Page 1022 of 15 
Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices 40139 

Appendix B to Part 26—Uniform 

Report of DBE Awards or Commitments 

and Payments Form 

Instructions for Completing the Uniform 

Report of DBE Awards/Commitments and 

Payments 

Recipients of Department of Transportation 

(DOT) funds are expected to keep accurate 

data regarding the contracting opportunities 

available to firms paid for with DOT dollars. 

Failure to submit contracting data relative to 

the DBE program will result in 

noncompliance with Part 26. All dollar 

values listed on this form should represent 

the DOT share attributable to the Operating 

Administration (OA): Federal Highway 

Administration (FHWA), Federal Aviation 

Administration (FAA) or Federal Transit 

Administration (FTA) to which this report 

will be submitted. 

1. Indicate the DOT (OA) that provides 

your Federal financial assistance. If 

assistance comes from more than one OA, 

use separate reporting forms for each OA. If 

you are an FTA recipient, indicate your 

Vendor Number in the space provided. 

2. If you are an FAA recipient, indicate the 

relevant AIP Numbers covered by this report. 

If you are an FTA recipient, indicate the 

Grant/Project numbers covered by this report. 

If more than ten attach a separate sheet. 

3. Specify the Federal fiscal year (i.e., 

October 1–September 30) in which the 

covered reporting period falls. 

4. State the date of submission of this 

report. 

5. Check the appropriate box that indicates 

the reporting period that the data provided in 

this report covers. For FHWA and FTA 

recipients, if this report is due June 1, data 

should cover October 1–March 31. If this 

report is due December 1, data should cover 

April 1–September 30. If the report is due to 

the FAA, data should cover the entire fiscal 

year. 

6. Provide the name and address of the 

recipient. 

7. State your overall DBE goal(s) 

established for the Federal fiscal year of the 

report being submitted to and approved by 

the relevant OA. Your overall goal is to be 

reported as well as the breakdown for 

specific Race Conscious and Race Neutral 

projections (both of which include genderconscious/neutral projections). The Race 

Conscious projection should be based on 

measures that focus on and provide benefits 

only for DBEs. The use of contract goals is 

a primary example of a race conscious 

measure. The Race Neutral projection should 

include measures that, while benefiting 

DBEs, are not solely focused on DBE firms. 

For example, a small business outreach 

program, technical assistance, and prompt 

payment clauses can assist a wide variety of 

businesses in addition to helping DBE firms. 

Section A: Awards and Commitments Made 

During This Period 

The amounts in items 8(A)–10(I) should 

include all types of prime contracts awarded 

and all types of subcontracts awarded or 

committed, including: professional or 

consultant services, construction, purchase of 

materials or supplies, lease or purchase of 

equipment and any other types of services. 

All dollar amounts are to reflect only the 

Federal share of such contracts and should be 

rounded to the nearest dollar. 

Line 8: Prime contracts awarded this 

period: The items on this line should 

correspond to the contracts directly between 

the recipient and a supply or service 

contractor, with no intermediaries between 

the two. 

8(A). Provide the total dollar amount for 

all prime contracts assisted with DOT funds 

and awarded during this reporting period. 

This value should include the entire Federal 

share of the contracts without removing any 

amounts associated with resulting 

subcontracts. 

8(B). Provide the total number of all prime 

contracts assisted with DOT funds and 

awarded during this reporting period. 

8(C). From the total dollar amount awarded 

in item 8(A), provide the dollar amount 

awarded in prime contracts to certified DBE 

firms during this reporting period. This 

amount should not include the amounts sub 

contracted to other firms. 

8(D). From the total number of prime 

contracts awarded in item 8(B), specify the 

number of prime contracts awarded to 

certified DBE firms during this reporting 

period. 

8(E&F). This field is closed for data entry. 

Except for the very rare case of DBE-set 

asides permitted under 49 CFR part 26, all 

prime contracts awarded to DBES are 

regarded as race-neutral. 

8(G). From the total dollar amount awarded 

in item 8(C), provide the dollar amount 

awarded to certified DBEs through the use of 

Race Neutral methods. See the definition of 

Race Neutral in item 7 and the explanation 

in item 8 of project types to include. 

8(H). From the total number of prime 

contracts awarded in 8(D), specify the 

number awarded to DBEs through Race 

Neutral methods. 

8(I). Of all prime contracts awarded this 

reporting period, calculate the percentage 

going to DBEs. Divide the dollar amount in 

item 8(C) by the dollar amount in item 8(A) 

to derive this percentage. Round the 

percentage to the nearest tenth. 

Line 9: Subcontracts awarded/committed 

this period: Items 9(A)-9(I) are derived in the 

same way as items 8(A)-8(I), except that these 

calculations should be based on subcontracts 

rather than prime contracts. Unlike prime 

contracts, which may only be awarded, 

subcontracts may be either awarded or 

committed. 

9(A). If filling out the form for general 

reporting, provide the total dollar amount of 

subcontracts assisted with DOT funds 

awarded or committed during this period. 

This value should be a subset of the total 

dollars awarded in prime contracts in 8(A), 

and therefore should never be greater than 

the amount awarded in prime contracts. If 

filling out the form for project reporting, 

provide the total dollar amount of 

subcontracts assisted with DOT funds 

awarded or committed during this period. 

This value should be a subset of the total 

dollars awarded or previously in prime 

contracts in 8(A). The sum of all subcontract 

amounts in consecutive periods should never 

exceed the sum of all prime contract amounts 

awarded in those periods. 

9(B). Provide the total number of all sub 

contracts assisted with DOT funds that were 

awarded or committed during this reporting 

period. 

9(C). From the total dollar amount of sub 

contracts awarded/committed this period in 

item 9(A), provide the total dollar amount 

awarded in sub contracts to DBEs. 

9(D). From the total number of sub 

contracts awarded or committed in item 9(B), 

specify the number of sub contracts awarded 

or committed to DBEs. 

9(E). From the total dollar amount of sub 

contracts awarded or committed to DBEs this 

period, provide the amount in dollars to 

DBEs using Race Conscious measures. 

9(F). From the total number of sub 

contracts awarded or committed to DBEs this 

period, provide the number of sub contracts 

awarded or committed to DBEs using Race 

Conscious measures. 

9(G). From the total dollar amount of sub 

contracts awarded/committed to DBEs this 

period, provide the amount in dollars to 

DBEs using Race Neutral measures. 

9(H). From the total number of sub 

contracts awarded/committed to DBEs this 

period, provide the number of sub contracts 

awarded to DBEs using Race Neutral 

measures. 

9(I). Of all subcontracts awarded this 

reporting period, calculate the percentage 

going to DBEs. Divide the dollar amount in 

item 9(C) by the dollar amount in item 9(A) 

to derive this percentage. Round the 

percentage to the nearest tenth. 

Line 10: Total contracts awarded or 

committed this period. These fields should 

be used to show the total dollar value and 

number of contracts awarded to DBEs and to 

calculate the overall percentage of dollars 

awarded to DBEs. 

10(A)–10(B). These fields are unavailable 

for data entry. 

10(C–H). Combine the total values listed on 

the prime contracts line (Line 8) with the 

corresponding values on the subcontracts 

line (Line 9). 

10(I). Of all contracts awarded this 

reporting period, calculate the percentage 

going to DBEs. Divide the total dollars 

awarded to DBEs in item 10(C) by the dollar 

amount in item 8(A) to derive this 

percentage. Round the percentage to the 

nearest tenth. 

Section B: Breakdown by Ethnicity & Gender 

of Contracts Awarded to DBEs This Period 

11–17. Further breakdown the contracting 

activity with DBE involvement. The Total 

Dollar Amount to DBEs in 17(C) should equal 

the Total Dollar Amount to DBEs in 10(C). 

Likewise, the total number of contracts to 

DBEs in 17(F) should equal the Total Number 

of Contracts to DBEs in 10(D). 

Line 16: The ‘‘Non-Minority’’ category is 

reserved for any firms whose owners are not 

members of the presumptively disadvantaged 

groups already listed, but who are either 

‘‘women’’ OR eligible for the DBE program on 

an individual basis. All DBE firms must be 

certified by the Unified Certification Program 

to be counted in this report. 


sradovich on DSK3GMQ082PROD with NOTICES
40140 Federal Register / Vol. 83, No. 156 / Monday, August 13, 2018 / Notices 

Section C: Payments on Ongoing Contracts 

Line 18(A–E). Submit information on 

contracts that are currently in progress. All 

dollar amounts are to reflect only the Federal 

share of such contracts, and should be 

rounded to the nearest dollar. 

18(A). Provide the total number of prime 

and sub-contracts where work was performed 

during the reporting period. 

18(B). Provide the total dollar amount paid 

to all firms performing work on contracts. 

18(C). From the total number of contracts 

provided in 18(A) provide the total number 

of contracts that are currently being 

performed by DBE firms for which payments 

have been made. 

18(D). From the total dollar amount paid to 

all firms in 18(A), provide the total dollar 

value paid to DBE firms currently performing 

work during this period. 

18(E). Provide the total number of DBE 

firms that received payment during this 

reporting period. For example, while 3 

contracts may be active during this period, 

one DBE firm may be providing supplies or 

services on all three contracts. This field 

should only list the number of DBE firms 

performing work. 

18(F). Of all payments made during this 

period, calculate the percentage going to 

DBEs. Divide the total dollar value to DBEs 

in item 18(D) by the total dollars of all 

payments in 18(B). Round the percentage to 

the nearest tenth. 

Section D: Actual Payments on Contracts 

Completed This Reporting Period 

This section should provide information 

only on contracts that are closed during this 

period. All dollar amounts are to reflect the 

entire Federal share of such contracts, and 

should be rounded to the nearest dollar. 

19(A). Provide the total number of 

contracts completed during this reporting 

period that used Race Conscious measures. 

Race Conscious contracts are those with 

contract goals or another race conscious 

measure. 

19(B). Provide the total dollar value of 

prime contracts completed this reporting 

period that had race conscious measures. 

19(C). From the total dollar value of prime 

contracts completed this period in 19(B), 

provide the total dollar amount of dollars 

awarded or committed to DBE firms in order 

to meet the contract goals. This applies only 

to Race Conscious contracts. 

19(D). Provide the actual total DBE 

participation in dollars on the race conscious 

contracts completed this reporting period. 

19(E). Of all the contracts completed this 

reporting period using Race Conscious 

measures, calculate the percentage of DBE 

participation. Divide the total dollar amount 

to DBEs in item 19(D) by the total dollar 

value provided in 19(B) to derive this 

percentage. Round to the nearest tenth. 

20(A)–20(E). Items 21(A)-21(E) are derived 

in the same manner as items 19(A)-19(E), 

except these figures should be based on 

contracts completed using Race Neutral 

measures. 

20(C). This field is closed. 

21(A)–21(D). Calculate the totals for each 

column by adding the race conscious and 

neutral figures provided in each row above. 

21(C). This field is closed. 

21(E). Calculate the overall percentage of 

dollars to DBEs on completed contracts. 

Divide the Total DBE participation dollar 

value in 21(D) by the Total Dollar Value of 

Contracts Completed in 21(B) to derive this 

percentage. Round to the nearest tenth. 

22. Name of the Authorized Representative 

preparing this form. 

23. Left blank for future use. 

24. Signature of the Authorized 

Representative. 

25. Phone number of the Authorized 

Representative. 

**Submit your completed report to your 

Regional or Division Office. 

[FR Doc. 2018–17301 Filed 8–10–18; 8:45 am] 

BILLING CODE 4910–9X–P 

DEPARTMENT OF THE TREASURY 

Internal Revenue Service 

Art Advisory Panel—Notice of 

Availability of Report of 2017 Closed 

Meetings 

AGENCY: Internal Revenue Service, 

Treasury. 

ACTION: Notice. 

SUMMARY: Pursuant to the Federal 

Advisory Committee Act, and the 

Government in the Sunshine Act, a 

report summarizing the closed meeting 

activities of the Art Advisory Panel 

during Fiscal Year 2017 has been 

prepared. A copy of this report has been 

filed with the Assistant Secretary for 

Management of the Department of the 

Treasury. 

DATES: Effective Date: This report is 

available August 2, 2018. 

ADDRESSES: The report is available at 

https://www.irs.gov/compliance/ 

appeals/art-appraisal-services. 

FOR FURTHER INFORMATION CONTACT: 

Maricarmen R. Cuello, AP:SPR:AAS, 

Internal Revenue Service/Appeals, 51 

SW 1st Avenue, Room 1014, Miami, FL 

33130, Telephone number (305) 982– 

5364 (not a toll free number). 

SUPPLEMENTARY INFORMATION: Pursuant 

to 5 U.S.C. App. 2, section 10(d), of the 

Federal Advisory Committee Act, and 5 

U.S.C. 552b, of the Government in the 

Sunshine Act, a report summarizing the 

closed meeting activities of the Art 

Advisory Panel during Fiscal Year 2017 

has been prepared. A copy of this report 

has been filed with the Assistant 

Secretary for Management of the 

Department of the Treasury. 

It has been determined that this 

document is not a major rule as defined 

in Executive Order 12291 and that a 

regulatory impact analysis is, therefore, 

not required. Additionally, this 

document does not constitute a rule 

subject to the Regulatory Flexibility Act 

(5 U.S.C. chapter 6). 

Donna Hansberry, 

Chief, Appeals. 

[FR Doc. 2018–17286 Filed 8–10–18; 8:45 am] 

BILLING CODE 4830–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

Privacy Act of 1974; System of 

Records 

AGENCY: Department of Veterans Affairs 

(VA), Debt Management Center. 

ACTION: Notice of modified system of 

records. 

SUMMARY: The Privacy Act of 1974 (5 

U.S.C. 522a (e) (4)) requires that all 

agencies publish in the Federal Register 

a notice of the existence and character 

of their systems of records. Notice is 

hereby given that the Department of 

Veterans Affairs (VA) is modifying a 

system of records entitled ‘‘Centralized 

Accounts Receivable System/ 

Centralized Accounts Receivable OnLine System (CARS/CAROLS) 

(88VA244)’’. This system was 

previously called ‘‘Accounts Receivable 

Records VA’’ (88VA244). This system 

had also been previously numbered 

‘‘88VA20A6’’. 

DATES: Comments on this modified 

system of records must be received no 

later than September 12, 2018. If no 

public comment is received during the 

period allowed for comment, or unless 

otherwise published in the Federal 

Register by VA, the modified system 

will become effective a minimum of 30 

days after publication in the Federal 

Register. If VA receives public 

comments, VA shall review the 

comments to determine whether any 

changes to the notice are necessary. 

ADDRESSES: Written comments may be 

submitted through 

www.Regulations.gov; by mail or handdelivery to Director, Regulation Policy 

and Management (00REG), Department 

of Veterans Affairs, 810 Vermont Ave. 

NW, Room 1064, Washington, DC 

20420; or by fax to (202) 273–9026 (not 

a toll-free number). Comments should 

indicate that they are submitted in 

response to ‘‘Centralized Accounts 

Receivable System/Centralized 

Accounts Receivable On-Line System 

(CARS/CAROLS)’’. Copies of comments 

received will be available for public 

inspection in the Office of Regulation 

Policy and Management, Room 1063B, 

between the hours of 8:00 a.m. and 4:30 

p.m., Monday through Friday (except 

holidays). Please call (202) 461–4902 for 


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