### Environmental Protection Agency

EPA DBE Certification Application For a Minority Business Enterprise (MBE) /Women-owned Busin ess Enterprise (WBE) Under EPA’s Disadvantaged Busi ness Enterprise (DBE) Program

**Community Development Corporation (CDC) Owned Concern**

Name of Parent Community Development Corporation (CDC):

_________________________________________________________________________________

Address of Pa rent CD C: _____________________________________________________________

Name of wholly-owned subsid iary (if app licable ): _______________________________________

Address of wholly-ow ned subsid iary: _________________________________________________

**Name of applicant firm** :

_________________________________________________________________________________ Applicant concern is:  C orporat ion  L imited Liability Compan y  Partn ershi p

Name of President/Managing Member/Managing Partner: ________________________________

EIN: _______________________ E-mail Address: _______________________________________

Business Address: ___________________________________________County: _______________

City: _______________________________ State: _______________ Zip Code: ________________

Phone Numb er: __________________________ Fax Numb er: ______________________________

Mailing Address (if different than above): _______________________County: ________________

City: _______________________________ State: _______________ Zip Code: ________________

What is the firm’s (4-digit) primary stan dard industrial cl assificati on code? __________________

Is the firm certified by the Small Business Ad ministration under its 8(a) Business Development Program? ___ Yes ___ No. If yes, provide Pro- Net number________________________________

Is the firm certified by the Small Business Administration under its Small Disadvantaged Business (SDB) Program? ___ Yes ___ No. If yes, provide Pro- Net number____________________

Is the firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide State(s) and ID nu mber(s) ___________________________________________________

Is the firm certified by a Stat e government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the cert ifying entity ____________________________________________________________

EPA DBE Certification Application (EPA Form 6100-1i) (Community Development Corporation (CDC) Owned Concern) OMB Control No: 2090-0030 Approval Expires: XX/XX/XXHas yo ur firm ever been den i ed certificati on by a Fed e ra l a g ency, S t a t e government, loca l
g o vern m e n t , I n di an t r i b al g o vern m e n t , o r i n depen d en t pri v at e o r g a n i zat i o n ? ___ Y e s ___ N o

. I f y e s , pro v i d e expl an at i o n / do cu m e n t at i o n :

_____________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

D o es th e fi rm h a ve an y o t h e r certi f i c ati o n as a di s a dvan tag e d bus i n e s s en ti ty , i

. e., MBE, D BE, W BE, et c? ___Y es ___ N o . I f y e s , pr o v i d e t h e St at e(s ) an d I D n u m b er(s )__________________

__________________________________________________________________________________



# SECTION A **Eligibility Stateme nt** 

**Social and Economic Disadvantage**

1. A Co m m

u n ity Dev e lo p m en t Co rp o r atio n (CDC) is co n s idered to be a s o cially an d econ o m i cally d i sad v an tag e d en tity if

th e p a ren t C D C is a nonpr o f i t or ga niz a t ion r e sponsible to r e sid e nts of the area i t s e rves w h i c h h a s recei v ed fi n a n c i a l as s i s t an ce u n der 42 U.S.C. 9805, et s e q

.

D o es th e paren t CD C o f th e applican t co n c ern m eet th is criteria? ___ Y e s ___ N o

. If y e s , prov ide ev iden ce of n o n p rof it org a n i zation an d docu m en tation of as s i s t an ce as A ttach m e n t A

- 1.



# SECTION B

**Owne r**  **ship**

1

. Is the a pplica n t concern a t lea s t 5 1 perc ent owned by a CDC or a wholly owned business

en t i t y o f a CD C? ____ Y e s ____ N o . I f y e s , pl eas e pro v i d e evi d en ce o f o w n e rs h i p as A tta chment B- 1

.

**Co r**  **p o**  **r atio**  **ns O n**  **ly :** 

2

. If mor e tha n one c l a ss of stoc k, pr ovid e inf o r m a t ion f o r e a c h c l a ss: Vo tin g No n To tal Vo tin g a) To t a l n u m b er o f s h ares au t h o r i z ed:

_____ ______ _____ b) To t a l n u m b er o f s h ares cu rren t l y o u t s t a n d i n g :

_____ ______ _____

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1i) ( C o m m unity D e v e l o pm e n t Co r p o r atio n ( C D C ) O w ne d Co nce r n) 

### 2**Limited Liability Co**  **mpanies O n**  **ly :** 

3. If m o re th an o n e clas s m e m b ers h ip in teres t , pro v ide in fo rm atio n fo r each clas s : Vo tin g No n To tal Vo tin g a) To t a l n u m b er o f m e m b ers h i p s au t h o r i z ed:

_____ ______ _____ b) To t a l n u m b er o f m e m b ers h i p s cu rren t l y o u t s t a n d i n g :

_____ ______ _____

**Par t**  **ner s**  **hips O n**  **ly :** 

4

. Pr ovid e the na me , title
, a n d pe r c e n ta ge of owne r s hip f o r e a c h pa r t ne r of the f i r m

. Doe s the part n e rs h i p ag reem en t refl ect t h e o w n e rs h i p o f each part n e r? ___Y es ___N o

.

N a m e T i t l e O w n e r s h i p %

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

**Q u**  **estio ns 5 thr**  **o ug**  **h 9 ar e f**  **o r**  **C o**  **r p**  **o r**  **atio ns &**  **LLC s O**  **N L**  **Y :** 

5. Li s t al l en ti ti es , i n di vi dual s , an d/ o r trus ts whic h ha ve a n owne r s hip inte r e st in the a pplic a n t firm

.

N a m e T i t l e O w n e r s h i p % V o t i n g N o n V o t i n g T o t a l

___________________________ ____________________ ______ _________ _____

___________________________ ____________________ ______ __________ _____

___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

6

. Does the pa rent CDC or its wholly- owned su bsid ia ry receive a t lea s t 5 1 % of the a nnua l di s t ri bu t i o n s o f di vi den d s pai d o n t h e s t o c k o f a co rpo r at e appl i c an t fi rm ? ___Y es ___ N o . I f

no, ple a se e x pla i n a s A tta c h me nt B

- 2

.

7. Will th e paren t CDC o r its wh o lly-o w n e d su bsidiary receive 100% o f th e un en cum b ered val u e o f each s h are o f s t o c k o w n e d i n t h e even t t h at t h e s t o c k i s s o l d ? ___Y es ___ N o . I f n o , pl eas e expl ai n as At t a ch m e n t B-3.

8

. If the corpora t ion d i ssolves, will the pa rent CDC or its wholly- owned subsid ia ry receive a t l e as t 51% o f t h e ret a i n ed earn i n g s an d 100% o f t h e u n en cu m b ered val u e o f each s h are o f

s t o c k o w n e d? ___Y es ___ N o . I f n o , pl eas e expl ai n as At t a ch m e n t B-4.

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1i) ( C o m m unity D e v e l o pm e n t Co r p o r atio n ( C D C ) O w ne d Co nce r n) 

### 39

. Is ownership by the pa rent CDC or its w holly owned subsid ia ry subject to cond itions preceden t, co n d itio n s subseq uen t , executo r y agreem en ts, vo tin g trusts, sha r eholder

a g r e e m e n ts, or othe r simila r a r r a nge m e n ts whic h ma y impa c t the unc ond itiona l owne r s hip of
t h e CD C? ___Y es ___N o

. I f y e s , expl ai n as At t a ch m e n t B-5.

**Co r**  **p o**  **r atio**  **ns, LLCs & Par**  **t ner**  **s hips:** 

10. H a ve t h ere been an y ch an g e s i n o w n e rs h i p i n t h e l a s t y e ar? ___Y es ___N o

. I f y e s , di d

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

- 6

.



# SECTION C
**Contr o**  **l a nd Ma**  **na ge**  **me nt** 

1

. L i st a ll ind i vid u a l s who ma na ge or c ond uct d a ily business opera t ions of the a pplica n t

c onc e r n.

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

___________________________________________________ _____________

___________________________________________________ _____________

___________________________________________________ _____________

___________________________________________________ _____________

2

. A r e a n y of the ind i vid u a l s listed in ques tion 1 enga ged in or pla n to enga ge in outsid e

em pl o y m e n t ? ___ Y e s ___ N o . I f y e s , expl ai n as At t a ch m e n t C-1.

3

. L i st the tota l c o mpe n sa tion f r om the a pplic a n t f i r m of a ll owne r s a n d / or ke y ma na ge r s of the f i r m

. ( I f ne c e ssa r y , pr ovid e a d d i tiona l inf o r m a t ion a s A tta c h me nt C

- 2 )

.

Na me/Title Compensa tion f r om a pplica n t f i rm ( I n c l u d e s a l a r i e s , b o n u s e s , e t c

. )

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

4. D o es t h e appl i c an t fi rm o p erat e i n an i n d u str y whic h r e quir e s bond ing or pr of e ssiona l l i c en s e s ? ___ Y e s ___ N o . I f y e s , i d en t i fy t h e q u al i f y i n g i n di vi du al (s ) fo r t h e cri t i c al l i c en s e s , genera l ind e mnity a g reement, pe rmits, certif ica t ions, a n d bond in g req u ired to o p erate th e

a pplica n t f i rm on A tta chment C- 3

.

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1i) ( C o m m unity D e v e l o pm e n t Co r p o r atio n ( C D C ) O w ne d Co nce r n) 

### 45

. L i st the na me s of a ll ind i vid u a l s who ha ve a c c e ss to the f i r m ’s ba nk a c c o unt.

N a m e T i t l e

___________________________________ _________________________________

**___________________________________ _________________________________** 

___________________________________ __________________________________

___________________________________ __________________________________

6. D o es an y i n di vi du al (s ), o r en tities pro v ide:

a) F i n an ci al s u ppo rt t o t h e appl i c an t fi rm ? ___ Y e s ___ N o b) Su bco n t ract s , Jo i n t V e n t u r es , o r Team i n g Arran g em en t s ? ___ Y e s ___ N o c) O ffi ce s p ace (ren t o r l e as ed). ___ Y e s ___ N o d) Eq u i pm en t (ren t o r l e as ed). ___ Y e s ___ N o e) Em pl o y ees (o t h er t h an fro m em pl o y m e n t ag en ci es ). ___ Y e s ___ N o

If th e an sw er is yes to an y o f th e abo v e, plea s e pro v ide s p ecific details (i.e., n a m e s , titles
, co pies o f agreem en ts, leases , etc.) o f s u ch arran g em en ts as Attach m e n t C- 4.

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1i) ( C o m m unity D e v e l o pm e n t Co r p o r atio n ( C D C ) O w ne d Co nce r n) 

### 5**Each person signing below:**

**1. Certifies that the information provided with regard to the applicant firm’s so**  **cial and economic disadvantaged status is true, accu**  **rate, and complete to the best of his/her knowledge and belief.** 

**2. Certifies that the information provided with regard to the applicant firm’s ownership**  **and control status is true, accurate, and complete**  **to the best of his/her knowledge and belief.**

**3. Certifies that the information provided with regard to his/her individual disadvantage**  **d status is true, accurate, and complete to**  **the best of his/her knowledge and belief.**

**4. Certifies that the information provided, including that shown on do**  **cuments accompanying this application, is true, accu**  **rate, and complete to the best of his/her knowledge and belief.** 

**5. Acknowledges that the EPA, at its discretion, may give the information submitted to**  **Federal, State, and local agencies to determine violations of law.**

**6. Acknowledges that the EPA’s approval of an application does not affect the Govern**  **ment’s right to pursue criminal prosecution for incorrect or incomplete information given on**  **the application form, even if correct information has been included in other materi**  **als submitted to**  **EPA.**

Name SSN Date

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________ The public reporting and recordkeeping burden for this collection of information is estimated to average 1 hour per response. Send comments on the Agency's need for this information, the a ccuracy of the provided burden estima tes, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA DBE Certification Application (EPA Form 6100-1i) (Community Development Corporation (CDC) Owned Concern) 

### 6