Environmental Protection Agency

EPA DBE Certification Application 

For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE) 

Under EPA’s Disadvantaged Business Enterprise (DBE) Program

Community Development Corporation (CDC) Owned Concern 

Name of Parent Community Development Corporation (CDC): 

_________________________________________________________________________________ 

Address of Parent CDC: _____________________________________________________________ 

Name of wholly-owned subsidiary (if applicable): _______________________________________ 

Address of wholly-owned subsidiary: _________________________________________________ 

Name of applicant firm: 

_________________________________________________________________________________ 

Applicant concern is:  Corporation  Limited Liability Company  Partnership

Name of President/Managing Member/Managing Partner: ________________________________ 

EIN: _______________________ E-mail Address: _______________________________________ 

Business Address: ___________________________________________County: _______________ 

City: _______________________________ State: _______________ Zip Code: ________________ 

Phone Number: __________________________ Fax Number: ______________________________ 

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

City: _______________________________ State: _______________ Zip Code: ________________ 

What is the firm’s (4-digit) primary standard industrial classification code? __________________ 

Is the firm certified by the Small Business Administration 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 number(s) ___________________________________________________

Is the firm certified by a State government, local government, Indian tribal government, or 

independent private organization? ___ Yes ___ No. If yes, provide ID number and a contact 

point at the certifying entity ____________________________________________________________ 

EPA DBE Certification Application (EPA Form 6100-1i) 

(Community Development Corporation (CDC) Owned Concern) 

OMB Control No: 2090-0030 

Approval Expires: XX/XX/XX
Has your firm ever been denied certification by a Federal agency, State government, local 

government, Indian tribal government, or independent private organization? ___ Yes ___ No. 

If yes, provide explanation/documentation: _____________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

Does the firm have any other certification as a disadvantaged business entity, i.e., MBE, DBE, 

WBE, etc? ___Yes ___ No. If yes, provide the State(s) and ID number(s)__________________ 

__________________________________________________________________________________ 

SECTION A 

Eligibility Statement 

Social and Economic Disadvantage 

1. A Community Development Corporation (CDC) is considered to be a socially and economically

disadvantaged entity if the parent CDC is a nonprofit organization responsible to residents of the

area it serves which has received financial assistance under 42 U.S.C. 9805, et seq.

Does the parent CDC of the applicant concern meet this criteria? ___Yes ___ No. If yes,

provide evidence of nonprofit organization and documentation of assistance as Attachment A-1. 

SECTION B 

Ownership 

1. Is the applicant concern at least 51 percent owned by a CDC or a wholly owned business 

entity of a CDC? ____ Yes ____ No. If yes, please provide evidence of ownership as

Attachment B-1.

 

Corporations Only: 

2. If more than one class of stock, provide information for each class:

 Voting Non Total 

 Voting

a) Total number of shares authorized: _____ ______ _____ 

b) Total number of shares currently outstanding: _____ ______ _____ 

EPA DBE Certification Application (EPA Form 6100-1i)

(Community Development Corporation (CDC) Owned Concern)

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Limited Liability Companies Only: 

3. If more than one class membership interest, provide information for each class:

 Voting Non Total 

 Voting

a) Total number of memberships authorized: _____ ______ _____ 

b) Total number of memberships currently outstanding: _____ ______ _____ 

Partnerships Only: 

4. Provide the name, title, and percentage of ownership for each partner of the firm. Does the

partnership agreement reflect the ownership of each partner? ___Yes ___No. 

Name Title Ownership % 

 

___________________________ ____________________ ____________________ 

___________________________ ____________________ ____________________ 

___________________________ ____________________ ____________________ 

___________________________ ____________________ ____________________ 

Questions 5 through 9 are for Corporations & LLCs ONLY:

5. List all entities, individuals, and/or trusts which have an ownership interest in the applicant 

firm. 

Name Title Ownership %

 Voting NonVoting Total

___________________________ ____________________ ______ _________ _____ 

___________________________ ____________________ ______ __________ _____ 

___________________________ ____________________ ______ __________ ______ 

___________________________ ____________________ ______ __________ ______ 

6. Does the parent CDC or its wholly-owned subsidiary receive at least 51% of the annual

distributions of dividends paid on the stock of a corporate applicant firm? ___Yes ___ No. If

no, please explain as Attachment B-2. 

7. Will the parent CDC or its wholly-owned subsidiary receive 100% of the unencumbered 

value of each share of stock owned in the event that the stock is sold? ___Yes ___ No. If no,

please explain as Attachment B-3. 

8. If the corporation dissolves, will the parent CDC or its wholly-owned subsidiary receive at

least 51% of the retained earnings and 100% of the unencumbered value of each share of

stock owned? ___Yes ___ No. If no, please explain as Attachment B-4. 

EPA DBE Certification Application (EPA Form 6100-1i)

(Community Development Corporation (CDC) Owned Concern)

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9. Is ownership by the parent CDC or its wholly owned subsidiary subject to conditions 

precedent, conditions subsequent, executory agreements, voting trusts, shareholder 

agreements, or other similar arrangements which may impact the unconditional ownership of

the CDC? ___Yes ___No. If yes, explain as Attachment B-5. 

Corporations, LLCs & Partnerships: 

10. Have there been any changes in ownership in the last year? ___Yes ___No. If yes, did 

ownership affect the disadvantaged status of your firm? Please explain as Attachment B-6. 

SECTION C 

Control and Management 

1. List all individuals who manage or conduct daily business operations of the applicant 

concern.

Name/Title Date

___________________________________________________ _____________ 

___________________________________________________ _____________ 

___________________________________________________ _____________ 

___________________________________________________ _____________ 

2. Are any of the individuals listed in question 1 engaged in or plan to engage in outside 

employment? ___ Yes ___ No. If yes, explain as Attachment C-1. 

3. List the total compensation from the applicant firm of all owners and/or key managers of the

firm. (If necessary, provide additional information as Attachment C-2).

Name/Title Compensation from applicant firm 

 (Include salaries, bonuses, etc.)

___________________________________ __________________________________ 

___________________________________ __________________________________ 

___________________________________ __________________________________ 

___________________________________ __________________________________ 

4. Does the applicant firm operate in an industry which requires bonding or professional 

licenses? ___ Yes ___ No. If yes, identify the qualifying individual(s) for the critical licenses,

general indemnity agreement, permits, certifications, and bonding required to operate the 

applicant firm on Attachment C-3.

EPA DBE Certification Application (EPA Form 6100-1i)

(Community Development Corporation (CDC) Owned Concern)

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

Name Title

___________________________________ _________________________________ 

___________________________________ _________________________________ 

___________________________________ __________________________________ 

___________________________________ __________________________________

6. Does any individual(s), or entities provide: 

a) Financial support to the applicant firm? ___ Yes ___ No

b) Subcontracts, Joint Ventures, or Teaming Arrangements? ___ Yes ___ No

c) Office space (rent or leased). ___ Yes ___ No

d) Equipment (rent or leased). ___ Yes ___ No

e) Employees (other than from employment agencies). ___ Yes ___ No 

If the answer is yes to any of the above, please provide specific details (i.e., names, titles, 

copies of agreements, leases, etc.) of such arrangements as Attachment C- 4. 

EPA DBE Certification Application (EPA Form 6100-1i)

(Community Development Corporation (CDC) Owned Concern)

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Each person signing below: 

1. Certifies that the information provided with regard to the applicant firm’s social and

economic disadvantaged status is true, accurate, 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 disadvantaged

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 documents

accompanying this application, is true, accurate, 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 Government’s

right to pursue criminal prosecution for incorrect or incomplete information given on the

application form, even if correct information has been included in other materials

submitted to EPA.

Name SSN Date 

________________________ _______________________ ______________________ 

________________________ _______________________ ______________________ 

________________________ _______________________ ______________________ 

________________________ _______________________ ______________________ 

The public reporting and recordkeeping burden for this collection of information is estimated to average 

1 hour per response. Send comments on the Agency's need for this information, the accuracy of the 

provided burden estimates, and any suggested methods for minimizing respondent burden, including 

through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. 

Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. 

Include the OMB control number in any correspondence. Do not send the completed form to this 

address.

EPA DBE Certification Application (EPA Form 6100-1i) 

(Community Development Corporation (CDC) Owned Concern) 

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