### 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
**Tribally Owned Businesses**

Name of Indian tribe:_______________________________________________________________

Address of tribe:___________________________________________________________________

Name of wholly-owned Subsidiary (if applicable):____________________________________________________________

Address of wholly-owned Subsidia ry:_______________________________________________________________________
**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 Numb er:___________________________ Fax Number :______________________________
Mailing Address (if different than above): ________________________ County:________________

City:_________________________________ State:_______________ Zip Code:________________

What is the firm’s 4-digit pr imary North American Industrial Classification (NAIC) code?

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

**-** Net number:________________________________

Is your firm certified by the Small Business Administration under its Small Disadvantaged Business (SDB) Program? ___Yes ___No. If yes, provide Pro

**-** Net number:

**____________________** Is your firm certified as a DBE by a U.S. Department of Transportation recipient? ___ Yes ___ No. If yes, provide State(s) and ID number(s):

**_________________________________________**

EPA DBE Certification Application (EPA Form 6100-1f) (Tribally Owned Businesses) OMB Control No: 2090-0030 Approval Expires: XX/XX/XXIs your f i rm certif ied by a S t a t e government, loca l government, 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 I D n u m b er an d t h e cert i f y i n g

en t i t y : ______________________

**______________________________________________________** Has yo ur firmever 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 yes, provid e expl an at i o n / do cu m e n t at i o n :

_________________________ **___________________________________**

**_____________________________________________________________________________________**

D o y o u 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, WBE, etc? ___Y es

__ **_**N o . I f y e s , pro v i d e St at e(s ) an d I D n u m b er(s ): ________________________________

I s t h e appl i c an t fi rm a fo r pro f i t bu s i n e s s ? ___ Y e s ___ N o

.

Do the tr ibe ’ s a r tic l e s of inc o r p or a t ion/ a r tic l e s of or ga niz a t ion/ pa r t ne r s hip a g r e e m e n t c onta i n express sovereign immunity wa iver l a n g u a g e o r a “s u e an d be s u ed” cl au s e w h i c hdes i g n at es Un ited States Federal Co urts to be a co m p eten t jurisdiction f o r a ll ma tters rela ting to EPA ’ s DBE P r o g ram ?

___ Y e s ___ N o

. If ye s, pr ovid e a c o mple te c o py of the d o c u me nta t ion a s a tta c h me nt D- 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- 1f ) ( T r i bal l y O w ne d Bus i ne s s e s ) 2

### B **u siness Elig**  **ibility**



## SECTI **ON A**
**Social Disadvantage**

1

. A n Ind i a n tribe tha t meet s the f o llowing criteria is consid ered socia lly d i sa d v a n ta ged :

Ind i a n tr ibe me a n s a n y Ind i a n tr ibe
, ba nd
, na tion, or othe r or ga niz e d gr oup or c o mmunity of Ind i a n s which is recogniz ed a s eligible f o r the specia l progra ms a n d services provid ed by the Un i t ed St at es t o I n di an s becau s e o f t h ei r s t at u s as I n di an s , o r i s reco g n i z ed as s u ch by t h e S t a t e in whic h the tr ibe
, ba nd
, na tion, gr oup or c o mmunity r e sid e s.

Provide documenta t ion tha t the a pplica n t enti ty m eets th ese criteria as Attach m e n t A-1.

2

. Pr ovid e c o pie s of the tr ibe ’ s a r tic l e s of inc o r p or a t ion a n d byla ws a s f ile d with the or ga niz i ng

or c h a r te r i ng a u thor ity, or simila r d o c u me nts ne e d e d to e s ta blish a n d gove r n a non- c o r p or a t e lega l entity a s A tta chment A

- 2

.



## SECTI **ON B**

**Economic Disadvantage**

1

. Ha s the tr ibe pr e v iously e s ta blishe d e c onomic d i sa d v a n ta ge to qua lif y a s DB E ? ___ Y e s ___ N o . I f y e s , pro v i d e do cu m e n t at i o n t o veri fy di s a dvan t a g e d s t at u s as At t a ch m e n t B-1.

If n o , res p o n d to th e fo llo w i n gq u es tio n s as Attach m e n t B-2:

a ) Wha t is the numbe r of tr iba l me mbe r s on tr iba l r o lls a s of the d a te of a pplic a t ion? b) Wh at is tribe’s presen t un em plo y m e n t rate? c) Wh at is th e per capita in co m e o f tr iba l members exclud ing jud g ment a w a r d s ? d) Wh at is th e percen tage of the loca l Ind i a n popula ti on below the poverty level? e) Wha t is the tota l triba l in come f o r the a pplica n t tribe? f) W h at are t h e t r i b e’ s as s e t s as di s c l o s e d i n a t r i b al fi n a n c i a l s t at em en t ? g) Provid e a list of a ll wholly or pa rtia lly owned triba l enterpri ses or a f f ilia tes a n d the prima r y ind u stry cla ssif i ca tion of each . Th e listin gsh o u ld in clude th e

me mbe r s of the tr ibe who ma na ge or c ontr o l suc he n te r p r i se s by se r v ing a s of f i c e r s or d i r e c t or s.

2. Th e I n di an Tri b e m u s t al s o s u bm i t t h e fo l l o w i n gdo cu m e n t at i o n t o s u bs t a n t i a t e a cl ai mo f

e c onomic d i sa d v a n ta ge :

a ) A c o py of a ll gove r n ing d o c u me nts suc ha s the tr ibe ’ s c onstitution or busine ss ch arter. b) E v id ence of its recognition a s a tr ibe eligible f o r the specia l progra ms a n d services pro v ided by th e Un ited Stat es or by its sta t e of resid e nce.

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1f ) ( T r i bal l y O w ne d Bus i ne s s e s ) 3

## SECTI **ON C**

**Owne r**  **ship**

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

1. D o es t h e t r i b e fi rm o w n at l e as t 51% o f t h e vo t i n gs t o c k ? ____ Y e s

____ N o

. P l eas e pro v i d e d o c u me nta t ion a s a tta c h me nt C

- 1

.

2. D o es t h e t r i b e o w n at l e as t 51% o f t h e ag g r eg at e i f al l cl as s e s o f s t o c k ? ___ Y e s

___ N o

. Ple a se pr ovid e d o c u me nta t ion a s a tta c h me nt C

- 2

.

3

. 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 hc l a ss:

V o t i n g N o n

- T o t a l V o t i n 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 :

_____ ______ ______

**N o**  **n-Co r**  **p o**  **r ate Entities O**  **n ly**  **:**

4. D o es t h e t r i b e o w n at l e as t 51% i n t e res t i n t h e fi rm ? ___ Y e s ___ N o . P l eas e pro v i d e d o c u me nta t ion a s a tta c h me nt C

- 3

.

5. 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 eachclas s :

V o t i n g N o n

- T o t a l V o t i n 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 :

_____ ______ _____

**F o**  **r Co**  **r p**  **o r**  **ate and N o**  **n-Co r**  **p o**  **r ate Entities:** 

6

. Doe s the tr ibe c u r r e ntly own 5 1 % or mor e of a nothe r f i r m und e r the sa me pr ima r y NA IC

co de? ___ Y e s ___ N o

.

7

. Within the la st two ye a r s ha s the tr ibe owne d 5 1 % or mor e of a nothe r f i r m und e r the sa me pri m ary N A I C co de as t h e appl i c an t ? ___ Y e s ___ N o

.



## SECTI **ON D**

**Contr o**  **l a nd Ma**  **na ge**  **me nt** 

1

. A r e the ma na gement a n d d a ily business opera t i ons of the tribe controlle d by the tribe through

o n e o r m o re di s a dvan tag e d i n di vi dual members who possess su f f i c i e n t ma na ge me nt experien ce o f an exten t an d co m p lexity to run th e co n c ern ? ___Y es ___N o. If yes, provid e d o c u me nta t ion to ve r i f y tr iba l me mbe r ship a n d ma na ge me nt c o mpe t e n c y a s A tta c h me nt D- 1

.

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1f ) ( T r i bal l y O w ne d Bus i ne s s e s ) 42

. Is the ma na ge me nt of the tr ibe c ontr o lle d by c o mmitte e s , te a m s, B o a r d s of Dir e c t or s, or one or more members of an economically disadv antaged tribe? ___ Y e s ___ No. Please provide d o c u me nta t ion a s a tta c h me nt D- 2

.

M a n a g e m e n t ma y be pr ovid e d by non- tr iba l me mbe r s if it is d e te r m ine d tha t suc h

ma na gement is required to a ssist the concer n’s d e velopment, provid ed tha t the tribe will

r e ta in c ontr o l of a ll ma na ge me nt d e c i sions c o mmon to B o a r d s of Dir e c t or s, inc l ud ing
str a te gic pla nning, bud g e t a ppr ova l a n d the e m ployme nt a n d c o mpe n sa tion of of f i c e r s

. Howe ve r , a wr itte n ma na ge me nt d e ve lopme n t pla n must e x ist whic h shows how d i sa d v a n ta ged triba l members will d e velop ma na geria l skills suf f i cient to ma na ge the concern or simila r triba lly- ow ned concerns in the f u ture.

3

. A r e me mbe r s of the ma na ge me nt te a m , busine ss c o mmitte e me mbe r s, of f i c e r s , a n d d i r e c t or s

e n ga ge d in a n y outsid e e m ployme nt or othe r busine ss inte r e sts whic h c onf lic t with the

m a n a g e m e n t o f t h e t r i b e? ___ Y e s ___ N o

.

4

. L i st the title s of a ll of f i c e r s , d i r e c t or s, ma na ge me nt me mbe r s, pa r t ne r s a n d ke y ma na ge r s a n d th e h o u rs devo ted, by s u chi n di vi dual ( s ) to the ma na gement of the tribe.

N a m e T i t l e H o u r s

____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

5. L i st the na mes of a ll ind i vid u a l s who ha ve a ccess to the tribe’s ba nk a ccount.

N a m e T i t l e

___________________________ __________________________

**__________________________ __________________________** 

**__________________________ __________________________**

**__________________________ __________________________**

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1f ) ( T r i bal l y O w ne d Bus i ne s s e s ) 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 EPA, at its discretion, may give the information submitted to Federa**  **l, state, and local agencies to determine violations of law.** 

**6. Acknowledges that 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 informa tion is estimated to average 1 hour per response. Send comments on the Agency's need for this information, the accuracy 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 6100-1f) (Tribally Owned Businesses) 6