### 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

**For Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged** 

Name of Organization:_____________________________________________________________________

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 stan dard industrial cla ssification code? _______________________

Is the firm certified by the Small Business Administ ration 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) an d ID number(s) ___________________________________________________________

Is the firm certified by a State go vernment, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying entity ____________________________________________________________________________________

Has your firm ever been denied certification by a Federal agency, State gove rnment, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide explanation/do cumentation:________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

EPA DBE Certification Application (EPA Form 6100-1g) (Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged) OMB C on tr ol No: 2090-0030 Approval Expires: XX/XX/XXD o es t h e fi rm h a ve an y o t h e r cert i f i c at i o n as a di s a dvan t a ged bus i n e s s en tity, i.e., MBE, D BE, WBE, etc?
___Y es ___ N o . I f y e s , pro v i d e t h e St at e(s ) an d I D n u m b er(s )__________________________________

I n accord an ce w i th 13 C F R §124.103, d e s i gn ated grou p m e m b ers are p res u m ed to b e s o ci al l y d i s a d van taged

. D e s i gn ated grou p m e m b ers are i n d i vi d u a l s w h o h o l d th em s e lves out to be and are iden ti fi ed b y oth ers as Bl ac k

Am ericans , Native Am ericans (Am erican I ndians
, E s k i m o s , Aleuts , or Native Haw a iians ), His p anic Am ericans
, Subco n t i nent Asia n Am erica ns, Asia n P a cif i c Am erica ns , a nd a n y o t her g r o ups desig n a t ed by t h e Sm a ll

Bu s i n e s s A d m i n i s t rati on (S BA ). I f an i n d i vi d u a l i s cl ai m i n g to b e a m e m b er of a d e s i gn ated grou p , com p l e te
S ecti o n A of th i s ap p l i c ati o n

. I f an i n d i vi d u a l i s n o t cl ai m i n g to b e a m e m b er of a d e s i gn ated grou p , com p l e te
Sectio n B o f this a pplica t io n

. A l l a pplica n ts m u st co m p lete Sectio ns C, D, a nd E o f this a pplica t io n

.



# SECTION A **Eligibility Statement - De signated Group Members** 

**Social Disadvantage**

1. Li s t al l i n di vi dual s cl ai m i n gdi s a dvan tag e d s t atus :

Nam e o f In dividual O t h e r la st U

. S

. C i tiz e n Pla c e of Gr oup S e x Nam e s Us ed Y / N Birth Mem b ers h ip M/ F

___________________ ___________ ________ ___________ _______ _____

___________________ ___________ ________ ___________ _______ _____

___________________ ___________ ________ ___________ _______ _____



# SECTION B **Eligibility Statement - Non Designated Group Members** 

1. Li s t al l i n di vi dual s cl ai m i n gdi s a dvan tag e d s t atus :

Nam e o f In di vi dual U.S. Ci tizen R a ce Sex

Y / N M/ F

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

**F o**  **r this sectio**  **n, any indiv**  **i dual claiming**  **so cial di**  **sadv antag**  **e must pr**  **o v**  **i de**  **a s**  **e p**  **a ra**  **t e**  **re s**  **p on**  **s e**  **for questio**  **ns 3 and 4.**

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1g ) ( P r i v a te and V o l untar y O r g a niz a tio n s Co ntr o l l e d by I

ndiv i dual s w h o ar e S o cial l y and E c o n o m ical l y D i s a dv antag e d) 

### 2

### Social Disadvantage

2. I, ____________________________________ h a ve perso n a lly suffered so cial disadvan tage based

on my id e n tif i c a tion a s **__________________________________. (A claim o**  **f so**  **cial disadv antag**  **e must include at least**  **o n**  **e o**  **b jectiv**  **e f**  **eatur e**  **that has** 

**co ntr**  **i buted to**  **so cial disadv**  **antag e**  **, such as r a**  **ce, ethnic o r**  **ig in, g**  **e nder** 

**, phy**  **sical handicap,** 
**lo ng**  **-ter m**  **r e**  **sidence in an env i**  **r o**  **nment iso l**  **ated f r**  **o m the**  **mainstr eam**  **o f**  **Amer ican**  **so ciety** 

**, o**  **r**

**o t**  **her similar**  **causes no t co**  **mmo n to**  **indiv i**  **duals w h**  **o ar**  **e no t so**  **cially disadv**  **antag e**  **d.)**

3. Document how your a b ility to compete in the f r ee enterprise system ha s b een impa ired by such things a s ina b ility to obta in a d equa te bond ing, cr ed it or f i na ncing; ina b ilit y to obta in licenses or

le a s e s ; r e str i c t ion of your ma r k e t to c e r t a i n r a c i a l

, e t hnic

, or soc i a l gr oups; und e r e mployme n t or

une m ployme nt, e t c

. , a s c o mpa r e d to othe r s in the sa me or simila r line of busine ss who a r e not

socia lly d i sa d v a n ta ged

. M a r k a s A tta chment B

- 1

.

4. **Attach a nar r**  **a tiv**  **e descr ibing**  **ho w**  **y o**  **u per**  **s o**  **n ally**  **exper ienced**  **so cial**  **disadv antag**  **e in** 

**Amer ican so**  **ciety**

**.** When writing your na rra tive, be a s s p e c i f ic an d d e t a i l e d as po ssible. Wh ere

a pplica b le, ea ch sta t ement of a lleged d i scri mina tion should be suppor t e d by d o c u me nte d

e v id e n c e suc h a s a f f i d a vits, d e nia l s of loa n a pplic a t ions, d e nia l s of e m ployme nt oppor t unitie s ( i nc lud i ng non- se le c t ion f o r pa r t ic ula r jobs, d e nia l s of pr omotions, or une q ua l wor k e n vir onme n t

or trea tment) , a n d documents to support a n y f o rma l a c tion ta ken by you beca use of a lleged

d i sc r i mina tion. You must d e monstr a t e how your id e n tif i c a tion, a s d e sc r i be d in the pa r a gr a p h

a b ove, ha s nega tively impa cted your entry into or a d va ncement in business. You must a d d r ess d i sa d v a n ta ge in e d uc a t ion, e m ployme nt, a n d busine ss histor y, whe r e a pplic a b le

. E x a m ple s of

d i sc r i mina tion inc l ud e , but a r e not limite d to: une q ua l a c c e ss to c o lle ge s or pr of e ssiona l sc hools;

e x c l usion f r om pr of e ssiona l or busine ss a ssoc i a t ions; be ing d e nie d e d uc a t iona l honor s or

r e c o gnition; e x pe r i e n c i ng d i sc r i mina tor y soc i a l pr e ssur e whic h d i sc our a ge d you f r om pur s uing a

pr of e ssiona l or highe r e d uc a t ion or f o r c e d you into non- pr of e ssiona l or non- busine ss f i e l d s ; d i sc r i mina tion in e m ployme nt oppor t unitie s or pa y a n d f r inge be ne f i ts; une q ua l a c c e ss to
busine ss c r e d it or c a pita l; a n d d i sc r i mina tion in the a w a r d i ng, bid d i ng pr oc e ss, or ne gotia t ing of

gove r n me nt or pr iva t e se c t or c ontr a c t s. M a r k a s A tta c h me nt B

- 2

.



# SECTION C
**(A ll applicant firms must co**  **mplete)**



## Economic Disadvantage

1. I s t h e n e t w o rt h o f al l i n di vi du al (s ) cl ai m i n gdi s a dvan t a g e d s t at u s l e s s t h an $750,000, excl u d i n g ownership interest in the a pplic an t fi rm an d eq u i t y i n t h e i n di vi du al (s ) pri m ary res i den c e?
____Y es N o

____.

2. F o r i n di vi dual (s ) cl ai m i n gdi s a dvan tag e d s t a t us, list your persona l net worth, exclud ing the ownership interest in the a pplic a n t f i rm a n d the equity in the ind i vid u a l ( s ) prima r y resid e nce. N a m e Averag e 2-y e ar P e rs o n a l To t a l

I n c o m e N e t W o r t h A s s e t s

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1g ) ( P r i v a te and V o l untar y O r g a niz a tio n s Co ntr o l l e d by I

ndiv i dual s w h o ar e S o cial l y and E c o n o m ical l y D i s a dv antag e d) 

### 33. Each i n di vi du al l i s t e d i n n u m b er 2 abo v e cert i f i e s t h at , becau s e o f raci al an d/ o r et h n i c prej u d i c e,

a n d / or cultura l bia s , his/her a b ility to compete in the f r ee enterprise syst em ha s been impa ired

due to di m i n i s h ed capi tal an d cred it opportunities a s compa r ed to othe r s in the sa me or simila r line of business tha t a r e not socia lly d i sa d v a n ta ged

.



# SECTION D
**(A ll applicant firms must co**  **mplete)**



## Owne **r ship** 

**Co r**  **p o**  **r atio**  **n:**

1

. 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 gNo 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 :

_____ ______ _____

**Limited Liability Co**  **mpany :** 

2. 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 gNo 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**  **hip:**

3

. 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 P e r c e n t a g e

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

**Q u**  **estio ns 4 thr**  **o ug**  **h 8 ar e f**  **o r**  **C o**  **r p**  **o r**  **atio ns &**  **LLC s O**  **N L**  **Y :** 

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

.

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

___________________________ ____________________ ______ _________ _____

___________________________ ____________________ ______ __________ _____

___________________________ ____________________ ______ __________ _____

___________________________ ____________________ ______ __________ _____
E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1g ) ( P r i v a te and V o l untar y O r g a niz a tio n s Co ntr o l l e d by I

ndiv i dual s w h o ar e S o cial l y and E c o n o m ical l y D i s a dv antag e d) 

### 45

. Does the priva t e or volunta r y orga niz a t ion or its wholly- owned subsid ia ry receive a t lea s t 5 1 % of the

an n u al 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 D- 1

.

6. Will th e private o r vo lun t ary o r gan i zatio n o r its wh o lly-o w n e d subsidiary receive 100% o f th e

u n en cu m b ered val u e o f eachs 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

____ No . If n o , pleas e explain as Attach m e n t D

- 2.

7

. If the priva t e or volunta r y orga niz a t ion d i ssolves , will the priva t e or volunta r y orga niz a t ion or its
wh o lly-o w n e d subsidiary receive at least 51% o f th e retain ed earn in gs an d 100% o f th e

u n en cu m b ered val u e o f eachs 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 A tta chment D- 3

.

8

. Is ownership by the priva t e or volunta r y orga niz a t ion or its wholly- owned subsid ia ry subject to

c ond itions pr e c e d e n t, c ond itions subse q ue nt, e x e c utor y a g r e e m e n ts, voting tr usts, sha r e hold e r

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 the pri v at e o r vo l u n t ary o r g a n i zat i o n ? ___Y es ___N o

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

- 4.

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

9. 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 o w n e rs h i p affect t h e di s a dvan t a g e d s t at u s o f y o u r fi rm ? P l eas e expl ai n as At t a ch m e n t D

- 5.



# SECTION E
**(A ll applicant firms must co**  **mplete)**



## Contr **o l** 

**Co rpo**  **r atio**  **ns Only :** 

1

. T h e pr iva t e or volunta r y or ga niz a t ion c ontr o ls the boa r d of d i r e c t or s by vir t ue of the f a c t tha t : **(select**

**on l**  **y on**  **e b**  **e l**  **o w)** 

___ a) Th e pri v at e o r vo l u n t ary o r g a n i zat i o n o w n s at l e as t 100% o f al l t h e **v o**  **ting** stoc k of the

a pplic a n t c onc e r n.

___ b) Th e pri v at e o r vo l u n t ary o r g a n i zat i o n o w n s at l e as t 51% o f al l **v o**  **ting** stoc k, is on the

B o a r d of Dir e c t or s, a n d no supe r ma jor i ty voting r e quir e m e n ts e x ist f o r sha r e hold e r s to

a ppr ove c o r p or a t e a c tions.

___ c) Th e pri v at e o r vo l u n t ary o r g a n i zat i o n o w n s at l e as t 51% o f al l **v o**  **ting** stoc k, is on the

B o a r d of Dir e c t or s, a n d owns a t le a s t the pe r c e n ta ge of voting stoc k ne e d e d to ove r c o me the super ma jority voting requ irem en ts w h ich exist fo r sh areh o l ders to appro v e co rpo r ate

a c tions.

___ d) Th e pri v at e o r vo l u n t ary o r g a n i zat i o n co n t ro l s t h e Bo ard o f D i rect o r s t h ro u g h act u al

numbe r s of voting d i r e c t or s.

___ e) Th e pri v at e o r vo l u n t ary o r g a n i zat i o n co n t ro l s t h e Bo ard o f D i rect o r s t h ro u g h w e i g h t e d voting and such voti ng is permitted by a pplica b le sta t e la w.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1g ) ( P r i v a te and V o l untar y O r g a niz a tio n s Co ntr o l l e d by I

ndiv i dual s w h o ar e S o cial l y and E c o n o m ical l y D i s a dv antag e d) 

### 5

### Partnerships Only:

2

. A r e pa r t ne r s hip d e c i sions d e te r m ine d by ge ne r a l pa r t ne r s ? If no, e x pla i n a s A tta c h me nt E

- 1

.



### Corporations, LLCs & Partnerships:

3

. 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 the

h o u rs devo ted, by s u ch i n di vi dual (s ) to the ma na ge me nt of the a pplic a n t f i r m

.

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

____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

4. Are t h e CEO

, P r es i d en t

, Man ag i n gMem b er, Man a ging Pa r t ne r , 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 or d i r e c t or s 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 , pro v i d e det a i l s as t o t h e ext e n t o f o u t s i d e em pl o y m e n t o r o t h e r business d e a lings to includ e d a ily hours of employ ment, loca tion a n d expla n a t ion a s to how this

outsid e employment d o es not conf lict with the a b ilit y to ma na ge a n d control the d a ily opera t ions of

the a pplic a t ion c onc e r n. Pr ovid e a s A tta c h me nt E

- 2

.

5. 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

. A r e the ma na gement a n d d a ily business opera t ions of the concern contro lled by the priva t e or volunta r y or ga niz a t ion thr o ugh one or mor e d i sa d v a n ta ge d ind i vid u a l me mbe r s who posse ss suf f i c i e n t ma na ge me nt e x pe r i e n c e of a n e x te nt a n d c o mple x i ty to r u n the c onc e r n ? ___Y es ___N o. If

ye s, pr ovid e d o c u me nta t ion to ve r i f y ma na ge me nt c o mpe t e n c y a s A tta c h me nt E

- 3

.

E P A D B E Ce r tif

icatio n A ppl icatio n ( E P A F o r m 6100- 1g ) ( P r i v a te and V o l untar y O r g a niz a tio n s Co ntr o l l e d by I

ndiv i dual s w h o ar e S o cial l y and E c o n o m ical l y D i s a dv antag e d) 

### 6**Each person signing below:**

**1. Certifies that the information provided with regard to my social and economic disadvantage**  **d status is true, accurate, and complete to**  **the best of my knowledge and belief.**

**2. Certifies that the information provided with regard to my ownership and control status is tr**  **ue, accurate, and complete to the best of my knowledge and belief.** 

**3. Certifies that the information provided with regard to my individual disadvantaged status is tr**  **ue, accurate, and complete to the best of my 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 my knowledge and belief.**

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

**6. Acknowledges that EPA’s approval of an application does not affect th**  **e Government’s right to**  **pursue criminal prosecution for incorrect or incomplete information given on the applicatio n**  **form, even if correct information has been included in other materials submitted to EPA.** 

Name S SN D ate

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

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 (2822 T), 120 0 Pennsylvania Ave., NW, Wa shington, D.C. 2046 0. Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA DBE Certification Application (EPA Form 6100-1g) (Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged) 

### 7