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 

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 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 ____________________________________________________________________________________ 

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:________________________________________________________________ 

________________________________________________________________________________________ 

________________________________________________________________________________________ 

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

(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged) 

OMB Control No: 2090-0030 

Approval Expires: XX/XX/XX
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)__________________________________ 

In accordance with 13 CFR §124.103, designated group members are presumed to be socially disadvantaged.

Designated group members are individuals who hold themselves out to be and are identified by others as Black

Americans, Native Americans (American Indians, Eskimos, Aleuts, or Native Hawaiians), Hispanic Americans,

Subcontinent Asian Americans, Asian Pacific Americans, and any other groups designated by the Small 

Business Administration (SBA). If an individual is claiming to be a member of a designated group, complete

Section A of this application. If an individual is not claiming to be a member of a designated group, complete

Section B of this application. All applicants must complete Sections C, D, and E of this application. 

SECTION A 

Eligibility Statement - Designated Group Members 

Social Disadvantage

1. List all individuals claiming disadvantaged status: 

 

 Name of Individual Other last U.S. Citizen Place of Group Sex

Names Used Y/N Birth Membership M/F 

 ___________________ ___________ ________ ___________ _______ _____ 

 

 ___________________ ___________ ________ ___________ _______ _____ 

 ___________________ ___________ ________ ___________ _______ _____ 

SECTION B 

Eligibility Statement - Non Designated Group Members 

1. List all individuals claiming disadvantaged status:

 

Name of Individual U.S. Citizen Race Sex 

 Y/N M/F 

_______________________________ ________ ________ _____ 

_______________________________ ________ ________ _____ 

_______________________________ ________ ________ _____ 

_______________________________ ________ ________ _____ 

For this section, any individual claiming social disadvantage must provide a separate response for 

questions 3 and 4. 

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

(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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Social Disadvantage 

2. I, ____________________________________ have personally suffered social disadvantage based 

on my identification as __________________________________. 

(A claim of social disadvantage must include at least one objective feature that has 

contributed to social disadvantage, such as race, ethnic origin, gender, physical handicap, 

long-term residence in an environment isolated from the mainstream of American society, or

other similar causes not common to individuals who are not socially disadvantaged.) 

3. Document how your ability to compete in the free enterprise system has been impaired by such 

things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses or 

leases; restriction of your market to certain racial, ethnic, or social groups; underemployment or

unemployment, etc., as compared to others in the same or similar line of business who are not 

socially disadvantaged. Mark as Attachment B-1.

4. Attach a narrative describing how you personally experienced social disadvantage in 

American society. When writing your narrative, be as specific and detailed as possible. Where 

applicable, each statement of alleged discrimination should be supported by documented

evidence such as affidavits, denials of loan applications, denials of employment opportunities 

(including non-selection for particular jobs, denials of promotions, or unequal work environment 

or treatment), and documents to support any formal action taken by you because of alleged

discrimination. You must demonstrate how your identification, as described in the paragraph 

above, has negatively impacted your entry into or advancement in business. You must address 

disadvantage in education, employment, and business history, where applicable. Examples of

discrimination include, but are not limited to: unequal access to colleges or professional schools;

exclusion from professional or business associations; being denied educational honors or

recognition; experiencing discriminatory social pressure which discouraged you from pursuing a

professional or higher education or forced you into non-professional or non-business fields;

discrimination in employment opportunities or pay and fringe benefits; unequal access to 

business credit or capital; and discrimination in the awarding, bidding process, or negotiating of

government or private sector contracts. Mark as Attachment B-2. 

SECTION C 

(All applicant firms must complete) 

Economic Disadvantage 

1. Is the net worth of all individual(s) claiming disadvantaged status less than $750,000, excluding

ownership interest in the applicant firm and equity in the individual(s) primary residence? 

____Yes No ____. 

2. For individual(s) claiming disadvantaged status, list your personal net worth, excluding the 

ownership interest in the applicant firm and the equity in the individual(s) primary residence. 

Name Average 2-year Personal Total 

 Income Net Worth Assets

________________________________ ______________ __________ __________ 

________________________________ ______________ __________ __________ 

________________________________ ______________ __________ __________ 

________________________________ ______________ __________ __________ 

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

(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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3. Each individual listed in number 2 above certifies that, because of racial and/or ethnic prejudice, 

and/or cultural bias, his/her ability to compete in the free enterprise system has been impaired

due to diminished capital and credit opportunities as compared to others in the same or similar

line of business that are not socially disadvantaged.

SECTION D 

(All applicant firms must complete) 

Ownership 

Corporation: 

1. 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: _____ ______ _____ 

Limited Liability Company:

2. 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: _____ ______ _____ 

Partnership: 

3. 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 Percentage 

 

___________________________ ____________________ ____________________ 

___________________________ ____________________ ____________________ 

___________________________ ____________________ ____________________ 

___________________________ ____________________ ____________________ 

Questions 4 through 8 are for Corporations & LLCs ONLY:

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

Name Title Ownership %

 Voting NonVoting Total

___________________________ ____________________ ______ _________ _____ 

___________________________ ____________________ ______ __________ _____ 

___________________________ ____________________ ______ __________ _____ 

___________________________ ____________________ ______ __________ _____ 

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

(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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5. Does the private or voluntary organization 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 D-1. 

6. Will the private or voluntary organization 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 D-2. 

7. If the private or voluntary organization dissolves, will the private or voluntary organization 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 D-3.

8. Is ownership by the private or voluntary organization 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

private or voluntary organization? ___Yes ___No. If yes, explain as Attachment D-4. 

Corporations, LLCs & Partnerships: 

9. 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 D-5. 

SECTION E 

(All applicant firms must complete) 

Control 

Corporations Only: 

1. The private or voluntary organization controls the board of directors by virtue of the fact that: (select 

only one below)

___ a) The private or voluntary organization owns at least 100% of all the voting stock of the

applicant concern.

___ b) The private or voluntary organization owns at least 51% of all voting stock, is on the

Board of Directors, and no super majority voting requirements exist for shareholders to 

approve corporate actions.

___ c) The private or voluntary organization owns at least 51% of all voting stock, is on the

Board of Directors, and owns at least the percentage of voting stock needed to overcome

the super majority voting requirements which exist for shareholders to approve corporate 

actions.

___ d) The private or voluntary organization controls the Board of Directors through actual

numbers of voting directors.

___ e) The private or voluntary organization controls the Board of Directors through weighted 

voting and such voting is permitted by applicable state law.

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

(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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Partnerships Only: 

2. Are partnership decisions determined by general partners? If no, explain as Attachment E-1. 

Corporations, LLCs & Partnerships: 

3. List the titles of all officers, directors, management members, partners and key managers and the

hours devoted, by such individual(s) to the management of the applicant firm.

Name Title Hours

 ____________________________ _______________________________ __________ 

 ____________________________ _______________________________ __________ 

 ____________________________ _______________________________ __________ 

 ____________________________ _______________________________ __________ 

4. Are the CEO, President, Managing Member, Managing Partner, members of the management team,

business committee members, officers or directors engaged in or plan to engage in outside 

employment? ___ Yes ___ No. If yes, provide details as to the extent of outside employment or other 

business dealings to include daily hours of employment, location and explanation as to how this 

outside employment does not conflict with the ability to manage and control the daily operations of

the application concern. Provide as Attachment E-2.

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

Name Title

_______________________________ _______________________________ 

_______________________________ _______________________________ 

_______________________________ _______________________________ 

_______________________________ _______________________________ 

6. Are the management and daily business operations of the concern controlled by the private or 

voluntary organization through one or more disadvantaged individual members who possess 

sufficient management experience of an extent and complexity to run the concern? ___Yes ___No. If 

yes, provide documentation to verify management competency as Attachment E-3.

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

(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged)

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Each person signing below: 

1. Certifies that the information provided with regard to my social and economic disadvantaged

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 true,

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 true,

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 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 6100-1g) 

(Private and Voluntary Organizations Controlled by Individuals who are Socially and Economically Disadvantaged) 

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