Document ID: EPA-HQ-OA-2006-0278-0012
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2012-07-11T04:00Z

EPA FORM 6100-4
                           EPA Disadvantaged Business Enterprise (DBE) Program 
                                             DBE Subcontractor Utilization Form

This form is intended to capture the prime contractor's actual and/or anticipated use of identified certified DBE[1] subcontractors[2] and the estimated dollar amount of each subcontract.  An EPA Financial Assistance Agreement Recipient must require its prime contractors to complete this form and include it in the bid or proposal package.  Prime contractors should also maintain a copy of this form on file.
Subcontractor Name

Project Name
Bid/ Proposal No.
Assistance Agreement ID No. (if known)
Point of Contact

Address

Telephone No.

Email Address
Prime Contractor Name
Issuing/Funding Entity:

I have identified potential DBE certified subcontractors
                                    ___ YES
                                    ___ NO
If yes, please complete the table below. If no, please explain:

                                 Company Name
                                       
                                       
                         Company Address/ Phone/ Email
                                       
                                Est. Dollar Amt
                           Currently DBE Certified?

                          Continue on back if needed

I certify under penalty of perjury that the forgoing statements are true and correct.  Signing this form does not signify a commitment to utilize the subcontractors above.  I am aware of that  in the event of a replacement of a subcontractor, I will adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c).  

                          Prime Contractor Signature
                                  Title/ date