Epa Form 6100 1C – Fill Out and Use This PDF

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 a copy of the prior determination of attempts to obtain certification: ____________________________________

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Does your firm have any other certification as a disadvantaged business entity, i.e., MBE, DBE, WBE, etc.?

___ Yes ___ No. If yes, provide 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.Is your firm at least 51% owned by a U.S. citizen? ____ Yes ____ No. If your firm is not at least 51% owned by a U.S. Citizen, stop here. You are not eligible to participate as a DBE under EPA’s DBE Certification Program.

2.List all individuals claiming disadvantaged status.

2a. If you are a naturalized Citizen, please provide the following as Attachment A-1:

(a) naturalization number; (b) date of citizenship; and (c) county, state and court.

SECTION B

Eligibility Statement – Non Designated Group Members

1.List all individuals claiming disadvantaged status:

1a. If you are a naturalized Citizen, please provide the following as Attachment B-1: naturalization number; (b) date of citizenship; and (c) county, state and court.

For this section, all individuals claiming social disadvantage must provide a separate response for questions 3 and 4.

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. Provide as Attachment B-2.

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. Provide as Attachment B-3.

SECTION C

(All applicant firms must complete)

Economic Disadvantage

1.Is the net worth of each 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.

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

1.Provide the name, title, and percentage of ownership (class, if applicable) for each partner of the firm. Does the partnership agreement reflect the ownership of each partner? ____ Yes ____ No.

2.Has 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-1.

3.For community property residents only. If you are a married disadvantaged owner, and your spouse is not disadvantaged, please complete the chart below, and provide evidence that you have a majority interest in the business as Attachment D-2.

4.Has any individual(s) claiming disadvantaged status transferred any assets within two years, in full or in part, to a spouse or any other person or entity, including a trust? ___ Yes ___ No. If yes, provide the following information as Attachment D-3: the date of transfer; to whom the assets were transferred; amount paid for the assets; and the market value of the assets at the time of transfer. Individuals may exclude assets transferred to an immediate family member that are consistent with the customary recognition of special occasions, such as birthdays, graduations, anniversaries and retirements. Individuals may also exclude any transfers to an immediate family member if for educational, medical or essential support purposes.

SECTION E

(All applicant firms must complete)

Control

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

3.Is a general partner, or any disadvantaged full-time manager engaged in or plan to engage in outside employment? ___ Yes ___ No. If yes, explain as Attachment E-2.

4. Have any of the nondisadvantaged individuals involved in the management of the applicant firm, partners, or their immediate family members, had a prior business relationship with any individual claiming disadvantage status? This includes such relationships as employer-employee, supervisor- employee, co-workers, investor-employee, etc. ___ Yes ___ No. If yes, identify the person(s) and the type of business relationship as Attachment E-3.

5.List the total compensation from the applicant firm of all partners and/or key managers of the firm. (If necessary, provide additional information as Attachment E-4).

6.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 as Attachment E-5.

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

8.Does any individual(s), (other than the individual(s) claiming disadvantaged status) or entities provide:

If you answered yes to any of the above, please provide specific details (i.e., names, titles, copies of agreements, leases, etc.) of such arrangements as Attachment E-6.

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 status as a United States citizen is true, accurate and complete to the best of my knowledge and belief.

4.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.

5.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.

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

7.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.

The public reporting and recordkeeping burden for this collection of information is estimated to average three (3) hours. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, disclose or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

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 the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed EPA DBE Certification Form to this address.