Tennessee Uniform Certification PDF Details

The Tennessee Uniform Certification Program is a statewide initiative designed to ensure that all students in the state receive a high-quality education. The program establishes clear standards and expectations for educators, and provides a framework for improving teaching effectiveness and student achievement. In order to become certified in Tennessee, teachers must complete an approved educator preparation program, demonstrate competency in core subjects, and pass a rigorous certification assessment. Thanks to the Tennessee Uniform Certification Program, students in Tennessee can be confident that they are receiving an education that meets the highest standards.

Here is the details about the form you were in search of to fill in. It will show you the time you will need to fill out tennessee uniform certification, what fields you will need to fill in, and so forth.

QuestionAnswer
Form NameTennessee Uniform Certification
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesTennessee, tnucp certification, DBE, CFR

Form Preview Example

Tennessee

Uniform

Certification

Program

Member Agencies

Tennessee Department of Transportation

Metropolitan Knoxville Airport Authority

Chattanooga

Metropolitan

Airport Authority

Memphis Shelby County Airport Authority

Metropolitan Nashville Airport Authority

Chattanooga Area

Regional

Transportation Authority

Memphis Area

Transit Authority

Nashville Metropolitan Transit Authority

Jackson Transit

Authority

Smyrna Airport

Authority

Tri-Cities Airport

Commission

Clarksville Transit

System

Regional Transportation Authority [Middle TN]

Knoxville Area Transit

Jackson Airport

TENNESSEE UNIFORM CERTIFICATION PROGRAM

(TNUCP)

Thank you for your interest in participating in the Tennessee Uniform Certification Program (TNUCP) to become a Disadvantaged Business Enterprise (DBE)/Airport Concession Disadvantaged Business Enterprise (ACDBE). Our DBE objective is to ensure that disadvantaged business firms have the maximum opportunity to participate in DOT assisted contracts.

The TNUCP is charged with the responsibility of certifying firms for the purpose of maintaining a database of certified DBEs for the United States Department of Transportation (U.S. DOT) grantees in the state of Tennessee. This is pursuant to the Final Rule 49 Code of Federal Regulations (CFR) Part 26 that requires U.S. DOT recipients to take part in a statewide uniform certification process.

Please complete the attached application if you wish to be considered for DBE certification. In order to avoid unnecessary delays, please complete all portions of the Uniform Certification Application and include all copies of documents requested on the application. In addition, the Affidavit of Certification and the Personal Financial Statement must both be notarized.

Additional documentation may be requested if it is considered necessary to make a certification determination. Incomplete applications will not be evaluated until all requested documentation has been submitted for review. We highly recommend that you keep a copy of all submitted documents for your records.

It is no longer necessary to apply for DBE certification at more than one of the member agencies. If your firm meets the criteria for certification, it will be entered in the TNUCP database. Only firms currently certified as eligible DBEs for the TNUCP may participate in the DBE program of U.S.

DOT grantees within the state of Tennessee. The TNUCP is not required to process an application for certification from a firm having its principal place of business outside the state of Tennessee if the firm is not certified in its home state. If the firm has its principal place of business in another state and is currently certified in that state, please contact the Tennessee Department of Transportation.

To participate in the TNUCP DBE/ACDBE program, please send the completed application and all supporting documentation to the appropriate member agency listed on the following page.

Page 1 of 18

Rev. 12-2008

The following member agency processes ACDBE/ DBE applications. Please forward your completed certification packet to MMBC Uniform Certification Agency serving the area where your firm has its principal place of business:

Uniform Certification Agency P.O. Box 3060

158 Madison Avenue, Suite 300 Memphis, TN 38173 (901)525-6512(T) (901)525-5204(Fax) www.mmbc-memphis.org

Tennessee Uniform Certification Program (TNUCP)

Application for Certification as a Disadvantaged Business Enterprise

(DBE)

INSTRUCTIONS AND INFORMATION

Please read these instructions completely and thoroughly!!!

1.All questions must be answered. Questions that do not apply to your firm should be marked “N/A.”

2.All documents requested on the Certification Checklist must be provided. Mark “N/A” for any items that do not pertain to your company.

3.The Personal Financial Statement enclosed must be filled out in its entirety leaving no line blank. This form

must be completed for each DBE applicant and this form must be signed by each DBE applicant in the presence of a Notary Public.

4.The Affidavit of Certification must be signed by the principal owner(s) in the presence of a Notary Public.

Please note that failure to complete the application as instructed above will delay processing and may result in a denial of certification as a Disadvantaged Business Enterprise.

For Your Information

1.An on-site interview will be required for all in-state applicants, as part of the certification process. Once the application is complete, this should occur within 90 business days of receipt of the certification package.

2.Additional information may be required during the processing period. Delays in submitting requested information will cause a delay in processing the application.

3.Changes in ownership, control, or operation of the business should be reported within 30 days of the occurrence. Any changes in ownership or transfer of ownership two (2) years prior to submission of an application with the Tennessee Uniform Certification Program will not be acceptable and will be seriously scrutinized for timing and reasons for ownership change.

4.An applicant has the right to protest a Denial of Certification by filing an appeal with the U.S. Department of Transportation.

5.All certified businesses will be listed in the Directory of Disadvantaged Business Enterprises for the Tennessee Uniform Certification Program.

Page 2 of 18

Rev. 12-2008

Tennessee Uniform Certification Program

(TNUCP)

Disadvantaged Business Enterprise

(DBE)

Renewal Application

→This document and its attachment must be completed in their entirety for each DBE owner←

PRINT NAME AND TITLE OF MAJORITY DISADVANTAGED OWNER(S):

___________________________________________________________________________________________________

BUSINESS NAME: ___________________________________________________________________________________________

MAILING ADDRESS: ________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

BUSINESS PHONE NUMBER: ___________________________

FAX NUMBER: ______________________________

EMAIL ADDRESS: _____________________________________

 

DBE FIRM’S GROSS RECEIPTS (attach a copy of the firm’s most recent corporate tax return and all attachments, if applicable)

DBE OWNER’S PERSONAL TAX RETURN (attach a copy of the most recent personal tax return and all attachments for each individual applying for disadvantaged status)

PERSONAL FINANCIAL STATEMENT (This attached document must be filled out in its entirety, signed, dated and notarized by the applicant)

HAS THERE BEEN A CHANGE IN OWNERSHIP/MANAGEMENT THIS PAST YEAR? YES____ NO ____

(If “YES,” you must submit all pertinent information to show changes in ownership)

I agree that the TNUCP will be notified in writing within 30 days of any changes in ownership and/or control, personal net worth and/or size standard that would impact the firm’s eligibility to remain in the program.

I, _____________________________________(NAME OF DBE FIRM OWNER{S}), swear (or affirm) that there have been no changes in

____________________________(NAME OF DBE FIRM) circumstances affecting its ability to meet the size, disadvantaged status, ownership

or control requirements of 49 CFR Part 26 and 13 CFR Part 121. I swear (or affirm) there have been no material changes in the information provided with __________________________________(NAME OF DBE FIRM) application for certification, except for any

changes about which I have provided written notice to_____________________________________(name of DOT recipient) pursuant to

49 CFR 26.83(i).

I swear (or affirm) that I am socially disadvantaged because I have been subjected to racial or ethnic prejudice or cultural bias, or have suffered the effects of discrimination, because of my identity as a member of one or more of the groups identified in 49 CFR 26.5, without regard to my individual qualities. I further swear (or affirm) that my personal net worth does not exceed $750,000, and that I am economically disadvantaged because 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 who are not socially and economically disadvantaged.

I specifically swear (or affirm) _____________________________(NAME OF DBE FIRM) continues to meet the Small Business

Administration (SBA) business size criteria and the overall gross receipts cap of 49 CFR Part 26 and _________________________(NAME

OF DBE FIRM) average annual gross receipts (as defined by SBA rules) over the previous three fiscal years do not exceed

_______________(dollar amount). I provide the attached size and gross receipts documentation to support this affidavit.

I certify that the above information is true and complete to the best of my knowledge and understand that knowingly and willfully providing false information to the Federal government is a violation of 18 U.S.C. 1001 (False Statements) which could result in fines, imprisonment or both.

Signature_____________________________________________ Date____________________________________________________

NOTARY CERTIFICATE:

 

PERSONAL FINANCIAL STATEMENT

 

As of _________________ ,__________________

Name

Business Phone

 

 

Residence Address

Residence Phone

 

 

City, State, & Zip Code

Business Name of Applicant

 

ASSETS

(Omit Cents)

 

LIABILITIES

(Omit Cents)

 

 

Cash on hand & in Banks…………

$_______________

 

Accounts Payable…………………………...

$________________

 

 

Savings Accounts…………………..

$_______________

 

Notes Payable to Banks and Others………

$________________

 

 

 

 

 

 

 

IRA or Other Retirement Account...

$_______________

 

(Describe in Section 2)

 

 

 

 

 

 

Installment Account (Auto)…………………

$________________

 

 

Accounts & Notes Receivable…….

$_______________

 

Mo. Payments $_______

 

 

 

Life Insurance-Cash Surrender

 

 

Installment Account (Other)………………..

$________________

 

 

 

 

Mo. Payments $_______

 

 

 

Value Only ………………………….

 

 

 

 

 

$_______________

 

Loan on Life Insurance……………………..

$________________

 

 

(Complete Section 8)

 

 

 

 

 

 

 

 

 

Stocks and Bonds…………………..

$_______________

 

Mortgages on Real Estate………………….

$________________

 

 

(Describe in Section 3)

 

(Describe in Section 4)

 

 

 

 

 

 

 

 

Real Estate………………………….

$_______________

 

Unpaid Taxes………………………………..

$________________

 

 

(Describe in Section 4)

 

(Describe in Section 6)

 

 

 

 

 

 

 

 

Automobile-Present Value…………

$_______________

 

Other Liabilities………………………………

$________________

 

 

 

 

 

 

Personal Property…………………..

 

 

(Describe in Section 7)

 

 

 

$_______________

 

 

 

 

 

(Describe in Section 5)

 

 

 

 

 

 

 

Total Liabilities

$________________

 

 

Other Assets……………………...

 

 

 

 

$_______________

 

 

 

 

 

(Describe in Section 5)

 

 

 

 

 

 

 

 

 

 

 

Total Assets

$_______________

 

Total Assets – Total Liabilities=

 

 

 

 

 

Net Worth

$________________

 

 

 

 

 

 

 

Section 1.

Source of Income

 

 

Contingent Liabilities

 

 

 

Salary………………………………

$_______________

 

 

As Endorser or Co-Maker…………………..

$_______________

 

 

Net Investment Income…………….

$_______________

 

 

Legal Claims & Judgments…………………

$_______________

 

 

Real Estate Income………………...

$_______________

 

 

Provision for Federal Income Tax………….

$_______________

 

 

Other Income………………………..

$_______________

 

 

Other Special Debt…………………………..

$_______________

 

 

(Describe in section 1 below)

 

 

 

 

 

 

Description of Other Income in Section 1.

*Alimony or child support payments need not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.

Section 2. Notes Payable to Banks and Other. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)

 

 

 

 

Original

 

 

Current

 

Payment

 

 

Frequency

 

 

How Secured or Endorsed Type of

 

 

Name and Address of Noteholder(s)

 

 

 

 

Balance

 

 

Balance

 

Amount

 

 

(monthly, etc.)

 

 

Collateral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Number of Shares

Name of Securities

Cost

Market Value

Quotation/Exchange

Date of

Quotation/Exchange

Total Value

Section 4. Real Estate Owned

(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a

 

part of this statement and signed.)

 

 

 

Primary Residence

Property B

Property C

Type of Property

 

 

 

Address

 

 

 

 

 

 

 

Date Purchased

 

 

 

 

 

 

 

Original Cost

 

 

 

 

 

 

 

Present Market Value

 

 

 

 

 

 

 

Name &

 

 

 

Address of Mortgage Holder

 

 

 

 

 

 

 

Mortgage Account Number

 

 

 

 

 

 

 

Mortgage Balance

 

 

 

 

 

 

 

Amount of Payment per Month/Year

 

 

 

 

 

 

 

Status of Mortgage

Section 5. Personal Property and Other Assets. (Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency)

Section 6.

Unpaid Taxes (Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

Section 7. Other Liabilities (Describe in detail.)

Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies – name of insurance company and beneficiaries.)

I authorize the Tennessee Uniform Certification Program to make inquiries as necessary to verify the accuracy of the statements made and to determine my eligibility. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of determining Disadvantaged Business Enterprise eligibility. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001)

Signature:

Date: Social Security Number

 

 

Signature:

Date: Social Security Number

NOTARY

Subscribed and sworn to before me this ____day of _________20__

Signed_____________________________, Notary Public in and for the

County of __________________, State_________________

My Commission Expires____________________________

Watch Tennessee Uniform Certification Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .