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.

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Form NameTennessee Uniform Certification
Form Length5 pages
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namestennessee tnucp, TNUCP, tennessee uniform certification program 878 form, tnucp certification

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Member Agencies

Tennessee Department of Transportation

Metropolitan Knoxville Airport Authority



Airport Authority

Memphis Shelby County Airport Authority

Metropolitan Nashville Airport Authority

Chattanooga Area


Transportation Authority

Memphis Area

Transit Authority

Nashville Metropolitan Transit Authority

Jackson Transit


Smyrna Airport


Tri-Cities Airport


Clarksville Transit


Regional Transportation Authority [Middle TN]

Knoxville Area Transit

Jackson Airport



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



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


Disadvantaged Business Enterprise


Renewal Application

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



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)


(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____________________________________________________





As of _________________ ,__________________


Business Phone



Residence Address

Residence Phone



City, State, & Zip Code

Business Name of Applicant



(Omit Cents)



(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








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.)
















How Secured or Endorsed Type of



Name and Address of Noteholder(s)













(monthly, etc.)





















































































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


Market Value


Date of


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












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)


Date: Social Security Number




Date: Social Security Number


Subscribed and sworn to before me this ____day of _________20__

Signed_____________________________, Notary Public in and for the

County of __________________, State_________________

My Commission Expires____________________________

How to Edit Tennessee Uniform Certification Online for Free

The PDF editor allows you to fill out the DBE form. You will be able to prepare the form as soon as possible through using these easy steps.

Step 1: First, click the orange button "Get Form Now".

Step 2: Now you can change your DBE. You may use our multifunctional toolbar to add, eliminate, and change the content material of the form.

Get the DBE PDF and type in the material for every single area:

completing tnucp part 1

Provide the appropriate data in the I name of DBE firm owners swear or, name of DBE firm circumstances, or control requirements of CFR, information provided with name of, changes about which I have, I swear or affirm that I am, I specifically swear or affirm, and I certify that the above field.

tnucp I name of DBE firm owners swear or, name of DBE firm circumstances, or control requirements of  CFR, information provided with name of, changes about which I have, I swear or affirm that I am, I specifically swear or affirm, and I certify that the above blanks to insert

Describe the most essential details of the Signature Date, and NOTARY CERTIFICATE field.

part 3 to finishing tnucp

Through field PERSONAL FINANCIAL STATEMENT, As of, Name, Business Phone, Residence Address, Residence Phone, City State Zip Code, Business Name of Applicant, Cash on hand in Banks, ASSETS Omit Cents, Savings Accounts, IRA or Other Retirement Account, Accounts Notes Receivable, Life InsuranceCash Surrender Value, and Stocks and Bonds Describe in, define the rights and obligations.

tnucp PERSONAL FINANCIAL STATEMENT, As of, Name, Business Phone, Residence Address, Residence Phone, City State  Zip Code, Business Name of Applicant, Cash on hand  in Banks, ASSETS Omit Cents, Savings Accounts, IRA or Other Retirement Account, Accounts  Notes Receivable, Life InsuranceCash Surrender Value, and Stocks and Bonds Describe in blanks to fill

Fill out the document by reading the next fields: Stocks and Bonds Describe in, AutomobilePresent Value, Personal Property Describe in, Mortgages on Real Estate Describe, Other Liabilities Describe in, Total Liabilities, Total Assets, Total Assets Total Liabilities, Section Source of Income Salary, Description of Other Income in, Contingent Liabilities, As Endorser or CoMaker Legal, Alimony or child support payments, Section Notes Payable to Banks, and Name and Address of Noteholders.

Entering details in tnucp stage 5

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