Uniform Certification Form – Fill Out and Use This PDF

Uniform Certification Form – Fill Out and Use This PDF

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Are you looking for a way to reduce time-consuming paperwork and streamline the process of certification? Uniform Certification Forms can be used as an important tool in any organization’s record-keeping system. Not only do they simplify the task of guaranteeing that essential qualifications are met, but they also add consistency across the board. In this blog post, we'll discuss why uniform certification forms are so important and walk through how to create your own set. So clear some space on your desk and get ready to dive into all things related to these powerful documents!

Question	Answer
Form Name	Uniform Certification Form
Form Length	23 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min 45 sec
Other names	DBE, Financial, certification dbe has, uniform certification

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Maryland Department of Transportation

RETURN TO:	COMPLETE ALL ITEMS.
Minority Business Enterprise Office	If an item does not apply, mark
Maryland Department of Transportation	“N.A.”
7201 Corporate Center Dr.	Use separate sheet(s) for
Hanover, MD 21076	Additional information
410-865-1269
1-800-544-6056

DISADVANTAGED BUSINESS ENTERPRISE PROGRAM

49 C.F.R. PART 26

UNIFORM CERTIFICATION APPLICATION

ROADMAP FOR APPLICANTS

•Should I apply?

oIs your firm at least 51% owned by a socially and economically disadvantaged individual(s) who also controls the firm?

oIs the disadvantaged owner a U.S. citizen or lawfully admitted permanent resident of the U.S.?

oIs your firm a small business that meets the Small Business Administration’s (SBA) size standard and does not exceed $22.41 million in gross annual receipts?

oIs your firm organized as a for-profit business?

If you answered “Yes” to all of the questions above, you may be eligible to participate in the U.S. DOT DBE program.

•Be sure to attach all of the required documents listed in the Document Checklist at the end of this form with your completed application.

•Where can I find more information?

oU.S. DOT – http://osdbuweb.dot.gov/business/dbe/index.html (this site provides useful links to the rules and regulations governing the DBE program, questions and answers, and other pertinent information)

oSBA – http://www.ntis.gov/naics (provides a listing of NAICS codes) and http://www.sba.gov/size/indextableofsize.html (provides a listing of SIC codes)

o49 CFR Part 26 (the rules and regulations governing the DBE program)

Under Sec. 26.107 of 49 CFR Part 26, dated February 2, 1999, if at any time, the Department or a recipient has reason to believe that any person or firm has willfully and knowingly provided incorrect information or made false statements, the Department may initiate suspension or debarment proceedings against the person or firm under 49 CFR part 29, take enforcement action under 49 CFR Part 31, Program Fraud and Civil Remedies, and/or refer the matter to the Department of Justice for criminal prosecution under 18 U.S.C. 1001, which prohibits false statements in Federal programs.

Page 1 of 14

Maryland Department of Transportation

A. Prior/Other Certifications

Section 1: CERTIFICATION INFORMATION

Is your firm currently certified for any of the following programs?

If Yes, check appropriate box(es))

DBE	Name of certifying agency:

Has your firm's state UCP conducted an on-site visit?

Yes, on Date:

State:

8(a)

SDB

B.Prior/Other Applications and Privileges

Has your firm (under any name) or any of its owners, Board of Directors, officers or management personnel, ever withdrawn an application for any of the programs listed above, or ever been denied certification, decertified, or debarred or suspended or otherwise had bidding privileges denied or restricted by any state or local agency, or Federal entity?

Yes, on Date:

If yes, identify State and name of state, local or Federal agency and explain the natural of the action:

Contact Information

Section 2: GENERAL INFORMATION

(1) CONTACT PERSON

Name

(3) Phone #

(4)

Other Phone

Title

(2)

Legal name of firm:

(5)

Fax #:

(6) E-mail:

(7)

Website (if you have one):

(8)

Street address of firm (No P.O.Boxes)

Address 1

City

County/Parish:

Address 2

State

Zip Code

(9) Mailing address of firm (if different):

Address 1

City

County/Parish:

Address 2

State

Zip Code

B.Business Profile

(1)

Describe the primary activities of your firm:

(2)

Federal Tax ID (if any):

(3)

This firm was established on

Date:

(4)

I/We have owned this firm since

Date:

(5)

Method of acquisition (check all that apply):

Start new business

Bought existing business

Inherited business

Secured concession

Merger or consolidation

Other (explain)

(6)

Is your firm "for profit"?

Yes

STOP! If your firm is NOT for-profit, then you do NOT qualify for this program and

do NOT need to fill out this application.

Page 2 of 14

Maryland Department of Transportation

(7)Type of firm (check all that apply):

Sole Proprietorship

Partnership

Corporation

Limited Liability Partnership

Limited Liability Company

Joint Venture

Other, Describe:

(8)Has your firm ever existed under different ownership, a different type of ownership, or a different name?

Yes	No
If Yes,	explain:

(9) Number of employees: Full-time		Part-time	Total
(10) Specify the gross receipts of the firm for the last 3	years: Year		Total receipts

		Year	Total receipts

		Year	Total receipts

C.Relationships with Other Businesses

(1)Is your firm co-located at any of its business locations, or does it share a telephone number, P.O. Box, office space, yard, warehouse, facilities, equipment, or office staff, with any other business, organization, or entity?

Yes

If Yes, identify: Other Firm's name:

Explain nature of shared facilities:

(2)

At present, or at any time in the past, has your firm:

(a)

been a subsidiary of any other firm?

Yes

(b) consisted of a partnership in which one or more of the

partners are other firms?

Yes

(c)

owned any percentage of any other firm?

Yes

(d)

had any subsidiaries?

Yes

(3)

Has any other firm had an ownership interest in your firm at present or at any time in the past?

Yes

(4)

If you answered "Yes" to any of the questions in (2)(a)-(d) and/or (3), identify the following for each

(attach extra sheets, if needed):

Name

Address

Type of Business

Immediate Family Member Businesses

Do any of your immediate family members own or manage another company?

Yes

If Yes, then list (attach extra sheets, if needed):

Name

Relationship

Company

Type of Business

Own or Manage?

Page 3 of 14

(If more than one owner, duplicate and attach separate sheets for each additional owner):

Maryland Department of Transportation

Section 3: OWNERSHIP

Identify all individuals or holding companies with any ownership interest in your firm, providing the information requested below

A.Background Information

(1) Name:

(2) Title:

(3) Home Phone #:

(4) Home Address (street and number):

Address 1

City

Address 2

State

Zip Code

(5)

Gender:

Male

Female

(6) Ethnic group membership (Check all that apply):

(7)

U. S. Citizen:

Yes

Black

Hispanic

Native American

(8)

Lawfully Admitted Permanent Resident:

Asian Pacific

Subcontinent Asian

Yes

Other (specify)

B.Ownership Interest

(1)

Number of years as owner:

(2) Initial investment to acquire ownership interest in firm:

Type

Dollar Value

(3)

Percentage owned:

Cash

Real Estate

(4)

Familial relationship to other owners:

Equipment

Other

(5)

Shares of Stock:

Number

Percentage

Class

Date acquired

Method Acquired

(6)

Does this owner perform a management or supervisory function for any other business?

Yes

If Yes, identify: Name

of Business:

Function/Title:

(7)

Does this owner own or work for any other firm(s) that has a relationship with this firm (e.g., ownership interest,

shared office space,

financial investments, equipment, leases, personnel sharing, etc)?

Yes

If Yes, identify: Name

of Business:

Function/Title:

Nature of Business Relationship:

C.Disadvantaged Status - NOTE: Complete this section only for each owner applying for DBE qualification (i.e., for each owner claiming to be socially and economically disadvantaged)

(1)What is the Personal Net Worth (PNW) of the owner(s) applying for DBE qualification? (Use and attach the Personal Net Worth calculator form at the end of this application; attach additional sheets if more than one owner is applying)

(2) Has any trust been created for the benefit of this disadvantaged owner(s)?	Yes	No
If Yes, explain (attached additional sheets if needed):

Page 4 of 14

Maryland Department of Transportation

Section 4: CONTROL

A.Identify your firm's Officers & Board of Directors (If additional space is required, attach a separate sheet):

Name

Title

Date Appointed

Ethnicity

Gender

(1)

Officers

(a)

of the

(b)

Company

(c)

(d)

(e)

(2)

Board of

(a)

Directors

(b)

(c)

(d)

(e)

(3)

Do any of the persons listed in (1) and/or (2) above perform a management or supervisory function for any other business?

Yes

If Yes, identify for each: Person:

Title:

Business:

Function:

(4)

Do any of the person listed (1) and/or (2) above own or work for any other firm(s) that has a relationship with this firm

(e.g., ownership interest, shared office space, financial investments, equipment, leases, personnel sharing. etc)?

Yes

If Yes, identify for each: Firm Name:

Person:

Nature of Business Relationship:

B.Identify your firm's management personnel who control your firm in the following areas (If more than two persons, attach a separate sheet):

(1)

Financial Decisions

Name

Title

Ethnicity

Gender

(responsibility for acquisition of lines

of credit, surety bonding, supplies,

etc.)

(2)

Estimating and bidding

(3)

Negotiating and Contract

Execution

(4)

Hiring/firing of management

personnel

(5)

Field/Production Operations

Supervisor

(6) Office Management

(7)

Marketing / Sales

(8)

Purchasing of major

equipment

(9) Authorized to Sign Company

Checks (for any purpose)

(10) Authorized to make

Financial Transactions

Page 5 of 14

Maryland Department of Transportation

(11) Do any of the persons listed in (1) through (10) have perform a management or supervisory function for any other business?

Yes

If Yes, identify for each: Person:		Title:
Business:		Function:

(12) Do any of the persons listed in (1) through (10) above own or work for any other firm(s) that has a relationship with this firm

(e.g., ownership interest, shared office space, financial investments, equipment, leases, personnel sharing. etc.)?

If Yes, identify for each: Firm Name:

Person:

Nature of Business Relationship:

C.Indicate your firm's inventory in the following categories (attach additional sheets if needed)

(1)Equipment

Yes No

Type of Equipment

(a)

Make / Model

Current Value

Owned or Leased?

(b)

(c)

(2)Vehicles

Type of Vehicle

Make / Model

Current Value

Owned or Leased?

(a)

(b)

(c)

(3)

Office Space

Street Address

Owned or Leased?

Current Value of Property or Lease

(a)

(b)

(4)

Storage Space

Street Address

Owned or Leased?

Current Value of Property or Lease

(a)

(b)

Does your firm rely on any other firm for management functions or employee payroll?

Yes

If Yes, explain:

E.Financial Information

(1)Banking Information:

(a) Name of bank:	(b) Phone No:
(b) Address of bank:

	City:	State:	Zip:

Page 6 of 14

Maryland Department of Transportation

(2) Bonding Information: If you have bonding capacity, identify:

(a) Binder No:

(b) Name of agent/broker:

(d)

Address of agent/broker:

City:

State:

Zip:

(e)

Bonding limit: Aggregate limit

Project limit

F.Identify all sources, amounts, and purposes of money loaned to your firm, including the names of any persons or firms securing the loan, if other than the listed owner:

Name of Source	Address of Source	Name of Person	Original	Current	Purpose of Loan
		Securing the Loan	Amount	Balance

G.List all contributions or transfers of assets to/from your firm and to/from any of its owners over the past two years

(attach additional sheets if needed):

H.List current licenses / permits held by any owner and / or employee of your firm

(e.g., contractor, engineer, architect, etc.) (attach additional sheets if needed):

Name of License / Permit Holder

Type of License / Permit

Expiration Date

License Number and State

I.List the three largest contracts completed by your firm in the past three years, if any:

Name of Owner / Contractor

Name / Location of Project

Type of Work Performed

Dollar Value of Contract

Page 7 of 14

Maryland Department of Transportation

J.List the three largest active jobs on which your firm is currently working:

Name of Prime

Contractor and

Project Number

Location of Project

Type of Work

Project Start Date

Anticipated

Completion

Date

Dollar

Value of

Contract

Go to page 9 for further requirements

Page 8 of 14

Maryland Department of Transportation

Required MDOT Specific Information:

Name of Attorney

Address 1

City

County/Parish:

Address 2

State

Zip Code

Telephone #:

Name of CPA

Address 1

City

County/Parish:

Address 2

State

Zip Code

Telephone #:

In addition to the required supporting documents listed on the DBE Uniform Certification Application checklist MDOT requires that the applicant:

Submit resumes for Owner(s), Director(s), and all KEY PERSONNEL

Submit documented proof of the contributions made for stock purchase

Submit documented proof of minority status

Submit the firm's last four quarterly unemployment reports

If a corporation, submit the firm's first and last stockholder(s) and Board of Directors minutes

Submit only the Personal Net Worth form for each individual whose ownership and control are relied upon for DBE certification IF IN BUSINESS FOR LESS THAN A YEAR: Submit a Business Plan

Page 9 of 14

Maryland Department of Transportation

AFFIDAVIT OF CERTIFICATION

This form must be signed and notarized for each owner upon which disadvantaged status is relied.

A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS SUFFICIENT CAUSE FOR DENIAL OF CERTIFICATION, REVOCATION OF A PRIOR APPROVAL, INITIATION OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR ENTITY MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES AVAILABLE PURSUANT TO APPLICABLE FEDERAL AND STATE LAW.

I		(full name printed), swear or affirm under penalty of law that I am
	(title) of applicant firm		(firm name) and that I have read and
	(title) of applicant firm		(firm name) and that I have read and

understood all of the questions in this application and that all of the foregoing information and statements submitted in this application and its attachments and supporting documents are true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material information. The responses include all material information necessary to fully and accurately identify and explain the operations, capabilities and pertinent history of the named firm as well as the ownership, control, and affiliations thereof.

I recognize that the information submitted in this application is for the purpose of inducing certification approval by a government agency. I understand that a government agency may, by means it deems appropriate, determine the accuracy and truth of the statements in the application, and I authorize such agency to contact any entity named in the application, and the named firm's bonding companies, banking institutions, credit agencies, contractors, clients, and other certifying agencies for the purpose of verifying the information supplied and determining the named firm's eligibility.

I agree to submit to government audit, examination and review of books, records, documents and files, in whatever form they exist, of the named firm and its affiliates, inspection of its places(s) of business and equipment, and to permit interviews of its principals, agents, and employees. I understand that refusal to permit such inquiries shall be grounds for denial of certification.

If awarded a contract or subcontract, I agree to promptly and directly provide the prime contractor, if any, and the Department, recipient agency, or federal funding agency on an ongoing basis, current, complete and accurate information regarding (1) work performed on the project; (2) payments; and (3) proposed changes, if any, to the foregoing arrangements.

I agree to provide written notice to the recipient agency or Unified Certification Program (UCP) of any material change in the information contained in the original application within 30 calendar days of such change (e.g., ownership, address, telephone number, etc.).

I acknowledge and agree that any misrepresentations in this application or in records pertaining to a contract or subcontract will be grounds for terminating any contract or subcontract which may be awarded; denial or revocation of certification; suspension and debarment; and for initiating action under federal and/or state law concerning false statement, fraud or other applicable offenses.

I certify that I am a socially and economically disadvantaged individual who is an owner of the above-referenced firm seeking certification as a Disadvantaged Business Enterprise (DBE). In support of my application. I certify that I am a member of one or more of the following groups, and that I have held myself out as a member of the group(s) (check all that apply):

I hereby certify that I am a (check all that apply):

Female		Hispanic American
Black American		Native American
Asian - Pacific American		Subcontinent Asian American
Other (specify)
		Page 10 of 14

*Do not sign this Affidavit of Certification with an electronic or digital signature. The Affidavit of Certification requires an original signature that has been properly notarized. It should be submitted with a complete application including all required supporting documentation.

Maryland Department of Transportation

DBE UNIFORM CERTIFICATION APPLICATION SUPPORTING DOCUMENTS CHECKLIST

In order to complete your application for DBE certification, you must attach copies of all of the following

documents as they apply to you and your firm.

All Applicants

Work experience resumes (that include places of ownership/employment with corresponding dates), for all owners and officers of your firm

Personal Financial Statement (form available with this application)

Personal tax returns for the past three years, if applicable, for each owner claiming disadvantaged status

Your firm's tax returns (gross receipts) and all related schedules for the past three years

Documented proof of contributions used to acquire ownership for each owner (e.g. both sides of cancelled checks)

Your firm's signed loan agreements, security agreements, and bonding forms

Descriptions of all real estate (including office/storage space, etc.) owned/leased by your firm and documented proof of ownership/signed leases

List of equipment leased and signed lease agreements

List of construction equipment and/or vehicles owned and titles/proof of ownership

Documented proof of any transfers of assets to/from your firm and/or to/from any of its owners over the past two years

Year-end balance sheets and income statements for the past three years (or life of firm, if less than three years); a new business must provide a current balance sheet

All relevant licenses, license renewal forms, permits, and haul authority forms

DBE and SBA 8(a) or SDB certifications, denials, and/or decertifications, if applicable

Bank authorization and signatory cards

Schedule of salaries (or other compensation or remuneration) paid to all officers, managers, owners, and/or directors of the firm Trust agreements held by any owner claiming disadvantaged status, if any

Partnership or Joint Venture

Original and any amended Partnership or Joint Venture Agreements

Corporation or LLC

Official Articles of Incorporation (signed by the state official)

Both sides of all corporate stock certificates and your firm's stock transfer ledger

Shareholders' Agreement

Minutes of all stockholders and board of directors meetings

Corporate by-laws and any amendments

Corporate bank resolution and bank signature cards

Official Certificate of Formation and Operating Agreement with any amendments (for LLCs)

Trucking Company

Documented proof of ownership of the company

Insurance agreements for each truck owned or operated by your firm

Title(s) and registration certificate(s) for each truck owned or operated by your firm

List of U.S. DOT numbers for each truck owned or operated by your firm

Regular Dealer

Proof of warehouse ownership or lease

List of product lines carried

List of distribution equipment owned and/or leased

NOTE: The specific state UCP to which you are applying may have additional required documents that you must also supply with your application. Contact the appropriate certifying agency to which you are applying to find out if more is required.

Page 12 of 14

Maryland Department of Transportation	OMB APPROVAL NO. 3245-0188
	EXPIRATION DATE: 11/30/2004
PERSONAL FINANCIAL STATEMENT	As of Date:

Name

Residence Address

City

Business Name of Applicant/Borrower

State

Business Phone Residence Phone

Zip Code

ASSETS

(Omit Cents)

LIABILITIES

(Omit Cents)

Cash on hand & in Banks

Accounts Payable

Savings Accounts

Notes Payable to Banks and Others

(Describe in Section 2)

IRA or Other Retirement Account

Installment Account (Auto)

Accounts & Notes Receivable

Mo. Payments

...................................

Life Insurance-Cash Surrender Value Only

Installment Account (Other)

(Complete Section 8)

Mo. Payments

......................................................Stocks and Bonds

Loan on Life Insurance

(Describe in Section 3)

Mortgages on Real Estate

(Do not include ownership interest in applicant firm.)

(Describe in Section 4)

Real Estate

(Do not include primary residence.)

(Describe in Section 4)

(Do not include primary residence.)

Unpaid Taxes

Automobile-Present Value

(Describe in Section 6)

Other Personal Property

Other Liabilities

(Describe in Section 7)

(Describe in Section 5)

.................................................Total Liabilities

.............................................................Other Assets

(Describe in Section 5)

Net Worth

Total

Section 1.

Source of Income

Contingent Liabilities

Salary

As Endorser or Co-Maker

Net investment Income

Legal Claims & Judgements

Real Estate Income

Provision for Federal Income Tax

Other Income (Describe below)*

Other Special Debt

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

Name and Address of Noteholder(s)

Original Balance

Current Balance

Payment

Amount

Frequency

(monthly, etc.)

How Secured or Endorsed

Type of Collateral

Page 13 of 14

Maryland Department of Transportation

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
	Section 4. Real Estate Owned.	statement and signed.)
		statement and signed.)

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

Property A

Property B

Property C

Section 5. Other 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 deliquency)

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 authorized MDOT/MBE to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. 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 their obtaining a loan or guaranteeing a loan. 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:

Page 14 of 14

Maryland Department of Transportation

35560 Federal Register / Vol. 68, No. 115 / Monday, June 16, 2003 / Rules and Regulations

INSTRUCTIONS FOR COMPLETING THE DISADVANTAGED BUSINESS ENTERPRISE (DBE) PROGRAM

UNIFORM CERTIFICATION APPLICATION

NOTE:	If you require additional space for any question in this application, please attach additional sheets or copies as needed,
	taking care to indicate on each attached sheet/copy the section and number of this application to which it refers.

Section 1: CERTIFICATION INFORMATION

A.Prior/Other Certifications

Check the appropriate box indicating for which program your firm is currently certified. If you are already certified as a DBE, indicate in the appropriate box the name of the certifying agency that has previously certified your firm, and also indicate whether your firm has undergone an onsite visit. If your firm has already undergone an onsite visit/review, indicate the most recent date of that review and the state UCP that conducted the review.

B.B. Prior/Other Applications and Privileges

Indicate whether your firm or any of the persons listed has ever

withdrawn an application for a DBE program or an SBA 8(a) or SDB program, or whether any have ever been denied certification, decertified, debarred, suspended, or had bidding privileges denied or restricted by any state or local agency or Federal entity. If your answer is yes, indicate the date of such action, identify the name of the agency, and explain fully the nature of the action in the space provided.

Section 2: GENERAL INFORMATION

A.Contact Information

(1)State the name and title of the person who will serve as your firm's primary contact under this application.

(2)State the legal name of your firm, as indicated in your firm's Articles of Incorporation.

(3)Indicate the primary phone number of your firm

(4)Indicate a secondary phone number, if any.

(5)Indicate your firm's fax number, if any.

(6)Indicate your firm's or your contact person's email address.

(7)Indicate your firm's website address, if any.

(8)State the street address of your firm (i.e. the physical location of its offices -- not a post office box address).

(9)State the mailing address of your firm, if it is different from your firm's street address.

B.Business Profile

(1)In the box provided, briefly describe the primary business and professional activities in which your firm engages.

(2)Give the Federal Tax ID number of your firm as provided on your firm's filed tax returns, if you have one. This could also be the Social Security number of the owner of your firm.

(3)Give the date on which your firm was officially established, as Stated in your firms Article of incorporation.

(4)Give the date on which you and/or each other owner took ownership of the firm.

(5)Check the appropriate box that describes the manner in which you and each other owner acquired ownership of your firm. If you checked "Other," explain in the space provided.

(6)Check the appropriate box that indicates whether your firm is "for profit."

NOTE: If you checked "No," then you do NOT

qualify for the DBE program and therefore do not need to complete the rest of this application. The DBE program requires all participating firms be for-profit enterprises.

(7)Check the appropriate box that describes the legal form of ownership of your firm, as indicated in your firm's Articles of Incorporation. If you checked "Other," briefly explain in the space provided

(8)Check the appropriate box that indicates whether your firm has ever existed under different ownership, a different type of ownership, or a different name. If you checked "Yes," specify which and briefly explain the circumstances in the space provided.

(9)Indicate in the spaces provided how many employees your firm has, specifying the number of employees who work on a full-time and part-time basis.

(10)Specify the total gross receipts of your firm for each of the past three years, as declared in your firm's filed tax returns.

C.Relationships with Other Businesses

(1)Check the appropriate box that indicates whether your firm is co-located at any of its business locations, or whether your firm shares a telephone number(s), a post office box, any office space, a yard, warehouse, other facilities, any equipment, or any office staff with any other business, organization, or entity of any kind. If you answered "Yes," then specify the name of the other firm(s) and briefly explain the nature of the shared facilities or other items in the space provided.

(2)Check the appropriate box that indicates whether at present, or at any time in the past:

(a)your firm has been a subsidiary of any other firm;

(b)your firm consisted of a partnership in which one or more of the partners are other firms;

(c)your firm has owned any percentage of any other firm; and

(d)your firm has had any subsidiaries of its own.

(3)Check the appropriate box that indicates whether any other firm has ever had an ownership interest in your firm.

Page 1 of 3

Maryland Department of Transportation

(4)If you answered "Yes" to any of the questions in (2)(a)-(d) or (3), identify the name, address and type of business for each

D.Immediate Family Member Businesses

Check the appropriate box that indicates whether any of your immediate family members own or manage another company. An "immediate family member" is any person who is your father, mother, husband, wife, son, daughter, brother, sister, grandmother, grandfather, grandson, granddaughter, mother-in-law, or father-in-law. If you answered "Yes," provide the name of each relative, your relationship to them, the name of the company they own or manage, the type of business, and whether they own or manage the company.

Section 3: OWNERSHIP

Identify all individuals or holding companies with any ownership interest in your firm, providing the information requested below (if your firm has more than one owner, provide completed copies of this section for each additional owner):

A.Background Information

(1)Give the name of the owner.

(2)State his/her title or position within your firm

(3)Give his/her home phone number.

(4)State his/her home (street) address.

(5)Check the appropriate box that indicates this owner's gender.

(6)Check the appropriate box that indicates this

owner's ethnicity (check all that apply). If you checked "Other," specify this owner's ethnic group/identity not otherwise listed.

(7)Check the appropriate box to indicate whether this owner is a U.S. citizen.

(8)If this owner is not a U.S. citizen, check the appropriate box that indicates whether this owner is a lawfully admitted permanent resident. If this owner is neither a U.S. citizen nor a lawfully admitted permanent resident of the U.S., then this owner is NOT eligible for certification as a DBE owner. This, however, does not necessarily disqualify your firm altogether from the DBE program if another owner is a U.S. citizen or lawfully admitted permanent resident and meets the program's other qualifying requirements.

B.Ownership Interest

(1)State the number of years during which this owner has been an owner of your firm.

(2)Indicate the dollar value of this owner's initial

investment to acquire an ownership interest in your firm, broken down by cash, real estate, equipment, and/or other investment.

(3)State the percentage of total ownership control of your firm that this owner possesses.

(4)State the familial relationship of this owner to

(5)Indicate the number, percentage of the total,

each other owner of your firm.

class, date acquired, and method by which this owner acquired his/her shares of stock in your firm.

(6)Check the appropriate box that indicates whether this owner performs a management or supervisory function for any other business. If you checked "Yes," state the name of the other business and this owner's title or function held in that business.

(7)Check the appropriate box that indicates whether

this owner owns or works for any other firm(s) that has any relationship with your firm. If you checked "Yes," identify the name of the other business and this owner's title or function held in that business. Briefly describe the nature of the business relationship in the space provided.

C.Disadvantaged Status

NOTE: You only need to complete this section for

each owner that is applying for DBE qualification (i.e. for each owner who is claiming to be "socially and economically disadvantaged" and whose ownership interest is to be counted toward the control and 51% ownership requirements of the DBE program)

(1) Indicate in the space provided the total Personal

Net Worth (PNW) of each owner who is applying for DBE qualification. Use the PNW calculator form at the end of this application to compute each owner's PNW.

(2)Check the appropriate box that indicates whether any trust has ever been created for the benefit of this disadvantaged owner. If you answered "Yes," briefly explain the nature, history, purpose, and current value of the trust(s).

Section 4: CONTROL

A.Identify your firm's Officers and Board of Directors:

(1) In the space provided, state the name, title, date

of appointment, ethnicity, and gender of each officer of your firm.

(2) In the space provided, state the name, title, date

of appointment, ethnicity, and gender of each individual serving on your firm's Board of Directors.

(3) Check the appropriate box that indicates whether

any of your firm's officers and/or directors listed above perform a management or supervisory function for any other business. If you answered "Yes," identify each person by name, his/her title, the name of the other business in which s/he is involved, and his/her function performed in that other business.

(4)Check the appropriate box that indicates whether

any of your firm's officers and/or directors listed above own or work for any other firm(s) that has a relationship with your firm. If you answered "Yes," identify the name of the firm, the officer or director, and the nature of his/her business relationship with that other firm.

B. Identify your firm's management personnel (by

name, title, ethnicity, and gender) who control your firm in the following areas:

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Maryland Department of Transportation

(1)Making of financial decisions on your firm's

behalf, including the acquisition of lines of credit, surety bonds, supplies, etc.;

(2)Estimating and bidding, including calculation of cost estimates, bid preparation and submission;

(3)Negotiating and contract execution, including

participation in any of your firm's negotiations and executing contracts on your firm's behalf;

(4)Hiring and/or firing of management personnel,

including interviewing and conducting performance evaluations;

(5)Field/Production operations supervision

including site supervision, scheduling, project management services, etc.;

(6)Office management;

(7)Marketing and sales;

(8)Purchasing of major equipment;

(9)Signing company checks (for any purpose); and

(10)Conducting any other financial transactions on your firm's behalf not otherwise listed.

(11)Check the appropriate box that indicates whether

any of the persons listed in (1) through (10) above perform a management or supervisory function for any other business. If you answered "Yes," identify each person by name, his/her title, the name of the other business in which s/he is involved, and his/her function performed in that other business.

(12)Check the appropriate box that indicates whether

any of the persons listed in (1) through (10) above own or work for any other firm(s) that has a relationship with your firm. If you answered "Yes," identify the name of the firm, the name of the person, and the nature of his/her business relationship with that other firm.

C.Indicate your firm's inventory in the following categories:

(1)Equipment

State the type, make and model, and current dollar value of each piece of equipment held and/or used by your firm. Indicate whether each piece is either owned or leased by your firm.

(2) Vehicles

State the type, make and model, and current dollar value of each motor vehicle held and/or used by your firm. Indicate whether each vehicle is either owned or leased by your firm.

(3) Office Space

State the street address of each office space held and/or used by your firm. Indicate whether your firm owns or leases the office space and the current dollar value of that property or its lease.

(4)Storage Space

State the street address of each storage space held and/or used by your firm. Indicate whether your firm owns or leases the storage space and the current dollar value of that property or its lease.

D.Does your firm rely on any other firm for management functions or employee payroll?

Check the appropriate box that indicates whether your firm relies on any other firm for management functions or for employee payroll. If you answered

"Yes," briefly explain the nature of that reliance and the extent to which the other firm carries out such functions.

E.Financial Information

(1)Banking Information

(a)State the name of your firm's bank.

(b)Give the main phone number of your firm's bank branch.

(c)Give the address of your firm's bank branch.

(2)Bonding Information

(a)State your firm's Binder Number.

(b)State the name of your firm's bond

agent and/or broker.

(c)Give your agent's/broker's phone number.

(d)Give your agent's/broker's address.

(e)State your firm's bonding limits (in dollars), specifying both the Aggregate and Project Limits.

F.Identify all sources, amounts, and purposes of

money loaned to your firm, including the names of persons or firms securing the loan, if other than the listed owner:

State the name and address of each source, the original dollar amount and the current balance of each loan, and the purpose for which each loan was made to your firm.

G.List all contributions or transfers of assets to/from

your firm and to/from any of its owners over the past two years:

Indicate in the spaces provided, the type of contribution or asset that was transferred, its current dollar value, the person or firm from whom it was transferred, the person or firm to whom it was transferred, the relationship between the two persons and/or firms, and the date of the transfer.

H.List current licenses/permits held by any owner or employee of your firm.

List the name of each person in your firm who holds a professional license or permit, the type of permit or license, the expiration date of the permit or license, and the license/permit number and issuing State of the license or permit.

I.List the three largest contracts completed by your firm in the past three years, if any.

List the name of each owner or contractor for each contract, the name and location of the projects under each contract, the type of work performed on each contract, and the dollar value of each contract.

J.List the three largest active jobs on which your firm is currently working.

For each active job listed, state the name of the prime contractor and the project number, the location, the type of work performed, the project start date, the anticipated completion date, and the dollar value of the contract.

AFFIDAVIT & SIGNATURE

Carefully read the attached affidavit in its entirety. Fill in the required information for each blank space, and sign and date the affidavit in the presence of a Notary Public, who must then notarize the form.

Page 3 of 3

DOCUMENT CHECKLIST FOR A CORPORATION

1.Completed certification application.

2.Completed Affidavit of Certification (DBE/MBE) or Statement of Disadvantage (MBE) for all applicants claiming disadvantaged status.

3.Copy of the firm’s official articles of incorporation signed by the State official.

4.Copy of the firm’s by-laws.

5.A Certificate of Good Standing from the Maryland Department of Assessments and Taxation (www.dat.state.md.us) is required for all certified firms. If not submitted with the application package, proof of good standing must be provided prior to certification.

6.Copies of minutes from all stockholder and board of directors meetings.

7.Copy of stock ledger for a stock corporation or list of members for a non-stock corporation.

8.Copies of all stock certificates. For purposes of the MBE/DBE Programs, stock must be issued to show ownership.

9.Copies of shareholders’ agreements.

10.Documented proof of contributions used to acquire ownership showing that the owner paid for the value of his/her interest in the business or in some way invested personal funds into the business. Acceptable proof includes both sides of cancelled checks or receipts. If unavailable and the firm is more than five (5) years old, a signed and notarized statement describing the personal investment may be acceptable.

11.Resumes of all owners, all officers, all directors, and all key employees. Resumes must be in detailed chronological order and include places of ownership/employment with corresponding dates.

12.Proof of U.S. citizenship in the form of a U.S. Passport or Permanent Resident Card or Certificate of Naturalization or birth certificate and government issued photo identification (e.g. driver’s license).

13.Completed Personal (Financial) Net Worth Statement for all minority owners constituting 51% ownership.

14. Copy of personal federal tax returns for the past three (3) years for each owner constituting 51% ownership. Include all schedules.

15. Copy of business federal tax returns for the past three (3) years. Include all schedules.

16. Year-end financial statements of the business for the past three (3) years or life of the firm if less than three years. A new business must provide a current financial statement. Non-CPA statements are acceptable.

17. Copy of the firm’s quarterly state unemployment tax wage report for last four (4) quarters. Include all attachments.

18. Businesses less than one year old are encouraged, but not required, to submit a business plan.

19. Copy of home state MBE/DBE/ACDBE/WBE certification for non-Maryland firms only.

20. Copy of all MBE/DBE/ACDBE/WBE certifications and denials of certification by other agencies, if any.

21. Copies of professional licenses and permits, including all licenses and permits held by

the business, the owner(s), and employees of the business in the areas of work in which the business is seeking certification.

22. Copy of bank signature authorization form or a letter signed by a bank official indicating who has authority to sign checks on the business account.

23. Agreements such as lease, loan, distributorship, or any other type of formal written agreements related to the operation, management, and or funding of the business. Include agreements with any financial institutions or other types of businesses/individuals and proof of payment on loans, if applicable.

24. List of equipment used to provide services for which the business is seeking certification.

25. Copy of vehicle title(s) or registration(s) and current insurance policy for all vehicles used by the business.

26. Copies of three (3) job contracts, if applicable. Task orders, purchase orders, and invoices are acceptable.

27. If applicable, provide copies of trust agreements held by any owner claiming disadvantaged status.

MDOT/Office of Minority Business Enterprise

Rev. 07/01/2011

DOCUMENT CHECKLIST FOR A LIMITED LIABILITY COMPANY (LLC)

1.Completed certification application.

2.Completed Affidavit of Certification (DBE/MBE) or Statement of Disadvantage (MBE) for all applicants claiming disadvantaged status.

3.Copy of the firm’s official articles of organization signed by the State official.

4.Copy of the original and amended operating agreement.

6.Documented proof of contributions used to acquire ownership showing that the owner paid for the value of his/her interest in the business or in some way invested personal funds into the business. Acceptable proof includes both sides of cancelled checks or receipts. If unavailable and the firm is more than five (5) years old, a signed and notarized statement describing the personal investment may be acceptable.

7.Resumes of all owners, all officers, all directors, and all key employees. Resumes must be in detailed chronological order and include places of ownership/employment with corresponding dates.

8.Proof of U.S. citizenship in the form of a U.S. Passport or Permanent Resident Card or Certificate of Naturalization or birth certificate and government issued photo identification (e.g. driver’s license).

9.Completed Personal (Financial) Net Worth Statement for all minority owners constituting 51% ownership.

10.Copy of personal federal tax returns for the past three (3) years for each owner constituting 51% ownership. Include all schedules.

11.Copy of business federal tax returns for the past three (3) years. Include all schedules.

12.Year-end financial statements of the business for the past three (3) years or life of the firm if less than three years. A new business must provide a current financial statement. Non-CPA statements are acceptable.

13.Copy of the firm’s quarterly state unemployment tax wage report for the last four (4) quarters. Include all attachments.

14. Businesses less than one year old are encouraged, but not required, to submit a business plan.

15. Copy of home state MBE/DBE/ACDBE/WBE certification for non-Maryland firms only.

16. Copy of all MBE/DBE/ACDBE/WBE certifications and denials of certification by other agencies, if any.

17. Copies of professional licenses and permits, including all licenses and permits held by the business, the owner(s), and employees of the business in the areas of work in which the business is seeking certification.

18. Copy of bank signature authorization form or a letter signed by a bank official indicating who has authority to sign checks on the business account.

19. Agreements such as lease, loan, distributorship, or any other type of formal written agreements related to the operation, management, and or funding of the business. Include agreements with any financial institutions or other types of businesses/individuals and proof of payment on loans, if applicable.

20. List of equipment used to provide services for which the business is seeking certification.

21. Copy of vehicle title(s) or registration(s) and current insurance policy for all vehicles used by the business.

22. Copies of three (3) job contracts, if applicable. Task orders, purchase orders, and invoices are acceptable.

23. If applicable, provide copies of trust agreements held by any owner claiming disadvantaged status.

MDOT/Office of Minority Business Enterprise

Rev. 07/01/2011

DOCUMENT CHECKLIST FOR A SOLE PROPRIETORSHIP

1.Completed certification application.

2.Completed Affidavit of Certification (DBE/MBE) or Statement of Disadvantage (MBE) for all applicants claiming disadvantaged status.

3.Resume of the owner and key employees, if applicable. Resumes must be in detailed, chronological order and include places of ownership/employment with corresponding dates.

4.Proof of U.S. citizenship in the form of a U.S. Passport or Permanent Resident Card or Certificate of Naturalization or birth certificate and government issued photo identification (e.g. driver’s license).

5.Documented proof of contributions used to acquire ownership showing that the owner paid for the value of his/her interest in the business or in some way invested personal funds into the business. Acceptable proof includes both sides of cancelled checks or receipts. If unavailable and the firm is more than five (5) years old, a signed and notarized statement describing the personal investment may be acceptable.

6.Completed Personal (Financial) Net Worth statement.

7.Copy of personal federal tax returns for the past three (3) year. Include all schedules.

8.Businesses less than one year old are encouraged, but not required, to submit a business plan.

9.Copy of home state MBE/DBE/ACDBE/WBE certification for non-Maryland firms only.

10.Copy of all MBE/DBE/ACDBE/WBE certifications and denials of certification by other agencies, if any.

11.Copies of professional licenses and permits, including all licenses and permits held by the business, the owner(s), and employees of the business in the areas of work in which the business is seeking certification.

12.List of equipment used to provide services for which the business is seeking certification.

13.Copy of vehicle title(s) or registration(s) and current insurance policy for all vehicles used by the business.

14.Agreements such as lease, loan, distributorship, or any other type of formal written agreements related to the operation, management, and or funding of the business. Include agreements with any financial institutions or other types of businesses/individuals and proof of payment on loans, if applicable.

15. Copies of three (3) job contracts, if applicable. Task orders, purchase orders, and invoices are acceptable.

16. Copy of bank signature authorization form or a letter signed by a bank official indicating who has authority to sign checks on the business account.

17. Copies of year-end financial statements of the business for the past three (3) years or the life of firm, if less than three years. A new business must provide a current financial statement. Non-CPA statements are acceptable.

18. Quarterly state unemployment tax wage report for last four (4) quarters. Include all attachments.

MDOT/Office of Minority Business Enterprise

Rev 7/1/2011

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Contribution / Asset

Dollar Value

To Whom Transferred

Relationship

Date of Transfer

Transferred