6100-1h EPA DBE Certification Application (Concerns Owned by Nat

Environmental Protection Agency

OMB Control No: 2090-0030
Approval Expires: XX/XX/XX

EPA DBE Certification Application
For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE)
Under EPA’s Disadvantaged Business Enterprise (DBE) Program
Native Hawaiian Organization Owned Concern
Name of Parent Native Hawaiian Organization: _________________________________________
Address of Parent Native Hawaiian Organization: _______________________________________
Name of wholly-owned subsidiary (if applicable) : _______________________________________
Address of wholly-owned subsidiary: __________________________________________________
Name of applicant firm: ______________________________________________________________
Applicant concern is:

‚ Corporation

‚ Limited Liability Company

‚ Partnership

Name of President/Managing Member/Managing Partner: _______________________________
EIN: _________________________ E-mail Address: _____________________________________
Business Address: _____________________________________________County: _____________
City: _________________________________ State: _______________Zip Code: _______________
Phone Number: ___________________________ Fax Number: _____________________________
Mailing Address (if different than above): ________________________County: _______________
City: _________________________________ State: _______________Zip Code: _______________
What is the firm’s (4-digit) primary standard industrial classification code? _________________
Is the firm certified by the Small Business Administration under its 8(a) Business Development Program?
___ Yes ___ No. If yes, provide Pro-Net Number________________________________
Is the firm certified by the Small Business Administration under its Small Disadvantaged Business (SDB)
Program? ___ Yes ___ No. If yes, provide Pro-Net number___________________
Is the firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes,
provide State(s) and ID number(s) __________________________________________________
Is the firm certified by a State government, local government, Indian tribal government, or independent
private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying
entity ____________________________________________________________

EPA DBE Certification Application (EPA Form 6100-1h)
(Native Hawaiian Organization Owned Concern)

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
explanation/documentation: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Does the firm have any other certification as a disadvantaged business entity, i.e., MBE, DBE, WBE, etc?
___Yes ___ No. If yes, provide the State(s) and ID number( s) : __________________
__________________________________________________________________________________

Business Eligibility
SECTION A
Social Disadvantage
1. A Native Hawaiian Organization that meets the following criteria is considered socially
disadvantaged:
Native Hawaiian Organization means any community service organization serving Native Hawaiians
in the State of Hawaii, which is a not-for profit organization, chartered by the State of Hawaii. A
Native Hawaiian Organization is controlled by Native Hawaiians whose business activities will
principally benefit such Native Hawaiians.
Provide documentation that the applicant entity meets these criteria as Attachment A-1.

SECTION B
Economic Disadvantage
1.

Is the net worth of all 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.

Name

Average 2-year
Income

Personal
Net Worth

Total U.S.
Assets Citizen (Y/N)

____________________________ ______________

__________

_______ ___________

____________________________ ______________

__________

_______ ___________

____________________________ ______________

__________

_______ ___________

____________________________ ______________

__________

_______ ___________

EPA DBE Certification Application (EPA Form 6100-1h)
(Native Hawaiian Organization Owned Concern)

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3.

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

4.

Personal Financial Statement - All individuals claiming disadvantaged status and his/her spouse,
please provide documentation verifying your assets and liabilities (split your assets and
liabilities, if married) as Attachment B-1.

5.

All individuals claiming disadvantaged status or individuals owning more than 10% of the
concern please provide the following documentation as Attachment B-2:
a) Signed copies of individual Federal income tax returns filed for the past two years, including
all W-2 forms and all schedules and attachments.
b) Signed and dated IRS Form 4506 (Request for Copy or Transcript of Tax Form)

SECTION C
Ownership

1.

Do Native Hawaiians own a majority of both the total equity of the Native Hawaiian Organization
and the total voting powers to elect directors of the Native Hawaiian Organization? ___ Yes ___ No.
If yes, provide verification of the percentage of Native Hawaiian ownership as attachment C-1.

2.

Is the applicant concern at least 51 percent owned by a Native Hawaiian Organization?
____ Yes ____ No. If yes, please provide evidence of ownership as Attachment C-2.

Corporations Only:
3.

If more than one class of stock, provide information for each class:
Voting
a) Total number of shares authorized:
b) Total number of shares currently outstanding:

4.

Non Total
Voting
_____ ______ _____
_____ ______ _____

Please provide the following documentation as Attachment C-3:
a) Copies of all governing documents, such as the concern’s constitution or business charter.
b) Copies of all minutes of shareholders meeting electing board of directors and minutes of last
shareholders meeting.
c) Copies of all stock certificates (front and back) and stock register.
d) Copy of the current Certificate of Good Standing from state where concern is incorporated. If
concern conducts business in a state other than where it was incorporated, a copy of the filing
as a Foreign Corporation and a current Certificate of Good Standing from that state are
required as well.

Limited Liability Companies Only:
5.

If more than one class membership interest, provide information for each class:
Voting Non Total
Voting
a) Total number of memberships authorized:
_____ ______ _____
b) Total number of memberships currently outstanding:
_____ ______ _____

EPA DBE Certification Application (EPA Form 6100-1h)
(Native Hawaiian Organization Owned Concern)

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6.

Please provide the following documentation as attachment C-4:
a) Copy of Operating Agreement
b) Copy of Articles of Organization as filed with the state

Partnerships Only:
7.

8.

Provide the name, title, and percentage of ownership for each partner of the firm. Does the
partnership agreement reflect the ownership of each partner? ___Yes ___No.
Name

Title

Ownership %

___________________________

____________________

____________________

___________________________

____________________

____________________

___________________________

____________________

____________________

___________________________

____________________

____________________

Please provide a copy of the concern’s Partnership Agreement as Attachment C-5.

Questions 9 through 13 are for Corporations & LLCs ONLY:
9.

List all entities, individuals, and/or trusts which have an ownership interest in the applicant firm.
Name

Title

___________________________

Ownership
Voting NonVoting
____________________ ______ _________

%
Total
_____

___________________________

____________________ ______ __________

_____

___________________________

____________________ ______ __________

______

___________________________

____________________ ______ __________

______

10. Does the parent Native Hawaiian Organization or its wholly owned subsidiary receive at least 51% of
the annual distributions of dividends paid on the stock of a corporate applicant firm? ___Yes ___ No.
If no, please explain as Attachment C-6.
11. Will the parent Native Hawaiian Organization or its wholly owned subsidiary receive 100% of the
unencumbered value of each share of stock owned in the event that the stock is sold? ___Yes ___ No.
If no, please explain as Attachment C-7.
12. If the corporation dissolves, will the parent Native Hawaiian Organization or its wholly owned
subsidiary receive at least 51% of the retained earnings and 100% of the unencumbered value of each
share of stock owned? ___Yes ___ No. If no, please explain as Attachment C-8.
13. Is ownership by the parent Native Hawaiian Organization or its wholly owned subsidiary subject to
conditions precedent, conditions subsequent, executory agreements, voting trusts, shareholder
agreements or other similar arrangements which may impact the unconditional ownership of the
Native Hawaiian Organization? ___Yes ___No. If yes, explain as Attachment C-9.

EPA DBE Certification Application (EPA Form 6100-1h)
(Native Hawaiian Organization Owned Concern)

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Corporations, LLCs & Partnerships:
14. Have 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 C-10.
For All Concerns:
15. Please provide copies of buy/sell agreements, conditions precedent, conditions subsequent, executory
agreements, voting trusts, shareholder agreements or other similar arrangements, which may impact
the unconditional ownership of the disadvantaged individuals as Attachment C-11.

SECTION D

Control and Management
1.

List all individuals who manage or conduct daily business operations of the applicant concern.
Name/Title

Date

___________________________________________________

_____________

___________________________________________________

_____________

___________________________________________________

_____________

___________________________________________________

_____________

2.

Are any of the individuals listed in question 1 engaged in or plan to engage in outside employment?
___ Yes ___ No.

3.

If members of the management team, business committee members, officers, and directors are
currently employed outside the applicant concern, provide information on this employment and
evidence that the activity does not conflict with the day-to-day management of the applicant concern.
Please indicate the number of hours per week and the normal working hours of this outside
employment as Attachment D-1.

4.

Please provide resumes of the education, technical training and business and employment experience,
including employer’s names, dates of employment, for general manager, officers, and key employees
(Please account for any missing gaps in employment) as Attachment D-2.

5.

List the total compensation from the applicant firm of all owners and/or key managers of the firm. (If
necessary, provide additional information as Attachment D-3).
Name/Title

Compensation from applicant firm
(Include salaries, bonuses, etc.)

___________________________________

__________________________________

___________________________________

__________________________________

___________________________________

__________________________________

___________________________________

__________________________________

EPA DBE Certification Application (EPA Form 6100-1h)
(Native Hawaiian Organization Owned Concern)

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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 on Attachment
D-4.

7.

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

8.

Name

Title

___________________________________

__________________________________

___________________________________

__________________________________

___________________________________

__________________________________

___________________________________

__________________________________

Do any individual(s), or entities provide:
a)
b)
c)
d)
e)

Financial support to the applicant firm?
Subcontracts, Joint Ventures or Teaming Arrangements?
Office space (rent or leased).
Equipment (rent or leased).
Employees (other than from employment agencies).

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

If the answer is yes to any of the above, please provide specific details (i.e., names, titles, copies of
agreements, leases, etc.) of such arrangements as Attachment D-5.

EPA DBE Certification Application (EPA Form 6100-1h)
(Native Hawaiian Organization Owned Concern)

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Each person signing below:
1.

Certifies that the information provided with regard to the applicant firm’s social and economic
disadvantaged status is true, accurate, and complete to the best of his/her knowledge and belief.

2.

Certifies that the information provided with regard to the applicant firm’s ownership and control
status is true, accurate, and complete to the best of his/her knowledge and belief.

3.

Certifies that the information provided with regard to his/her individual disadvantaged status is
true, accurate, and complete to the best of his/her knowledge and belief.

4.

Certifies that the information provided, including that shown on documents accompanying this
application, is true, accurate, and complete to the best of his/her knowledge and belief.

5.

Acknowledges that EPA, at its discretion, may give the information submitted to Federal, State,
and local agencies to determine violations of law.

6.

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.

All officers, directors, partners, members of the governing board and owners of more than 10% must sign
below.
Name

SSN

Date

________________________

_______________________

______________________

________________________

_______________________

______________________

________________________

_______________________

______________________

________________________

_______________________

______________________

The public reporting and recordkeeping burden for this collection of information is estimated to average 1 hour per
response. 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 through the use of automated
collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T),
1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence.
Do not send the completed form to this address.

EPA DBE Certification Application (EPA Form 6100-1h)
(Native Hawaiian Organization Owned Concern)

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