INSTRUCTIONS FOR COMPLETING THE DISADVANTAGED BUSINESS ENTERPRISE (DBE) PROGRAM UNIFORM CERTIFICATION APPLICATION (UCP)

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

SECTION 1: CERTIFICATION INFORMATION

  1. Prior/Other Certifications

    Check the appropriate box indicating for which program your firm is currently certified. If you are already certified as 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.
    NOTE: If your firm is currently certified under the SBA's 8(a) and/or SDB programs, you may not have to complete this application. You should contact your state UCP to find out about a streamlined application process for firms that are already certified under the 8(a) and SDB programs.

  2. Prior/other Applications and Privileges

    Indicate whether your firm or any of the persons listed has ever withdrawn for a DBE program or an SBA 8(a) or SDB program, or whether any have ever been denied certification, decertified, debarred, suspended, or had bidding priviledges 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

  1. 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 lncorporation.
    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.
  2. 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 firm's Articles 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.
  3. 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:
      1. your firm has been a subsidiary of any other firm;
      2. your firm consisted of a partnership in which one or more of the partners are other firms;
      3. your firm has owned any percentage of any other firm; and
      4. 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.
    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.
  4. IMMEDIATE FAMILY MEMBER BUSINESSES

    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.

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):

  1. 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.
  2. 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. Give his/her home phone number.
    4. State the familial relationship of this owner to each other owner of your firm.
    5. Indicate the number, percentage of the total, 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 perfonns 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.
  3. 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 fonn 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

  1. 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.
  2. IDENTIFY YOUR FIRM'S MANAGEMENT PERSONNEL (BY NAME, TITLE, ETHNICITY, AND GENDER) WHO CONTROL YOUR FIRM IN THE FOLLOWING AREAS:
    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.
  3. 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.
  4. 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.

  5. FINANCIAL INFORMATION
    1. Banking Information
      1. State the name of your firm's bank.
      2. Give the main phone number of your firm's bank branch.
      3. Give the address of your firm's bank branch.
    2. Bonding Information
      1. State your firm's Binder Number.
      2. State the name of your firm's bond agent and/or broker.
      3. Give your agent's/broker's phone number.
      4. Give your agent's/broker's address.
      5. State your firm's bonding limits (in dollars), specifying both the Aggregate and Project Limits.
  6. 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.

  7. 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.

  8. LIST CURRENT LICENSES/PERMITS HELD BY ANY OWNER OR EMPLOYEE OF YOUR FIRM.
    List the name of each person in your finn who holds a professional license or pennit, 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.

  9. 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 ofthe projects under each contract, the type of work performed on each contract, and the dollar value of each contract.

  10. 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.