ANNUAL AFFIDAVIT DISADVANTAGED BUSINESS ENTERPRISE PROGRAM TITLE 49 OF THE CODE OF FEDERAL REGULATIONS, PART 26

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1 DISADVANTAGED BUSINESS ENTERPRISE PROGRAM TITLE 49 OF THE CODE OF FEDERAL REGULATIONS, PART 26 ANNUAL AFFIDAVIT The purpose of the annual affidavit is to identify owner or company changes that may effect DBE certification. This information is required to maintain or renew DBE certification. Contents: Section 1, Company Information Section 2, Annual Affidavit Questions Section 3, Company Owners and Representatives Section 4, Certification Information Section 5, Supporting Documents Checklist Affidavit of Certification To complete this document: Enter the Company Information in section Check the Yes/No boxes for section 2, Annual Affidavit Questions. Where required, provide details. Provide supporting documents as required in section 3, Supporting Documents Checklist. 4. Sign the Affidavit in the back of the document and have it notarized. 5. Submit the entire document with supporting documents to your certifying agent by the due date.

2 SECTION 1: COMPANY INFORMATION *Legal name of business: *Other names used by business: Website (if have one): 4. *Federal tax ID: 5. *Company phone #: 6. Other phone #: 7. Company fax #: 8. communications: Yes No 9. *County (only if an Ohio company) 10. *Street address of company (No P.O. box): City: State: Zip: 1 Mailing address of company (if different): City: State: Zip: *Indicates required field for new applicants or new records. Section 1 Company Information Page 1

3 SECTION 2: ANNUAL AFFIDAVIT QUESTIONS Has the ownership, management, or control of the company changed in any way in the past year? Yes No If Yes, please use section 3, the Company Owners and Representatives form, to indicate modifications. Have there been any investments or contributions of capital in the company over the past year? Yes No If Yes, please provide details under the Asset Transfers heading in section 4C. Has the company or any of its owners, board members, officers, or management been denied certification, denied re-certification, or been decertified as a DBE in the past year? Yes No If Yes, please provide details on the denial or decertification in section 4A. 4. Has the company purchased or liquidated any real estate or facilities including office and/or storage space in the past year? Yes No If Yes, please list those things that have been acquired or liquidated in section 4C. 5. Has the company purchased or liquidated any equipment or vehicles in the past year? Yes No If Yes, please list those things that have been acquired or liquidated in section 4C. 6. Has the company or individual owners entered into any new loans, notes payable, promissory notes, etc. in the past year? Yes No If Yes, please use the Loan Information heading in section 4C to list them. 7. Has the company or individuals within the company acquired new (or lost) licenses and/or permits in the past year? Yes No If Yes, please list details about those that have been acquired or lost in section 4D. 8. Have the areas of work performed by the company changed in the past year? Yes No If Yes, please use section 4B, Types of Work, to list those areas that are new or are no longer applicable. Be as descriptive as possible. 9. Please record the company s annual gross receipts for the most recent fiscal year. 10. Please make sure to record a Personal Net Worth statement for each owner in the company for the most recent tax year. Personal Net Worth statements can be found in the Company Owners and Representatives forms (section 3) of this document. Section 2 Annual Affidavit Questions Page 1

4 SECTION 3: COMPANY OWNERS AND REPRESENTATIVES Instructions: Complete this section for any new company owner, any new officer or member of the board of directors, or any new employee with significant responsibilities as listed in section B. (Asterisks indicate required fields for all new records.) If necessary, copy the pages of this section to enter information for additional individuals. At the top of each page is a place for the owner or representative s name. This is critical if you are providing information for more than one individual it will allow you to keep track of which owner or representative the information pertains to. A. General Information (Company Owner or Representative) *Name (first, middle initial, last): *Role: Company Owner Company Representative *Title: 4. *Gender: Male Female 5. *Ethnic group membership (check all that apply): White Caucasian African American Hispanic Native American Asian Pacific Subcontinent Asian 6. *Salary: Other (specify) 7. *Phone #:( ) - ext 8. *Is this owner or representative the company contact? (One, and only one, owner or representative must be designated as the company contact.) Yes No 9. *Enable online account? Yes No If Yes, enter address: *Indicates required field for new applicants or new records. Section 3 Company Owners and Representatives Page 1

5 Name (first, middle initial, last): B. Responsibilities (Company Owner or Representative) Check all that apply: Financial decisions (responsible for acquisition of lines of credit, surety bonding, supplies, etc.) Estimating and bidding Negotiating and contract execution Hiring/firing of management personnel Field/production operations supervisor Office management Marketing/sales Purchasing of major equipment Authorized to sign company checks (for any purpose) Authorized to make financial transactions *Is the employee an officer of the company? Yes No If Yes, date appointed: / / *Is the employee a member of the board of directors? Yes No If Yes, date appointed: / / 4. Please list any businesses this individual owns or works for that have relationships with this company: Business Name Relationship Title Function 5. Please list any management or supervisory roles this individual has in other businesses: Business Name Title Function *Indicates required field for new applicants or new records. Section 4 Certification Information Page 2

6 Name (first, middle initial, last): Instructions: Owner information must be provided for every company owner, regardless of the percentage of ownership. If necessary, copy the pages of this application to add additional owners. C. Personal Information (Company Owner) *Home address (street and number): City: State: Zip: *Home phone #: *Ownership percentage: 4. *Married status: 5. *U.S. citizen? Yes No 7. Familial relationship to other owners: 6. If No, legal permanent resident? Married Single Yes No 8. Has any trust been created for the benefit of this disadvantaged owner? Yes No If Yes, explain: 9. *Number of years as an owner? 10. Please list all investments made to acquire current ownership stake in the company: Date Ownership % # of Shares Share Class Investment * Cash Real Estate Equipment Other Cash Real Estate Equipment Other Cash Real Estate Equipment Other 1 Do any of your immediate family members own or manage another company? Yes No If Yes, then list (use additional space if needed): Name Relationship Company Type of Business Own or Manage? *Indicates required field for new applicants or new records. Section 3 Company Owners and Representatives Page 3

7 Name (first, middle initial, last): Instructions: Complete the following worksheets first, then use the information to complete the balance sheet at the end of the section. Complete all fields of an applicable worksheet. For example, if an owner has stocks, be sure to provide Security Name, Number of Shares, and Year-end Market Value per Share. Supply a personal net worth statement for each owner (make copies of these pages if necessary). D. Personal Net Worth Statement (Required for all owners) Enter year for which the following net worth worksheets apply: Life Insurance Worksheet Insurance Company Face Amount Cash Surrender Value Beneficiaries 4. Stocks and Bonds Worksheet Security Name Number of Shares Year-end Market Value per Share 4. Unpaid Taxes Worksheet Type of Tax Amount 4. Section 3 Company Owners and Representatives Page 4

8 Name (first, middle initial, last): Real Estate and Real Estate Mortgages Worksheet Type of Property Street Address Date Purchased Original Cost Current Estimated Value Is there a mortgage on the property? Yes No (If Yes, complete the mortgage holder information for each mortgage on the property.) Name of mortgage holder: Mortgage balance: Mortgage holder address: Street (No P.O. box): City: State: Zip: Type of Property Street Address Date Purchased Original Cost Current Estimated Value Is there a mortgage on the property? Yes No (If Yes, complete the mortgage holder information for each mortgage on the property.) Name of mortgage holder: Mortgage balance: Mortgage holder address: Street (No P.O. box): City: State: Zip: Type of Property Street Address Date Purchased Original Cost Current Estimated Value Is there a mortgage on the property? Yes No (If Yes, complete the mortgage holder information for each mortgage on the property.) Name of mortgage holder: Mortgage balance: Mortgage holder address: Street (No P.O. box): City: State: Zip: Section 4 Certification Information Page 5

9 Name (first, middle initial, last): Other Personal Property Worksheet Asset Name Asset Type Current Estimated Value 4. Other Assets Worksheet Asset Name Asset Type Current Estimated Value 4. Notes Payable Worksheet Noteholder Name Noteholder Address Original Balance Current Balance Payment Amount Payment Frequency Collateral Type 4. Other Liabilities Worksheet Liability Amount 4. Section 4 Certification Information Page 6

10 Name (first, middle initial, last): E. Personal Net Worth Statement (Required for all owners) Balance Sheet Assets (Omit cents) Liabilities (Omit cents) Cash on hand and in banks: Accounts payable: Savings accounts: Notes payable to banks and others (worksheet): IRA or other retirement accounts: Accounts and notes receivable: Installment account (other): Life insurance (worksheet): Loan on life insurance: Stocks and bonds (worksheet): Unpaid taxes (worksheet): Real estate (worksheet): Mortgages on real estate (worksheet): Automobiles-estimated current value: Other personal property (worksheet): Installment account (auto): Other assets (worksheet): Other liabilities (worksheet): Total assets: Total liabilities: (minus total liabilities) (- ) Owner net worth: Year: Section 4 Certification Information Page 7

11 SECTION 4: CERTIFICATION INFORMATION A. Prior/Other Certifications, Applications, and Privileges (required if new or changed) Is your company currently certified as a DBE in its home state? No Yes If Yes, name of certifying agency: If Yes, has your company s state UCP conducted an on-site visit? No Yes, on / /, in State Has your company (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 / / No If Yes, identify State and name of state, local, or Federal agency and explain the nature of the action: B. Type of Work (required if new or changed) (NAICS code will be assigned based on type of work description. Provide as much description as possible.) a. Type of work description: b. Type of work description: c. Type of work description: Section 4 Certification Information Page 1

12 C. Equipment, Vehicles and Facilities (required if new or changed) Indicate your company s inventory in the following categories. Equipment Type of Equipment Make/Model Current Value Owned or Leased? a. b. c. d. Vehicles a. Type of Vehicle Make/Model Current Value Owned or Leased? b. c. d. Office space a. Street Address Owned or Leased? Current Value of Property or Lease b. c. d. Storage space a. Street Address Owned or Leased? Current Value of Property or Lease b. c. Section 4 Certification Information Page 2

13 Loan Information Identify all sources, amounts, and purposes of money loaned to your company, including the names of any persons or companies securing the loan, if other than the listed owner. Name of source: Name of person securing the loan: Source phone: ( ) - Loan amount: Loan purpose: Street address: Name of source: Name of person securing the loan: Source phone: ( ) - Loan amount: Loan purpose: Street address: Name of source: Name of person securing the loan: Source phone: ( ) - Loan amount: Loan purpose: Street address: Asset Transfers List all contributions or transfers of assets to/from your company and to/from any of its owners over the past two years. Contribution /Asset Dollar Value From Whom Transferred To Whom Transferred Relationship Date of Transfer Section 4 Certification Information Page 3

14 D. Licenses and Permits (required if new or changed) License/Permit Information List current licenses/permits held by any owner and/or employee of your company (e.g., contractor, engineer, architect, etc.) License/permit holder: State: Expiration date: / / Name/Type of License/Permit: License/Permit number: License/permit holder: State: Expiration date: / / Name/Type of License/Permit: License/Permit number: License/permit holder: State: Expiration date: / / Name/Type of License/Permit: License/Permit number: 4. License/permit holder: State: Expiration date: / / Name/Type of License/Permit: License/Permit number: Section 4 Certification Information Page 4

15 SECTION 5: SUPPORTING DOCUMENTS CHECKLIST In order to complete your annual affidavit for DBE certification, you must attach copies of all of the following documents as they apply to you and your company. All Applicants Annual Financial Business Statement for the most recent year. Lease/Rental/Purchase Agreements for all NEW real estate including office and storage space. Documentation for all NEW equipment and vehicles leased or purchased. Signed personal Federal income tax returns for all existing owners for the past year (copies of all schedules and forms referenced by the tax returns must be included. Past 3-years of signed personal Federal income tax returns for all new owners (copies of all schedules and forms referenced by the tax returns must be included). Documentation from all active loan, security, and bond agreements entered into for the past year (itemized based on line item list in the application). Current resume of owner(s) and key personnel added in the past year (list all owners and personnel with decision-making authority of any kind as noted in the mgmt and control). Copies of Bank Account Signature Cards for any accounts added in the past year. Documentation for all new licenses, registrations, and permits. Personal Net Worth statement for all new owners for the most recent year (form available in this affidavit). Documented proof of any transfers of assets to-or-from your firm and/or to-or-from any of its owners for the most recent year. Trust agreements, newly created within the most recent year, held by any owner claiming disadvantaged status. Partnership (all types) Partnership return for the past year (copies of all schedules and forms referenced by the tax returns must be included). K-1s for the past year. Copies of all meeting minutes from the past year. Amendments to any agreements or bylaws over the past year. Section 5 Supporting Documents Checklist Page 1

16 Sole Proprietorship Form 1040 and all schedules for the past year (copies of all schedules and forms referenced by the tax returns must be included). Corporation (S & C) or Limited Liability Company (LLC) Corporate Return for the past year (copies of all schedules and forms referenced by the tax returns must be included). K-1s for the past year. Copies of all meeting minutes from the past year. Amendments to any agreements or bylaws over the past year. Trucking Company Insurance agreements for each truck owned or operated by the company that has been added in the past year. Title(s) and registration certificate(s) for each truck owned or operated by the company that has been added in the past year. List of U.S. DOT number for each truck owned or operated by the company that has been added in the past year. Regular Dealer Proof of warehouse ownership or lease that has acquired in the past year. List of product lines carried that have been added in the past year. 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. Section 5 Supporting Documents Checklist Page 2

17 AFFIDAVIT The business named in this document agrees: To abide by the requirements of the Disadvantaged Business Enterprise (DBE) Program and Title 49 of the United States Code of Federal Regulations, Part 26. To notify the Ohio Department of Transportation within thirty (30) calendar days, of any change in the ownership, control, management, or status of the business, and of any denial or decertification of this business as a DBE by any other certifying agency. To allow the Ohio Department of Transportation the right to conduct a review of the business contracts, facilities, and records and to request and review whatever other additional information as deemed necessary to monitor continued DBE eligibility. 4. To answer any question and to supply the Ohio Department of Transportation with any documentation requested during the period of certification and that failure to do so may be cause to deny DBE certification. 5. That the Ohio Department of Transportation may deny certification or rescind certification and initiate action under Federal or State laws concerning false statements, if during or after the certification process it finds that the undersigned has submitted false, inaccurate, or misleading information. 6. That the Ohio Department of Transportation has the right to refuse certification of any business based on the implementation of the DBE eligibility standards, despite the fact that said business may be certified by another entity. 7. That the firm meets the Small Business Administration (SBA) criteria for being a small business concern and its average annual gross receipts (as defined by the SBA rules) over the firm s previous three fiscal years do not exceed the work type limit. I recognize and accept the seven (7) statements above governing the consideration of this affidavit and the maintenance of my business certified status. By my signature, I swear that I have read and understand this affidavit and that I have the authority to sign this affidavit and that the affidavit responses, the foregoing statements, and accompanying documents are true, complete, and correct and include all materials requested and/or necessary to identify and explain the ownership and operation of: Name of Applicant Business: Print Name: Signature: Date: On this day of before me appeared (name of above who signed affidavit) to me personally known, who, being duly sworn, did execute the foregoing affidavit, and did state that he or she was properly authorized to execute the affidavit and did so of his or her own free act and deed. Notary Public: State of: Commission Expires: Page 1

UNIFORM CERTIFICATION APPLICATION

LEE COUNTY PORT AUTHORITY OFFICE OF SMALL BUSINESS DEVELOPMENT DISADVANTAGED BUSINESS ENTERPRISE (DBE) PROGRAM 49 C.F.R. PART 26 UNIFORM CERTIFICATION APPLICATION ROADMAP FOR APPLICANTS Should I apply?