AppendixBExhibit5CBEForm.pdf

This is a Disadvantaged Business Enterprise (DBE) Certification Form related to the Los Angeles County Department of Public Health's Request for Applications for Domestic Violence Shelter-Based Program (DVSBP) services. The form serves as Appendix B, Exhibit 5 and is designed to verify applicant organizations' eligibility status as disadvantaged business enterprises. Applications for the DVSBP services are due February 26, 2026, by 3:00 p.m. Pacific Time. The form requires detailed information about the applicant organization's ownership structure, management, and operational control to determine whether the entity qualifies for DBE designation under applicable federal and state guidelines.

The DBE certification form collects comprehensive data regarding ownership percentages, years of business operation, financial information, and documentation of disadvantaged status. Organizations must demonstrate that socially and economically disadvantaged individuals own and control the business, with specific attention to African American, Hispanic, Asian Pacific American, Native American, and women-owned business categories. The form requires submission of supporting documentation and certification statements, and completion of this exhibit is a mandatory requirement for consideration in the DVSBP services procurement process. Applicants should ensure accurate completion and timely submission of all required supporting materials to avoid disqualification from the competitive process.