[E]_250036_Agreement_Exhibit_C_ATTACHMENT_A_idedits.docx

ATTACHMENT CA

DBE INFORMATION

DISADVANTAGED BUSINESS ENTERPRISE (DBE) PROGRAM REQUIREMENTS

(Revised on 03/06/19)

1.0 DBE Goal

To assist Offerors in ascertaining DBE availability based on the specific items of work associated with this procurement, the Authority has determined that DBEs are ready, willing and able to compete for subcontracting opportunities on this project. There is no DBE Goal for this contract. .

2.0 DBE Policy and Applicability

In accordance with federal financial assistance agreements with the U.S. Department of Transportation (U.S. DOT), the Orange County Transportation Authority (Authority) has adopted a Disadvantaged Business Enterprise (“DBE”) Policy and Program, in conformance with Title 49 CFR part 26, “Participation by Disadvantaged Business Enterprises in Department of Transportation Financial Assistance Programs.” The contract is subject to the following stipulated regulations. Pursuant to the intent of these Regulations, it is the policy of the Authority to fulfill the spirit and intent of the DBE Program regulations published under U.S. DOT Title 49 CFR, Part 26, by ensuring that DBEs have an equitable opportunity to compete for and participate in Authority’s U.S. DOT-assisted contracts and subcontracts. The Authority is firmly committed to its DBE Program objectives, which are designed to:

2.1 Ensure non-discrimination in the award and administration of Authority’s DOT-assisted contracts.

2.2 Create a level playing field on which DBEs can fairly compete for the Authority’s DOT-assisted contracts.

2.3 Ensure that the DBE Program and Overall Goal are narrowly tailored in accordance with applicable law.

2.4 Ensure that only firms that meet 49 CFR part 26 eligibility standards are permitted to participate as DBEs in the Authority’s DBE program.

2.5 Help remove barriers which impede the participation of DBEs in the Authority’s U.S. DOT-assisted contracts.

2.6 Promote the use of DBEs in all types of U.S. DOT-assisted agreements and procurement activities conducted by the Authority.

2.7 Provide training and other assistance through our resource partners to address capital, bonding and insurance needs.

2.8 Assist in the development of DBE firms that can compete successfully in the marketplace outside the DBE Program; and

2.9 Establish and provide opportunities for DBEs by providing flexibility in the implementation of the Authority’s DBE Program.

Offerors shall not discriminate on the basis of race, color, national origin, or sex in the award and performance of subcontracts.

Any terms used in this section that are defined in 49 CFR part 26, or elsewhere in the Regulations, shall have the meaning set forth in the Regulations. In the event of any conflicts or inconsistencies between the Regulations and the Authority’s DBE Program with respect to U.S. DOT-assisted contracts, the Regulations shall prevail.

Race-Neutral/Race-Conscious DBE Program Measures The Authority will utilize both race-neutral and race-conscious means to meet its Overall DBE Program goals.

Race-neutral measures will include but are not limited to conducting outreach, training, providing other resource assistance, and assessing proposal delivery schedules to ensure that DBEs interested in proposing for U.S. DOT-assisted solicitations are provided accurate and adequate information about the plans, specifications, and requirements of the solicitation in a timely manner to assist them in responding to the proposal. Additional Authority race-neutral measures include ensuring that DBEs and other small business are afforded ample opportunity to participate in the Authority’s U.S. DOT-assisted solicitations by unbundling large contracts to make them more accessible to small businesses and requiring or encouraging prime contractors to subcontract portions of work that they might otherwise perform with their own forces. Race-neutral participation also includes any time a DBE obtains a Prime Contract through customary competitive procurement procedures or is awarded a subcontract on a prime contract that does not carry a DBE goal.

In conjunction with the race-neutral measures listed above, the Authority will implement race-conscious measures through the use of contract goals and good faith efforts. When a contract-specific goal is assigned to a project, offerors must demonstrate responsiveness by committing to meet the DBE goal or documenting a bona fide good faith effort to do so, as a condition of award. Contract-specific goals are specifically targeted at DBEs certified through the California Unified Certification Program (“CUCP”).

3.0 Definitions

The following definitions apply to the terms as used in these provisions:

3.1 "Disadvantaged Business Enterprise (“DBE”)" means a for-profit small business concern: (a) which is at least 51 percent owned by one or more individuals who are both socially and economically disadvantaged or, in the case of a corporation, in which 51 percent of the stock is owned by one or more such individuals; and (b) whose management and daily business operations are controlled by one or more of the socially and economically disadvantaged individuals who own it.

3.2 "Small Business Concern" means a small business as defined pursuant to Section 3 of the Small Business Act and Small Business Administration (SBA) regulations implementing it (13 CFR Part 121) that also does not exceed the cap on average annual gross receipts specified in §26.65(b).

3.3 "Socially and Economically Disadvantaged Individuals" means any individual who is a citizen (or lawfully admitted permanent resident) of the United States and who has been subjected to racial or ethnic prejudice or cultural bias within American society because of his or her identity as a member of a group and without regard to his or her individual qualities. The social disadvantage must stem from circumstances beyond the individual’s control:

3.3.1 Any individual who a recipient finds to be a socially and economically disadvantaged individual on a case-by-case basis. An individual must demonstrate that he or she has held himself or herself out, as a member of a designated group if you require it.

3.3.2 Any individual in the following groups, members of which are rebuttably presumed to be socially and economically disadvantaged:

3.3.2.1 "Black Americans," which includes persons having origins in any of the Black racial groups of Africa;

3.3.2.2 "Hispanic Americans," which includes persons of Mexican, Puerto Rican, Cuban, Dominican, Central or South American, or other Spanish or Portuguese culture or origin, regardless of race;

3.3.2.3 "Native Americans," which includes persons who are enrolled members of a federally or State recognized Indian tribe, Alaska Natives, or Native Hawaiians;

3.3.2.4 "Asian-Pacific Americans," which includes persons whose origins are from Japan, China, Taiwan, Korea, Burma (Myanmar), Vietnam, Laos, Cambodia (Kampuchea), Thailand, Malaysia, Indonesia, the Philippines, Brunei, Samoa, Guam, the U.S. Trust Territories of the Pacific Islands (Republic of Palau), Republic of the Northern Marianas Islands, Samoa, Macao, Fiji, Tonga, Kirbati, Tuvalu, Nauru, Federated States of Micronesia, or Hong Kong;

3.3.2.5 "Subcontinent Asian Americans," which includes persons whose origins are from India, Pakistan, and Bangladesh, Bhutan, the Maldives Islands, Nepal or Shri Lanka;

3.3.2.6 Women; and

3.3.2.7 Any additional groups whose members are designated as socially and economically disadvantaged by the SBA, at such time as the SBA designation becomes effective.

3.3.3 Being born in a particular country does not, standing alone, mean that a person is necessarily a member of one of the groups listed in this definition.

3.4 "Owned and Controlled" means a business: (a) which is at least 51 percent owned by one or more "Socially and Economically Disadvantaged Individuals," or, in the case of a publicly-owned business, at least 51 percent of the stock of which is owned by one or more "Socially and Economically Disadvantaged Individuals;" and (b) whose management and daily business operations are controlled by one or more such individuals.

3.5 "Manufacturer" means a firm that operates or maintains a factory or establishment that produces on the premises the materials or supplies obtained by the contractor.

3.6 "Regular Dealer" means a firm that owns, operates or maintains a store, warehouse, or other establishment in which the materials or supplies required for the performance of the contract are bought, kept in stock, and regularly sold to the public in the usual course of business. The firm must engage in, as its principal business, and in its own name, the purchase and sale of the product in question. A regular dealer in such bulk items as steel, cement, gravel, stone, and petroleum products need not keep such products in stock if it owns or operates distribution equipment.

3.7 “Fraud” includes a firm that does not meet the eligibility criteria of being a certified DBE and that attempts to participate in a U.S. DOT-assisted program as a DBE on the basis of false, fraudulent, or deceitful statements or representations, or under circumstances indicating a serious lack of business integrity or honesty. The Authority may take enforcement action under 49 CFR part 31, Program Fraud and Civil Remedies, against any participant in the DBE program whose conduct is subject to such action under 49 CFR part 31. The Authority may refer cases of identified fraud to the Department of Justice, for prosecution under 18 U.S.C. 1001, or any other applicable provisions of law. Any person who makes a false or fraudulent statement in connection with participation of a DBE in any U.S. DOT-assisted program or otherwise, violates applicable Federal statutes.

3.8 "Other Socially and Economically Disadvantaged Individuals" means those individuals who are citizens of the United States (or lawfully admitted permanent residents), and who, on a case-by-case basis, are determined by the Small Business Administration or the Authority to meet the social and economic disadvantage criteria described below.

3.8.1 Social Disadvantage

3.8.1.1 The individual's social disadvantage must stem from his/her color, national origin, gender, physical handicap, long-term residence in an environment isolated from the mainstream of American society, or other similar cause beyond the individual's control.

3.8.1.2 The individual must demonstrate that he/she has personally suffered social disadvantage.

3.8.1.3 The individual's social disadvantage must be rooted in treatment which he/she has experienced in American society, not in other countries.

3.8.1.4 The individual's social disadvantage must be chronic, longstanding and substantial; not fleeting or insignificant.

3.8.1.5 The individual's social disadvantage must have negatively affected his/her entry into and/or advancement in the business world.

3.8.1.6 A determination of social disadvantage must be made before proceeding to make a determination of economic disadvantage.

3.8.2 Economic Disadvantage

3.8.2.1 The individual's 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 line of business and competitive market area that are not socially disadvantaged.

3.8.2.2 The following criteria will be considered when determining the degree of diminished credit and capital opportunities of a person claiming social and economic disadvantage:

With respect to the individual:

• availability of financing

• bonding capability

• availability of outside equity capital

• available markets

With respect to the individual and the business concern:

• personal and business assets

• personal and business net worth

• personal and business income and profits

4.0 DBE Proposal Submission Requirements

Offeror shall complete and submit the following DBE Exhibits (forms) with their proposal:

· DBE Participation Commitment Form

· Offerors List- NA

To be a responsible and responsive offeror, the offeror must submit a DBE Letter of Acknowledgement and Commitment for each DBE firm listed on the DBE Participation Commitment Form to the Authority at time of Proposal.

Offeror must complete and submit the following DBE Exhibits (forms) to the Authority no later than 4:00 p.m. on the 2nd business day after the proposal due date:

· DBE Letter of Acknowledgement and Commitment (required from each proposed DBE firm listed on the DBE Participation Commitment Form)

· DBE Information – Good Faith Efforts (if sufficient participation to meet the DBE goal has not been proposed on the DBE Participation Commitment Form)

4.1 “DBE Participation Commitment Form” (Exhibit E-1) required at time of Proposal. The Offeror is to provide the following information for each DBE that will participate in the contract:

4.1.1 The complete name and address of each DBE who will participate in the contract;

4.1.2 Valid DBE Certification ID to confirm eligibility status through the CUCP, in conformance with 49 CFR Part 26;

4.1.3 A description of the work that each DBE will perform or provide;

4.1.4 The dollar amount of the work to be performed or provided by the DBE;

4.1.5 The proposal item (#) associated with the proposed scope(s) of work;

4.1.6 The dollar amount of the work eligible to be credited for each DBE towards the DBE goal (should not include lower-tier participation and should account for the type of work to be performed);

4.1.7 The offeror shall also submit, for each DBE to perform under this Agreement, a DBE Letter of Acknowledgement and Commitment (Exhibit E-2) form signed and dated from each DBE listed, acknowledging that the DBE is participating in the contract for the specified dollar value and scope of work listed on the DBE Participation Commitment Form. The dollar amount and scope(s) in the DBE Letter of Acknowledgement and Commitment and the dollar amount and scope(s) reflected on the DBE Participation Commitment Form must match identically. The DBE Letter of Acknowledgement and Commitment must be submitted no later than 4:00 p.m. on the 2nd business day after the proposal due date.

4.2 “DBE Information - Good Faith Efforts” (Exhibit E-3)

To be a responsible and responsive offeror, the offeror must make good faith efforts to meet the goal. The Offeror can meet this requirement in two ways: (i) the offeror can meet the goal by documenting commitments for participation by DBE firms sufficient for this purpose; or (ii) the offeror can demonstrate that he/she took all necessary and reasonable steps to achieve the DBE goal, or other requirement of this part, which, by their scope, intensity, and appropriateness to the objective, could reasonably be expected to obtain sufficient DBE participation, even if they were not fully successful.

If the Offeror did not meet or obtain enough DBE participation to meet the DBE goal, the offeror must complete and submit the “DBE Information – Good Faith Efforts,” form demonstrating that the Offeror made adequate good faith efforts to meet the goal.

If the offeror has met the DBE goal based on the participation of DBEs listed on the offeror’s “DBE Participation Commitment Form,” it is at the offeror’s discretion (i.e. this is not mandatory) to submit “DBE Information – Good Faith Efforts,” form However, the submission of good faith efforts documentation can protect the offeror’s eligibility for award of the contract if the Authority determines that the offeror failed to meet the goal for various reasons (e.g., a DBE firm was not certified at proposal submission or the offeror made a mathematical error). Submittal of only the “DBE Information – Good Faith Efforts,” form may not provide sufficient documentation to demonstrate that adequate good faith efforts were made; therefore, the offeror is encouraged to attach additional information and supporting documents as necessary.

Good Faith Efforts documentation must be submitted to the Authority no later than 4:00 p.m. on the 2nd business day after the proposal due date.

For further guidance, refer to instructions on Exhibit E-3 “DBE Information – Good Faith Efforts” form and the United States Department of Transportation’s (“U.S. DOT”) DBE Program, Appendix A of Title 49 CFR Part 26 “Guidance Concerning Good Faith Efforts,” and the DBE Section of the Authority’s Pre-Proposal PowerPoint.

4.3 “Offerors List” (Exhibit E-4)- NOT APPLICABLE

The Authority is required by Regulations to create and maintain a “Offerors List (Exhibit E-4),” of all firms proposing or quoting on the Authority’s U.S. DOT-assisted contracts for use in calculating the Authority’s DBE goal(s). Offerors are required to complete and submit the requested information listed on the “Offerors List” form, for all firms (DBE[s] and Non-DBE[s]) who submitted a bid, proposal or quote, including firms who were contracted by the prime offeror.

The “Offerors List” must be submitted to the Authority at time of proposal.

RFP 250036

ATTACHMENT CA

SECTION V: CALIFORNIA UNIFIED CERTIFICATION PROGRAM

Dear Business Owner:

Thank you for your interest in participating in the Unified Certification Program (UCP) of California for Disadvantaged Business Enterprises (DBEs). As mandated by the United States Department of Transportation (U.S. DOT) in the DBE Program, Final Rule 49 Code of Federal Regulations (CFR), Part 26, all U.S. DOT recipients of federal financial assistance must participate in a statewide UCP by March 2002. The UCP is a “One-Stop Shopping” certification procedure that will eliminate the need for DBE firms to obtain certifications from multiple agencies within the State.

The UCP of California is charged with the responsibility of certifying firms and compiling and maintaining the Database of certified DBEs for U.S. DOT grantees in California, pursuant to 49 CFR Part 26. The Database is intended to expand the use of DBE firms by maintaining complete and current information on those businesses and the products and services they can provide to all grantees of California.

Complete the attached application and supplemental questionnaire if you wish to be considered for DBE certification and your business meets the following general guidelines:

The firm must be at least 51% owned by one or more socially and economically disadvantaged individuals.

The firm must be an independent business, and one or more of the socially and economically disadvantaged owners must control its management and daily operations.

Only existing for-profit “Small Business Concerns,” as defined by the Small Business Act and Small Business Administration (SBA) regulations may be certified. DBE applicants are first subject to the applicable small business size standards of the SBA. Second, the average annual gross receipts for the firm (including its affiliates) over the previous three fiscal years must not exceed U.S. DOT’s cap of $17.42 million.

For firm applying for airport concession DBE certification: The average annual gross receipts for the firm (including its affiliates) over the previous three fiscal years must not exceed $30 million.

The Personal Net Worth (PNW) of each socially and economically disadvantaged owner must not exceed $750,000. The PNW excludes the individual’s ownership interest in the applicant firm and the equity in his/her primary residence.

For firm applying for airport concession DBE certification: A PNW is not required at this time.

Socially and economically disadvantaged individual means any individual who is a citizen of the United States (or lawfully admitted permanent resident) and who is a member of the following groups: Black American, Hispanic American, Native American, Asian-Pacific American, Subcontinent Asian American, or Women, or Any individual found to be socially and economically disadvantaged on a case-by-case basis by a certifying agency pursuant to the standards of the U.S. DOT 49 CFR part 26.

In order to avoid unnecessary delays, complete all portions of the application and supplemental questionnaire, placing "N/A" next to items that are not applicable. Include all copies of documents requested on the application, and have the Affidavit of Certification, Affidavit of Social and Economic Disadvantage and Personal Net Worth Statement notarized. Additional documentation may be requested if it is considered necessary to make a certification determination. Incomplete applications/supplemental questionnaires or applications/supplemental questionnaires without all the required documents will not be evaluated until such documents are submitted. We recommend keeping a copy of all submitted documents for your records.

REMEMBER: It is no longer necessary to apply at more than one agency. If your firm meets the criteria for certification, it will be entered into the Database of DBEs for all U.S. DOT grantees in California. Only firms currently certified as eligible DBEs may participate in the DBE programs of U.S. DOT grantees of California.

The California UCP has established four Regional DBE Certification Clusters throughout the State to effectively facilitate statewide DBE certification activities. Forward your completed certification packet to one of the agencies serving the county where your firm has its principal place of business. (See enclosed Roster of Certifying Agencies.)

For Out-of-State Firms: The California UCP will not process a new application for DBE certification from a firm having its principal place of business in another state unless the firm has already been certified in that state. If your firm is located outside of California and is certified as a DBE at its home state, forward your completed certification packet, along with a copy of your DBE certificate, to the California Department of Transportation. (See page 3 of the enclosed Roster of Certifying Agencies.)

CALIFORNIA UNIFIED

CERTIFICATION PROGRAM

CALIFORNIA UNIFIED

CERTIFICATION PROGRAM (CUCP)

RFP 5-4033

ATTACHMENT C

Definitions of Terms Used in Uniform Certification Application

Alaska Native Corporation (ANC) – Any Regional Corporation, Village Corporation, Urban Corporation, or Group Corporation organized under the laws of the State of Alaska in accordance with the Alaska Native Claims Settlement Act, as amended.

Concession – A grant of property made by a government or other controlling authority in return for stipulated services or a promise that the property will be used for a specific purpose.

Corporate Tax Returns – Federal Tax Return Form 1120 or 1120S, including Schedules E or C.

Indian Tribe – Any Indian tribe, band, nation, or other organized group or community of Indians, including any ANC, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians, or is recognized as such by the State in which the tribe, band, nation, group, or community resides. See definition of Tribally-Owned Concern.

Key Person Insurance – Life insurance and long-term disability income insurance on major employees, with benefits payable to the business.

Native Hawaiian – Any individual whose ancestors were natives, prior to 1778, of the area, which now comprises the State of Hawaii.

Native Hawaiian Organization – 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, is controlled by Native Hawaiians and whose business activities will principally benefit such Native Hawaiians.

Partnership Tax Returns – Federal Tax Return Form 1065, including Schedules K and K-1.

Personal Net Worth – The net value of the assets of an individual remaining after total liabilities are deducted. An individual’s personal net worth does not include: The individual’s ownership interest in an applicant or participating DBE firm; or the individual’s equity in his or her primary place of residence. An individual’s personal net worth includes only his or her own share of assets held jointly or as community property with the individual’s spouse.

Personal Tax Returns – Federal Tax Return Form 1040, including Schedules B and C.

Regular Dealer – A firm that owns, operates, or maintains a store, warehouse, or other establishment in which the materials, supplies, articles or equipment are bought, kept in stock, and regularly sold or leased to the public in the usual course of business. Packagers, brokers, manufacturers’ representatives, or other persons who arrange or expedite transactions are not regular dealers.

Socially and Economically Disadvantaged Individual – Any individual who is a citizen (or lawfully admitted permanent resident) of the United States and who is –

Any individual who a recipient finds to be a socially and economically disadvantaged individual on a case-by-case basis.

Any individual in the following groups, members of which are rebuttably presumed to be socially and economically disadvantaged:

· “African Americans” or “Black Americans,” which includes persons having origins in any of the Black racial groups of Africa.

· “Hispanic Americans,” which includes persons of Mexican, Puerto Rican, Cuban, Dominican, Central or South American, or other Spanish or Portuguese culture or origin, regardless of race.

· “Native Americans,” which includes persons who are American Indians, Eskimos, Aleuts, or Native Hawaiians.

· “Asian-Pacific Americans,” which includes persons whose origins are from Japan, China, Taiwan, Korea, Burma (Myanmar), Vietnam, Laos, Cambodia (Kampuchea), Thailand, Malaysia, Indonesia, the Philippines, Brunei, Samoa, Guam, the U.S. Trust Territories of the Pacific Islands (Republic of Palau), the Commonwealth of the Northern Marianas Islands, Macao, Fiji, Tonga, Kirbati, Tuvalu, Nauru, Federated States of Micronesia, or Hong Kong.

· “Asian Indian Americans” or “Subcontinent Asian Americans,” which includes persons whose origins are from India, Pakistan, Bangladesh, Bhutan, the Maldives Islands, Nepal or Sri Lanka.

· Women.

· Any additional groups whose members are designated as socially and economically disadvantaged by the SBA, at such time as the SBA designation becomes effective.

Tribally-Owned Concerns – Any concern at least 51 percent owned by an Indian tribe.

DISADVANTAGED BUSINESS ENTERPRISE PROGRAM

49 CFR PART 26

UNIFORM CERTIFICATION APPLICATION

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 2 CFR Parts 180 and 1200, take enforcement action under 49 CFR Part 31, Program Fraud and Civil Remedies, and/or refer the matter to the Department of Justice under 18 U.S.C. 1001.

2/20/2002

ROADMAP FOR APPLICANTS

· Should I apply?

Your firm must meet the following requirements to qualify as a DBE under the United States Department of Transportation (DOT) DBE program:

· Disadvantaged owners are U.S. citizens or legal permanent residents.

· Firm’s annual gross income does NOT exceed $23.98 million (averaged over 3 years).

· Firm is at least 51% owned and controlled by socially and economically disadvantaged individuals.

· Firm meets SBA small business size in the primary industry group (13 CFR Part 121).

· Firm owned by ANCs, Indian Tribes, and Native Hawaiian Organizations meet the small business size requirements and are controlled by socially and economically disadvantaged individuals.

· Firm and owners meet the requirements of Part 26 concerning licenses and credentials.

· Firm must be for-profit.

Note: Firm must undergo an on-site review.

· Is there an easier way to apply?

If you are currently certified as an 8(a), or SDB firm, you may be eligible for a streamlined certification application process pursuant to a Memorandum of Understanding (MOU) between DOT and the SBA. Under the MOU, the certifying agency to which you are applying will accept your current SBA application package in lieu of requiring you to submit an entirely new application. You must still meet the requirements for the DBE program.

· What documents must I submit with this application?

The following documents must be attached to your application. Missing documents or incomplete information will delay the processing of your application.

All Applicants

· Work experience resumes that include places of ownership/employment and corresponding dates.

· Personal Net Worth statement or statement from CPA.

· Social & economic disadvantage statement.

· Entire copy of personal tax returns for the last 3 years, if applicable.

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

· Signed loan agreement and security agreements.

· Description of real estate and proof of ownership listed.

· List of equipment leased and signed lease agreements.

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

· Signed leases for office/storage space.

· End of Year Balance Sheets and Income Statements for the past 3 years (or life of firm if less than 3 years). A new business must provide a current Balance Sheet.

· Copies of relevant licenses.

· DBE/MBE/WBE, SBA 8(a) or SDB certifications or denials and decertifications.

· Bank Authorizations and Signatory cards.

· Schedule of salaries paid to all officers, managers, owners or directors of the firm (W-2s).

Sole Proprietorship

· Assumed name, fictitious name or other registration certificate from appropriate governmental agency.

Partnership or Joint Venture

· Original and any amended Partnership or Joint Venture Agreements.

· Assumed name, fictitious name, or other registration Certificate from appropriate governmental agency, if applicable.

· Partnership tax returns for last 3 years.

Corporation or LLC

· Official Articles of Incorporation (signed by the state official).

· Both sides of all Corporate Stock Certificates and Stock.

· Transfer Ledger.

· Entire copy of corporate tax returns for the last 3 years.

· Shareholders’ Agreement.

· Minutes of all Stockholders’ and Board of Directors’ meetings.

· Corporate By-laws and any amendments.

NOTE: The specific state or recipient to which you are applying may have additional requirements.

· Where can I find more information?

U.S. DOT – http://osdbuweb.dot.gov/business/dbe/index.html

RFP 5-4033

ATTACHMENT C

Section 1: CERTIFICATION INFORMATION

1. Prior/Other Certifications.

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

(If Yes, attach a copy of your certification(s)).

Has this firm’s home state conducted an on-site visit?

Yes, on _____/_____/______ No

8(a)

SDB

Stop! You may not have to complete this application. Ask about the streamlined application process under the SBA/DOT MOU.

(b) Has your firm applied for certification for any program listed in 1(a) in the past? Yes, on____/____/____ No If Yes, identify: Other names your company has used:

Identification and certification numbers:

(c) Has this firm or any of its owners, Board of Directors, officers or management personnel been denied certification or decertified before by any agency in any state, local or Federal entity? Yes, on ____/____/____ No If Yes, identify State and name of agency:

Section 2: GENERAL INFORMATION

Street address of firm: (No P.O. box no.)

Mailing address of firm:

Federal identification number or Applicant’s Social Security number:

Did the business exist under a different type of ownership prior to the date indicated above? Yes No If Yes, Explain.

Has this firm operated under a different name during the past five years? Yes No If Yes, explain.

Has this firm applied for reorganization under Chapter 11 and/or liquidation under Chapter 7, within the last 3 years? (If Yes, provide court papers) Yes No

Where do you obtain seasonal employees?

Does your firm directly pay, in its own name, all its employees? Yes No If No, explain.

Section 3: OWNERSHIP

4. Identify all individuals or holding companies with any ownership interest. List their cash, equipment and/or real estate and/or other investment in the firm; and attach the documentation of the source of these investments.

(Attach work experience resumes of each person; If more than two owners, attach a separate sheet.)

First Person

Home Address (street and number):

Other Ethnic Group (explain)__________________________

U.S. Citizen: Yes No

Legal permanent resident: Yes No

Percentage owned:

Familial relationship to other owners:

Shares of Stock: Number Percentage Class Date Acquired Method Acquired

Additional contributions made by anyone since the business was started/acquired:

Second Person

Home Address (street and number):

Other Ethnic Group (explain)__________________________

U.S. Citizen: Yes No

Legal permanent resident: Yes No

Percentage owned:

Familial relationship to other owners:

Shares of Stock: Number Percentage Class Date Acquired Method Acquired

Additional contributions made by anyone since the business was started/acquired:

Section 4: CONTROL

5. Identify Officers & Board of Directors. (Attach work experience resumes of each person; If additional space is required, attach a separate sheet.)

2.

3.

4.

5.

2.

3.

5.

6. Identify management personnel who control the firm in the following areas. (Attach work experience resumes, including dates of employment at each company for each person; if more than two persons, attach a separate sheet)

2.

Estimating, bidding and negotiating (cost estimates, proposal preparation and submission, negotiation or contract execution) 1.

7. Identify persons or firms who provide the following services.

External management or technical/ Computer service

Accountant

Attorney

Principal Suppliers

1.

Materials or equipment supplied 2.

Materials or equipment supplied

1.

2.

3.

9. Attach a list of equipment and/or vehicles within your firm’s possession or under your control (indicate separately), office space (owned or leased) and storage space (owned or leased), including signed leasing agreements.

Name of bank: ____________________________________________________Phone No. ( )_______________ Name of officer: __________________________________________________ Address of bank: _____________________________________City: _________________State: ______ Zip:______

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

Name of agent or broker:______________________________________ Phone No: ( )____________________ Address of agent/broker:_____________________________________ City_____________State: _____Zip :______ Bonding limit: Aggregate limit $___________ Project limit $_______________

(c) Attach copies of year end balance sheet and profit and loss (income) statements for the last 3 years, or if business has been in operation for less than one year, provide a current balance sheet, a projected profit and loss statement for the next 12 month period and a projected balance sheet for the end of that period.

1.

2.

3.

Date License Number

1.

2.

3.

1.

2.

3.

1.

2.

3.

Section 5: AFFILIATION

16. Affiliation with other businesses.

(a) Affiliate companies:

(b) Do any of the people listed in question 4, 5, or 6 perform a management or supervisory function for any other business? Yes No If Yes, identify: Person:_______________________________ Title:_____________________________ Business:______________________________ Function:_________________________

(c) Do any of the people listed in questions 4, 5, or 6 own or work for other firms that have a business relationship with yours? (e.g., ownership interest, shared office space, financial investments, equipment leases or personnel sharing)? Yes No If Yes, identify: Firm: _________________________________________ Person:____________________________ Business Relationship_________________________________________

(d) Whether affiliated or not, is the applicant firm co-located at any of it 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 No If Yes, identify: Firm’s name:_______________________________________ Tax ID number________________ Explain nature of shared facilities: _________________________________________________________ ______

(e) At present or in the past 5 years:

If you answered Yes to any to any of these questions, identify on a separate piece of paper any relevant names, addresses, dates and explanations.

Has this firm been a subsidiary of any other firm? Yes No

Has this firm consisted of a partnership in which one or more of the partners are other firms? Yes No

Has any other firm owned 5% or more of this firm? Yes No

Has this firm had any subsidiaries? Yes No

Has this firm owned 5% or more of any other firm? Yes No

Section 6: OTHER

AFFIDAVIT OF CERTIFICATION

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), swear or affirm under penalty of law that I am ____________________________(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 place(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 declare under penalty of perjury that the foregoing is true and correct.

Signature of owner, officer or partner________________________________________Date(mm/dd/yy)____________

I declare under penalty of perjury that the information provided in this application and supporting documents relating to my disadvantaged status and me is true and correct.

Print Name: Signature: Date:

Print Name: Signature: Date:

Print Name: Signature: Date:

Print Name: Signature: Date:

Print Name: Signature: Date:

NOTARY CERTIFICATION

STATE OF____________________________________

}SS:

COUNTY OF__________________________________

Subscribed and sworn to before me this _____________________day of __________________, 20___

Signature of Notary Public______________________________________________________________

Printed/typed name of Notary Public_____________________________________________________

County of residence________________________________ Date commission expires ____________

AFFIDAVIT OF SOCIAL AND ECONOMIC DISADVANTAGE

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

SOCIAL DISADVANTAGE

I hereby certify under penalty of perjury that I am a member of one of the following groups:

And that I have held myself out as a member of that group and have acted as a member of that group.

I further certify that I am an owner of the company seeking DBE certification and that I have experienced social disadvantage due to the effect of discrimination based upon my (check all that apply) race ethnicity gender other (explain)

Print Name:__________________________________Signature:_______________________________Date:________

PERSONAL FINANCIAL STATEMENT

I hereby certify under penalty of perjury that my personal net worth does not exceed $1,320,000.

Print Name:__________________________________Signature:_______________________________Date:________

This statement is supported by (check one) A signed, notarized statement of personal net worth, with appropriate supporting documentation.

A signed, notarized statement from a certified public accountant (CPA) attesting that he/she has examined my personal net worth and determined, consistent with the provisions of 49 CFR Section 26.67(a)(2) and generally accepted accounting standards, that my personal net worth does not exceed $1,320,000.

NOTARY CERTIFICATION

STATE OF____________________________________

}SS:

COUNTY OF__________________________________

Subscribed and sworn to before me this _____________________day of __________________, 20___

Signature of Notary Public______________________________________________________________

Printed/typed name of Notary Public______________________________________________________

County of residence________________________________ Date commission expires ____________

PERSONAL NET WORTH STATEMENT

(49 CFR PART 26)

As of _________________________

For firm applying for airport concession DBE certification: A PNW is not required at this time.

Each individual owner of a DBE firm whose ownership or control is relied upon for DBE certification is required to provide Personal Net Worth (PNW) information and include it in the notarized DBE Certification Application package. For a firm with more than one owner relied upon for DBE certification, make additional copies of this Statement. The Unified Certification Program of California reserves the right to request additional information as necessary and may conduct an on-site visit to verify the information contained in this Statement.

I understand that all personal financial information I submit will remain confidential unless I give my written consent to release this information to a third party. I also understand that the only exception to this confidentiality provision is if I decide to appeal a decision by the Unified Certification Program of California.

Name Phone Business Address City, State, & Zip Code Business Name

Total Assets $____________

Total Liabilities $____________

NET WORTH $______________

Is any portion of the equity in the individual’s primary residence attributable to withdrawal(s) from the firm applying for DBE certification? ___________ If yes, how much? $_______________________

The undersigned does hereby swear that the foregoing statements are true, accurate, and complete.

Signature__________________________________________ Date _________________________________

1. Exclude an individual's ownership interest in the firm applying for DBE…