Personel Networth Statement
U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility • Page 1 of 5 U.S. Department of Transportation Personal Net Worth Statement OMB APPROVAL NO: 2105-0510 For DBE/ACDBE Program Eligibility EXPIRATION DATE: 10/31/2021 As of __________________ This form is used by all participants in the U.S. Department of Transportation’s Disadvantaged Business Enterprise (DBE) and Airport Concession DBE (ACDBE) Programs. Each individual owner of a firm applying to participate as a DBE or ACDBE, whose ownership and control are relied upon for DBE certification must complete this form. Each person signing this form authorizes the certifying agency to make inquiries as necessary to verify the accuracy of the statements made. The agency you apply to will use the information provided to determine whether an owner is economically disadvantaged as defined in the DBE program regulations 49 C.F.R. Parts 23 and 26. Return form to appropriate certifying agency, not U.S. DOT. …
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U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility • Page 1 of 5 U.S. Department of Transportation Personal Net Worth Statement OMB APPROVAL NO: 2105-0510 For DBE/ACDBE Program Eligibility EXPIRATION DATE: 10/31/2021 As of __________________ This form is used by all participants in the U.S. Department of Transportation’s Disadvantaged Business Enterprise (DBE) and Airport Concession DBE (ACDBE) Programs. Each individual owner of a firm applying to participate as a DBE or ACDBE, whose ownership and control are relied upon for DBE certification must complete this form. Each person signing this form authorizes the certifying agency to make inquiries as necessary to verify the accuracy of the statements made. The agency you apply to will use the information provided to determine whether an owner is economically disadvantaged as defined in the DBE program regulations 49 C.F.R. Parts 23 and 26. Return form to appropriate certifying agency, not U.S. DOT. Applicant Name: Residence: (As reported to the IRS) Address, City, State and Zip Code Residence Phone Business Name of Applicant Firm Business Phone Marital Status: