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 For DBE/ACDBE Program Eligibility OMB APPROVAL NO: 2105-0510 EXPIRATION DATE: 03/31/2025 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. …
Download the original document · Plain text (TXT) · Browse the archive · How this archive works
Original source: https://dpw.vi.gov/wp-content/uploads/2024/01/PNW-Statement-2023.pdf
SHA-256 174c63dc15485fea28d764e8575fae767cd9654666f89d16241c84ff862c9b14
Re-using this document
territorial public record
Our description, tagging, arrangement, extracted text and machine transcripts are released under CC0 1.0. We assert nothing about the document itself.
Archive identifier LF-174c63dc1548
Document text
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 For DBE/ACDBE Program Eligibility OMB APPROVAL NO: 2105-0510 EXPIRATION DATE: 03/31/2025 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: