Personal Net Worth Statement for DBE/ACDBE Program Eligibility
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:
For DBE/A CDBE Program Eligibility EXPIRATION DATE:
As of __________________
This form is used by all participants i n the U.S. Department of Transportation’ s Disadvant aged B usiness E nterpris e (DBE) Programs. Each individual
owner of a firm applying to participate as a DBE or ACDBE, whose ownership and cont rol are reli ed upon for DBE certificati on must complete t his form.
Each person signing this form authorizes the Unified Certific at i on Program (UCP) recipient to make inquiries as necessary to verify the accuracy of the
statements made. The agency you apply to will use the informat i on provided to determi ne whether an owner i s economicall y disadvant aged as defined in
the DBE program regulati ons 49 C.F.R. Parts 23 and 26. Return form to appropriate UCP certifying member, not U.S. DOT.
Name Busi ness P hone
Residence Address (As reported to the IRS)
City, St ate and Zip Code
Residence Phone
Busi ness Name of Applicant Firm
Spouse’s F ull Name
(Marital St atus: Singl e, Married, Divorced, Union)
ASSETS (Omit Ce n ts)
LIABILITIES (Omit Ce n ts)
Cash and Cash Equival ents $ Loan on Life Insurance
(Compl ete S ection 5)
$
Retirement Accounts (IRAs, 401Ks, 403Bs,
Pensi ons, etc.) (Report full value minus tax and
interes t penal t i es that would apply if assets were
distributed today) (Complete Section 3)
$ Mortgages on Real Estat e
Excluding P rimary Residence Debt
(Compl ete S ection 4)
$
Brokerage, Investment Accounts $ Notes, Obl i gations
on Personal Property
(Compl ete S ection 6)
$
Assets Hel d in Trust $ Notes & Accounts Payable to Banks
and Others (Complete Section 2)
$
Loans t o Shareholders &
Other Receivables
(Complete section 6)
$ Other Liabi l iti es
(Compl ete S ection 8)
$
Real Estate Excluding Primary Residence
(Compl ete S ection 4)
$ Unpaid Taxes
(Compl ete S ection 8)
$
Life I nsuranc e (Cash Surrender Value Only)
(Compl ete S ection 5)
$
Other Personal Property and Assets
(Compl ete S ection 6)
$
Busi ness I nterests O t her Than the Applic ant Fi rm
(Compl ete S ection 7 )
$
Total Assets $ Total Li abili t i es $
NET WORTH
Sectio n 2. Notes Payable to Banks an d Others
Name of Noteholder(s )
Original
Balance
Current
Balance
Payment
Amount
Frequency
(monthly, etc.)
How Secured or Endorsed Type of
Collateral
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