Fillable Printable Personal Net Worth Statement for DBE/ACDBE Program Eligibility
Fillable Printable Personal Net Worth Statement for DBE/ACDBE Program Eligibility
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 WorthStatement
OMB APPROVAL NO:
For DBE/A CDBE Program EligibilityEXPIRATION 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) recipientto 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 agedas defined in
the DBE program regulati ons 49 C.F.R. Parts 23 and 26. Return form to appropriate UCPcertifying member, not U.S. DOT.
NameBusi 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)
$
Loanst 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 nterestsO 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
U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility•Page 2 of 5
Sectio n 3. Brokerage and custodial accounts, stocks, bonds, retirement accounts. (Full Valu e) (Use attac hm ents if necessary).
Name of Security / Brokerage Account / Retirem ent
Account
Cost
Market V al ue
Quotation/Exchange
Date of
Quotation/Exchange
Total Value
Sectio n 4. Real Estate Owned (Includin g PrimaryResiden ce, Investment Properties, Per sonal Property Leased or Rented for Business
Purposes, Farm Properties, or any Other Income Producing property). (List each parc el separately. Add additi onal s heets if necessary).
Prim ary Resi dence
Property B
Property C
Type of Property
Address
Date Acquired and Method
of Acquisi tion (purchase,
inherit , di vorce, gif t, etc.)
Names on Deed
Purchase Price
Present Market Value
Source of Market Val uation
Name of all Mortgage
Holders
Mortgage Acc . # and
balance (as of date of form)
Equit y line of credit balance
Amount of Payment P er
Month/Year (Specify)
Section 5. Life Insurance Held(Give face amount and cash surrender value of policies, name of insurance company and beneficiari es).
Ins uranc e Company
Face Value
Cash Surrender AmountBeneficiariesLoan on Policy Inform ation
U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility•Page 3 of 5
Section 6. Other Personal Property and A ssets(Use attachments as necessary)
Type of Property or Asset
Total Present
Value
Amount of
Liability
(Balance)
Is this
asset
insured?
Lien or Note amount
and Terms of
Payment
Autom obiles and V ehicl es (including recreation vehicles, motorcycles,
boats , etc. ) Include pers onally owned vehicles that are leased or rented to
business es or other indivi dual s.
Household Goods/ Jewelry
Other (List )
Accounts and Notes Receivabl es
Section 7. Value o f Other Business Investmen ts, Other Businesses Owned (excluding appli can t firm)
Sole Propriet orships, General Partners, Joint Ventures, Limi ted Liability Companies, Closel y -held and Public Traded Corporations
Section 8. Other Liabilitiesand U npaid Taxes(Describe)
Section 9. Transfer of Assets: Have you within 2 years of this personal net worth statemen t, transferred assets to a spouse, domestic
partner, relative, or entity in which you have an ownership or beneficial interest including a trust? YesNo If yes, describe.
I declare under penalty of perjury that the information provided i n this personal net worth statem entand supporting documents is complete, true and
correct. I certify t hat no assets have been transferred to any beneficiary for less than fair market value in the last two years. I recognize t hat the
inform at i on submitted i n this applicati on is for t he purpose of inducing certif ication 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 applicationand this pers onal net worth
statement, and I authorize such agency to cont act any entity named in the application or this personal financ i al st atement, incl udi ng the names
banking i nst itutions, credit agencies, contractors, clients, and other certifyi ng agencies f or the purpose of verifying the information suppl i ed and
determi ni ng the named firm’s eli gibil i t y.I acknowledge and agree that any mis repres entat i ons in this applic ation or in records pertaining to a contract
or subc ontract will be grounds f or termi nating any contract or subcontract which may be awarded; denial or revocat i on of certification; suspension and
debarm ent; and for initi ati ng act i on under federal and/ or state law concerning false statement, fraud or other applicable offenses.
NOTARY CERTIFICATE:
___________________________________ ___________(Insert applic abl e st at e acknowledgm ent, aff i rm ation, or oath)
Signature (DBE/ACDBE Owner) Date
In collecting the information requested by this form, the Department of Transportation complies with Federal Freedom of Information and Privacy Act (5 U.S.C.
552 and 552a)
provisions. The Privacy Act provides comprehensive protections for your personal information. This includes how information is coll ect e d, use d, di scl o sed , st ore d, an d
disca rd ed. Y ou r inform a t ion will not be disc los ed t o thir d parties wi tho utyour consent. The information collectedwill be used solely to determine your firm's eligibility to
participate in the Disadvantaged Business Enterprise (DBE) Program or Airport Concessionaire DBE Programs as defined in 49 C.F.R. Parts 23 and 26.You may review
DOT’s complete Privacy Act Statement in the Federal Register published on April 11, 2000 (65 FR 19477).
U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility•Page 4 of 5
General Instructions for Completingthe
Personal Net Worth Statement
for DBE/ACDBE Program Eligibility
Please do not make adjustments to your figures pursuant to
U.S. D OT regulatio ns 49 C.F.R. Parts 23 and 26. The
agency that yo u apply to will use the information provided
on your completed Per sonal Net Wo r th (PNW) Statement to
determine whether you meet the economic disadvantage
requirements of 49 C.F.R. Parts 23 and 26. If there are
discrepancies or questions regarding your form, it may be
returned to you to correct and complete again.
An ind i vidual’s personal net worth according to 49 C.F.R.
Parts 23 and 26 inc l ude s only hi s or her own sha re of asse ts
held separately, jointly, or as communityproperty with the
individual’s spouse and excludes the following:
•Individua l’s o wners hip interest in the applic ant firm;
•Individual’s equity in his or he rprimaryresidence;
•Tax and interest penalties that would accrue if retire ment
savings or investment s (e.g., pens ion p lans, Individ ual
Retireme nt Acco unts, 401( k) accounts, etc.) were
distrib uted a t the presen t time.
Indicate on the form, if any items are jointly owned. If the
personal net worth of the majority owner(s) of the firm
exceeds $1.32 million, as defined by 49 C.F.R. Pa rts 23 and
26, the firm is not eligib le for DBE or ACDBE certification.
If the personal net worth of the majority owner(s) exceeds
the $1.32 million cap at any time after your firm i s c e r tified ,
the firm i s no longer e ligib le fo r certificatio n. Should that
occur, it is your responsibilit y to c ontact your certifying
agency in writi ng to advise that your fi rm no lo nger quali fi es
as a DBE or ACDBE. You must fill out all line items on the
Per sonal Net Worth State ment.
If necessary, use additional sh eets of paper to report all
information and details. If yo u have any questions about
complet ing this for m, please contact one of the UCP
certi fying agencies.
Assets
All a ssets must be repo rted at their current fair market values
as of the date o f yo ur statement. Assessor’s as sessed v alue
for real estate, for example,is not acceptable. As sets hel d
in a t rust should be i ncluded.
Cash and Cash Equivalents: On page 1, enterthe total
amount of cash or cash equivalents in bank accounts,
including che cking, s avings , money mar ket, certific ate s of
deposit held domestic or foreign. Provide copies of the bank
statement.
Retirement Accounts, IRA, 401Ks, 403Bs, Pensions: On
page 1,ent er t hefull value minus tax and interest penalti es
that would apply if assets were d istributed as of the date of
the form. Describe the number o f shares, name of securities,
cost market value, d a te of quotation, a nd total val ue in
section 3 on page 2.
Brokerageand Custodial Accounts, Stocks, Bonds,
Retirement Accounts: Report total value on page 1, and on
page 2, section 3, enter the name of the securi ty, brokerage
account, retirement account, etc.; the cost; market value of
the asset; the date of q uo ta tion; and total value as of the date
of the PNW statement.
Assets Held in Trust:Enter the tot al va lue of the assets held
in truston page 1, and providethe names of beneficiaries
and trustees, and other infor mation in Section 6 on page 3.
Loans to Shareholders and Other Receivables not listed:
Enter amounts loaned to you from your firm, from any other
business enti ty in which you hold an owners hi p intere s t, a nd
other receivables not listed above. Complete Section 6 on
page 3.
Real Estate: The total value of real estate excluding your
primaryresidence should be listed on page 1. In section 4 on
page 2, please list your primary residence in column 1,
including theaddress, method of acquisition, date of
acquired, names o fdeed, purchase price, present fair market
value , s our c e of mar ke t val ua t i on, na mes of all mortgage
holders, mortgage account numberandbalance, equity line
of credit balance, and amount of payment. List this
information for all real estate held. Please ensure tha t thi s
section contains all real estate owned, includi ng rental
properties, vacation properties, commercial properties,
personal property leased or rented for business purposes,
farm properties and any other income producing properties,
etc. Attach additional sheets if needed.
Life Insurance: On page 1, e nter the cash surr ender value of
this asset. Insection 5on page 2, ent er t he name of the
insurance company, the face value of the polic y, cash
surrender value, beneficiary names, and loans on the policy.
Other Personal Property and Assets: Enterthe tota l value
of personal property and assets you own on p age 1. Personal
pro perty includes motor ve hicles, b oats, traile r s, jewelry,
furniture, household goods, collectibles, clothing, and
personally owned vehicles that are leased or rented to
businesses or other individuals. In section 6 o n pa ge3, list
these asset s and enter the present value, t he balance of any
liabilities, whether the asset is insured, a nd li en or no te
information and terms of payments. For accounts and notes
receivable, enter the total valu e of all monies owed to yo u
personall y, if any. This s houldinclude shareholder loans to
the applicant fir m, if those exist. If the asset is insured, you
may be as ked toprovide a copy of the policy. You may also
be asked to provide a copy of any liens or notes on the
property.
Other Business Interests Other than Applicant Firm: On
page 1, enter t he total value of your other business
investments (excl uding the app licant f irm). In secti on 7 on
page 3, enter information concerning thebus i nes se s yo u
U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility•Page 5 of 5
hold an ownership in te rest in, such as sole proprie torships,
partner ships, joint ventures, co r pora tions, or limited liability
corporations (o ther than the applicant firm). Do not r e duce
the val ue o f the s e entr ies by an y lo ans fr om the outsi de firm
to the DBE/ACDBE a pplicant business.
Liabilities
Mortgages on Real Estate: Enter the total ba la nce on all
mort ga ges pa yable on real estateon page 1.
Loans on Life Insurance: En te r the total val ue of all loans
due on life insurance policies on page 1, and complete
section 5 on page 2.
Notes & Accounts Payable to Bank and Others: On page
1, sectio n 2,enterde ta ils conce r nin g any liabilit y, includi ng
name of notehol de rs, or iginaland current balances, payment
terms, and security/collater a l information. The entrie s should
include automobile i ns tallment a ccounts. This shoul d no t,
however, include any mortgag e b alances as this information
is captured in section 4. Do not include loans for your
business or mortgages for your properties in this sectio n.
You may be asked to submit copy of note/sec urity
agr eement , and the mos t recen t account statement.
Other Liabilities: On page 1, enter the total value due on all
other liabilities not listedin the previous ent ries. In sect ion
8, page 3, report the name of t he individ ual obl igated, names
of co -si gners, description o f the liability, the name of the
entity owed, the date of the obligation, payment amounts and
terms. No te : Do not i nclude co ntin gent liabilities in thi s
section. Continge nt liabilities are lia bilities that belong to
you only if an event(s) should occur. For e xamp le, if you
have co-signe d on a r ela ti ve’s loan, b ut you a re no t
responsible for the de bt until your re la tive defaults, that is a
contingent liability. Contin gent liabilities do not count
to ward your net worth u ntil they become actual liabilities.
Unpaid Taxes: Enter the total amount of all ta xes that are
cur rent ly due, b ut are unpa i don page 1, and co mplete
section 8on page 3. Contingent tax liabilitie s or ant ic ipated
taxes for current year should not be included. Describe in
detail the name of the individ ual obligated, names of co-
signers, the type of unpaid tax, to whom the tax is payable,
due date, amo unt, and to what proper ty, if any, the tax lien
attaches. If none, state “NONE.” Yo u must include
documentation, such as tax liens, to support the amounts.
Transfers of Assets:
Transfers of Assets: If you che cked the box indi cat ing yes
on page 3 i n thi s cat egory, provide details on all asset
transfers (withi n 2 years ofthedate of this personal net
worth statement) to a spo use, domestic partner, re la tive, or
enti ty i n which you have an own ership o r b eneficia l i nter est
including a trust. Includea descr iption of the asset; na mes o f
individuals on the dee d, title, note oro ther instrument
indicating ownersh ip rights; the names of individuals
receiving the assets and their relation to the transferor; the
date of the transfer; and the value or consideration received.
Submit documentation requested on the form related to the
transfer.
Affidavit
Be sure to sign and date the state ment. The Personal Net
Worth Statement mu st b e no tariz e d
.
