This form must be completed to apply for the Disadvantaged Business Enterprise (DBE) designation within
the Certified Business Enterprise (CBE) program. The majority owner (at least 51%) or each owner whose
combined ownership interest totals at least 51% must submit this form, the personal financial statement
and a letter describing how he or she is socially and economically disadvantaged, as described below.
Business Phone
Residence Address
Residence Phone
Residence City
Residence State
Residence Zip
Company Name
Company Address
Company City
Enter Full Name
Enter Phone #
Enter Street Address
Enter Phone #
Enter City
Enter State
Enter Zip Code
Enter Company Name
Enter Street Address
Enter City
Company State
In completing the narrative for consideration, the owner/owners of at least 51% of the business must
demonstrate that he or she is socially disadvantaged because t
hey have faced chronic, non-fleeting
instances of prejudice or bias without regard to their qualities as an individual, over which they have no
control, due to their identity as a member of a group as evidenced by the following:
1. Documentation proving that the individuals seeking social disadvantaged status as members of a group hold
themselves out as members of the group;
2. Documentation proving that the individuals seeking socially disadvantaged status have been isolated from
the mainstream of American society not common to business persons generally; and
3. Documentation proving that the individuals seeking socially disadvantaged status have personally suffered
social disadvantage through treatment they have experienced; and
Economically disadvantaged because of diminished opportunities that have precluded these
individuals from successfully competing in the open marketplace as evidenced by documentation on the
1. The personal financial condition of the individual(s) seeking economically disadvantaged status;
2. The financial condition of the business enterprise; and
3. The applicant’s lack of access to credit and capital as compared to others in the same line of business.
I declare, certify, verify, attest or state under penalty of perjury that thi
s form and the supporting documents
are true and correct to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2402, any
person convicted of perjury shall be fined not more than $ 5,000 or imprisoned for not more than 10 years, or
I certify that I am socially and economically disadvantaged in accordance with the requirements found under
Title 27 DCMR Section 803. I certify that the information provided in my narrative describing my personal
experience is true, accurate and complete to the best of my knowledge and belief.
By selecting the "I Accept" buttons above and typing your name in the Signature Box below, you are signing
this document electronically. You agree your electronic signature is the legal equivalent of your manual
signature on this document. By selecting "I Accept" you consent to be legally bound by the statute and
regulations governing the Certified Business Enterprise (CBE) program.
Company Zip
Enter Zip Code
I decline
I accept
I decline
I accept
Signature Box (Name, Ownership Percentage)
27 DCMR Section 803 requires information regarding the personal financial condition of the individual(s)
seeking economically disadvantaged status. Please provide the following information regarding your personal
net worth. Personal net worth means the value of the assets remaining after total liabilities are deducted. Do
not include ownership in the business seeking certification or CBE. Please note the personal net worth of
the individual(s) must be less than $1,000,000.00 for DBE eligibility.
Cash on Hand and in Banks
Accounts Payable
Savings Accounts
Notes Payable to Banks and Others
IRA or other Retirement Accounts
Installment Accounts (auto)
Accounts & Notes Receivable
Installment Accounts (other)
Life Insurance-Cash Surrender Value Only
Loan on Life Insurance
Value of Stocks & Bonds
Mortgage on Real Estate
Value of Real Estate
Unpaid Taxes
Automobile(s) Present Value
Other Liabilities
Other Personal Property
Total Liabilities
Other Assets Value
Minus Mortgage on Primary Residence
Total Adjusted Liabilities
Minus Primary Residence
Total Adjusted Assets
Total Adjusted Assets minus Total Adjusted Liabilities = Personal Net Worth