Environmental Improvement Fund (EIF)
Disadvantaged Business Enterprise (DBE)
Good Faith Certification
Form 8700-294 (R 8/10)
Date Review Completed
State of Wisconsin
Department of Natural Resources
Bureau of Community Financial Assistance
101 S. Webster St., PO Box 7921
Madison WI 53707-7921
Phone No. (608) 266-7555 FAX (608) 267-0496
website: dnr.wi.gov/org/caer/cfa/cfindex.html
Notice: Under ss. NR 162.09(3) and NR 166.12(4)(b), Wis. Adm. Code, a municipality is required to provide complete information, as requested on
this form, to verify that it has complied with requirements regarding solicitation of minority-and women-business enterprises (MBE/WBEs) and other
Disadvantaged Business Enterprises (DBEs). The Department will not complete a financial assistance agreement unless the municipality submits
documentation regarding DBE solicitation or utilization. Failure to provide information requested, or make a good faith effort, may result in sanctions
described in s. NR 162.09(3)(b) or s. NR 166.12(4), Wis. Adm. Code.
Personally identifiable information provided on this form will be used to review participation in a project and may also be made available to
requesters as required by Wisconsin Open Records law [ss. 19.31 - 19.39, Wis. Stats.].
I. Project Information
Safe Drinking Water Loan Program Clean Water Fund Program
1. Name of Municipality
2. EIF Project Number
4.Title of Authorized Representative (Print or Type)3. Name of Authorized Representative (Print or Type)
1. Are any DBEs performing any type of work on this project? If yes, attach EPA Form 6100-4 for each DBE
utilized.
Yes No
II. Good Faith Effort
2. Did your municipality either:
a. Contact DBEs included on the Unified Certification Program List (e.g., WisDOT UCP) when soliciting bids?
OR
b. Publish an advertisement in the official newspaper of record that included language encouraging DBEs to
submit bids?
Yes No
3. Did each primary contractor either:
a. Contact DBEs included on the Unified Certification Program List (e.g., WisDOT UCP) when soliciting bids?
OR
b. Publish an advertisement in an industry trade publication and/or the official newspaper of record that included
language encouraging DBEs to submit proposals?
Yes No
4. Did your municipality, your primary engineer, and/or primary contractor divide the total scope of work into smaller
tasks and packages to permit maximum utilization of DBEs?
Yes No
6. Did your municipality, your primary engineer, and/or primary contractor use the disadvantaged business services
(obtain lists of certified disadvantaged businesses or request other assistance) of agencies such as the
Wisconsin Department of Transportation or the Small Business Administration?
Yes No
7. Were solicited DBEs provided a reasonable amount of time to respond to requests for bids?
Yes No
8. If you answered "No" to any of the questions in numbers II.1-II.7 above, provide justification or an explanation of why you could not
answer "Yes" to that question. Attach an additional sheet of paper if extra space is required.
5. Did your municipality, your primary engineer, and/or primary contractor establish delivery schedules that enabled
DBEs to compete for contracts or subcontracts?
Yes No
Municipal Certification
I certify that, to the best of my knowledge, the information provided on this form is true, accurate and complete.
Date Signed Signature of Authorized Representative
Project Manager Signature
Yes No
a. Is form filled out completely?
Yes No
b. Did authorized representative sign the form?
Yes No
b. Are submitted justifications and explanations acceptable?
NA
DO NOT WRITE BELOW THIS LINE - DNR USE ONLY
Check applicable program:
