MARYLAND DEPARTMENT OF TRANSPORTATION
Office of Minority Business Enterprise
I, , a principal of,________________________________________________,
hereby swear and affirm that the information provided in this affidavit and the supporting documentation is true and correct.
CHECK IF NEW
Company Name: _______________________________________________________________________
Mailing Address: _______________________________________________________________________
_____________________________________________________________________
Telephone Number: Fax Number: _______________________
E-mail Address: ________________________________________________________
Website address: _________________________________________________________
NOTE: For purposes of this agreement, the company named above (for which this affidavit is submitted), will henceforth be identified as ‘the firm’.
(Select all boxes that apply):
There are no changes to the information reported on the firm’s most recent certification application, on file with the Maryland
Department of Transportation (MDOT).
There are no changes in the ownership of the firm.
There are no changes in the firm’s operational and/or managerial control, including the board of directors and/or its officers, that may
affect the MBE/DBE/SBE status of the firm.
The firm has not been denied, or decertified by any other certifying agency.
The firm, its directors or officers, have not been found guilty of any violations of the MBE and/or DBE Program in Maryland or any
other state.
The disadvantaged owner(s) Personal Net Worth does not exceed the income caps of $1,788,677 for the MBE program or
$1.32 million for the DBE, SBE or ACDBE programs.
The firm continues to meet the size standard set by the U.S. Small Business Administration (SBA) as determined by industry NAICS
codes.
The firm, if a Maryland domiciled firm or MBE certified firm, remains in Good Standing with the Maryland State Department of
Assessments and Taxes (SDAT).
*Please provide an explanation for any of the boxes not selected (unchecked). You should submit the explanation information on a separate sheet of paper.
PLEASE PROVIDE THE NUMBER OF EMPLOYEES (FULL AND PART TIME) OF THE FIRM FOR EACH OF THE LAST THREE YEARS.
I AM PERSONALLY AUTHORIZED AS THE OWNER OF, ___________________________________, TO MAKE THIS AFFIDAVIT.
Date: _____________________ Signature:______________________________________________
Official notary public to complete the following:
On this, the ________ day of _______________________________, 20______, before me a notary public, the undersigned officer,
personally appeared ____________________________________________________, known to me (or satisfactorily proven) to be the person
whose name is subscribed to the within instrument, and acknowledged that he executed the same in the capacity therein stated, for the purposes therein
contained and that the statements contained therein are true and correct.
IN WITNESS HEREOF, I HEREUNTO SET MY HAND AND OFFICIAL SEAL.
____________________________________________
Notary Public Notary Public
Seal
__________________________________________________________________________
Commission expiration date
Enter Year 2:Enter Year 1 (yyyy):
# of employees:
# of employees:
# of employees: Enter Year 3:
