U.S. DOT Personal Net Worth Statement for DBE/ACDBE Program Eligibility • Page 4 of 5
General Instructions for Completing the
Personal Net Worth Statement
for DBE/ACDBE Program Eligibility
Please do not make adjustments to your figures pursuant to
U.S. DOT regulations 49 C.F.R. Parts 23 and 26. The
agency that you apply to will use the information provided
on your completed Personal Net Worth (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 individual’s personal net worth according to 49 C.F.R.
Parts 23 and 26 includes only his or her own share of assets
held separately, jointly, or as community property with the
individual’s spouse and excludes the following:
• Individual’s ownership interest in the applicant firm;
• Individual’s equity in his or her primary residence;
• Tax and interest penalties that would accrue if retirement
savings or investments (e.g., pension plans, Individual
Retirement Accounts, 401(k) accounts, etc.) were
distributed at the present 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. Parts 23 and
26, the firm is not eligible 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 is certified,
the firm is no longer eligible for certification. Should that
occur, it is your responsibility to contact your certifying
agency in writing to advise that your firm no longer qualifies
as a DBE or ACDBE. You must fill out all line items on the
Personal Net Worth Statement.
If necessary, use additional sheets of paper to report all
information and details. If you have any questions about
completing this form, please contact one of the UCP
certifying agencies.
Assets
All assets must be reported at their current fair market values
as of the date of your statement. Assessor’s assessed value
for real estate, for example, is not acceptable. Assets held
in a trust should be included.
Cash and Cash Equivalents: On page 1, enter the total
amount of cash or cash equivalents in bank accounts,
including checking, savings, money market, certificates of
deposit held domestic or foreign. Provide copies of the bank
statement.
Retirement Accounts, IRA, 401Ks, 403Bs, Pensions: On
page 1, enter the full value minus tax and interest penalties
that would apply if assets were distributed as of the date of
the form. Describe the number of shares, name of securities,
cost market value, date of quotation, and total value in
section 3 on page 2.
Brokerage and Custodial Accounts, Stocks, Bonds,
Retirement Accounts: Report total value on page 1, and on
page 2, section 3, enter the name of the security, brokerage
account, retirement account, etc.; the cost; market value of
the asset; the date of quotation; and total value as of the date
of the PNW statement.
Assets Held in Trust: Enter the total value of the assets held
in trust on page 1, and provide the names of beneficiaries
and trustees, and other information 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 entity in which you hold an ownership interest, and
other receivables not listed above. Complete Section 6 on
page 3.
Real Estate: The total value of real estate excluding your
primary residence should be listed on page 1. In section 4 on
page 2, please list your primary residence in column 1,
including the address, method of acquisition, date of
acquired, names of deed, purchase price, present fair market
value, source of market valuation, names of all mortgage
holders, mortgage account number and balance, equity line
of credit balance, and amount of payment. List this
information for all real estate held. Please ensure that this
section contains all real estate owned, including 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, enter the cash surrender value of
this asset. In section 5 on page 2, enter the name of the
insurance company, the face value of the policy, cash
surrender value, beneficiary names, and loans on the policy.
Other Personal Property and Assets: Enter the total value
of personal property and assets you own on page 1. Personal
property includes motor vehicles, boats, trailers, jewelry,
furniture, household goods, collectibles, clothing, and
personally owned vehicles that are leased or rented to
businesses or other individuals. In section 6 on page 3, list
these assets and enter the present value, the balance of any
liabilities, whether the asset is insured, and lien or note
information and terms of payments. For accounts and notes
receivable, enter the total value of all monies owed to you
personally, if any. This should include shareholder loans to
the applicant firm, if those exist. If the asset is insured, you
may be asked to provide 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 the total value of your other business
investments (excluding the applicant firm). In section 7 on
page 3, enter information concerning the businesses you
