Fillable WISCONSIN DEPARTMENT of TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISES PROGRAM (Wisconsin)

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WISCONSIN DEPARTMENT of TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISES PROGRAM (Wisconsin)

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  • 25 check-boxes
  • 51 other fields

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Wisconsin DOT Office of Business Opportunity & Equity Compliance
6150 W. Fond Du Lac Avenue, Milwaukee, WI 53218
Phone: (608) 266-0658; Fax: (414)438-5392
Email: DBE_Alert@dot.wi.gov
***
Note: Knowingly and willfully providing false information to the Federal government is
a violation of 18 U.S.C. Section 1001 (False Statements) and could subject you to fines,
imprisonment, or both.
WISCONSIN DEPARTMENT of TRANSPORTATION
DISADVANTAGED BUSINESS ENTERPRISES PROGRAM
Annual No-Change Affidavit Form
This form must be submitted by all firms to verify that they meet the eligibility criteria for participation in the DBE program.
Please complete all sections.
Failure to submit this affidavit and documentation can result in the loss of your firm's DBE certification.
Firm Name:
Mailing Address:
Street Number City State Zip
Billing Address:
(If different)
Street Number City State Zip
Phone Number: ( ) Fax Number: ( )
Business E-mail:
Disadvantaged Owner(s) Information
(please list below and attach an Affidavit Signature Page for each owner):
Name: Phone #: ( ) Email:
Name: Phone #: ( ) Email:
Name: Phone #: ( ) Email:
List of annual gross receipts for the last three years:
Year 20 $
Year 20 $
Year 20 $
List number of employees: Full Time: Part Time:
Business Structure (Check one):
Sole Proprietorship
Partnership
Corporation
Limited Liability Corp
Other (Describe)
Wisconsin DOT Office of Business Opportunity & Equity Compliance
6150 W. Fond Du Lac Avenue, Milwaukee, WI 53218
Phone: (608) 266-0658; Fax: (414)438-5392
Email: DBE_Alert@dot.wi.gov
***
Note: Knowingly and willfully providing false information to the Federal government is
a violation of 18 U.S.C. Section 1001 (False Statements) and could subject you to fines,
imprisonment, or both.
1.
Has the legal structure of your business changed since your last approved affidavit?
NO
If yes, please submit a DBE Change to Business form and all documentation supporting this change
2.
Has the legal management, ownership or control of this firm changed since your last approved affidavit?
NO
If yes, please explain, submit a DBE Change to Business form and provide documentation reflecting this change.
3.
Did any of the disadvantaged owners of this firm obtain ownership interest in another firm since your last approved
affidavit?
NO
If yes, please submit a DBE Change to Business form, provide the name of the firm(s) and all ownership percentages.
4.
Did any of the disadvantaged owners of this firm obtain management duties in another firm since your last approved
affidavit?
NO
If yes, please submit a DBE Change to Business form, provide the name of the firm(s) and list responsibilities
5.
Did any of the disadvantaged owners of this firm obtain employment (fulltime or part-time) elsewhere since your last
approved affidavit?
NO
If yes, please submit a DBE Change to Business form, provide the name of the employer and list your responsibilities
6.
Considering all your assets and liabilities (excluding the value of your personal residence and the value of your
disadvantaged business) is your current personal net worth
greater than $1.32 million dollars,
pursuant to 49 CFR
Part 26, § 26.67 (a)(2){i). (See form below for reference)
NO
If yes, please submit a copy of your current Personal Financial Statement.
7.
Have you added any new work areas to your firm since your last approved affidavit?
NO
If yes, you may contact the DBE Office to request an expansion of your firm’s certified work areas.
8.
Have you submitted your most recent company federal tax returns?
NO
If no, please submit your most recently filed Federal Business Tax form or submit a completed DBE Request for Tax Filing
Extension form.
Forms:
➢
DBE Change to Business form:
https://wisconsindot.gov/Documents/formdocs/dt1012.docx
➢
Personal Financial Statement form:
https://www.transportation.gov/sites/dot.gov/files/docs/DBE%20PNW%20Statement%2011-3-2014.pdf
➢
DBE Request for Tax Filing Extension Form:
https://wisconsindot.gov/Documents/doing-bus/civil-rights/dbe/extenstion-request-fillable-form.pdf
Wisconsin DOT Office of Business Opportunity & Equity Compliance
6150 W. Fond Du Lac Avenue, Milwaukee, WI 53218
Phone: (608) 266-0658; Fax: (414)438-5392
Email: DBE_Alert@dot.wi.gov
***
Note: Knowingly and willfully providing false information to the Federal government is
a violation of 18 U.S.C. Section 1001 (False Statements) and could subject you to fines,
imprisonment, or both.
AFFIDAVIT SIGNATURE PAGE
(Each disadvantaged individual claiming ownership must submit a separate signature page)
I
affirm that there have been no changes in circumstances affecting the above referenced firm's
ability to meet the disadvantaged status, ownership and control requirements of 49 CFR Part 23
and Part 26, and Small Business Administration (SBA) size standard(s) and 13 CFR Part 121.
I
affirm that none of the following have changed:
This means that:
□
I/We know my NAICS code size/threshold and can provide the average of my/our last three years
of gross receipts
□
I/We can certify that this firm does not exceed an average annual gross receipt, over the firm's
previous three fiscal years, in excess of $26.29 million
□
My personal net worth does not exceed $1.32 million, pursuant to 49 CFR Part 26, § 26.67
(a)(2)(i).
□
I am a member of one or more of the groups:
Women, Black Americans, Hispanic Americans, Native Americans, Asian-Pacific Americans,
Subcontinent Asian Americans, or other groups found to be socially and economically
disadvantaged individuals by the SBA identified in 49 CFR Part 26, § 26.5.
There have been no material changes in the information provided with this firm's original certification application,
except for any changes about which I/we have provided written notice to WisDOT pursuant to 49 CFR Part 26, §
26.83(i).
NOTICE TO PROVIDE ALL NECESSARY INFORMATION
Y
ou are required to submit a copy of your most recent company federal taxes to WisDOT annually.
Acceptable documentation includes:
•
Your Firm's most recent Federal Tax Returns including all schedules, or
•
A signed statement from your firm's Bookkeeper or CPA verifying gross receipts.
I understand that failure to submit this affidavit and required documentation within a month of my firm's DBE certification
anniversary could result in decertification from the Disadvantaged Business Enterprise Program of the Wisconsin Department
of Transportation.
(Signature of Owner, Title) Date
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WISCONSIN DEPARTMENT of TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISES PROGRAM (Wisconsin)

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Completed 15 March 2021

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