ODOT Small Business Enterprise Application

Ohio Department of Transportation Central Office • 1980 West Broad Street • Columbus, OH 43223 John R. Kasich, Governor • Jerry Wray, Director

The purpose of the Small Business Enterprise (SBE) Certification Application is to verify eligibility in the program for the owner(s) and company. This information is required to become certified as a Small Business Enterprise.

ELIGIBILITY REQUIREMENTS AND CERTIFICATION PROCESS: All firms must complete the application form. DBE certified firms that meet the size standards are rebuttably presumed to be eligible for SBE Certification. Regardless of gender and ethnicity of the firm’s owner, the company and ODOT will follow the certification procedures and application process outlined in 49 CFR Part 26. This may include a site visit to the applicant’s primary business location.

A Small Business Enterprise is: 1) A firm 51% or more owned and controlled by an individual whose personal net worth and adjusted gross income do not exceed the amount stated in 49 CFR Part 26.67. 2) A for-profit business whose annual receipts for the firm averaged over the most recent three years does not exceed $15,000,000 (construction firms) or $7,000,000 (construction-related consultant services firms).

To complete this document: V. Enter the Company Information in Section 1. VI. Check the appropriate box for documents in Section 2. VII. Provide supporting documents as required. VIII. Sign and date the Application. Submit the entire document with supporting documents to your certifying agent with the application.

Section 1: Company Information

IX. Legal name of business: X. Other names used by business:

XI. Website (if have one): XII. Federal tax ID:

XIII. Company phone #: XIV. Mobile phone #: XV.Company fax #:

XVII. County (only if an Ohio XVI. E-mail address: company)

XVIII. Street address of company (No P.O. City: State: Zip: box): Ohio Department of Transportation Central Office • 1980 West Broad Street • Columbus, OH 43223 John R. Kasich, Governor • Jerry Wray, Director

XIX. Mailing address of company (if City: State: Zip: different):

of 2 Section 2: Supporting Documents Checklist In order to complete your SBE certification, you must attach copies of all of the following documents as they apply to you and your company.

All Applicants Signed Federal Business Taxes for the past three years (copies of all schedules and forms referenced by the tax returns must be included). Signed Federal Individual Taxes for the past three years (copies of all schedules and forms referenced by the tax returns must be included). Personal Net Worth Statement (exclude equity in personal residence and equity interest in the firm) transportation.ohio.gov/dbe

Section 3: Declaration I declare, that as an owner, I have full knowledge of the operation of my firm and that to the best of my knowledge and belief, the information submitted to the Ohio Department of Transportation to support my firm’s certification as a Small Business Enterprise is true. The gross income for my firm is as shown below.

I declare that the firm meets the Small Business Administration (SBA) criteria for being a small business concern and its number of employees and average annual gross receipts (as defined by the SBA rules) over the firm’s previous three fiscal years do not exceed $15,000,000 for construction firms or $7,000,000 for construction-related consultant services firms.

Legal name of business:

Year: Firm’s Gross Income:

I declare that each owner on whom the firm is relying for certification in the program does not exceed the personal net worth limit of $1.32 million or the adjusted gross income limit of $350,000 (Average AGI over the most recent three year period). (Attach additional signature pages for each owner).

I recognize and accept the statements above governing the consideration of this declaration and the maintenance of my firm’s certified status. I agree to provide written notice to ODOT of any material change in the information contained in the original application within 30 days of such change (e.g., ownership, address, telephone number, etc.). By my signature, I declare that I have read and understand this statement and that I have the authority to sign this declaration and that the responses, foregoing statements, and accompanying documents are true, complete, and correct and include all materials requested under penalty of perjury under the laws of the United States; and further that a material or false statement or omission made in connection with the application is sufficient cause for denial of certification, revocation of a prior approval, initiation of suspension or debarment proceedings, and may subject the person and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable federal and state laws.

Name of Firm: Authorized Representative Print Name and Title:

Signature: Date:

OFFICE USE ONLY Due Date Date Reviewed

Certifying Agent

Certifying Agency Form SB-1 Created 2014102