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Get EPA Form 6100-3

EPA FORM 6100-3 DBE Subcontractor Performance Form The public reporting and recordkeeping burden for this collection of information is estimated to average fifteen 15 minutes. OMB Control No Approved Approval Expires 2090-0030 05/01/2008 01/31/2011 Environmental Protection Agency Disadvantaged Business Enterprise Program DBE Subcontractor Performance Form NAME OF SUBCONTRACTOR1 PROJECT NAME ADDRESS BID/PROPOSAL NO. TELEPHONE NO. E-MAIL ADDRESS PRIME CONTRACTOR NAME CONTRACT ITEM NO. ITEM OF WORK OR DESCRIPTION OF SERVICES BID TO PRIME PRICE OF WORK SUBMITTED TO Currently certified as an MBE or WBE under EPA s DBE Program Yes No Signature of Prime Contractor Date Print Name Title Signature of Subcontractor Date Name Title Subcontractor is defined as a company firm joint venture or individual who enters into an agreement with a contractor to provide services pursuant to an EPA award of financial assistance. Burden means the total time effort or financial resources expended by persons to generate maintain retain or disclose or provide information to or for a Federal agency. This includes the time needed to review instructions develop acquire install and utilize technology and systems for the purposes of collecting validating and verifying information processing and maintaining information and disclosing and providing information adjust the existing ways to comply with any previously applicable instructions and requirements train personnel to be able to respond to a collection of information search data sources complete and review the collection of information and transmit or otherwise disclose the information* An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments on the Agency s need for this information the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden including the use of automated collection techniques to the Director Collection Strategies Division U*S* Environmental Protection Agency 2822 1200 Pennsylvania Ave. NW Washington D*C* 20460. Include the OMB control number in any correspondence. Do not send the completed EPA DBE Subcontractor Performance Form to this address. OMB Control No Approved Approval Expires 2090-0030 05/01/2008 01/31/2011 Environmental Protection Agency Disadvantaged Business Enterprise Program DBE Subcontractor Performance Form NAME OF SUBCONTRACTOR1 PROJECT NAME ADDRESS BID/PROPOSAL NO. TELEPHONE NO. E-MAIL ADDRESS PRIME CONTRACTOR NAME CONTRACT ITEM NO. ITEM OF WORK OR DESCRIPTION OF SERVICES BID TO PRIME PRICE OF WORK SUBMITTED TO Currently certified as an MBE or WBE under EPA s DBE Program Yes No Signature of Prime Contractor Date Print Name Title Signature of Subcontractor Date Name Title Subcontractor is defined as a company firm joint venture or individual who enters into an agreement with a contractor to provide services pursuant to an EPA award of financial assistance. .

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  • Subcontractor
  • validating
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