Ohio DBE Annual Affidavit Form

1. Has the ownership, management, or control of the company changed in any way in the past year? Yes No

If Yes, please use section 3, the Company Owners and Representatives form, to indicate modifications.

2. Have there been any investments or contributions of capital in the company over the past year? Yes No

If Yes, please provide details under the Asset Transfers heading in section 4C.

3. Has the company or any of its owners, board members, officers, or management been denied certification, denied re-certification, or been decertified as a DBE in the past year? Yes No

If Yes, please provide details on the denial or decertification in section 4A.

4. Has the company purchased or liquidated any real estate or facilities including office and/or storage space in the past year? Yes No

If Yes, please list those things that have been acquired or liquidated in section 4C.

5. Has the company purchased or liquidated any equipment or vehicles in the past year? Yes No

If Yes, please list those things that have been acquired or liquidated in section 4C.

6. Has the company or individual owners entered into any new loans, notes payable, promissory notes, etc. in the past year? Yes No

If Yes, please use the Loan Information heading in section 4C to list them.

7. Has the company or individuals within the company acquired new (or lost) licenses and/or permits in the past year? Yes No

If Yes, please list details about those that have been acquired or lost in section 4D.

8. Have the areas of work performed by the company changed in the past year? Yes No

If Yes, please use section 4B, Types of Work, to list those areas that are new or are no longer applicable. Be as descriptive as possible.

9. Please record the company’s annual gross receipts for the most recent fiscal year.

10. Please make sure to record a Personal Net Worth statement for each owner in the company for the most recent tax year.

Check all that apply:

Is the employee an officer of the company? Yes No

Is the employee a member of the board of directors? Yes No

Please list any businesses this individual owns or works for that have relationships with this company:

Please list any management or supervisory roles this individual has in other businesses:

Please list all investments made to acquire current ownership stake in the company:

Do any of your immediate family members own or manage another company?

If Yes, then list (use additional space if needed):

Is your company currently certified as a DBE in its home state?

If Yes, has your company’s state UCP conducted an on-site visit?

Equipment

Vehicles

Office space

Storage space

Asset Transfers

In order to complete your annual affidavit for DBE certification, you must attach copies of all of the following documents as they apply to you and your company.

Additional document types:

I recognize and accept the statements above governing the consideration of this affidavit and the maintenance of my business’ certified status.

On this day of before me appeared

to me personally known, who, being duly sworn, did execute the foregoing affidavit.