Form OBEO-0013 "Disadvantaged Business Enterprise out-Of-State Certification Declaration" - California

What Is Form OBEO-0013?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form OBEO-0013 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

ADVERTISEMENT
ADVERTISEMENT

Download Form OBEO-0013 "Disadvantaged Business Enterprise out-Of-State Certification Declaration" - California

151 times
Rate (4.3 / 5) 7 votes
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
DISADVANTAGED BUSINESS ENTERPRISE
CALIFORNIA UNIFIED
OUT-OF-STATE CERTIFICATION DECLARATION
CERTIFICATION PROGRAM
(CUCP)
OBEO-0013 (NEW 01/2020)
Instructions: As an out of state applicant, your firm must be currently certified as a Disadvantaged Business Enterprise (DBE) or Airport
Concession Disadvantaged Business Enterprise (ACDBE) pursuant to 49 Code of Federal Regulations Part 23 or 26 in your “home” state
before you can apply to the California Unified Certification Program (CUCP). Pursuant to 49 CFR § 26.85(c), the firm’s owner(s) (hereinafter
“you”) acknowledge and agree to comply with the following regulations:
(1) You must provide to the CUCP, along with this declaration form, a complete copy of the application form, all supporting documents, and any
other information you have submitted to your home state or any other state related to your firm’s DBE or ACDBE certification. This includes
affidavits of no change (see § 26.83(j)) and any notices of changes (see § 26.83(i)) that you have submitted to your home state, as well as
any correspondence you have had with your home state’s UCP or any other government entity concerning your application or status as a
DBE or ACDBE firm.
(2) You must also provide to the CUCP any notices or correspondence from states other than your home state relating to your status as an
applicant or certified DBE in those states, if applicable. For example, if you have been denied certification or decertified by a state UCP
other than your home state, or subject to a decertification action there, you must inform the CUCP of this fact and provide all documentation
concerning this action to the CUCP.
(3) If you have filed a certification appeal with the U.S. Department of Transportation (DOT) (see § 26.89), you must inform the CUCP of this
fact and provide your letter of appeal and DOT’s response to the CUCP.
(4) You must submit this declaration form executed under penalty of perjury of the laws of the United States.
(i) This declaration must affirm that you have submitted all the information required by 49 CFR 26.85(c) and the information is complete
and, in the case of the information required by § 26.85(c)(1), is an identical copy of the information submitted to your home state.
(ii) If the on site report from your home state supporting your certification in your home state is more than three years old, as of the date of
your application to the CUCP, please acknowledge in your declaration that you also affirm that the facts in the on site report remain true
and correct.
A. Home State Certification
Name of Certifying Agency in Firm’s State
Is your firm currently certified as a DBE or ACDBE in
DBE
your home state? (If Yes, check appropriate box and
provide requested information. If No, please STOP
Has your firm’s state UCP conducted an on-site visit?
and apply to your state Unified Certification Program
ACDBE
before applying to California.)
Yes, on
/
/
No
I affirm that the facts in the on-site report conducted by my state UCP over three years ago from the date of this
Check if applicable
declaration remain true and correct.
B. Contact Information
(1) Contact Person and Title
(2) Legal Name of Firm
(3) Phone #
(4) Other Phone #
(5) Fax #
(6) E-mail
(7) Website (If available)
City
County/Parish
(8) Street Address of Firm (No P.O. Box)
State Zip
(9) Mailing Address of Firm (If different)
City
County/Parish
State Zip
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
DISADVANTAGED BUSINESS ENTERPRISE
CALIFORNIA UNIFIED
OUT-OF-STATE CERTIFICATION DECLARATION
CERTIFICATION PROGRAM
(CUCP)
OBEO-0013 (NEW 01/2020)
Instructions: As an out of state applicant, your firm must be currently certified as a Disadvantaged Business Enterprise (DBE) or Airport
Concession Disadvantaged Business Enterprise (ACDBE) pursuant to 49 Code of Federal Regulations Part 23 or 26 in your “home” state
before you can apply to the California Unified Certification Program (CUCP). Pursuant to 49 CFR § 26.85(c), the firm’s owner(s) (hereinafter
“you”) acknowledge and agree to comply with the following regulations:
(1) You must provide to the CUCP, along with this declaration form, a complete copy of the application form, all supporting documents, and any
other information you have submitted to your home state or any other state related to your firm’s DBE or ACDBE certification. This includes
affidavits of no change (see § 26.83(j)) and any notices of changes (see § 26.83(i)) that you have submitted to your home state, as well as
any correspondence you have had with your home state’s UCP or any other government entity concerning your application or status as a
DBE or ACDBE firm.
(2) You must also provide to the CUCP any notices or correspondence from states other than your home state relating to your status as an
applicant or certified DBE in those states, if applicable. For example, if you have been denied certification or decertified by a state UCP
other than your home state, or subject to a decertification action there, you must inform the CUCP of this fact and provide all documentation
concerning this action to the CUCP.
(3) If you have filed a certification appeal with the U.S. Department of Transportation (DOT) (see § 26.89), you must inform the CUCP of this
fact and provide your letter of appeal and DOT’s response to the CUCP.
(4) You must submit this declaration form executed under penalty of perjury of the laws of the United States.
(i) This declaration must affirm that you have submitted all the information required by 49 CFR 26.85(c) and the information is complete
and, in the case of the information required by § 26.85(c)(1), is an identical copy of the information submitted to your home state.
(ii) If the on site report from your home state supporting your certification in your home state is more than three years old, as of the date of
your application to the CUCP, please acknowledge in your declaration that you also affirm that the facts in the on site report remain true
and correct.
A. Home State Certification
Name of Certifying Agency in Firm’s State
Is your firm currently certified as a DBE or ACDBE in
DBE
your home state? (If Yes, check appropriate box and
provide requested information. If No, please STOP
Has your firm’s state UCP conducted an on-site visit?
and apply to your state Unified Certification Program
ACDBE
before applying to California.)
Yes, on
/
/
No
I affirm that the facts in the on-site report conducted by my state UCP over three years ago from the date of this
Check if applicable
declaration remain true and correct.
B. Contact Information
(1) Contact Person and Title
(2) Legal Name of Firm
(3) Phone #
(4) Other Phone #
(5) Fax #
(6) E-mail
(7) Website (If available)
City
County/Parish
(8) Street Address of Firm (No P.O. Box)
State Zip
(9) Mailing Address of Firm (If different)
City
County/Parish
State Zip
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
DISADVANTAGED BUSINESS ENTERPRISE
CALIFORNIA UNIFIED
OUT-OF-STATE CERTIFICATION DECLARATION
CERTIFICATION PROGRAM
(CUCP)
OBEO-0013 (NEW 01/2020)
C. Indicate Counties Where You Prefer to Perform Work
01 Alameda
11 Glenn
21 Marin
31 Placer
41 San Mateo
51 Sutter
02 Alpine
12 Humboldt
22 Mariposa
32 Plumas
42 Santa Barbara
52 Tehama
03 Amador
13 Imperial
23 Mendocino
33 Riverside
43 Santa Clara
53 Trinity
04 Butte
14 Inyo
24 Merced
34 Sacramento
44 Santa Cruz
54 Tulare
05 Calaveras
15 Kern
25 Modoc
35 San Benito
45 Shasta
55 Tuolumne
06 Colusa
16 Kings
26 Mono
36 San Bernardino
46 Sierra
56 Ventura
07 Contra Costa
17 Lake
27 Monterey
37 San Diego
47 Siskiyou
57 Yolo
08 Del Norte
18 Lassen
28 Napa
38 San Francisco
48 Solano
58 Yuba
09 El Dorado
19 Los Angeles
29 Nevada
39 San Joaquin
49 Sonoma
10 Fresno
20 Madera
30 Orange
40 San Luis Obispo
50 Stanislaus
Checklist
Attach a copy of your complete DBE/ACDBE application package, all supporting documents, and any other information that was submitted
to your state UCP, including but not limited to affidavits or declarations of no change, and notices of changes. Failure to do so will render
your application to California incomplete and will be cause for rejection.
Any and all notices or correspondence from states other than your home state relating to your status as an applicant or certified DBE in
those states.
Letter of appeal and DOT response, if any.
DECLARATION OF CERTIFICATION
{This form must be signed by the owner(s) upon which disadvantaged status is relied}
A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS 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 LAW.
I,
(full name printed), swear or affirm under penalty of law that I am
(title) of applicant firm
(firm name) and declare under penalty of perjury that the accompanying
application package and documentation is identical to that provided to my state unified certification program. I further affirm that the information
gathered by my state unified certification program during its on-site review remains true and correct. I recognize that the information submitted in
this application and accompanying documentation are for the purpose of obtaining certification approval by a government agency. I understand
that a government agency may, by means it deems appropriate, determine the accuracy and truth of the statements in the application, and I
authorize such agency to contact any entity named in my home state application, and the named firm’s bonding companies, banking institutions,
credit agencies, contractors, clients, and other certifying agencies for the purpose of verifying the information supplied and determining the
named firm’s eligibility. I further understand that I may be required to provide additional information and documentation not previously submitted,
including but not limited to updated tax returns, business and personal financial information, and changes affecting ownership and control.
I agree to submit to government audit, examination and review of books, records, documents and files, in whatever form they exist, of the named
firm and its affiliates, inspection of its place(s) of business and equipment, and to permit interviews of its principals, agents, and employees. I
understand that refusal to permit such inquiries shall be grounds for denial of certification.
I declare under penalty of perjury of the laws of the United States that I have submitted all the information required by 49 CFR 26.85(c) and the
information is complete and, in the case of the information required by § 26.85(c)(1), is an identical copy of the information submitted to my home
state.
Executed on
(Date)
Signature
(DBE/ACDBE Applicant)
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
Page of 2