Instructions for Completing the Nebraska Department of Transportation

DBE Annual Affidavit of No Change

Completion and submission of the Nebraska Department of Transportation’s (NDOT) Disadvantaged Business Enterprise (DBE) Annual Affidavit of No Change (Annual Affidavit) is required each year within 30 days prior to a DBE firm’s certification anniversary date. NDOT will not accept affidavits earlier than 30 days prior to the anniversary date.

By signing the Annual Affidavit, the firm’s owner declares, under penalty of perjury, that there have been no unreported changes in the firm’s circumstances affecting its business size, disadvantaged status, ownership or control.

If there have been changes in your firm’s circumstances that may affect its DBE eligibility, you are required to notify the NDOT Highway Civil Rights Office (HCRO) in writing within 30 days of the change. Failure to do so may result in the removal of the firm’s DBE eligibility. Events that may affect your firm’s DBE eligibility include: change in ownership or ownership structure; a change in your personal net worth; the firm’s acquisition of or acquisition by another firm; or an action of decertification, certification suspension, or certification denial taken by another state in which your firm has been or has attempted to be DBE certified. If there have been unreported changes in your firm’s circumstances, submit notice of them with the completed Annual Affidavit.

The Annual Affidavit affirms that your firm continues to meet the Small Business Administration’s (SBA) business size standards for small businesses and does not exceed the U.S. Department of Transportation’s (USDOT) DBE business size cap of $30.40 million. Firms having average annual gross receipts in excess of the $30.40 million over the previous three (3) fiscal years do not qualify as a DBE regardless of the SBA’s business size standards.

In addition to the signed and notarized Affidavit, include the most recent federal business tax return, including all schedules and attachments, for the DBE firm and any of its affiliates and subsidiaries. If you are a sole proprietor or your firm is a LLC and you report the firm’s income on Schedule C of your personal federal tax return, submit your most recent federal personal tax return, including all schedules and attachments.

If you fail to provide a completed Affidavit along with the required tax return and any other applicable documentation in a timely manner, you may be deemed to have failed to cooperate under § 26.109(c) of the federal DBE program regulations, and NDOT will be required to take steps to remove your firm’s eligibility.

If you have any questions regarding the Affidavit, please contact the NDOT HCRO at:

NDOT HCRO – Annual Affidavit

1500 Nebraska Parkway

PO Box 94759

Lincoln NE 68509-4759

(402) 479-4531

ndot.hcro-dbe@nebraska.gov

NDOT DBE ANNUAL AFFIDAVIT OF NO CHANGE

I , as the DBE-qualifying owner of record of the certified DBE firm , do hereby swear and affirm there have been no unreported changes in circumstance or information which affect or may affect the firm’s ability to meet the business size, ownership, control, disadvantaged status, or other eligibility requirements for continued DBE certification as set forth under 49 CFR Part 26 and 13 CFR Part 121 of the federal regulations governing the DBE program.

I swear and affirm that I am socially disadvantaged because I have been subjected to racial or ethnic prejudice or cultural bias, or have suffered the effects of discrimination because of my identity as a member of one or more of the groups identified in 49 CFR Part 26, without regard to my individual qualities. I further swear and affirm that my personal net worth does not exceed $1.32 million and that my adjusted gross income, as averaged over the previous three (3) tax years, does not exceed $350 thousand, and that I am economically disadvantaged because my ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities, as compared to others in the same or similar industry, who are not socially and economically disadvantaged.

I swear and affirm that the firm continues to meet the Small Business Administration’s (SBA) size criteria for small businesses in my industry, as measured by the firm’s annual gross receipts as averaged over the previous three (3) fiscal years. I further swear and affirm that the firm’s three-year averaged annual gross receipts do not exceed $30.40 million. In evidence, I have provided complete copies of the applicable business tax return(s) as required.

DBE Owner Name -- Print	Signature	Date
Phone	Email

Notary Public

County of:	(seal)
State of:
Subscribed and sworn before me on this:
day of of
Notary Public:
Commission expires on:

Submit the completed form, along with any other required or applicable documents to: NDOT HCRO – Annual Affidavit, 1500 Nebraska Parkway, PO Box 94759, Lincoln, NE 68509-4759, or email: ndot.hcro-dbe@nebraska.gov