The Michigan Department of Transportation (MDOT) Form 4106 is a crucial document designed to ascertain the eligibility of non-Disadvantaged Business Enterprises (non-DBEs) for participation in MDOT's Small Business Program projects. It serves as an annual application that businesses must submit at least 30 days prior to bidding, whereas certified DBEs are exempt but must undergo annual small business size verification. This form is integral for businesses aiming to engage with MDOT's Small Business Program, assessing aspects such as business size based on gross receipts or employee count and affiliations. To ensure your business can compete for MDOT projects, click the button below to fill out Form 4106.
Unlocking opportunities and ensuring equal access to bidding on projects within the Michigan Department of Transportation (MDOT) Small Business Program necessitates a thorough understanding of the Michigan 4106 form. Serving as a critical tool, this form helps in determining the eligibility of non-Disadvantaged Business Enterprises (non-DBEs) to participate in MDOT's procurement process. It is a mandatory requirement that this form is submitted annually, at least 30 days before participating in bidding activities. However, it's worth noting that certified DBEs are exempt from this requirement as their small business status is verified annually as part of their certification maintenance. This application requires detailed business information, including the name and address of the business, the chief products or services provided, and the identification of significant stakeholders such as owners, partners, and principal stockholders. Additionally, the form delves into financial metrics to evaluate if a business qualifies as a small business under the standards set by the Small Business Administration (SBA), including gross receipts and the total number of employees. Furthermore, for businesses with affiliates or subsidiaries, the form requires detailed information on these entities to ensure comprehensive understanding and adherence to the size standards. With sections dedicated to small business size determination and certifications to affirm the accuracy of the information provided, the Michigan 4106 form stands as a crucial step for non-DBEs aimed at participating in MDOT's efforts to encourage small business participation in state projects.
Michigan Department
Of Transportation
4106 (10/12)
SMALL BUSINESS PROGRAM APPLICATION
Page 1 of 9
This form is used to determine eligibility of non-Disadvantaged Business Enterprises (non-DBEs) to bid on Michigan Department of Transportation (MDOT) Small Business Program projects. This application must be submitted once a year, at least 30 days in advance of bidding.
Certified DBEs do not need to complete this form - annual verification of small business size is a requirement of certification.
Part 1. Information relating to applicant business only
NAME OF BUSINESS
ADDRESS OF BUSINESS
CITY
STATE
ZIP CODE
NAME AND TITLE OF AUTHORZIED SIGNER FOR THIS BUSINESS
TELEPHONE NO.
FAX NO.
E-MAIL ADDRESS
WHAT IS THE FEDERAL YEAR END TAX DATE FOR THE APPLICANT BUSINESS (Month/Date)
DESCRIBE THE MAJOR PRODUCTS OR SERVICES YOUR BUSINESS PROVIDES
1A. Business Major Products or Services – see FHVVJRYHRVZZZDLFV
Products/Services
NAICS Code
1B. Name and address of owner, partners, principal stockholders, or members of business
organization. Please denote the type of partners
Percent of voting stock or
kinds of interest
1C. Name of all officers
Address for each officer
1D. Name of the Board of Directors of this
Address of each member of the Board of Directors
business, if a corporation
MDOT 4106 (10/12)
Page 2 of 9
1E. If any person listed in 1B, 1C, or 1D is an owner, partner, director, officer, member, employee or principal stockholder in
another business, please provide the following information (add extra pages if needed).
Name of Person
Business Name and Address
Position Held
%Interest in
Business
1F. Small Business Size Determination – Business Gross Receipts per tax form
Please complete this section if the NAICS codes identified is section 1A. base business size on gross receipts. The small business size table is available at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.xls Under “Table of Size Standards.” You must provide copies of U.S. business tax forms showing gross receipts earned for the three consecutive fiscal years reported below for this business.
YEAR
DOLLARS
20
$
Total
1G. Total number of employees of the applicant business
Please complete this section if the NAICS codes identified in 1A determine business size using total number of employees. See http://www.sba.gov/sites/default/files/files/Size_Standards_Table.xls “Table of Size Standards.” You must provide copies of U.S. business tax forms showing total number of employees.
TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)
Part 2. Affiliates and Subsidiaries, including those identified in Part 1E.
13 CFR 121 – Stock ownership has to be 50% or more in another company – including when ownership is shared among several people.
BUSINESS NAME
PRODUCTS/SERVICES
NAICS CODE
Page 3 of 9
2A. Gross sales or receipts of 1st affiliate business for the past three fiscal years
You must provide copies of U.S. business tax forms for the fiscal years reported below which show gross receipts of all subsidiaries or affiliates.
NAME AND ADDRESS OF AFFILIATE OR SUBSIDIARY
2B. Gross sales or receipts of 2nd affiliate business for the past three fiscal years
You must provide copies of U.S. business tax forms for the fiscal years reported below which show gross receipts of all subsidiaries or affiliates. If you have more than two affiliates or subsidiaries, please attach additional pages for those affiliates.
NAME AND ADDRESS OF 2nd AFFILIATE
2C. Total number of employees of 1st affiliate
Please complete this section if the NAICS codes identified in section 1A. base business size on number of employees. The small business size table is available at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.xls under “Table of Size Standards.” You must provide copies of U.S. business tax forms showing total numbers of full-time, part-time, temporary, or seasonal employees who have worked for this affiliate during each of the last three consecutive fiscal years.
2D. Total number of employees of 2nd affiliate
Please complete this section if the NAICS codes identified in section 1A. base business size on number of employees.
The small business size table is available at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.xls under “Table of
Size Standards.” You must provide copies of U.S. business tax forms showing total numbers of full-time, part-time, temporary, or seasonal employees who have worked for this affiliate during each of the last three consecutive fiscal years. If you have more than two affiliates, attach separate pages containing the required information.
CERTIFICATION
I hereby certify that all information provided on this form and in attachments are true and correct to the best of my knowledge and belief. This information is submitted for the purpose of assisting the MDOT in making a size determination in order that my business may participate in the Race-Neutral Small Business Program.
NAME OF SOLE PROPRIETORSHIP, PARTNERSHIP, LIMITED LIABILITY COMPANY, OR CORPORATION
SIGNATURE
NAME AND TITLE
DATE OF SIGNING
Page 4 of 9
Instructions FOR SMALL BUSINESS Program application
For participation in the Michigan Department of Transportation (MDOT)
SMALL BUSINESS PROGRAM
Carefully read these instructions and the United States Small Business Administration (SBA) size regulations found at 13 Code of Federal Regulations Part 121 before completing this form.
To qualify for the Small Business Program, applicants must meet SBA small business size standards for the industry in which the applicant will be bidding.
No business, including affiliates and subsidiaries, will qualify for this program if gross receipts as averaged over the previous three years exceed $22.41 million.
General Instructions
1.Information provided will be used by the MDOT to determine small business size of non- disadvantaged business enterprises (non-DBEs). MDOT may, at its discretion, request additional information not specifically identified on this form.
a.Non-DBEs must provide this information once a year, or at least 30 days before bidding, in order to bid on Small Business Program projects.
b.Michigan-certified DBEs do not need to complete this form. Annual verification of small business size is a condition of DBE certification.
2.Select North American Industry Classification System (NAICS) codes that best describe your business and then determine if the business meets size standards for the selected codes. SBA size standards are usually stated either in number of employees over the past 12 months, or average annual receipts over the past three years – whichever number represents the largest size of your business right now (including subsidiaries and affiliates). Size standards are available for every private sector industry in the U.S. economy, with the NAICS used to identify the industries. The steps are simple to determine your size:
a.Identify the NAICS code(s) that best describe(s) your business activities. http://www.census.gov/eos/www/naics/
See Identifying Industry Codes at http://www.sba.gov/content/identifying-industry- codes for more helpful resources.
b.Determine your Industry's size standard using the Table of Small Business Size Standards at http://www.sba.gov/content/table-small-business-size-standards. Match your NAICS code(s) with the appropriate size standard(s).
3.One copy of MDOT SBP Application, with additional sheets attached as needed, must be returned to the MDOT Office of Business Development.
4.The person signing this form must be authorized to do so. Non-employee representatives of the business, such as attorneys or accountants, must provide a letter authorizing them to represent the firm. The information requested must be complete. Failure to supply complete information may cause delays in making a size determination or impose adverse inferences that the business is not small.
5.All affiliates of the business, whether acknowledged or not, and whether foreign or domestic, must be disclosed. SBA's criteria for defining affiliates should be carefully reviewed. In 13 CFR §121.103, SBA identifies various forms of affiliation.
Page 5 of 9
6.Where the applicable size standard involves "number of employees", a business' average number of employees on payroll before for the 12 months preceding the application or offers is examined, including all individuals who are fulltime, part-time, temporary or other basis, of both domestic and foreign affiliates. See 13 CFR § 121.106 of SBA's regulations.
7.Where applicable size standards involve "average annual receipts", a business' annual receipts mean total income (or gross income in the case of a sole proprietorship) plus cost of goods sold as these terms are defined and reported on the business' Federal Income Tax Return, which must be attached to this eligibility request determination. See 13 CFR § 121.104 of SBA's regulations.
8.MDOT must determine the primary industry activity or the NAICS code of a business as part of its size determination for the Small Business Program. In making this size determination, consideration is given to various criteria, such as the distribution of a business' revenues, employment and costs associated with doing business. See 13 CFR 121.107.
9.For purposes of this form, MDOT considers a principal of the business as those persons or affiliated businesses that own 10 percent or more of its ownership. In cases where no individual or affiliated business owns at least 10 percent interest, the five largest interest holders and their percentages of interest must be listed. Additionally, the principal officers and their interest in the business must be listed.
10.Affiliation is defined in the Small Business Administration (SBA) regulations, 13 CFR part 121.
(1)Except as otherwise provided in 13 CFR part 121, concerns are affiliates of each other when, either directly or indirectly:
(i)One concern controls or has the power to control the other; or
(ii)A third party or parties controls or has the power to control both; or
(iii)An identity of interest between or among parties exists such that affiliation may be found.
(2)In determining whether affiliation exists, it is necessary to consider all appropriate factors, including common ownership, common management, and contractual relationships. Affiliates must be considered together in determining whether a concern meets small business size criteria and the statutory cap on the participation of firms in the DBE program.
(6)In determining the concern's size, SBA counts the receipts, employees, or other measure of size of the concern whose size is at issue and all of its domestic and foreign affiliates, regardless of whether the affiliates are organized for profit.
(b)Exceptions to affiliation coverage. (1) Business concerns owned in whole or substantial part by investment companies licensed, or development companies qualifying, under the Small Business Investment Act of 1958, as amended, are not considered affiliates of such investment companies or development companies.
(7)(c) Affiliation based on stock ownership. (1) A person (including any individual, concern or other entity) that owns, or has the power to control, 50 percent or more of a concern's voting stock, or a block of voting stock which is large compared to other outstanding blocks of voting stock, controls or has the power to control the concern.
(7)(4)(e) Affiliation based on common management. Affiliation arises where one or more officers, directors, managing members, or partners who control the board of directors and/or management of one concern also control the board of directors or management of one or more other concerns.
Page 6 of 9
(f)Affiliation based on identity of interest. Affiliation may arise among two or more persons with an identity of interest. Individuals or firms that have identical or substantially identical business or economic interests (such as family members, individuals or firms with common investments, or firms that are economically dependent through contractual or other relationships) may be treated as one party with such interests aggregated. Where SBA determines that such interests should be aggregated, an individual or firm may rebut that determination with evidence showing that the interests deemed to be one are in fact separate.
PENALTIES FOR CRIMINAL VIOLATIONS
It is a criminal offense to misrepresent in writing the status of a concern as a small business in order to obtain a prime or subcontract contract awarded pursuant to Section 9 or 15 of the Act (15 U.S.C. § 638 and § 644) and Section 8(a) of the Act ( 15 U.S.C. § 637(a)) or subcontract included as part or all of a goal contained in a subcontracting plan required according to the Section 8(d) of the Act (15 U.S.C. § 637 (d)), or prime or subcontract awarded under Federal Law that references Section 8(d) of the Act (15 U.S.C. § 637 (d)) that defines eligibility for such programs as the Small and Disadvantaged Business contracting program. Under Section 16(d) of the Act (15 U.S.C. 645(d)), the punishment for this offense is imprisonment of not more than 10 years or a fine of not more than $500,000 or both. It can also result in certain administrative penalties, such as suspension or debarment from further contracting with the US Government.
Page 7 of 9
PERSONAL FINANCIAL STATEMENT
As of
,
Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning or (4) any person or entity providing a guaranty loan.
Name
Business Phone
Residence Address
Residence Phone
City, State, & Zip Code
Business Name of Applicant/Borrower
ASSETS
(Omit Cents)
LIABILITIES
Cash on hand & in Banks
Accounts Payable
Savings Accounts
Notes Payable to Banks and Others
IRA or Other Retirement Account
(Describe in Section 2)
Accounts & Notes Receivable
Installment Account (Auto)
Life Insurance-Cash Surrender Value Only
Mo. Payments
(Complete Section 8)
Installment Account (Other)
Stocks and Bonds
(Describe in Section 3)
Loan on Life Insurance
Real Estate
Mortgages on Real Estate
(Describe in Section 4)
Automobile-Present Value
Unpaid Taxes
Other Personal Property
(Describe in Section 6)
(Describe in Section 5)
Other Liabilities
Other Assets
(Describe in Section 7)
Total Liabilities
Net Worth
Section 1.
Source of Income
Contingent Liabilities
Salary
As Endorser or Co-Maker
Net Investment Income
Legal Claims & Judgments
Real Estate Income
Provision for Federal Income Tax
Other Income (Describe below)*
Other Special Debt
Description of Other Income in Section 1.
*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.
Section 2. Notes Payable to Banks and Others. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Name and Address of Noteholder(s)
Original Balance
Current Balance
Payment
Amount
Frequency
(monthly,etc.)
How Secured or Endorsed
Type of Collateral
(tumble)
Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed).
Number of Shares
Name of Securities
Cost
Market Value
Quotation/Exchange
Date of
Total Value
Section 4. Real Estate Owned.
(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part
of this statement and signed.)
Property A
Property B
Property C
Type of Property
Address
Date Purchased
Original Cost
Present Market Value
Name &
Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage
Section 5. Other Personal Property and Other Assets.
(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms
of
payment and if delinquent, describe delinquency)
Section 6.
Unpaid Taxes.
(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)
Section 7. Other Liabilities. (Describe in detail.)
Section 8.
Life Insurance Held.
(Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)
I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001).
Signature:
Date:
Social Security Number:
Page 9 of 9
Small Business Program (SBP) Application Checklist and
required attachments:
Legal business name: ______________________________
PERSONAL NET WORTH (PNW)
All owners of businesses applying for the SBP must have a pnw less than $1.32 million. This figure excludes each owner’s primary residence, and the value of the business applying for participation in the SBP.
SMALL BUSINESS PROGAM SIZE
Businesses, including affiliates, qualifying for the SBP must not exceed the U.S. Small Business Administration size standard(s) for the North American Industry Classification (NAICS) code for the type(s) of work performed. In no case shall any eligible business, including affiliate businesses, have gross receipts over $22.41 million as averaged over the three most recent tax years.
The following documents must be provided in order for MDOT to determine eligibility to participate in the SBP:
A completed copy of the entire SBP application, signed and notarized with last 4 digits of SS #.
All assets listed as joint on PNW must provide a break down for each individual.
The personal financial statement must include the value of ownership in all other companies owned by the applicant.
United States 1040 Personal Income Tax Returns for the most recent three (3) consecutive years (i.e., 2009, 2010, 2011)
O Include all schedules and W-2’s.
Federal business tax returns for the most recent three (3) consecutive years for the applicant business and all affiliate businesses:
O Include all business tax schedules and required attachments and W-3’s.
Please DO NOT bind or staple the application
Mail completed application to the following address:
MDOT Office of Business Development,
P.O. Box 30050,
Lansing, Michigan 48909
Note: Incomplete application packages will be returned.
Completing the Michigan Department of Transportation (MDOT) 4106 form is a crucial step for non-Disadvantaged Business Enterprises (non-DBEs) that wish to participate in the Small Business Program for bidding on MDOT projects. This process is required annually, at least 30 days before bidding, to ensure eligibility based on small business standards. The following instructions are designed to assist in filling out the form accurately to avoid any possible delays or issues in the determination process.
Once the MDOT 4106 form is fully completed and reviewed for accuracy, it must be submitted to the MDOT Office of Business Development. It is critical to ensure all parts of the form are completed thoroughly, as missing or inaccurate information may delay the review process or adversely impact the size determination and eligibility to participate in the Small Business Program.
The Michigan 4106 form is an application utilized by the Michigan Department of Transportation (MDOT) to determine the eligibility of non-Disadvantaged Business Enterprises (non-DBEs) for participation in the Small Business Program on MDOT projects. This application is crucial for small businesses aiming to bid on MDOT Small Business Program projects, as it verifies their small business status according to specific size standards. It's required to be submitted annually, at least 30 days before bidding on projects. However, it’s important to note that certified DBEs are not required to complete this form due to undergoing an annual verification process that already confirms their small business size.
The Michigan 4106 form must be completed by non-Disadvantaged Business Enterprises (non-DBEs) that wish to participate in the Small Business Program for MDOT projects. These businesses include sole proprietorships, partnerships, limited liability companies, and corporations that are seeking to bid on MDOT Small Business Program projects. On the other hand, businesses that are already certified as Disadvantaged Business Enterprises (DBEs) are exempt from this requirement, as their small business status is verified annually through a different process.
To determine if your business meets the small business size standards for participating in MDOT’s Small Business Program, follow these steps:
When submitting the Michigan 4106 form, you must provide additional documentation to support the information you’ve provided in the application. These documents include:
It’s important to provide complete and accurate documentation to avoid delays in the review process or potential disqualification for the Small Business Program.
The Michigan 4106 form must be submitted annually, at least 30 days in advance of bidding on any MDOT Small Business Program projects. This ensures that your business's eligibility is up-to-date for the upcoming fiscal year and allows you to participate in bidding for MDOT projects. Keep in mind that any change in your business's size or structure that could affect your eligibility should prompt an update to your submission to reflect current information.
Filling out the Michigan 4106 form is crucial for non-Disadvantaged Business Enterprises (non-DBEs) aiming to bid on Michigan Department of Transportation (MDOT) Small Business Program projects. However, mistakes can easily occur during this process, impacting one's eligibility. Below are nine common mistakes to avoid:
Each of these mistakes can significantly affect the outcome of your application to the MDOT Small Business Program. It's essential to approach this process carefully and precisely, ensuring all details are accurate and complete. Review every section thoroughly, consult the provided instructions, and when in doubt, seek clarification or assistance to guarantee your application is filled out correctly and on time.
When businesses in Michigan apply for participation in the Small Business Program through the Michigan Department of Transportation (MDOT) using the 4106 form, several other forms and documents might also be needed to complete the application process successfully. These additional documents play a crucial role in establishing a business's eligibility and ensuring compliance with all requirements of the program.
Together with the Michigan 4106 form, these documents offer a comprehensive view of a business's operations, financials, and legal status, providing MDOT with the necessary information to determine eligibility for the Small Business Program. Proper preparation and submission of these documents can significantly streamline the application process, helping businesses navigate it with greater ease.
The Michigan 4106 form is similar to a few other key documents required by different organizations and agencies for the purpose of identifying and verifying small business status for program eligibility or bidding on projects. Each document has its unique purpose but shares common elements with the Michigan 4106 form, such as requiring detailed business information and certifications to determine size and eligibility.
The Small Business Administration (SBA) 8(a) Business Development Program Application is quite similar to the Michigan 4106 form. Both applications aim to support small businesses in competing for contracts and opportunities, but they cater to different audiences and programs. The SBA's application focuses on businesses seeking to participate in the 8(a) Business Development Program, which targets small disadvantaged businesses offering them specialized business training, counseling, marketing assistance, and high-level executive development. Like the Michigan 4106 form, the SBA application requires detailed information about the business, including ownership structure, financial data, and the business’s potential for success. Both forms also require annual updates to ensure the ongoing eligibility of the participating businesses.
The Disadvantaged Business Enterprise (DBE) Certification Application used by state transportation agencies is another document with similarities to the Michigan 4106 form. This application is designed to verify whether a business qualifies as a disadvantaged business enterprise eligible to participate in U.S. Department of Transportation (DOT) assisted projects. Both applications share a common goal of promoting the participation of small and disadvantaged businesses in government contracts. However, while the Michigan 4106 form focuses on non-DBE small businesses looking to participate in MDOT's Small Business Program, the DBR Certification Application specifically targets businesses owned by socially and economically disadvantaged individuals. In both cases, applicants must provide comprehensive information about their business's size, operations, and ownership.
The General Services Administration (GSA) Schedule Proposal similarly demands detailed information about a company’s capabilities, financials, and compliance with federal standards, much like the Michigan 4106 form. While the GSA Schedule Proposal is more about establishing a long-term contract with the federal government for supplying products and services, it aligns with the 4106 form in its requirement for businesses to thoroughly demonstrate their suitability for government contracts. Both applications are complex and necessitate a rigorous review of the business’s structure, performance, and potential to fulfill government contracts, albeit serving slightly different end goals within the public sector procurement process.
When completing the Michigan Department of Transportation 4106 form for Small Business Program applications, there are critical dos and don'ts to ensure the process is handled correctly. Adhering to these guidelines will facilitate a smoother application process for eligibility determination. Below is a list of recommendations:
Following these recommendations will not only streamline the application process but also ensure that your business is accurately assessed for eligibility in the MDOT Small Business Program.
Misconceptions about the Michigan 4106 form can lead to confusion and errors when small businesses attempt to participate in the Michigan Department of Transportation (MDOT) Small Business Program. It's important to clarify these misunderstandings for businesses aiming to bid on MDOT projects.
Addressing these misconceptions is vital for ensuring that small businesses can accurately complete the Michigan 4106 form and participate in the MDOT Small Business Program. Understanding the form's requirements can significantly aid in the preparation and submission process, increasing the chances of eligibility for bidding on MDOT projects.
Understanding the Michigan Department of Transportation (MDOT) 4106 form is crucial for non-Disadvantaged Business Enterprises (non-DBEs) aiming to participate in the MDOT Small Business Program. Here are ten key takeaways for filling out and using this form:
By meticulously providing the correct information and ensuring compliance with SBA guidelines, businesses can effectively participate in MDOT's Small Business Program, expanding their opportunities for government contracts in Michigan.
Michigan Poa - For representation in specific tax-related matters, taxpayers can designate either general or limited authorization on this form.
Michigan 1099 Filing Requirements - The form serves as a critical tool for ensuring equal employment opportunities within MDOT by adhering to their Equal Opportunity Employer policy.