U.S. Department of Transportation
An individual’s personal net worth according to 49 C.F.R.
Parts 23 and 26 includes assets and liabilities that she or he
owns or is deemed to own without regard to community
property or equitable distribution laws.
If the personal net worth of the majority owner(s) of the firm
exceeds the PNW cap posted online at
https:/www.Transportation.gov/DBEPNW, as defined by 49
C.F.R. Parts 23 and 26, the firm is not eligible for DBE or
ACDBE certification.
Provide all Worksheets. Provide documents to support each
entry. If you have any questions about completing this form,
contact the certifying agency.
Assets
Report assets at their current fair market values as of the
date of your PNW form. In cases of joint ownership, report
only the value of your ownership unless Worksheet directs
otherwise. Do not report the value of the applicant firm.
Cash and Cash Equivalents: Enter total from Worksheet 1.
Investment Accounts and Individual Securities: Enter
total from Worksheet 2.
Real Estate: Enter total from Worksheet 3.
Personal Property and Other Assets: Enter total from
Worksheet 4.
Ownership in Other Businesses: Enter total from
Worksheet 5.
Life Insurance: Enter total from Worksheet 6.
Amounts Owed to You: Enter total from Worksheet 7.
Assets Held in Trust: Enter total from Worksheet 8.
OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)
INSTRUCTIONS
Transfers Within Preceding Two Years: If you transferred
assets worth at least $20,000 in aggregate to related parties
within the last two years, enter total from Worksheet 9.
Exclude transfers to applicant or DBE.
Relatives include your spouse or domestic partner, children
(whether biological, adopted, or stepchildren), siblings
(including stepsiblings and those of the spouse or domestic
partner), and parents (including stepparents and those of the
spouse or domestic partner). Related entities include for-
profit privately held companies of which any relative is an
owner, officer, director, or equivalent; and family or other
trusts of which you or any relative is grantor, trustee, or
beneficiary, except when the transfer is irrevocable. See 49
C.F.R. 26.68(c)(7)-(9).
Liabilities
Report current balances. Report only your own, direct
liabilities. Do not report guarantees or other contingent
liabilities. Do not report business debt, debt secured by
retirement assets, or any amount you owe, directly or
indirectly, to the applicant or DBE.
Mortgages: Enter total from Worksheet 10.
Loans on Life Insurance: Enter total from Worksheet 11.
Other Liabilities: Enter total from Worksheet 12.
Other Information
Retirement Assets. Complete Worksheet 13 but do not enter
value on PNW Statement.
Primary Residence. Complete Worksheet 14 but do not
enter value on PNW Statement.
Declaration
You must sign and date the statement.
Page 2 of 9