DBE Dollar Amount. Enter the subcontracted dollar amount of the work to be performed or service to be provided. Include the prime consultant if the prime is a DBE. See LAPM Chapter 9 for how to count full/partial participation.
DBE Dollar Amount. Local Agency to Complete this Section 13. Total Dollars Claimed $ 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No.
DBE Dollar Amount. Local Agency to Complete this Section 13. Total Dollars Claimed $ 0 20. Local Agency Contract Number:
DBE Dollar Amount. Traffic Engineering Services 26209 W-Trans Xxxxx Xxxxxxxxxx, Principal (000) 000-0000 $51,190 Local Agency to Complete this Section 14. TOTAL CLAIMED DBE PARTICIPATION $ $51,190 20. Local Agency Contract Number: 21. Federal-Aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and information on this form is complete and accurate. 23. Local Agency Representative's Signature 24. Date 25. Local Agency Representative's Name 26. Phone 27. Local Agency Representative's Title 20 % IMPORTANT: Identify all DBE firms being claimed for credit, regardless of tier. Written confirmation of each listed DBE is required. 6/7/2016 15. Preparer's Signature 16. Date Xxxxx Xxxxxxxx, PE, PLS (000) 000-0000 17. Preparer's Name 18. Phone President 19. Preparer's Title eparer's Signature DISTRIBUTION: 1. Original – Local Agency
DBE Dollar Amount. Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.008/ 1258405 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION
DBE Dollar Amount. Environmental/Permitting GPA Consulting 036278 $TBD (7%) 000 Xxxxxxxxxx Xxxxxx * GPA’s Scope of Xx Xxxxxxx, XX 00000 Work is in the 310.792.2690 PAED Phase (Next Phase) Local Agency to Complete this Section 13. Total Dollars Claimed $ _TBD 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No.
DBE Dollar Amount. Local Agency to Complete this Section 13. Total Dollars Claimed $ 20. Local Agency Contract Number: 130072 21. Federal-aid Project Number: 22. Contract Execution Date: March 25, 2014 Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: Xxxxx Xxxxxxx 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date Deputy Director, Engineering (000) 000-0000 26. Local Agency Representative Title 27. (Area Code) Tel. No. 14. Total % Claimed % 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Distribution: (1) Copy – Email a copy to the Caltrans District Local Assistance Engineer (DLAE) within 30 days of contract award. Failure to send a copy to the DLAE within 30 days of contract award may result in delay of payment.
