"DBE PARTICIPATION REPORT"
C2-98 PROJECT NO.(S) CONTRACTOR DBE PARTICIPATION REPORT COUNTY REPORT NO. DATE CONTRACT I. D. No. __ __ __ __ __ __ - __ __ - __ __ __ - __ __ CONTRACT AMOUNT $______________________ % DBE REQUIRED _________________________ APPROVED DBE VENDOR NUMBER DESCRIPTION OF WORK SUPPLIER QUARTER ENDING (CHECK ONE) ( ) MARCH 31 ( ) JUNE 30 ( ) SEPT 30 ( ) DEC 31 ( ) FINAL DBE AMOUNT $_______________________________ OWNER/ OPER. SUBCONTR ORIG. SUBCONTR. AMOUNT EARNINGS TO-DATE TOTAL DBE EARNINGS TO-DATE % CONTRACT I HEREBY CERTIFY THAT THE ABOVE STATEMENT IS TRUE AND CORRECT AND SUPPORTING DOCUMENTATION IS ON FILE AND IS AVAILABLE FOR INSPECTION BY DEPARTMENT PERSONNEL AT ANY TIME. ` SIGNED CONTRACTOR REMARKS REV. 6/95 FOR DEPARTMENT USE ONLY: THIS DOCUMENT HAS BEEN REVIEWED AT THE PROJECT LEVEL BY: SIGNED __________________________ TITLE ________ THIS DOCUMENT HAS BEEN REVIEWED AT THE DISTRICT LEVEL BY: SIGNED __________________________ TITLE ________ INSTRUCTIONS TO CONTRACTOR In order to receive credit toward the contractor DBE Goal, the prime contractor must complete the reverse side and submit this form quarterly to the engineer in charge of the contract. Failure to submit this form will result in no credit toward the contract DBE requirements. 1. Report Number: Reports must be consecutively numbered. It will only be necessary to submit a report in a quarter when the approved DBE has performed a portion of the work that has been designated for the contract. Date: Actual date of the quarterly period ending. Earnings To-Date: Show the actual amount that each DBE has earned to-date under the contract based on the unit prices paid to the DBE by the prime contractor and not contract unit prices. When a supplier is used to fulfill the DBE requirements, only 60% of the amount earned by the supplier may be entered. Show the total amount in the space provided. Percent of Contract: This percentage is calculated using the contract amount and the total DBE earnings-to-date. Certification: The contractor or his authorized representative must sign this form prior to submittal. Failure to complete and submit this form in a timely manner may delay monthly progress payments. GENERAL INFORMATION When the approved DBE is to provide materials, goods or services, this completed form must be submitted to the Area Engineer. The prime contractor may change DBE firms only with the approval of the District Engineer, provided the contract DBE Goal is met and the changes conform to contract regulations. This form should be updated and submitted to the Area Engineer. Upon completion of the work, a final “DBE Participation Report” will be required and submitted to the Area Engineer prior to final payment. All information shown on the form must be completed, including the final earnings of each approved DBE. When the prime contractor is an approved DBE, it will only be necessary to complete the total DBE earnings to-date. Joint ventures between non-DBE and certified DBE: Only that portion of the work for which the DBE is responsible may be used to satisfy the requirement. 2. 3. 4. 5.