Discrimination Affidavit by ypt17268

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									                                                 DBE/MBE/WBE COMMITMENT FORM (Part 1 of 3)
                                                         (To be returned under separate cover with your cost proposal)

      The following is the Offeror's commitment and summary to the participation goals of the IPTC for the services or supplies pursuant to this contract. PAGE 1 of 2
Mark Here
                                                                                                The undersigned firm certifies that it is a MBE (Minority-owned Business Enterprise)
            The undersigned firm certifies that it is a DBE contractor
                                                                                                The undersigned firm certifies that it is a WBE (Woman-owned Business Enterprise)

            The undersigned certifies that they are a Joint Venture in which the following firm is a Joint Venture Partner
              DBE           MBE        WBE       Co. Name:                                                 % Participation of employees:                           % of cost:
              DBE           MBE        WBE       Co. Name:                                                 % Participation of employees:                           % of cost:
              DBE           MBE        WBE       Co. Name:                                                 % Participation of employees:                           % of cost:


            The undersigned commits a percentage of the total offering price as a subcontract to disadvantaged / minority / woman business enterprise.
                          (Percent Committed       DBE           MBE      WBE                              (Percent Committed             DBE           MBE            WBE
                            for this Contract)    Ethnicity:                                                 for this Contract)         Ethnicity:
                Name:                                                                           Name:
            Address 1:                                                                      Address 1:
            Address 2:                                                                      Address 2:
              City, ST:                                        Zipcode:                       City, ST:                                              Zipcode:
            Telephone:                                 Fax:                                 Telephone:                                        Fax:
                Email:                                                                          Email:
                 POC:                                                                            POC:

                          (Percent Committed       DBE           MBE      WBE                              (Percent Committed             DBE           MBE            WBE
                            for this Contract)    Ethnicity:                                                 for this Contract)         Ethnicity:
                Name:                                                                           Name:
            Address 1:                                                                      Address 1:
            Address 2:                                                                      Address 2:
              City, ST:                                        Zipcode:                       City, ST:                                              Zipcode:
            Telephone:                                 Fax:                                 Telephone:                                        Fax:
                Email:                                                                          Email:
                 POC:                                                                            POC:

                          (Percent Committed       DBE           MBE      WBE                              (Percent Committed             DBE           MBE            WBE
                            for this Contract)    Ethnicity:                                                 for this Contract)         Ethnicity:
                Name:                                                                           Name:
            Address 1:                                                                      Address 1:
            Address 2:                                                                      Address 2:
              City, ST:                                        Zipcode:                       City, ST:                                              Zipcode:
            Telephone:                                 Fax:                                 Telephone:                                        Fax:
                Email:                                                                          Email:
                 POC:                                                                            POC:



                                                 DBE/MBE/WBE COMMITMENT FORM (Part 1 of 3)
                                               (To be returned under separate cover with your cost proposal)

The following is the Offeror's commitment and summary to the participation goals of the IPTC for the services or supplies pursuant to this contract. PAGE 2 of 2

     There are DBE/MBE/WBE firms employed by my company for services that are not directly responsible for the manufacture, supply, or service that my
     company provides, such as printing, cleaning, delivery, etc. These companies are:

                            $ Value of   DBE          MBE        WBE                                         $ Value of   DBE          MBE          WBE
                             Contract Ethnicity:                                                              Contract Ethnicity:
         Name:                                                                           Name:
     Address 1:                                                                      Address 1:
     Address 2:                                                                      Address 2:
       City, ST:                                    Zipcode:                           City, ST:                                     Zipcode:
     Telephone:                              Fax:                                    Telephone:                               Fax:
         Email:                                                                          Email:
          POC:                                                                            POC:

                            $ Value of   DBE          MBE        WBE                                         $ Value of   DBE          MBE          WBE
                             Contract Ethnicity:                                                              Contract Ethnicity:
         Name:                                                                           Name:
     Address 1:                                                                      Address 1:
     Address 2:                                                                      Address 2:
       City, ST:                                    Zipcode:                           City, ST:                                     Zipcode:
     Telephone:                              Fax:                                    Telephone:                               Fax:
         Email:                                                                          Email:
          POC:                                                                            POC:


     SUMMARY OF GOAL ATTAINMENT:
                                                                                                          DBE                   MBE                        WBE
1) One hundred percent (100%) of total amount to be subcontracted to subcontractors……….

2) One hundred percent (100%) of total amount to be paid to equipment leasers………………..
     One hundred percent (100%) of total amount to be paid to Manufacturers (e.g., asphalt
3)
     emulsions, cutback asphalts, fabricated signs, etc.), or delivery companies…
4) Sixty percent (60%) of total amount to be paid to regular dealers/suppliers…………………..

5) Net fee of DBE brokers or bonding agents…………………………………………………………

                                                                                       TOTAL
      TOTAL VALUE OF CONTRACT OFFERING TO THE IPTC                                                 $               -     $                 -    $                   -
         (Do NOT inclue any options / extras/ option yrs
                                                                                         %              #DIV/0!                #DIV/0!                    #DIV/0!
                                                                                                         2                      2                          2

                                      DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                               (To be returned under separate cover with your cost proposal)
               The following is the Offeror's Record of goal attainment or attempt to obtain for the services or supplies pursuant to this contract. PAGE 1 of 8

          SUBCONTRACTORS (List All Solicitations and Quotations, Including Non-DBE/MBE/WBE)

      Subcontractor Info             DBE                                    Items Quoted                          Amount Quoted            Commit to
 (Quotes Solicted From or Received   MBE                  (List by Contract Item Numbers and Describe Proposed   (If No Response, Enter       Use     If DBE/MBE/WBE Subcontractor is
               From)                 WBE       Non-BE                              Work)                                 NONE)            (Yes or No)     not Selected, Describe Why
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC




                                            DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                                     (To be returned under separate cover with your cost proposal)

               The following is the Offeror's Record of goal attainment or attempt to obtain for the services or supplies pursuant to this contract. PAGE 2 of 8
          SUBCONTRACTORS (List All Solicitations and Quotations, Including Non-DBE/MBE/WBE)                           CONTINUED 1

      Subcontractor Info             DBE                                    Items Quoted                          Amount Quoted            Commit to
 (Quotes Solicted From or Received   MBE                  (List by Contract Item Numbers and Describe Proposed   (If No Response, Enter       Use     If DBE/MBE/WBE Subcontractor is
               From)                 WBE       Non-BE                              Work)                                 NONE)            (Yes or No)     not Selected, Describe Why
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC




                                            DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                                     (To be returned under separate cover with your cost proposal)

               The following is the Offeror's Record of goal attainment or attempt to obtain for the services or supplies pursuant to this contract. PAGE 3 of 8

          SUBCONTRACTORS (List All Solicitations and Quotations, Including Non-DBE/MBE/WBE)                           CONTINUED 2
      Subcontractor Info             DBE                                    Items Quoted                          Amount Quoted            Commit to
 (Quotes Solicted From or Received   MBE                  (List by Contract Item Numbers and Describe Proposed   (If No Response, Enter       Use     If DBE/MBE/WBE Subcontractor is
               From)                 WBE       Non-BE                              Work)                                 NONE)            (Yes or No)     not Selected, Describe Why
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC




                                            DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                                     (To be returned under separate cover with your cost proposal)

               The following is the Offeror's Record of goal attainment or attempt to obtain for the services or supplies pursuant to this contract. PAGE 4 of 8

          SUBCONTRACTORS (List All Solicitations and Quotations, Including Non-DBE/MBE/WBE)                           CONTINUED 3

      Subcontractor Info             DBE                                    Items Quoted                          Amount Quoted           Commit to
 (Quotes Solicted From or Received   MBE                  (List by Contract Item Numbers and Describe Proposed   (If No Response, Enter     Use     If DBE/MBE/WBE Subcontractor is
 (Quotes Solicted From or Received   MBE                  (List by Contract Item Numbers and Describe Proposed   (If No Response, Enter                 If DBE/MBE/WBE Subcontractor is
               From)                 WBE       Non-BE                              Work)                                 NONE)            (Yes or No)       not Selected, Describe Why
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC




                                            DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                                     (To be returned under separate cover with your cost proposal)

               The following is the Offeror's Record of goal attainment or attempt to obtain for the services or supplies pursuant to this contract. PAGE 5 of 8

          SUPPLIES, MANUFACTURERS, LEASERS, AND DELIVERY FIRMS

          Company Info               DBE                    List Items to be Supplied (S), Leased (L),            Amount Quoted            Commit to
 (Quotes Solicted From or Received   MBE                  Manufactuered (M), or Delivered (D) by Item #          (If No Response, Enter       Use     If DBE/MBE/WBE Subcontractor is
               From)                 WBE       Non-BE      and Describe Proposed items         S-L-M-D                   NONE)            (Yes or No)     not Selected, Describe Why
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC




                                            DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                                     (To be returned under separate cover with your cost proposal)

               The following is the Offeror's Record of goal attainment or attempt to obtain for the services or supplies pursuant to this contract. PAGE 6 of 8

          SUPPLIES, MANUFACTURERS, LEASERS, AND DELIVERY FIRMS……….CONTINUED 1

          Company Info               DBE                    List Items to be Supplied (S), Leased (L),      Amount Quoted            Commit to
 (Quotes Solicted From or Received   MBE                  Manufactuered (M), or Delivered (D) by Item #    (If No Response, Enter       Use     If DBE/MBE/WBE Subcontractor is
               From)                 WBE       Non-BE      and Describe Proposed items         S-L-M-D             NONE)            (Yes or No)     not Selected, Describe Why
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC




                                            DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                                     (To be returned under separate cover with your cost proposal)

               The following is the Offeror's Record of goal attainment or attempt to obtain for the services or supplies pursuant to this contract. PAGE 7 of 8

          SUPPLIES, MANUFACTURERS, LEASERS, AND DELIVERY FIRMS……….CONTINUED 2

          Company Info               DBE                    List Items to be Supplied (S), Leased (L),      Amount Quoted            Commit to
 (Quotes Solicted From or Received   MBE                  Manufactuered (M), or Delivered (D) by Item #    (If No Response, Enter       Use     If DBE/MBE/WBE Subcontractor is
               From)                 WBE       Non-BE      and Describe Proposed items         S-L-M-D             NONE)            (Yes or No)     not Selected, Describe Why
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC




                                            DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                                     (To be returned under separate cover with your cost proposal)

               The following is the Offeror's Record of goal attainment or attempt to obtain for the services or supplies pursuant to this contract. PAGE 8 of 8

          SUPPLIES, MANUFACTURERS, LEASERS, AND DELIVERY FIRMS……….CONTINUED 3

          Company Info               DBE                    List Items to be Supplied (S), Leased (L),      Amount Quoted            Commit to
 (Quotes Solicted From or Received   MBE                  Manufactuered (M), or Delivered (D) by Item #    (If No Response, Enter       Use     If DBE/MBE/WBE Subcontractor is
               From)                 WBE       Non-BE      and Describe Proposed items         S-L-M-D             NONE)            (Yes or No)     not Selected, Describe Why
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC
Name:
Address
Address
City
State
Zip
Phone
POC




                                             DBE/MBE/WBE COMMITMENT FORM (Part 3 of 3)
                                                      (To be returned under separate cover with your cost proposal)

                        The following is the Offeror's summary of good faith effort for the services or supplies pursuant to this contract.   PAGE 1 of 2
Mark Here

            My company cannot meet the participation goal(s) for this contract             (YOU MUST COMPLETELY ANSWER THE QUESTIONS BELOW):


                                                               SUMMARY OF DBE/MBE/WBE GOOD FAITH EFFORT
If the dollar value goals for participation in this project have not been met, the Contractor/Offeror is REQUIRED to complete the following questions to dexcribe efforts to
obtain participation. Each following effort will require an explanation . Copies of correspondence, return receipts, telephone logs, or other documentation will be
required to support good faith efforts.

Attach Additional Sheets, if Necessary

       1) Has the Contractor/Offeror advertised in general circulation, trade association, and minority-focus media concerning the subcontracting opportunities? Explain.
      2) Has the Contractor/offeror provided written notice to a reasonable number of specific DBE/MBE/WBEs that their interest in the contract was being solicited in
         sufficient time to allow the DBE/MBE/WBEs to participate effectively? Submit a copy of all coorespondencee soliciting bids from DBE/MBE/WBEs. Explain.




      3) Has the Contractor/Offeror followed up initial solicitation of interest by contacting DBE/MBE/WBEs to determine with certantity whether the DBEs were interested?
         Submit telephone logs, letters, etc., to document follow-up activity.




      4) Has the Contractor/Offeror selected portions of the work to be performed by DBE/MBE/WBEs in order to increase the likelihood of meeting the participation goals,
         including, where appropriate, breaking down contracts into economically feasible units to facilitate DBE participation? Explain.




      5) Has the Contractor/Offeror provided interested DBE/MBE/WBEs with adequate information about the plans, specifications, and requirements of the contract?
         Describe what action was taken.




                                             DBE/MBE/WBE COMMITMENT FORM (Part 2 of 3)
                                                      (To be returned under separate cover with your cost proposal)

                       The following is the Offeror's summary of good faith effort for the services or supplies pursuant to this contract.   PAGE 2 of 2

                                                               SUMMARY OF DBE/MBE/WBE GOOD FAITH EFFORT
If the dollar value goals for participation in this project have not been met, the Contractor/Offeror is REQUIRED to complete the following questions to dexcribe efforts to
obtain participation. Each following effort will require an explanation . Copies of correspondence, return receipts, telephone logs, or other documentation will be
required to support good faith efforts.

Attach Additional Sheets, if Necessary

      6) Has the Contractor/Offeror negotiated in good faith with interested DBE/MBE/WBEs, not rejecting them as unqualified without sound reasons based on a thorough
         investigation of their capabilities? Explain.




      7) Has the Contractor made efforts to assist interested DBE/MBE/WBEs in obtaining bonding, lines of credit, or insurance required by the Indianapolis Public
         Transportation Corporation or Contractor? Explain.
        8) Has the Contractor/Offeror made efforts to assist interested DBE/MBE/WBEs in obtaining necessary equipment, supplies, materials, or related assistace or
           services?




        9) In addition to Number 1 above, has the Contractor/Offeror effectively used the services f available minority community organizations; minority contractors' groups;
           local state, and federal minority business assistance offices or listings; and other organizations that provide assistance in identifying and subcontracting with
           DBE/MBE/WBEs? Explain.




      10) Describe any other efforts not covered by Numbers 1 through 8 above that may indicate the Contractor/Offeror's affirmative action to obtain DBE/MBE/WBE
          participation in this project.




                                                                                                                                                                                                    /           /
       (Company Name - Typed)                                    (Agent Name - Typed)                                               ( Agent Signature)                                               (Date)


                                                               AFFIDAVIT OF CERTIFICATION
                 This form must be signed and notarized for each DBE/MBE/WBE owner upon which participation status is relied upon by the Prime Contractor/Offeror.

   A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS AFFIDAVIT IS SUFFICIENT CAUSE FOR DENIAL OF CERTIFICATION,
 REVOCATION OF A PRIOR APPROVAL, INITIATION OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR ENTITY MAKING
      THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENAL TIES AVAILABLE PURSUANT TO APPLICABLE FEDERAL AND STATE LAW.

          I                                                                , swear or affirm under penalty of law that I am                                                of the subcontracted firm of:
                              (Full Printed Name)                                                                                            (Title - printed)

                                                        and that I have read and understood all of the questions in this affidavit and that all of the foregoing information and statements
               (Full Printed Firm Name)
submitted in this affidavit and its attachments and supporting documents are true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material
information. The responses include all material information necessary to fully and accurately identify and explain the operations, capabilities and pertinent history of the named firm as well as the ownership,
control, and affiliations thereof.

I recognize that the information submitted in this affidavit is for the purpose of determining certification approval by a federal fund recipient agency. I understand that such an agency may, by means it deems
appropriate, determine the accuracy and truth of the statements in the affidavit, and I authorize such agency to contact any entity named in the affidavit, and the named firm's bonding compat1ies, banking
institutions, credit agencies, contractors, clients, and other certifying agencies for the purpose of verifying the information supplied and determining the named firm's eligibility.

I agree to submit to IPTC audit, examination and review of books, records, documents and files, in whatever form they exist, of the named firm and its affiliates, inspection of its place(s) of business and
equipment, and to permit interviews of its principals, agents, and employees. I understand that refusal to permit such inquiries shall be grounds for denial of acceptance as a DBE/MBE/WBE.

If awarded a contract or subcontract, I agree to promptly and directly provide the prime contractor, if any, and the IPTC, recipient agency, or federal funding agency on an ongoing basis, current, complete and
  If awarded a contract or subcontract, I agree to promptly and directly provide the prime contractor, if any, and the IPTC, recipient agency, or federal funding agency on an ongoing basis, current, complete and
  accurate information regarding ( 1) work performed on the project; (2) payments; and (3) proposed changes, if any, to the foregoing arrangements.

  I agree to provide written notice to the IPTC of any material change in the information contained in the original affidavit within 30 calendar days of such change ( e.g., ownership, address, telephone number,
  etc.).

  I acknowledge and agree that any misrepresentations in this affidavit or in records pertaining to a contract or subcontract will be grounds for terminating any contract or subcontract which may be awarded;
  denial or revocation of acceptance; suspension and/or debarment; and for initiating action under federal and/or state law concerning false statement, fraud or other applicable offenses.

  I certify that I am a socially and economically disadvantaged individual who is an owner of the above-referenced firm who has been certified as a:              DBE         MBE           WBE
               I further certify that my personal net worth does not exceed $750,000, 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 line of business who are not socially and economically disadvantaged.

               I certify that I am socially disadvantaged because I have been subjected to racial or ethnic prejudice or cultural basis, or have suffered the effects of discrimination, because of my identity as a
               member of one or more of the groups identified above, without regard to my individual qualities.

  In support of my affidavit, I certify that I am a member of one or more of the following groups, and that I have held myself out as a member of the group(s) (check all that apply):
               Female              Black American              Hispanic American            Native American              Asian-Pacific American        Subcontinent Asian American                 Other

                                                                                                                                     NOTARY
  I declare under penalty of perjury that the information provided in this application and supporting documents is true                    Witness my hand and notarial seal this___________day of ____________, 200__
  and correct.
                                                                                                                                     Printed name
Executed On:             /         /
                          (Date)                                      ( DBE/MBE/WBE Agent Signature)                                      Signature


                                                                                                                                        Residing in                      County, State of

                                            DISADVANTAGED, MINORITY AND WOMAN BUSINESS ENTERPRISES

                               IT IS ESSENTIAL THAT the following documents, as applicable, accompany this AFFIDAVIT form. NOTE: IF ANY OF THE ITEMS
                               DO NOT APPLY to your firm, please explain on a separate sheet. The effective date of the application is the date when ALL REQUIRED
                                                DOCUMENTATION has been received, not the date of submission of an incomplete packet.




  ALL DBE FIRMS must submit with attached affidavit:

           ► Notarized Certification Affidavit
           ► Current certification letter issued by Indiana D.O.T., City of Indianapolis, or Small Business Administration Section 8(a)
           ► Letter indicating any changes in ownership and/or management within the past 18 months
DBE EXCEPTIONS:

A DBE firm with a CURRENT certification letter issued by Indiana D.O.T., City of Indianapolis, or Small Business Administration Section 8(a) AND on
file with the Indianapolis Public Transportation Corporation;

Submit Only:

      ►   Notarized Certification Affidavit
      ►   Letter indicating any changes in ownership and/or management within the past 18 months




DISCLOSURE POLICY:

THE IPTC MUST SAFEGUARD FROM DISCLOSURE TO UNAUTHORIZED PERSONS INFORMATION GATHERED AS PART OF THE
AFFIDAVIT PROCESS THAT MAY REASONABLY BE REGARDED AS PROPRIETARY OR OTHER CONFIDENTIAL INFORMATION,
CONSISTENT WITH APPLICABLE FEDERAL AND STATE LAW.
             further certify penalty of disadvantaged because I exceed $750,000, and that I orand supporting documents is true or correct.
             declare under that my personal that the information provided in this application economically disadvantaged because my ability to
           I certify that I am socially perjurynet worth does nothave been subjected to racial amethnic prejudice or cultural basis,and have suffered

								
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