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Subcontractors Telephone

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					                                                                                                                                                                                 EXHIBIT A

                   MONTHLY DBE SUBCONTRACTORS PAID REPORT SUMMARY AND PAYMENT VERIFICATION (Form 103)
                                                                 Reporting Period (month): ________________, 200 ____

Contract/Project Number:                             Report Number:                                                      Report prepared by:
Contract Award Date:                                 Original Contract Award Amount:                                     Title:
Prime Name:                                          Current Contract Value:                                             Report reviewed by:
Address:                                             % of Project Complete:           #DIV/0!                            Signature:
Telephone Number: (      )                                                                                               Title:
                                                           Total Dollars Paid to DBEs this reporting period:
Contract DBE Goal: ______% (% of total Contract)           Total Dollars Paid to DBEs to date:                                                 DBE Goal Attainment to date:           #DIV/0!
Prime's DBE Commitment:                   %                Total Dollars Paid to Prime to date:
                                                                 Dollar           Dollar Amount           Type of Work   Original Dollar         $ +/- resulting      % of             FOR
                  DBE                                           Amount             Paid to Date            Performed     Amount                  from Change          Work            SCRRA
            SUBCONTRACTORS                                      Paid This                                   (Scope)      Committed to DBE        Order Activity     Completed           USE
                                                                 Month                                                   at Contract Award                                             ONLY
Name:
Address:
City, State, Zip Code:
Telephone Number: ( )                                                                                                    Current Contract
Subcontractor ‫ ٱ‬Broker ‫ٱ‬                                                                                                 Value:
Supplier: Regular Dealer ‫ ٱ‬or Manufacturer ‫ٱ‬
Attach Verification of Payment: ‫ ٱ‬YES ‫ ٱ‬NO

Name:
Address:
City, State, Zip Code:
Telephone Number: ( )                                                                                                    Current Contract
Subcontractor ‫ ٱ‬Broker ‫ٱ‬                                                                                                 Value:
Supplier: Regular Dealer ‫ ٱ‬or Manufacturer ‫ٱ‬
Attach Verification of Payment: ‫ ٱ‬YES ‫ ٱ‬NO
Name:
Address:
City, State, Zip Code:
Telephone Number: ( )                                                                                                    Current Contract
Subcontractor ‫ ٱ‬Broker ‫ٱ‬                                                                                                 Value:
Supplier: Regular Dealer ‫ ٱ‬or Manufacturer ‫ٱ‬
Attach Verification of Payment: ‫ ٱ‬YES ‫ ٱ‬NO
Comments/Issues and/or documented Good Faith Efforts performed during this reporting period:



If necessary, this form can be duplicated to list all DBE subcontractors paid in this reporting period.                                                            SCRRA Form 103 Rev. 5/21/03

				
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