12-N. FORM A - List of Subcontractors (DBE and non-DBE).NO GOAL INTERIM.docx

LIST OF SUBCONTRACTORS/SUPPLIERS - FORM A

Project DBE and non-DBE Subcontractor/Supplier Utilization Commitment Federal Disadvantaged Business Opportunity Program.

In accordance with the Interim Final Rule, dated October 3, 2025, the City of Charlotte is currently prohibited from assigning a contract goal. Please use this form to list any subcontractors you intend to use for this project, filling the information below.

Bidders Name:

Project Name:

Below list ALL SUBCONTRACTORS AND SUPPLIERS (including DBEs) that you intend to use on this Contract. Continue listing on the supplemental form on the next page.

Annual Gross Receipts: |_| Less than $500,000 |_| $500,000 - $1M |_| $1-2M |_| $2-5M |_| Over $5M

Annual Gross Receipts: |_| Less than $500,000

Annual Gross Receipts: |_| Less than $500,000

|_| I acknowledge that I have confirmed the certification of each DBE listed above on https://partner.ncdot.gov/VendorDirectory/default.html

Please read the following “Certification” statement before signing. “The undersigned certifies that he/she has read, understands, and agrees to be bound by the DBE Program Requirements, including these accompanying FORM(s) A, and the other terms and conditions in the Notice to Bidders. The undersigned further certifies that he/she is legally authorized by the Bidder to make the statements and representations and that said statements and representations are true and correct to the best of his/her knowledge and belief. It is the intent by the undersigned to enter into formal agreement(s) with subcontractors/suppliers named on this Form conditioned upon execution of a contract with the City. All DBE subcontractors/suppliers must provide proof of their DBE status or receive confirmation of their status from the City’s Civil Rights Officer prior to contract award. The undersigned understands and agrees that if any of the statements and representations are made by the Bidder knowing them to be false, or if there is a failure of the successful Bidder (i.e., the Contractor) to implement any of the stated agreements, intentions, objectives, goals, commitments and substitutions set forth herein without prior approval by the Civil Rights Officer or a designee, then in any of such events the Contractor's act or failure to act, as the case may be, shall constitute a material breach of the contract, entitling the City to terminate the contract for default. The right to so terminate shall be in addition to, and not in lieu of, any other rights and remedies the City may have for other defaults under the contract, or otherwise. Additionally, the Contractor will be subject to the loss of any future contract awards”.

Signature of Authorized Official Printed Name Title Submittal Date

LIST OF SUBCONTRACTORS/SUPPLIERS - FORM A -- CONTINUATION

Project DBE and non-DBE Subcontractor/Supplier Utilization Commitment Federal Disadvantaged Business Opportunity Program.

In accordance with the Interim Final Rule, dated October 3, 2025, the City of Charlotte is currently prohibited from assigning a contract goal. Please use this form to list any subcontractors you intend to use for this project, filling the information below

Bidders Name:

Project Name:

Annual Gross Receipts: |_| Less than $500,000

Annual Gross Receipts: |_| Less than $500,000

Annual Gross Receipts: |_| Less than $500,000

Annual Gross Receipts: |_| Less than $500,000

Annual Gross Receipts: |_| Less than $500,000

Annual Gross Receipts: |_| Less than $500,000

INSTRUCTIONS TO COMPLETE FORM A

Note: A correctly completed Form A will list all subcontractors and suppliers a bidder plans to directly utilize. Each company who will have 2nd or 3rd tier subcontractors or suppliers should submit individual Form A’s. Only DBEs certified by NCDOT may be submitted to meet the contract goal.

Form A- Instructions to fill out form

1. Bidder’s Name is the name of the company that will be entering into contract agreements or purchasing supplies and materials from the subcontractors listed in the document

2. Project Name is the name of the is listed on the solicitation

3. Name and address of each subcontractor/supplier that is intended to do work on the project :

a. “Annual Gross Receipts range” must be identified for each company according to the ranges provided

4. Contact Person and Phone Number (plus email address if available).

5. Age of the Firm approximate age of firm

6. Description of the Work or supplies to be provided by the subcontractor

7. NAICS Code (if available) for the work provided by the subcontractor

8. NCDOT Reporting number # (specifically for the DBE subcontractors and suppliers).

9. Total Project $ dollars that are projected to be spent with each subcontractor/supplier (Dollars committed to DBE subcontractor)

10. % of the total Bid Amount is the percent of dollars to be spent with each subcontractor or supplier.

a. Calculation = Total Projected $ divided by Total Bid Amount

b. DBE supplier utilization may only count 60% toward DBE goal

c. Total Bid Amount includes the contingency amount

11. Your company must acknowledge that you have confirmed that each DBE submitted is certified as such in the NCDOT database https://partner.ncdot.gov/VendorDirectory/default.html .

12. Print additional copies of the extended Form- A to list all subcontractors or suppliers which do not fit on one page. On each sheet the company with subcontractors and suppliers must Print:

a. The company name under “Bidders Name”

b. The solicitation title next to “Project Name”.

13. The project totals including for all vendors listed on a company’s Form A and extended Form A’s must be listed on the 1st page including the following.

a. The Total DBE Utilization in $ dollars

b. The Total Bid Amount in $ dollars

c. Percentage % of total DBE Utilization (Total DBE Utilization/Total Bid Amount including contingency)

14. Read the “Certification statement” before signing your Form A.

15. An Authorized Official from your company must sign the Form. That official must then Print:

a. Name

b. Title

c. Submittal Date.

16. Additional questions on filling relating to the completion of the form should be directed to the contact provided included with the solicitation.