5963_Proposal.pdf

PROPOSAL AND CONTRACT FORMS

FOR

BRIDGE DECK REHAB

BRIDGE NO. 24164-A -MASHEL RIVER

BRIDGE NO. 6195-A – PUYALLUP RIVER

BRIDGE NO. 5175-C - KAPOWSIN CREEK

CRP 5963, FEDERAL AID NO. BHOM-9927(069)

BID OPENING DATE:

Date: WEDNESDAY, MARCH 18, 2026

Bid Delivery Time: 1:00 p.m.

Bid Opening Time: 1:00 p.m., or as soon thereafter as possible.

PROPOSAL

TO THE PIERCE COUNTY DIRECTOR OF PLANNING & PUBLIC WORKS

TACOMA, WASHINGTON

This certifies that the undersigned has examined the location of

ITEM ITEM DESCRIPTION

NO. at $ . ct $ . ct

PREPARATION

1 Mobilization at .

2 0.1 HUND Removing Raised Pavement Marker at . per HUND .

GRADING

3 49 S.Y. Roadway Excavation Incl. Haul at . per S.Y. .

STRUCTURE

4 162 S.F. Further Deck Preparation at . per S.F. .

5 360 S.Y. Scarifying Conc. Surface at . per S.Y. .

6 360 S.Y.

Polyester Concrete Overlay Br. No. 24164-A at . per S.Y. .

SURFACING

9 33 TON Crushed Surfacing Base Course at . per TON .

HOT MIX ASPHALT

10 44 L.F. HMA Joint Seal at Bridge End at . per L.F. .

11 360 S.Y.

Removing Existing Overlay from Bridge Deck No. 24164-A at . per S.Y. .

COUNTYWIDE BRIDGE DECK REHABILITATION

Bridge Nos. 24164-A, 6195-A and 5175-C

LUMP SUM LUMP SUMLS

QUANTITY UNIT PRICE UNIT TOTAL AMOUNT

CRP 5963, Federal Aid No. BHOM-9927(069) Group 1 - Mashel River (Alder Road Cutoff Road East)

Bridge No. 24164-A and that the plans, specifications and contract governing the work embraced in this improvement, and the method by which payment will be made for said work is understood. The undersigned hereby proposes to undertake and complete the work embraced in this improvement, or as much thereof as can be completed with the material available in accordance with the said plans, specifications and contract, and the following schedule of rates and prices.

Note: Unit price(s) for all item(s), all extensions, and total amount of bid shall be shown. All entries must be typed or entered in ink.

Show price per unit in figures only. Figures written to the right of the dot (decimal) in the price per unit column shall be interpreted as cents.

5963 Proposal.xlsx P 1 2/4/2026

ITEM ITEM DESCRIPTION

NO. at $ . ct $ . ct

QUANTITY UNIT PRICE UNIT TOTAL AMOUNT

14 17 TON HMA CL. 1/2 In. PG 58H-22 at . per TON .

EROSION CNTL AND ROADSIDE

PLANTING

15 5 DAY ESC Lead at . per DAY .

16 5,000$ DOLLAR Erosion/Water Pollution Control at 1 . 00 per EST 5,000$ . 00

17 8 EACH

Temporary Blocking of Existing Bridge Drain at . per EACH .

TRAFFIC

19 1,520 L.F. Plastic Line at . per L.F. .

20 0.1 HUND Raised Pavement Marker Type 1 at . per HUND .

21 Permanent Signing at .

22 380 L.F.

Temporary Pavement Marking-Short Duration at . per L.F. .

23 432 HR Portable Changeable Message Sign at . per HR .

24 Project Temporary Traffic Control at .

25 Traffic Control Supervisor at .

26 547 S.F. Construction Signs Class A at . per S.F. .

27 500$ DOLLAR Work Zone Safety Contingency at 1 . 00 per EST 500$ . 00

OTHER ITEMS

29 5,000$ DOLLAR Reimbursement for Third Party Damage at 1 . 00 per EST 5,000$ . 00

30 5,000$ DOLLAR Minor Change at 1 . 00 per EST 5,000$ . 00

31 SPCC Plan at .

32 FDC Plan at .

LUMP SUM LUMP SUMLS

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

Group 1 Total

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

Show price per unit in figures only. Figures written to the right of the dot (decimal) in the price per unit column shall be interpreted as cents.

P 2 2/4/2026

TACOMA, WASHINGTON

This certifies that the undersigned has examined the location of

ITEM ITEM DESCRIPTION

NO. at $ . ct $ . ct

PREPARATION

1 Mobilization at .

2 0.1 HUND Removing Raised Pavement Marker at . per HUND .

GRADING

3 212 S.Y. Roadway Excavation Incl. Haul at . per S.Y. .

STRUCTURE

4 686 S.F. Further Deck Preparation at . per S.F. .

5 1,523 S.Y. Scarifying Conc. Surface at . per S.Y. .

7 1,523 S.Y.

Polyester Concrete Overlay Br. No. 6195-A at . per S.Y. .

SURFACING

9 136 TON Crushed Surfacing Base Course at . per TON .

HOT MIX ASPHALT

10 80 L.F. HMA Joint Seal at Bridge End at . per L.F. .

12 1,523 S.Y.

Removing Existing Overlay from Bridge Deck No. 6195-A at . per S.Y. .

14 68 TON HMA CL. 1/2 In. PG 58H-22 at . per TON .

COUNTYWIDE BRIDGE DECK REHABILITATION

Bridge Nos. 24164-A, 6195-A and 5175-C

CRP 5963, Federal Aid No. BHOM-9927(069) Group 2 - Puyallup River (96th Street East)

Bridge No. 6195-A

QUANTITY UNIT PRICE UNIT TOTAL AMOUNT

LUMP SUM LS LUMP SUM

and that the plans, specifications and contract governing the work embraced in this improvement, and the method by which payment will be made for said work is understood. The undersigned hereby proposes to undertake and complete the work embraced in this improvement, or as much thereof as can be completed with the material available in accordance with the said plans, specifications and contract, and the following schedule of rates and prices.

Note: Unit price(s) for all item(s), all extensions, and total amount of bid shall be shown. All entries must be typed or entered in ink.

Show price per unit in figures only. Figures written to the right of the dot (decimal) in the price per unit column shall be interpreted as cents.

P 3 2/4/2026

NO. at $ . ct $ . ct

QUANTITY UNIT PRICE UNIT TOTAL AMOUNT

EROSION CNTL AND ROADSIDE

PLANTING

15 5 DAY ESC Lead at . per DAY .

16 5,000$ DOLLAR Erosion/Water Pollution Control at 1 . 00 per EST 5,000$ . 00

18 4 EACH Inlet Protection at . per EACH .

TRAFFIC

19 2,560 L.F. Plastic Line at . per L.F. .

20 0.1 HUND Raised Pavement Marker Type 1 at . per HUND .

21 Permanent Signing at .

22 640 L.F.

Temporary Pavement Marking-Short Duration at . per L.F. .

23 432 HR Portable Changeable Message Sign at . per HR .

24 Project Temporary Traffic Control at .

25 Traffic Control Supervisor at .

26 433 S.F. Construction Signs Class A at . per S.F. .

27 500$ DOLLAR Work Zone Safety Contingency at 1 . 00 per EST 500$ . 00

OTHER ITEMS

28 4.0 EACH Adjust Catch Basin at . per EACH .

29 18,000$ DOLLAR Reimbursement for Third Party Damage at 1 . 00 per EST 18,000$ . 00

30 5,000$ DOLLAR Minor Change at 1 . 00 per EST 5,000$ . 00

31 SPCC Plan at .

32 FDC Plan at .

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

Group 2 Total $ .

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

Show price per unit in figures only. Figures written to the right of the dot (decimal) in the price per unit column shall be interpreted as cents.

P 4 2/4/2026

TACOMA, WASHINGTON

This certifies that the undersigned has examined the location of

ITEM ITEM DESCRIPTION

NO. at $ . ct $ . ct

PREPARATION

1 Mobilization at .

2 0.1 HUND Removing Raised Pavement Marker at . per HUND .

STRUCTURE

4 219 S.F. Further Deck Preparation at . per S.F. .

5 486 S.Y. Scarifying Conc. Surface at . per S.Y. .

8 486 S.Y.

Polyester Concrete Overlay Br. No. 5175-C at . per S.Y. .

HOT MIX ASPHALT

13 486 S.Y.

Removing Existing Overlay from Bridge Deck No. 5175-C at . per S.Y. .

EROSION CNTL AND ROADSIDE

PLANTING

15 5 DAY ESC Lead at . per DAY .

16 5,000$ DOLLAR Erosion/Water Pollution Control at 1 . 00 per EST 5,000$ . 00

18 2 EACH Inlet Protection at . per EACH .

COUNTYWIDE BRIDGE DECK REHABILITATION

Bridge Nos. 24164-A, 6195-A and 5175-C

CRP 5963, Federal Aid No. BHOM-9927(069) Group 3 - Kapowsin Creek (Orville Road East)

Bridge No. 5175-C

QUANTITY UNIT PRICE UNIT TOTAL AMOUNT

LUMP SUM LS LUMP SUM

and that the plans, specifications and contract governing the work embraced in this improvement, and the method by which payment will be made for said work is understood. The undersigned hereby proposes to undertake and complete the work embraced in this improvement, or as much thereof as can be completed with the material available in accordance with the said plans, specifications and contract, and the following schedule of rates and prices.

Note: Unit price(s) for all item(s), all extensions, and total amount of bid shall be shown. All entries must be typed or entered in ink.

Show price per unit in figures only. Figures written to the right of the dot (decimal) in the price per unit column shall be interpreted as cents.

P 5 2/4/2026

NO. at $ . ct $ . ct

QUANTITY UNIT PRICE UNIT TOTAL AMOUNT

TRAFFIC

19 1,260 L.F. Plastic Line at . per L.F. .

20 0.1 HUND Raised Pavement Marker Type 1 at . per HUND .

21 Permanent Signing at .

22 315 L.F.

Temporary Pavement Marking-Short Duration at . per L.F. .

23 432 HR Portable Changeable Message Sign at . per HR .

24 Project Temporary Traffic Control at .

25 Traffic Control Supervisor at .

26 488 S.F. Construction Signs Class A at . per S.F. .

27 1,000$ DOLLAR Work Zone Safety Contingency at 1 . 00 per EST 1,000$ . 00

OTHER ITEMS

29 7,000$ DOLLAR Reimbursement for Third Party Damage at 1 . 00 per EST 7,000$ . 00

30 5,000$ DOLLAR Minor Change at 1 . 00 per EST 5,000$ . 00

31 SPCC Plan at .

32 FDC Plan at .

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

LUMP SUM LS LUMP SUM

Group 3 Total $ .

Contract Total $ .

Group 3 Total $ .

Group 1 Total $ .

Group 2 Total $ .

Show price per unit in figures only. Figures written to the right of the dot (decimal) in the price per unit column shall be interpreted as cents.

P 6 2/4/2026

BRIDGE DECK REHAB

Bridge No. 24164-A -Mashel River Bridge No. 6195-A – Puyallup River Bridge No. 5175-C - Kapowsin Creek CRP 5963, Federal Aid No. BHOM-9927(069) _25WORD.SPC\5963 Federal Pack.docx P 7 1/29/26

PIERCE COUNTY PLANNING & PUBLIC WORKS

PROPOSAL BOND

KNOW ALL MEN BY THESE PRESENTS, That we of as principal, and the a corporation duly organized under the laws of the State of and authorized to do business in the State of Washington, as surety, are held and firmly bound unto Pierce County, State of Washington, in the full and penal sum of five (5) percent of the total amount of the bid proposal of said principal for the work hereinafter described, pursuant to and in compliance with the provisions of RCW 36.77.030, for the payment of which, well and truly to be made, we bind our heirs, executors, administrators and assigns, and successors and assigns, firmly by these presents.

The conditions of this bond are such, that whereas the principal herein is hereby submitting his/her or its sealed proposal for the following public works construction, to wit:

said bid and proposal, by reference thereto, being made a part hereof.

NOW, THEREFORE, if said proposal bid by said principal be accepted, and the contract be awarded to said principal, said principal shall duly make and enter into and execute said contract and shall furnish bond as required by RCW 36.77.040 within ten (10) days after notice of the award, exclusive of the day of notice, then this obligation shall be null and void, otherwise it shall remain and be in full force and effect.

IN TESTIMONY WHEREOF, the principal and the surety have caused these presents to be signed and sealed this __________________ day of __________________________, 20___.

Principal

Surety

Attorney-in-fact

Bridge No. 6195-A – Puyallup River Bridge No. 5175-C - Kapowsin Creek CRP 5963, Federal Aid No. BHOM-9927(069) _25WORD.SPC\5963 Federal Pack.docx P 6 1/29/26

Proposal--Continued

The bidder is hereby advised that by signature of this proposal he/she is deemed to have acknowledged all requirements and signed all certificates contained herein.

The undersigned hereby agrees to pay not less than the prevailing rates of wages in accordance with the requirements of the special provisions for this project.

A proposal guaranty in an amount of five percent (5%) of the total bid, based upon the approximate estimate of quantities at the above prices and in the form as indicated below, is attached hereto:

CASH IN THE AMOUNT OF

CASHIER’S CHECK

CERTIFIED CHECK ($_________) PAYABLE TO PIERCE COUNTY

PROPOSAL BOND TREASURER IN THE AMOUNT OF 5% OF THE BID

Receipt is hereby acknowledged of addendum(s) No.(s) _____, _____, and _____.

PROPOSAL MUST BE SIGNED

SIGNATURE OF AUTHORIZED OFFICIAL(S)

By: By:

(Print Name) (Print Name)

FIRM NAME

ADDRESS

Street City State Zip

PHONE FAX E-MAIL

The following information is required per RCW 39.04.350

Contractor’s License No. Contractor’s UBI No.

Industrial Insurance Account No. Excise Tax No.

Employment Security Account No.

Signed and sworn to (or affirmed) before me this day of , 20____.

Notary Public in and for the State of Washington

Residing at My Appointment Expires

Note: (1) This proposal form is not transferable, and any alteration of the firm’s name entered hereon without prior permission from the County will be cause for considering the proposal irregular and subsequent rejection of the bid.

(2) Please refer to Section 1-02.6 of the Standard Specifications, re: “Preparation of Proposal.”

Local Agency Subcontractor List Prepared in compliance with RCW 39.30.060 as amended

To Be Submitted with the Bid Proposal Project Name

Failure to list subcontractors with whom the bidder, if awarded the contract, will directly subcontract for performance of the work of structural steel installation, rebar installation, heating, ventilation and air conditioning, plumbing, as described in Chapter 18.106 RCW, and electrical, as described in Chapter 19.28 RCW or naming more than one subcontractor to perform the same work will result in your bid being non-responsive and therefore void.

Subcontractor(s) with whom the bidder will directly subcontract that are proposed to perform the work of structural steel installation, rebar installation, heating, ventilation and air conditioning, plumbing, as described in Chapter 18.106 RCW, and electrical as described in Chapter 19.28 RCW must be listed below. The work to be performed is to be listed below the subcontractor(s) name.

To the extent the Project includes one or more categories of work referenced in RCW 39.30.060, and no subcontractor is listed below to perform such work, the bidder certifies that the work will either (i) be performed by the bidder itself, or (ii) be performed by a lower tier subcontractor who will not contract directly with the bidder.

Subcontractor Name

Work to be performed

Subcontractor Name

Work to be performed

Subcontractor Name

Work to be performed

Subcontractor Name

Work to be performed

Subcontractor Name

Work to be performed

* Bidder’s are notified that it is the opinion of the enforcement agency that PVC or metal conduit, junction boxes, etc, are considered electrical equipment and therefore considered part of electrical work, even if the installation is for future use and no wiring or electrical current is connected during the project.

DOT Form 271-015LP Revised 06/2020

Pierce County Planning & Public Works

Tacoma Mall Plaza 2702 South 42nd Street Suite 109 Tacoma, WA 98409

P 8

Bridge No. 6195-A – Puyallup River Bridge No. 5175-C - Kapowsin Creek CRP 5963, Federal Aid No. BHOM-9927(069) _25WORD.SPC\5963 Federal Pack.docx P 9 1/29/26

REQUIRED CONTRACT PROVISIONS

FEDERAL-AID CONSTRUCTION CONTRACTS

III. NONSEGREGATED FACILITIES

(Applicable to all Federal-aid construction contracts and to all related subcontracts of $10,000 or more.)

a. By submission of this bid, the execution of this contract or subcontract, or the consummation of this material supply agreement or purchase order, as appropriate, the bidder, Federal-aid construction contractor, subcontractor, material supplier, or vendor, as appropriate, certifies that the firm does not maintain or provide for its employees any segregated facilities at any of its establishments, and that the firm does not permit its employees to perform their services at any location, under its control, where segregated facilities are maintained. The firm agrees that a breach of this certification is a violation of the EEO provisions of this contract. The firm further certifies that no employee will be denied access to adequate facilities on the basis of sex or disability.

b. As used in this certification, the term “segregated facilities” means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms, and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive, or are, in fact, segregated on the basis of race, color, religion, national origin, age or disability, because of habit, local custom, or otherwise. The only exception will be for the disabled when the demands for accessibility override (e.g., disabled parking).

c. The contractor agrees that it has obtained or will obtain identical certification from proposed subcontractors or material suppliers prior to award of subcontractors or consummation of material supply agreements of $10,000 or more and that it will retain such certifications in its files.

DOT Form 272-022 Revised 09/2024 P 10 (Previous Versions Obsolete)

Failure to return this Declaration as part of the bid proposal package will make the bid nonresponsive and ineligible for award.

NON-COLLUSION DECLARATION

I, by signing the proposal, hereby declare, under penalty of perjury under the laws of the United States, that the following statements are true and correct:

1. That the undersigned person(s), firm, association or corporation has (have) not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with the project for which this proposal is submitted.

2. That by signing the signature page of this proposal, I am deemed to have signed and have agreed to the provisions of this declaration.

NOTICE TO ALL BIDDERS

To report bid rigging activities call: 1-800-424-9071

The U.S. Department of Transportation (USDOT) operates the above toll-free “hotline” Monday through Friday, 8:00 a.m. to 5:00 p.m., Eastern Time. Anyone with knowledge of possible bid rigging, bidder collusion, or other fraudulent activities should use the “hotline” to report such activities.

The “hotline” is part of USDOT’s continuing effort to identify and investigate highway construction contract fraud and abuse and is operated under the direction of the USDOT Inspector General. All information will be treated confidentially, and caller anonymity will be respected.

Bridge No. 6195-A – Puyallup River Bridge No. 5175-C - Kapowsin Creek CRP 5963, Federal Aid No. BHOM-9927(069) _25WORD.SPC\5963 Federal Pack.docx P 11 1/29/26

LOCAL AGENCY CERTIFICATION FOR FEDERAL-AID CONTRACTS

The prospective participant certifies, by signing and submitting this bid or proposal, to the best of his or her knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

The prospective participant also agrees by submitting his or her bid or proposal that he or she shall require that the language of this certification be included in all lower tier subcontracts, which exceed $100,000 and that all such sub-recipients shall certify and disclose accordingly.

DOT 272-040A EF

7/2011

Bridge No. 6195-A – Puyallup River Bridge No. 5175-C - Kapowsin Creek CRP 5963, Federal Aid No. BHOM-9927(069) _25WORD.SPC\5963 Federal Pack.docx P 12 1/29/26

Proposal for Incorporating Recycled Materials into the Project

In compliance with RCW 70A.205.700, the Bidder shall propose below, the total percent of construction aggregate and concrete materials to be incorporated into the Project that are recycled materials. Calculated percentages must be within the amounts allowed in Section 9-03.21(1)E, Table on Maximum Allowable Percent (By Weight) of Recycled Material, of the Standard Specifications.

Proposed total percentage: _____________________________ percent.

Note: Use of recycled materials is highly encouraged within the limits shown above, but does not constitute a Bidder Preference, and will not affect the determination of award, unless two or more lowest responsive Bid totals are exactly equal, in which case proposed recycling percentages will be used as a tiebreaker, per the APWA GSP in Section 1-02.6 of the Special Provisions. Regardless, the Bidder’s stated proposed percentages will become a goal the Contractor should do its best to accomplish. Bidders will be required to report on recycled materials actually incorporated into the Project, in accordance with the APWA GSP in Section 1-06.6 of the Special Provisions.

Bidder Name:

Signature of Authorized Official:

Date:

Bridge No. 6195-A – Puyallup River Bridge No. 5175-C - Kapowsin Creek CRP 5963, Federal Aid No. BHOM-9927(069) _25WORD.SPC\5963 Federal Pack.docx P 13 1/29/26

CONTRACTOR CERTIFICATION WAGE LAW COMPLIANCE

The bidder hereby certifies that, within the three-year period immediately preceding the bid solicitation date March 11, 2026, the bidder is not a “willful” violator, as defined in RCW 49.48.082, of any provision of chapters 49.46, 49.48, or 49.52 RCW, as determined by a final and binding citation and notice of assessment issued by the Department of Labor and Industries or through a civil judgment entered by a court of limited or general jurisdiction.

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

Bidder’s Business Name

Signature of Authorized Official*

Printed Name

Title

Date City State

Check One:

Sole Proprietorship ☐ Partnership ☐ Joint Venture ☐ Corporation ☐

State of Incorporation, or if not a corporation, State where business entity was formed:

If a co-partnership, give firm name under which business is transacted:

* If a corporation, proposal must be executed in the corporate name by the president or vice-president (or any other corporate officer accompanied by evidence of authority to sign). If a co-partnership, proposal must be executed by a partner.

Washington State Department of Transportation Bidder Questionnaire

Agency Name Federal Aid Number

Prime Contractor Name Contract Number

Contract Name

Firm/Subcontractor Name Address (incl. Zipcode)

DBE

Status

NAICS

Codes Scope of Work Firm Age Firm Gross Receipts

If you have additional Firms or Subcontractors that submitted Bids, please complete additional forms.

Prime Contractor Representative Title Date

DOT Form 272-022 Revised 12/2025

● Previous Versions Obsolete ●

Form Instructions

The following information on each firm that submitted a bid is required as part of part of 49 CFR 26.11(c)(2):

Firm/Subcontractor Name: Enter the name of each firm or subcontractor who submitted a quote or a bid on the contract.

Address: Enter the date the main address of the firm/subcontractor. Include the zip code.

DBE Status: Enter the DBE status. Options are DBE and Non-DBE.

NAICS Codes: Enter the appropriate NAICS Codes for the work the bid was submitted.

Scope of Work: Enter the scope of the work the bid was submitted for.

Firm Age: Enter the age of the Firm.

Firm Gross Receipts: Enter the annual gross receipts. Options are “Less than $1 million”, “$1-$3 million”, “$3-$6 million”, “$6-$10 million”, “$10-$20 million ”, “$20-$30.72 million ”, “Greater than $30.72 million ”.

DOT Form 272-022 Revised 12/2025

● Previous Versions Obsolete ●