Attachment_19_-_STD_817_DVBE_Subcontractor__if_applicable_.pdf

State of California Department of General Services - Procurement Division Prime Contractor's Certification - DVBE Subcontractor Report STD 817, Formerly DGS PD 810P

STATE DEPARTMENT AND CONTRACT INFORMATION

State Department Information Contract Information FOR STATE USE ONLY Prime Contractor Information:

State Department Name: Contract #: Name::

State Department Address: FI$Cal Supplier ID#: Address::

Contract Manager Name: Contract Execution Date:

Date Received:

Phone #:

Contract Manager Phone #: Date Work Completed: Email:

Contract Manager Email Address: Contract Award Amount: Date Last Payment Received:

Contract Received Amount:

SECTION 3 List all Disabled Veteran Business Enterprise firms involved with this contract.

(A)

DVBE Subcontractor(s) Name

(B)

DVBE Subcontractor(s) Address

(C)

DVBE Certification

ID Number

(D)

Total Contract Commitment

Percentage to DVBE

(E)

Total Contract Commitment Amount to

DVBE

(F)

Total Payment Amount to

DVBE

(G) Difference in

Amount Paid to

DVBE

(F - E)

(H)

Percentage Paid to

DVBE

(F/Contract Received Amount)

Number of DVBE Subcontractors Grand Total $ $ $

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(I) Comments/Explanations

Use next page for additional lines

I certify under penalty of perjury under the laws of the State of California that all information submitted is true and correct.

Prime Contractor Print Name: Date:

Title:

Signature:

Return upon completion of contract.

Americans with Disabilities (ADA) Notice: Persons with disabilities requiring reasonable modifications should contact the OSDS Report Coordinator at OSDSReports@dgs.ca.gov

Page 2 of 5 Department of General Services - Procurement Division

Prime Contractor's Certification - DVBE Subcontractor Report STD 817, Formerly DGS PD 810P

STATE DEPARTMENT AND CONTRACT INFORMATION

State Department Information Contract Information FOR STATE USE ONLY Prime Contractor Information

State Department Name: Contract #: Name::

State Department Address: FI$Cal Supplier ID#: Address::

Contract Manager Name: Contract Execution Date:

Date Received:

Phone #:

Contract Manager Phone #: Date Work Completed: Email:

Contract Manager Email Address: Contract Award Amount: Date Last Payment Received:

Contract Received Amount:

List all Disabled Veteran Business Enterprise firms involved with this contract.

(A)

DVBE Subcontractor(s) Name

(B)

DVBE Subcontractor(s) Address

(C)

DVBE

Certification ID

Number

(D)

Total Contract

Commitment

Percentage to

DVBE

(E)

Total Contract

Commitment

Amount to DVBE

(F)

Total Payment Amount to

DVBE

(G)

Difference in Amount Paid to DVBE

(F - E)

(H)

Percentage Paid to

DVBE

(F/Contract Received Amount)

Number of DVBE Subcontractors Total $ $ $

Attach copies of this page for additional lines

I certify under penalty of perjury under the laws of the State of California that all information submitted is true and correct.

Americans with Disabilities (ADA) Notice: Persons with disabilities requiring reasonable modifications should contact the OSDS Report Coordinator at OSDSReports@dgs.ca.gov

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Department of General Services Procurement Division Prime Contractor’s Certification - DVBE Subcontracting Report STD 817, Formerly DGS PD 810P (Rev. 10/2021) Form Completion Instructions GENERAL INFORMATION: Military and Veteran Code (MVC) 999.5(d), 999.7 and Government Code (GC) 14841, and California Code of Regulations (CCR) 1896.78(e) requires all Prime Contractors that committed to have a Disabled Veteran Business Enterprise (DVBE) perform an element of work for a contract to report DVBE subcontractor participation information and certify to the state that all DVBE subcontracting payments were made.

Departments are required to withhold $10,000 from the final payment, or the full payment if less than $10,000, on contracts until the Prime Contractor complies with the certification requirements by submitting this form.

If prime contractors do not comply with the requirements after given notice to cure by the state departments, the withheld amount will be permanently deducted.

All contracted work must be completed before submission of invoice(s) and this certification form.

Prime Contractors are required to maintain records supporting the information submitted on this form and that all payments to DVBE subcontractor(s) were made. Upon request, proof of payment must be provided (MVC 999.5(d)).

INCLUDE

• ONLY ONE contract per Report

• All DVBEs that performed an element of work for this contract regardless of tier

State Department Information:

State Department Name: Enter the State Department name

State Department Address: Enter the State Department address

Contract Manager Name: Enter the Contract Manager name

Contract Manager Phone Number: Enter the Contract Manager phone #

Contract Manager Email Address: Enter the Contract Manager email address

Contract Information

Contract Number: Enter the Contract Number

Contractor's FI$Cal Supplier ID Number: Enter your FI$Cal supplier ID number

Contract Execution Date: Enter the date contract was signed

Date Work Completed: Enter the date the work was completed on the contract

Contract Award Amount: Enter the total dollar amount awarded for this contract including all financial amendments

Department of General Services Procurement Division Prime Contractor’s Certification - DVBE Subcontracting Report STD 817, Formerly DGS PD 810P (Rev. 10/2021) Form Completion Instructions

Prime Contractor Information:

Prime Contractor Name: Enter your name as shown on the contract

Prime Contractor Address: Enter your address

Phone Number: Enter your number (with area code)

Email Address: Enter your email address

Date Last Payment Received: Enter the date the last payment for work performed was received

Contract Received Amount: Enter the dollar amount of the last payment received

For State Use Only

Date STD 817 Received: Enter date the Contract Manager received the STD 817 from the Prime Contractor

TABLE INSTRUCTIONS

A) DVBE Subcontractor(s) Name: Enter the name of all DVBEs that are listed to perform an element of work or supplies for this contract and any formal approved substitution(s). (Use additional lines if the name does not fit on a single line) Use page two for additional lines.

B) DVBE Subcontractor(s) Address: Enter the address of each DVBE (Use page 2 for additional lines if address does not fit on a single line)

C) DVBE Certification ID Number: Enter each DVBE's certification number

D) Total Contract Commitment Percentage to DVBE: Enter the total percentage of contracted dollars to each DVBE at the time of award

E) Total Contract Commitment Amount to DVBE: Enter the entire amount contracted to each DVBE at the time of award

F) Total Payment Amount to DVBE: Enter the total amount paid to all DVBEs that performed an element of work or were suppliers for this contract

Department of General Services Procurement Division Prime Contractor’s Certification - DVBE Subcontracting Report– Page 5 of 5 STD 817, Formerly DGS PD 810P (Rev. 10/2021) Form Completion Instructions

G) Difference in Amount Paid to DVBE: The form will compute the difference of DVBE dollars contracted compared to dollars paid

H) Percentage Paid to DVBE: The form will compute the percentage paid to DVBEs using the Contract Received Amount entered under State and Contract Information

Instructions I

I) Comments/Explanations: Enter any relevant comments and explanations for any differences between the DVBE amounts or percentages committed and paid. Reference the line number if comments and explanations are used.

SIGNATURE BLOCK

Prime Contractor’s Signature: Enter your printed name, title, sign with an electronic signature or a wet signature, and date

Note: Complete and accurate certifications are due upon completion of contract.