Attachment_D-Form_A_BidProp_MDOT_Federal.pdf

MDOT-OP 016-2 (9/11)

MDOT DBE FORM A

FEDERALLY-FUNDED CONTRACTS

CERTIFIED DBE UTILIZATION AND FAIR SOLICITATION AFFIDAVIT

THIS AFFIDAVIT MUST BE INCLUDED WITH THE BID/ PROPOSAL. IF THE BIDDER/OFFEROR FAILS TO

ACCURATELY COMPLETE AND SUBMIT THIS AFFIDAVIT AS REQUIRED, THE BID SHALL BE DEEMED NOT

RESPONSIVE OR THE PROPOSAL SHALL BE DEEMED NOT SUSCEPTIBLE OF BEING SELECTED FOR AWARD.

In connection with the bid/proposal submitted in response to Solicitation No. , I affirm the following:

1. DBE Participation (PLEASE CHECK ONLY ONE)

I have met the overall certified Disadvantaged Business Enterprise (DBE) participation goal of percent ( %). I agree that this percentage of the total dollar amount of the Contract for the DBE goal will be performed by certified DBE firms as set forth in the DBE Participation Schedule - Part 2 of the MDOT DBE Form B (Federally-Funded Contracts).

OR

I conclude that I am unable to achieve the DBE participation goal. I hereby request a waiver, in whole or in part, of the goal. Within 10 business days of receiving notice that our firm is the apparent awardee or as requested by the Procurement Officer, I will submit a written waiver request and all required documentation in accordance with COMAR 21.11.03.11. For a partial waiver request, I agree that certified DBE firms will be used to accomplish the percentages of the total dollar amount of the Contract as set forth in the DBE Participation Schedule - Part 2 of the MDOT DBE Form B (Federally-Funded Contracts).

2. Additional DBE Documentation

I understand that if I am notified that I am the apparent awardee or as requested by the Procurement Officer, I must submit the following documentation within 10 business days of receiving such notice:

(a) Outreach Efforts Compliance Statement (MDOT DBE Form C - Federally-Funded Contracts );

(b) Subcontractor Project Participation Statement (MDOT DBE Form D - Federally-Funded Contracts);

(c) DBE Waiver Request documentation per COMAR 21.11.03.11 (if waiver was requested); and

(d) Any other documentation required by the Procurement Officer to ascertain bidder’s responsibility/ offeror’s susceptibility of being selected for award in connection with the certified DBE participation goal.

I acknowledge that if I fail to return each completed document (in 2 (a) through (d)) within the required time, the Procurement Officer may determine that I am not responsible and therefore not eligible for contract award or not susceptible of being selected for award.

MDOT-OP 016-2 (9/11)

MDOT DBE FORM A

FEDERALLY-FUNDED CONTRACTS

CERTIFIED DBE UTILIZATION AND FAIR SOLICITATION AFFIDAVIT

3. Information Provided to DBE firms

In the solicitation of subcontract quotations or offers, DBE firms were provided not less than the same information and amount of time to respond as were non-DBE firms.

4. Products and Services Provided by DBE firms

I hereby affirm that the DBEs are only providing those products and services for which they are MDOT certified.

I solemnly affirm under the penalties of perjury that the information in this affidavit is true to the best of my knowledge, information and belief.

Company Name Signature of Representative

Address Printed Name and Title

City, State and Zip Code Date