County:

General Info Prime Contractor

F.E.I.D. #

Contractor

By:

(Seal)

TO: THE STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

Total Contract Amount Total Work

Address

FEID # Subcontract to Whom Work Description Total Amt Sublet

State of Florida County of

Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization, this day of (year), by (Print name of person signing Certification)

Notary Public

Commission Expires

OR Produced Identification Type of Identification Produced Personally KnownS

700-010-36

CONSTRUCTION

01/23

A false statement or omission made in connection with this certification is sufficient cause for suspension, revocation, or denial of qualification to bid, and a determination of non-responsibility, and may subject the person and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable Federal and State Law.

All pertinent provisions and requirements of the prime contract including but not limited to Required Contract Provisions Federal-Aid Construction Contracts (FHWA-1273) and Special Provisions - Specific Equal Opportunity Responsibilities (Per 23 CFR-633B of Federal-Aid Policy Guide) will be part of the subcontract or agreement.

It is agreed that an Executed or a certified copy of the subcontract will be submitted upon request, to the Florida Department of Transportation. All sublets will be in continued compliance with all Contract provisions and that the Contractor will continue to perform the minimum percentage of Contract work with its own organization, as required by said Contract. It is recognized and agreed that, as prime contractor, the undersigned remains responsible for the proper performance of all requirements of said contract does not relieve or release the undersigned and his surety or either of them of any liability under the contract bond. The Contractor shall send a copy of this form to the subcontractor/ subordinate (with a copy of FHWA-1273 on Federal-Aid Projects) and the Surety Company. The Prime certify that firms or individuals, debarred or suspended by the FHWA or the Department, are not being used as subcontractors.

Subcontractor Name

Date:

Request No.:

FAP No.:

Fin. Proj. ID:

Cont. No.:

Ch an ge

Ti er

Pa rt ia l

D

BE

N

O N

D

BE

0.00

, not required when digital

TOTAL

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

CERTIFICATION OF SUBLET WORK

Instructions for Form:

The contractor must provide enough information through a Schedule "A" spreadsheet to determine which pay-item(s) are being sublet, the amounts, and cost. For sublet calculations, the amount will be calculated based on the actual contract unit price(s) unless there is a partial sublet. For partial sublets, use the unit prices from the actual sub-contract.

1) Enter the Date of the certification of sublet work was prepared.

2) Enter the sequential number of the request starting with number 1.

3) Enter the Federal Aid Project number for the Prime Contractor if any.

4) Enter the Financial Project Identification number of the Contract.

5) Enter the Contract number of the Contract with the Department.

6) Enter the County name where the work is being performed.

7) Enter the Name of the Prime Contractor.

8) Enter the FEID number of the Prime Contractor.

9) Enter the Original Contract dollar amount (round to nearest whole dollar).

10) Enter a "Y" in the space marked Change if any information on the line has changed since the previous certification of sublet work was prepared. Otherwise, leave blank.

11) Enter the Subcontractor names. Enter all the subcontractor(s) regardless of their tier.

12) Enter the tier number for the subcontractor. If the subcontractor works directly for the Prime

Contractor, enter a "1". If he works one level below, enter a "2" and so on.

13) Enter the FEID number of the Subcontractor(s).

14) Enter the name of the pertinent Contractor or Subcontractor that hired subcontractor.

15) Enter a short description of the work to be performed.

16) Enter a "P" if any pay-item for the sublet is a partial sublet (i.e., only part of the work for a pay item(s) is sublet).

17) Enter the DBE status for the subcontractor: "D" for DBE, "N" for non-DBE.

18) The Department may require subcontractor to be prequalified with the Department as described in the Special Provisions and the Bid Solicitation Notice whenever construction projects contain certain classes of work that require specific expertise.

19) One (1) copy of this form shall be submitted to the District Office by the contractor.

20) To be signed by principal of the firm or someone with the delegated authority and notarized.

a) Note: Notary not required when form is digitally signed.

700-010-36

CONSTRUCTION

08/19