Attachment O - VDOT Forms.pdf

25-05-3237TP ATTACHMENT O

ATTACHMENT O

SUBCONTRACTOR/SUPPLIER SOLICITATION AND UTILIZATION FORM

DBE GOOD FAITH EFFORTS DOCUMENTATION

MINIMUM DBE REQUIREMENTS

CERTIFICATION OF BINDING AGREEMENT WITH DBE FIRMS

Form C-48 Rev. 2-23-11

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

SUBCONTRACTOR/SUPPLIER SOLICITATION AND UTILIZATION FORM

(ALL BIDDERS)

PROJECT NO. CONTRACT I.D. NO.

FHWA NO. DATE SUBMITTED

All bidders, including DBEs bidding as Prime Contractors, shall complete and submit the following information as requested in this form within ten (10) business days after the opening of bids.

The bidder certifies this form accurately represents its solicitation and utilization or non-utilization, as indicated, of the firms listed below for performance of work on this contract. The bidder also certifies he/she has had direct contact with the named firms regarding participation on this project.

BIDDER SIGNATURE

TITLE

SUBCONTRACTOR/SUPPLIER SOLICITATION AND UTILIZATION (ALL)

VENDOR

NUMBER NAME OF SUBCONTRACTOR/SUPPLIER

TELEPHONE

NUMBER

DBE OR

NON-DBE

UTILIZED

(Y/N)

NOTE: ATTACH ADDITIONAL PAGES, IF NECESSARY.

BIDDER MUST SIGN EACH ADDITIONAL SHEET TO CERTIFY ITS CONTENT AND COMPLETION OF FORM.

Form C-49 2-24-14

Sheet 1 of 10

COMM0NWEALTH OF VIRGINIA

CONTRACT I.D. NUMBER________________________________

PROJECT NUMBER_____________________________________

FHWA NUMBER________________________________________

DISTRICT______________________________________________

DATE BID SUBMITTED___________________________________

BIDDER’S NAME________________________________________

SIGNATURE____________________________________________

TITLE_________________________________________________

VENDOR NUMBER______________________________________

DBE GOAL FROM BID PROPOSAL____________________________

--DO NOT DETACH--

THIS INFORMATION MUST BE SUBMITTED

WITHIN 2 DAYS AFTER BID OPENING IF YOUR

BID DOES NOT MEET THE PROJECT DBE

REQUIREMENTS, OR

WHEN REQUESTED BY VDOT

Sheet 2 of 10

COMM0NWEALTH OF VIRGINIA

CONTRACT I.D. NO.________________________________DATE SUBMITTED______________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE________________________________________________________________________________________

NAMES OF CERTIFIED DBEs AND THE DATES ON WHICH THEY WERE SOLICITED TO BID

ON THIS PROJECT

INCLUDE THE ITEMS OF WORK OFFERED AND THE DATES AND METHODS USED FOR

FOLLOWING UP INITIAL SOLICITATIONS TO DETERMINE WHETHER OR NOT DBEs WERE

INTERESTED.

NAMES AND VENDOR

NUMBERS OF DBEs

SOLICITED

DATE OF INITIAL

SOLICITATION

ITEM(S) OF WORK

FOLLOW-UP METHODS

AND DATES

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY

ATTACH COPIES OF SOLICITATIONS, TELEPHONE RECORDS, FAX CONFIRMATIONS,

ELECTRONIC INFORMATION, ETC.

Sheet 3 of 10

CONTRACT I.D. NO._________________DATE SUBMITTED___________________________

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

BIDDER_____________________________________SIGNATURE______________________________________

TELEPHONE LOG

DBE(s) CALLED

TELEPHONE

NUMBER

DATE

CALLED

TIME

CALLED

CONTACT PERSON OR

VOICE MAIL STATUS

Sheet 4 of 10

ITEM(S) OF WORK THAT THE BIDDER MADE AVAILABLE TO DBE FIRMS

IDENTIFY THOSE ITEM(S) OF WORK THAT THE BIDDER MADE AVAILABLE TO DBE

FIRMS OR THOSE ITEM(S) THE BIDDER IDENTIFIED AND DETERMINED TO SUBDIVIDE

INTO ECONOMICALLY FEASIBLE UNITS TO FACILITATE DBE PARTICIPATION. FOR

EACH ITEM LISTED, SHOW THE DOLLAR VALUE AND PERCENTAGE OF THE TOTAL

CONTRACT AMOUNT. IT IS THE BIDDER’S RESPONSIBILITY TO DEMONSTRATE THAT

SUFFICIENT WORK TO MEET THE GOAL WAS MADE AVAILABLE TO DBE FIRMS.

MADE AVAILABLE

BIDDER

NORMALLY

PERFORMS ITEM(S)

(Y/N)

ITEM(S) BROKEN

DOWN TO

FACILITATE

PARTICIPATION

(Y/N)

AMOUNT IN

DOLLARS

PERCENTAGE

OF

CONTRACT

NOTE: INFORMATION REQUIRED FOR THIS SECTION CONTINUED ON SHEET 5

ATTACH ADDITIONAL PAGES IF NECESSARY

Sheet 5 of 10

COMM0NWEALTH OF VIRGINIA

ADDITIONAL INFORMATION REGARDING ITEM(S) OF WORK THAT THE

BIDDER MADE AVAILABLE TO DBE FIRMS (Continued From Sheet 4)

ITEM(S) OF WORK MADE AVAILABLE, NAMES OF SELECTED FIRMS AND DBE STATUS,

DBEs THAT PROVIDED QUOTES, PRICE QUOTE FOR EACH FIRM, AND THE PRICE

DIFFERENCE FOR EACH DBE IF THE SELECTED FIRM IS NOT A DBE.

MADE

AVAILABLE(CONT.)

NAME OF

SELECTED

FIRM AND

VENDOR

NUMBER

DBE OR

NON-DBE

NAME OF

REJECTED

FIRM(S)

QUOTE IN

PRICE

DIFFERENCE IN

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY.

IF THE FIRM SELECTED FOR THE ITEM IS NOT A DBE, PROVIDE THE REASON(S) FOR

THE SELECTION ON A SEPARATE PAGE AND ATTACH.

PROVIDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS FOR THE FIRMS LISTED

ABOVE.

Sheet 6 of 10

ADVERTISEMENTS OR PROOFS OF PUBLICATION.

NAMES AND DATES OF EACH PUBLICATION IN WHCH A REQUEST FOR DBE

PARTICIPATION FOR THE PROJECT WAS PLACED BY THE BIDDER. ATTACH COPIES OF

PUBLISHED ADVERTISEMENTS OR PROOFS OF PUBLICATION.

PUBLICATIONS DATES OF ADVERTISEMENT

COMM0NWEALTH OF VIRGINIA

NAMES OF AGENCIES CONTACTED TO PROVIDE ASSISTANCE

NAMES OF AGENCIES (SEE SPECIAL PROVISION FOR 107.15) AND THE DATES THESE

AGENCIES WERE CONTACTED TO PROVIDE ASSISTANCE IN CONTACTING,

RECRUITING, AND USING DBE FIRMS. IF THE AGENCIES WERE CONTACTED IN

WRITING, ATTACH COPIES OF SUPPORTING DOCUMENTS.

NAME OF AGENCY

METHOD AND DATE OF

CONTACT

RESULTS

Sheet 8 of 10

TECHNICAL ASSISTANCE AND INFORMATION PROVIDED TO DBEs

EFFORTS MADE TO PROVIDE INTERESTED DBEs WITH ADEQUATE INFORMATION

ABOUT THE PLANS, SPECIFICATIONS, AND REQUIREMENTS OF THE BID DOCUMENTS

TO ASSIST THE DBEs IN RESPONDING TO A SOLICITATION.

IDENTIFY THE DBEs ASSISTED, THE INFORMATION PROVIDED, AND THE DATE OF

CONTACT. ATTACH COPIES OF SUPPORTING DOCUMENTS.

DBEs ASSISTED INFORMATION PROVIDED DATE OF CONTACT

Sheet 9 of 10

EFFORTS MADE TO ASSIST DBEs OBTAIN BONDING, LINES OF CREDIT, INSURANCE, ETC.

EFFORTS MADE TO PROVIDE INTERESTED DBEs IN OBTAINING BONDING, LINES OF

CREDIT, INSURANCE, NECESSARY EQUIPMENT, SUPPLIES, MATERIALS, OR RELATED

ASSISTANCE OR SERVICES, EXCLUDING SUPPLIES AND EQUIPMENT THE

SUBCONTRACTOR PURCHASES OR LEASES FROM THE PRIME CONTRACTOR OR ITS

AFFILIATES.

IDENTIFY THE DBEs ASSISTED, THE ASSISTANCE OFFERED, AND THE DATES OF

SERVICES OFFERED AND PROVIDED. ATTACH COPIES OF SUPPORTING DOCUMENTS.

DBEs ASSISTED ASSISTANCE OFFERED DATES SERVICES OFFERED

AND/OR PROVIDED

Sheet 10 of 10

ADDITIONAL DATA TO SUPPORT DEMONSTRATION OF GOOD FAITH EFFORTS

ADDITIONAL DATA TO SUPPORT DEMONSTRATION OF GOOD FAITH EFFORTS

NOTE: ATTACH ADDITIONAL PAGES, IF NECESSARY

Form C-111 Rev. 2-15-11

MINIMUM DBE REQUIREMENTS

PROJECT NO.

FHWA NO.

* * * INSTRUCTIONS * * *

THIS FORM CAN BE USED BY THE CONTRACTOR TO SUBMIT THE NAMES OF DBE FIRMS TO BE UTILIZED ON THE PROJECT. THE CONTRACTOR SHALL INDICATE THE DESCRIPTION OF THE CATEGORY (S, M, SP or H) AND THE TYPE OF WORK THAT EACH DBE WILL PERFORM AND THE ALLOWABLE CREDIT PER ITEM(S). ADDITIONAL SHEETS TO SHOW THE ALLOWABLE CREDIT PER ITEM MAY BE ATTACHED IF NECESSARY. PLEASE NOTE: THE AMOUNT OF ALLOWABLE CREDIT FOR A DBE SUPPLIER IS 60% OF THE TOTAL COST OF THE MATERIALS OR SUPPLIES OBTAINED AND 100% FOR A DBE MANUFACTURER OF THE MATERIALS AND SUPPLIES OBTAINED.

A CONTRACTOR MAY COUNT 100% OF THE FEES PAID TO A DBE HAULER FOR THE DELIVERY OF MATERIALS AND SUPPLIES TO THE

PROJECT SITE, BUT NOT FOR THE COST OF THE MATERIALS AND SUPPLIES THEMSELVES.

DBE REQUIREMENT %

PERCENT ATTAINED BY BIDDER %

NAMES(S) AND CERTIFICATION NO.

OF DBE(S) TO BE USED

USED AS

SUBCONTR. (S)

MFG. (M)

SUPPLIER (SP)

HAULER (H)

TYPE OF WORK AND ITEM

NO(S)

$ AMOUNT OF

ALLOWABLE

CREDIT PER ITEM

TOTAL $

TOTAL CONTRACT VALUE $ x REQUIRED DBE % = $

I/WE CERTIFY THAT THE PROPOSED DBE(S) SUBMITTED WILL BE USED ON THIS CONTRACT AS STATED HEREON AND ASSURE THAT DURING THE LIFE OF THE CONTRACT. I/WE WILL MEET OR EXCEED THE PARTICIPATION ESTABLISHED HEREON BY THE

DEPARTMENT.

BY

BIDDER SIGNATURE

BY

TITLE DATE

Form C-112 Rev. 3-1-11

CERTIFICATION OF BINDING AGREEMENT

WITH

DISADVANTAGED BUSINESS ENTERPRISE FIRMS

Project No.:

Federal Project No.:

This form is to be submitted in accordance with the Department’s Special Provision for Section 107.15.

It is hereby certified by the below signed Contractors that there exists a written quote, acceptable to the parties involved preliminary to a binding subcontract agreement stating the details concerning the work to be performed and the price which will be paid for the aforementioned work. This document is not intended to, nor should it be construed to, contain the entire text of the agreement between the contracting parties. This document does not take the place of, nor may it be substituted for, an official subcontracting agreement in those situations that may require such an agreement. A copy of the fully executed subcontract agreement shall be submitted to the Engineer within fourteen (14) business days after contract execution.

It is further certified that the aforementioned mutually acceptable quote and fully executed subcontract agreement represent the entire agreement between the parties involved and that no conversations, verbal agreements, or other forms of non-written representations shall serve to add to, delete, or modify the terms as stated.

The prime Contractor further represents that the aforementioned mutually acceptable quote and fully executed subcontract agreement shall remain on file for a period of not less than one year following completion of the prime's contract with the Department or for such longer period as provisions of governing Federal or State law or regulations may require. For purposes of this form, the term Prime Contractor shall refer to any Contractor utilizing a DBE subcontractor, regardless of tier, in which they are claiming DBE credit toward the contract goal.

Contractors further jointly and severally represent that said binding agreement is for the performance of a "commercially useful function" as that term is employed in 49 C.F.R. Part 26.55 (c), (d).

TO BE SIGNED BY THE SUBCONTRACTOR TO THE PRIME CONTRACTOR, AND ANY LOWER TIER

SUBCONTRACTORS HAVING A CONTRACT WITH THE BELOW NAMED DBE FIRM

Prime Contractor

By:

Signature Title

Date:

First Tier Subcontractor if Applicable

Form C-112 Rev. 3-1-11

Second Tier

Third Tier

DBE Contractor

Form C-112