CDOTRM_CDOT_FORM_-_1415_-_Civil_Rights_-_Commitment_Confirmation.pdf

COLORADO DEPARTMENT OF TRANSPORTATION

COMMITMENT CONFIRMATION (CDOT Form 1415) Section A. Bidder/Prime Contractor and DBE Information. This section must be completed by the Bidder/Prime Contractor.

1. Project S/A No. or PCN Number (5 digit #):

2. FHWA Project #, Subaward Agreement # from

COTRAMS (FTA

contracts), or PO # (for CM/GC-CM contracts):

3. Project Name:

4. Name of Bidder/Prime Contractor:

5. Bidder/Prime Contractor's Contact Name:

6. Bidder/Prime Contractor's Contact Title:

7. Bidder/Prime Contractor's Contact Phone Number:

8. Bidder/Prime Contractor's Contact Email Address:

9. Name of DBE Firm:

10. DBE Firm Physical Address:

11. DBE Contact Name:

12. DBE Contact Email Address:

13. DBE Contact Phone Number:

14. Subcontracted to Whom: if Prime

15. Is the DBE part of a Joint Venture?

(if Yes, attach joint venture agreement) Yes No 16. Anticipated Work

Start Date:

17. Applicable Small Business Goals (To be completed ONLY for FHWA-funded Design-Build contracts)

DBE Design Goal

DBE Construction Goal

Applicable Contract Year: (July 1, - June 30, )

Section B. Commitment Details

18. DBE Commitment Details

a. Work Category c. DBE Work Code(s) (NAICS + Descriptor)

Construction

Trucking

Supplies

Services

Other

Design Services (for FHWA-funded Design- Build contracts and FTA Consultant Contracts only)

b. Work to be Performed d. Commitment Amount

e. Amount Eligible for DBE Participation

Total:

19. Bidder/Prime Contractor Representative:

This section must be signed by an individual with the authority to contractually bind the Bidder/Prime Contractor to the DBE commitment listed on this form. You declare under penalty of perjury in the second degree and any other applicable state or federal laws that the statements made in this document are complete, true, and accurate to the best of your knowledge. If a DBE commitment is being made and the subcontract is between a lower-tier subcontractor and a DBE firm (not the Prime Contractor), the Prime Contractor shall provide this signed CDOT Form 1415 to that lower-tier subcontractor and the DBE Standard Specification shall be followed.

a. Name b. Title c. Signature d. Date

"Previous editions are obsolete and may not be used." CDOT Form No. 1415 [09/23] Page 1

COLORADO DEPARTMENT OF TRANSPORTATION

COMMITMENT CONFIRMATION (CDOT Form 1415) Section C. DBE Questionnaire. This section must be completed by the DBE firm. (Attach additional pages if necessary.)

This document is not a contract with the Bidder/Contractor; it is an acknowledgement of the obligation that the Bidder/Contractor is making to CDOT. The amounts listed above may be less than the subcontract or purchase order amount, but can never be more, and shall not reflect any mark up by the Bidder/Contractor. All questions must be answered.

20. Will the DBE firm be purchasing supplies or materials, or will the DBE firm be leasing or renting equipment from the Prime Contractor or its subcontractors? If so, explain.

21. Does the DBE firm intend to subcontract any portion of the work listed in Section B of this form? If yes, state to whom the DBE firm intends to sublet, what work is to be performed by said subcontractor, and the approximate written agreed upon dollar amount.

Include trucking subcontractors and owner-operators.

22. Will the DBE firm provide trucking services on this project? If yes, state how many trucks are owned by the DBE firm and employees that will work on this project.

23. Within the DBE firm, who will be supervising the work on this project?

24. Will the DBE firm be acting as a broker on this project? If yes, state what the DBE firm will be brokering and the approximate brokerage fee.

25. Will the DBE firm be acting as a supplier on this project? If yes, please state what the DBE firm will be supplying and whether or not they will manufacture the items.

This section must be signed by an individual with the authority to verify the DBE's anticipated participation on the contract as listed on this form. You, the DBE Representative, declare under penalty of perjury in the second degree and any other applicable state or federal laws that the statements made in this document are complete, true and to the best of your knowledge. You attest that you are eligible to participate as a DBE on this contract for the work listed above and have the capacity to perform the work as stated.

26. DBE Representative b. Title c. Signature d. Date

SECTION D. Determination. This section must be completed by the CDOT Region Civil Rights Office or the CDOT Civil Rights Business Resource Center staff member.

27. Review of Request Approved Denied

28. Comments

29. CDOT Representative

a. Name b. Title c. Signature d. Date of Decision

"Previous editions are obsolete and may not be used." CDOT Form No. 1415 [09/23] Page 2

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