CTDOT_Pre-Award_DBE_Approval_Request_Form.pdf

Rev09/2021

Only certified DBE firms and only for work which they have been certified for will be approved by CDOT toward the goal. Department's DBE directory is available on CTDOT's website or by calling 860-594-2171

Sheet of

CDOT Project Number (s): DBE Subcontractor:

Town(s) of: NAICS Code (s) associated with this submission:

Submitted By (Prime): Address:

Original Bid ($): Is this DBE firm a 1st or 2nd tier subcontractor? 1st 2nd*

Dollar amount subcontracted to this DBE firm ($):

Dollar amount requested for CREDIT for this DBE Firm ($): **

Is This item

Partial

Yes No

Firm Type

Code

Unit of

Item

Quantity bid by Prime

Contract Unit Price

Quantity Subcontracted

Subcontract Unit Price

Total Item price subcontracted

Total item prices credited to the subcontractor

If any of the items above are checked Yes as to Partial, please use the space provided or use an attachment to offer an explanation of the work involved. Also please identify who is responsible for the remainder of the partial items.

*** Firm Type Code: S (subcontractor), M (manufacturer), P (supplier), T (trucking), V (services). For items leased or rented please use code L under Firm Type Code instead of P.

Any DBE Trucking firm (T) nominated on this form must self-perform not less than 30% of their contract value.

**** In instances where the Prime is paying the Subcontractor a higher unit price than the bid, by submitting this form the Prime agrees to the higher subcontracted price without additional costs to the Department.

YES

NO Amount: $ ________________________

***** The credited amount includes adjustments for supply items including leased or rented at 60%.

Signature of Prime Contractor, Title Date Signature of Subcontractor, Title Date

After this submittal is approved by the Department, any proposed changes to it must be submitted to the Department for approval.

Item Number & Description

CONNECTICUT DEPARTMENT OF TRANSPORTATION (CTDOT)

PRE-AWARD DBE COMMITMENT APPROVAL REQUEST

TO BE SUBMITTED WITHIN THE TIME FRAME INDICATED IN THE BID DOCUMENTS

** Please be advised that by submitting this form you (the prime) agree that the total Credited amount will be the amount of commitment and will be measured by the Commercially Useful Function the Subcontractor performs.

* The CDOT prefers 1st tier subcontractors; however, credit for 2nd tier DBE firms will be approved provided this page is signed by both the prime and the DBE firm, the 1st tier subcontractor is identified, the extent of the 2nd tier work is clearly identified, and the prime makes the assertion that regardless of its arrangement with the 1st tier subcontractor, this DBE firm will be used and its replacement is subject to the conditions of the DBE specification and contract requirements.

****Is this DBE Purchasing any Material or Leasing any Equipment from the Prime or any of the Prime's Affiliates? If YES, state the amount and DO NOT include the amount in the amount toward the goal.