DBE Goal Form.pdf

First Use: March 23, 1990

DBE GOALS

VENDOR ID : BIDDER'S COMPANY NAME:

PROJECT NO. & COUNTY:

LET NO: LET DATE: TOTAL BID:

THE REQUIRED DBE GOAL ON THIS CONTRACT IS :

I PROPOSE TO UTILIZE THE FOLLOWING DBE'S:

LIST OF DBE PARTICIPANTS

*VENDOR

NUMBER

DBE NAME/

ADDRESS

(CITY, STATE)

TYPE OF

WORK RACE Neutral Race

Conscious

*WORK

CODE AMOUNT

TOTAL

* For Departmental use only. Do not fill in Work codes.

PLEASE NOTE : Only 60% of the participation of a DBE Supplier who does not manufacture or install the product will be counted toward the goal. See below for further instructions.

REPLACE THIS PAGE With Project Specific

Edward.McAdoo Typewritten text 10%

Edward.McAdoo Typewritten text 0015023 & Fulton

INSTRUCTIONS FOR LIST OF DBE PARTICIPANTS

If a DBE Goal is indicated, you must propose to achieve a goal that is equal or greater then the percentage required. If no goal is indicated, you may propose your own goal.

The DBE Firms to be utilized as counting toward the proposed goal must be listed on this form, along with their addresses, type of work and the amount to be paid to each of the minority firms. The amount entered will not necessarily be the contract amount, but must be the actual amount that will be paid to the DBE firm. In the case of a DBE supplier, the amount paid and 60% of that amount both will be entered; and only the 60% figure should be added to the total. An example of this is shown in the example chart:

Company

Vendor Name And Address Type of * Work Race Race Amount

Number (City and State) Work Code Neutral Conscious

ABC Oil Company Diesel $80.000.00

Atlanta, GA Fuel (60% =

Supplier $48,000.00)

* For Departmental use ONLY. Do not fill in Work

Codes.

The Contractor shall indicate for each DBE and Type of Work whether the DBE

Participant is Race Neutral or Race Conscious by placing a checkmark in the appropriate column.

PLEASE NOTE: For 60% of the amount paid to a DBE supplier to be eligible to count toward fulfilling the DBE goal, the supplier must be an established “regular dealer” in the product involved, and not just a broker. A “regular dealer” would normally sell the product to several customers and would usually have product inventory on hand.

S SC

RN

RC

RN

RC

RN

RC

RN

RC

RN

RC

RN

RC

NAME / TITLE

CONTRACT ID NO.:

CONTRACTOR:

MONTHLY DBE PARTICIPATION REPORT

REPORT SUBMISSION DATE:

PROJECT NO.:

COUNTY: REPORT NO.:

DATE WORK BEGAN: DBE REQUIRED %: 31-Mar 30-Sep

31-Jan 31-Jul NOTICE TO PROCEED: 28-Feb 31-Aug

DBE $ AMOUNT: % PROJECT COMPLETE: 31-May 30-Nov CONTRACT $ AMOUNT: % DOLLAR COMPLETE: 30-Apr 31-Oct

ORIGINAL SUBCONTRACT

AMOUNT

PREVIOUS PAYMENTS PAYMENTS THIS REPORT TOTAL PAYMENTS TO DATE

30-Jun 31-Dec

S = SUPPLIER SC = SUBCONTRACTOR

APPROVED DBE VENDOR ID DESCRIPTION OF WORK

RC COLUMN TOTALS:

RN COLUMN TOTALS:

PRINT NAME:

PRINT NAME:

SIGNATURE:

TOTAL % PAID TO DATE:

FOR DEPARTMENT USE ONLY

THIS DOCUMENT HAS BEEN REVIEWED AT THE PROJECT LEVEL BY:

SIGNATURE:

(Mandatory)

NAME / TITLE

(Mandatory)

NAME / TITLE

THIS DOCUMENT HAS BEEN REVIEWED AT THE DISTRICT LEVEL BY:

PRINT NAME:SIGNATURE:

I HEREBY CERTIFY THAT THE ABOVE STATEMENT IS TRUE AND CORRECT AND

SUPPORTING DOCUMENTATION IS ON FILE AND IS AVAILABLE FOR

INSPECTION BY DEPARTMENT PERSONNEL AT ANY TIME.

ALL PARTICIPATION COUNTED TOWARD FULFILLMENT OF THE DBE GOALS IS

(1) REAL AND SUBSTANTIAL; (2) ACTUALLY PERFORMED BY VIABLE,

INDEPENDENT DBE OWNED FIRMS; AND (3) IN ACCORDANCE WITH THE

SPIRIT OF APPLICABLE LAWS AND REGULATIONS.

$ 0.00

$ 0.00 $ 0.00

$ 0.00 $ 0.00

$ 0.00 $ 0.00

$ 0.00 $ 0.00

$ 0.00 $ 0.00

$ 0.00 $ 0.00

$ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00