DBE Participation Statement~3.pdf

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S:\Gen\Document Services\Forms Support\AEM Forms\DOTLOGO2.bmp BoBS Procurement Participation Statement BoBS 2575 (10/03/19) Participation Statement

(1) Instructions This form must be completed for each disadvantaged business participating in the Utilization Plan form. This form shall be submitted in accordance with the DBE Participation & Utilization Compliance and will be attached to the BoBS Procurement Utilization Plan (BoBS 2574) form. If additional space is needed, complete an additional form for the firm.

(2) Work:

Select One:

(3) Commitment The undersigned certify that the information included herein is true and correct, and that the DBE firm listed below has agreed to perform a commercially useful function in the work and to execute a contract with the prime contractor. The undersigned further understand that no changes to this statement may be made without prior approval from the Department's Bureau of Small Business Enterprises and that complete and accurate information regarding actual work performed on this project and the payment therefore must be provided to the Department.

The Department of Transportation is requesting disclosure of information that is necessary to accomplish the purpose as outlined under State and Federal law. Disclosure of this information is REQUIRED. Failure to provide any information will result in the contract not being awarded. This form has been approved by the State Forms Manager Center.

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