DEOD Forms.pdf

DEOD FORMS

Form No. Form Name To Be Completed By

Required Proposer (Includes DBE Primes)

All Subcontractors/ Suppliers

Form 1 Proposed Subcontractors & Suppliers (For Non-construction Only)

Attachment A to Form 1

Proposed Lower Tier Subcontractors & Suppliers (For Non-construction Only)

Form 2 NOT USED

Form 3 Business Data Sheet Form 4 NOT USED

Form 5 Bidders List Form

Form 6 NOT USED

NOTE: LACMTA encourages Proposers to engage with the small business community for contracting and subcontracting opportunities.

FORM 1 – NON-CONSTRUCTION – PROPOSED SUBCONTRACTORS & SUPPLIERS

TO BE COMPLETED BY PROPOSER ONLY1

The Proposer is requested to list ALL first-tier businesses proposed as Subcontractors (including suppliers)to be utilized to perform work, labor, and/or render service to the Proposer for this professional services and/or non-construction procurement. For a Proposal to be responsive, the Proposer must complete this form and submit it with the Proposal.

RFP Number: Contract Price:

Project Name: Authorized Signature / Date:

Proposal Due Date: Printed Name and Title:

A B C D E F G H

NAME OF BUSINESS SBE

(Y/N)

Manufacturer (Y/N)

Supplier (Y/N)

Distributor (Y/N)

Broker

(Y/N) Phase 1 Contract Price

Breakdown $ Not used

Your Firm

Su bc on tra ct or s

1.

2.

3.

4.

5.

6.

7.

8.

Total:

(Should match Phase 1 Contract Price listed on top of page) Not used

1 Form 1 – Non-construction (and Attachment A to Form 1 – Non-construction) should be submitted where it is expected that no construction work will be performed.

ATTACHMENT A TO FORM 1 – NON-CONSTRUCTION: PROPOSED LOWER TIER SUBCONTRACTORS &

SUPPLIERS

INSTRUCTIONS FOR PROPOSER:

The purpose of this Attachment A is to validate Form 1.

1. Send this Attachment A to each business listed on Form 1 and ask each such business to complete Attachment A and return to the Proposer.

2. Obtain all Attachment A forms and verify that the information provided in the Attachments is consistent with the aggregated numbers in

Form 1. Verify that the information provided in the Attachment A forms is consistent with the information provided in Forms 3 and 5.

3. Attach all Attachment A forms received to Form 1 as Attachment A. For a Proposal to be responsive, you must submit with your Proposal a completed Attachment A for each business listed on Form 1.

4. If there is any discrepancy or conflict between the information listed on Forms 1, 3, and 5 and the information in the Attachments, LACMTA may issue requests for clarification seeking information or clarification from the Proposer and the business in accordance with this RFP.

INSTRUCTIONS FOR EACH SUBCONTRACTOR LISTED ON FORM 1 THAT IS SUBCONTRACTING WORK:

1. Complete this Attachment A to Form 1 to the best of your knowledge and information.

2. Complete the row titled "Your Firm" with name in column A and complete the information in columns B and G for your contract.

3. List each lower-tier Subcontractor that you will be sub-contracting Work to in column A and complete the information in columns B and G for each of the lower-tier Subcontractors listed in column A.

4.

ATTACHMENT A TO FORM 1 – NON-CONSTRUCTION: PROPOSED LOWER TIER SUBCONTRACTORS &

SUPPLIERS

All Subcontractors listed on Form 1 that are subcontracting work are requested to list ALL lower-tier businesses to be utilized.

Your Business Name: Project Name:

Subcontractor Contract Price: Proposer Name:

Printed Name and Title: Authorized Signature/ Date:

A B C D E F G H

NAME OF BUSINESS SBE

(Y/N)

Manufacturer (Y/N)

Supplier (Y/N)

Distributor (Y/N)

Broker

(Y/N) Subcontractor Phase 1

Contract Price Breakdown $ Not used

Your Firm

Lo w er -T ie r S ub co nt ra ct or s

1.

2.

3.

4.

5.

6.

7.

8.

9.

Total:

(Should match Subcontractor Phase 1 Contract Price listed on top of page) Not used

FORM 2 – NOT USED

FORM 3 – BUSINESS DATA SHEET

TO BE COMPLETED BY PROPOSER AND ALL SUBCONTRACTORS IDENTIFIED AT ANY TIER ON

THE SUBCONTRACTOR LISTING FORM OR FORM 1 AND ATTACHMENT A TO FORM 1

Part A: Business Data

1. Business Name:

2. Is your business which will be performing the work on this Project a Joint Venture or participating in a Joint Venture for this Project?

(If answered YES, the Joint Venture Agreement must be submitted with the proposal) YES NO

3. If you answered yes to question 2, provide the name of the Joint Venture and provide the name of each Partner or

Member of the Joint Venture.

a. Name of Joint Venture: ________________________________________________

Business Name of Joint Venture Partner/Member: ___________________________ Business Name of Joint Venture Partner/Member: ___________________________ Business Name of Joint Venture Partner/Member: ___________________________

4. Primary Business Address:

(Street) (City) (State) (Zip)

5. Mailing Address:

(Street) (City) (State) (Zip)

6. County Business is located in:

7. Name of Contact Person:

(Name) (Title)

8. Phone: ( ) _________ - ______________ 9. Email Address:

10. Fax: ( ) _________ - ______________ 11. Age of Business: ____ Years, and _______ Months

12. If your business requires a license, complete below. 13. Business Annual Gross Receipts:

a. License Type: __________________________ a. Less than $500,000

b. $500,000 to $1,000,000

b. License #: __________________________ c. $1,000,000 to $2,000,000

d. $2,000,000 to $5,000,000

c. Expiration: __________________________ e. $5,000,000 to $25,000,000

f. Over $25,000,000

FORM 3 – BUSINESS DATA SHEET (Continued)

Part B: Work Descriptions

14. Identify the scope of work and corresponding North American Industry Classification System (NAICS) Code(s) that will be performed by this business on this Project.

DESCRIPTION OF WORK OR SERVICE TO BE

PERFORMED, OR MATERIALS SUPPLIED ON PHASE 1

OF THIS CONTRACT

ONLY LIST APPLICABLE NAICS CODE(S) (6

DIGITS) FOR WORK TO BE PERFORMED

Part C: Signature

The undersigned Director, Officer, General Partner, or similarly situated Principal of the business declares he/she is informed and believes, and thereon attests, that to the best of its knowledge and information, the information set forth on this page and any attachments, is current, complete and accurate.

Business Name:

Authorized Signature:

Printed Name:

Title:

Date:

FORM 4 – NOT USED

FORM 5 – BIDDERS LIST FORM

The Los Angeles County Metropolitan Transportation Authority (LACMTA) is required per 49 CFR § 26.11(c) to create and maintain a comprehensive Bidders List. The purpose of this Bidders List Form is to compile accurate data about the universe of contractors and subcontractors who seek to work on LACMTA's federally assisted contracts. The Bidders List is a compilation of all bidders, proposers, quoters, subcontractors, manufacturers, and suppliers of materials and services who have submitted proposals (to the Proposer) during the advertising period of a specific acquisition (whether or not they are successful in their attempt to obtain a contract).

Proposers are required to submit Form 5 with their Proposal. Please provide the following data:

Proposer 1: Business data

Business Name:

Business Address:

Street City State Zip

Name of Contact Person:

Phone: Email Address: NAICS code applicable to the scope of work to be performed by firm:

Age of Business: Years Months

Annual Gross Receipts:

a. Less than $500,000 b. $500,000 to $1,000,000 c. $1,000,000 to $2,000,000

d. $2,000,000 to $5,000,000 e. Over $5,000,000

Proposer 2: Business data

Business Name:

Business Address:

Street City State Zip

Name of Contact Person:

Phone: Email Address: NAICS code applicable to the scope of work to be performed by firm:

Age of Business: Years Months

Annual Gross Receipts: a. Less than $500,000 b. $500,000 to $1,000,000 c. $1,000,000 to $2,000,000

d. $2,000,000 to $5,000,000 e. Over $5,000,000 If necessary this "Bidders List" form can be duplicated to include all firms that have submitted a proposal or quote on this DOT-assisted project.

REVISION DATE: 07.22.2025

DBE FORM 6

NOT USED