FORM 4 - DBE AFFIRMATION.pdf

METRO

DBE INSTR TO BIDDERS/PROPOSERS (FEDERAL)

PRO FORM 068

REVISION DATE: 07.02.2024

FORM 4 – DBE AFFIRMATION

TO BE COMPLETED BY PRIME AND ALL SUBCONTRACTORS (DBE AND NON-DBE) THAT WILL

SUBCONTRACT TO A DBE BUSINESS.

INSTRUCTIONS: Complete and sign this DBE Affirmation on your behalf to affirm that you will utilize the DBE businesses listed on Form 1 and its Attachments. This form must be signed by the DBE business acknowledging that it has submitted a written quote to you and has been listed to perform work on this Contract.

ADDITIONAL INSTRUCTIONS TO PRIME (OFFEROR) ONLY:

1. In addition to completing and signing this DBE Affirmation on your behalf, obtain all completed and signed DBE Affirmations from all

Subcontractors (DBE and Non-DBE) of any tier that will subcontract to a DBE business and verify that the information provided in the DBE Affirmations are consistent with Form 1 and its Attachments.

2. Attach your DBE Affirmation and all DBE Affirmations received from Subcontractors (DBE and Non-DBE) of any tier that will subcontract to a DBE business. For a bid to be responsive, you must submit with your bid a completed and signed DBE Affirmation for your firm as the prime and for each Subcontractor (DBE and Non-DBE) of any tier that will subcontract to a DBE business.

3. If there is any discrepancy or conflict between the information listed on the submitted DBE Affirmations and any of the Forms 1 to 3, LACMTA may issue requests for clarification seeking information or clarification from the Prime (Offeror) and/or Subcontractor in accordance with this solicitation. In all events, Prime shall be required to meet the DBE commitment listed in the DBE Affidavit, which will be enforced by LACMTA under the Contract.

1. Solicitation Number: _____________________________________________________________________________

2. Project Name: _____________________________________________________________________________

3. Prime/Subcontractor Name: _________________________ ___________________________________________________

4. Prime/Subcontractor Business Address:____________________________________________________________________ (Street) (City) (State) (Zip)

5. Name of Proposed DBE Business: _____________________________________________________________________

6. DBE Business Address: _____________________________________________________________________ (Street) (City) (State) (Zip)

7. Financial Description: Total $ Amount listed for this DBE business is: $ ________________________________________

8. Technical Description: Identify the scope of work and corresponding North American Industry Classification System (NAICS)

Code(s) that will be performed by this DBE business. To receive credit, DBE firms must be certified in applicable NAICS Codes for listed scope of work.

DESCRIPTION OF WORK, SERVICE, OR MATERIALS

SUPPLIED TO BE PERFORMED ON THIS CONTRACT

ONLY LIST APPLICABLE NAICS CODE(S)

(6 DIGITS) FOR LISTED WORK TO BE PERFORMED

Affirmation: Signatures of the authorized representatives of the Prime/Subcontractor and of the DBE business below represent the commitment by both parties to enter into a formal subcontract agreement.

(Prime/Subcontractor Name) (DBE Business Name)

(Authorized Signature of Business)1 (Date) (Authorized Signature of Business) (Date)

(Typed or Printed Name of Signee) (Typed or Printed Name of Signee)

(Title of Signee) (Title of Signee)

(Email) (Email)

(Telephone) (Telephone) 1 Signature of the Prime/Subcontractor to which the DBE business will report to directly.