FORM 4 - DBE AFFIRMATION.pdf
PDF 120 KB Posted
- Attached to
- UPS Battery Replacement Location 64
- Solicitation number
- PS132603(2)
- Issued by
- California
About this file
This is a Disadvantaged Business Enterprise (DBE) Affirmation Form issued by the Los Angeles County Metropolitan Transportation Authority (LACMTA) for federal contracting purposes. The form requires completion by prime contractors and all subcontractors—both DBE and non-DBE entities—that will subcontract work to DBE businesses. The document serves as a binding commitment by both the prime/subcontractor and the DBE business to enter into a formal subcontract agreement. Prime contractors must obtain signed DBE Affirmations from all subcontractors of any tier that will subcontract to a DBE business and verify consistency with Form 1 and attachments. For a bid to be responsive, all completed and signed DBE Affirmations must be submitted with the bid package. The form requires identification of the solicitation number, project name, business addresses, financial amounts allocated to the DBE business, and technical descriptions of the work to be performed.
The form mandates that DBE firms identify the scope of work and corresponding North American Industry Classification System (NAICS) codes for which they are certified to receive credit toward the DBE commitment. Any discrepancies or conflicts between the DBE Affirmations and Forms 1 through 3 may trigger clarification requests from LACMTA, with the prime contractor required to meet the DBE commitment listed in the DBE Affidavit and subject to enforcement under the contract. The form is executed by authorized representatives of both the prime/subcontractor and the DBE business, with each signatory providing contact information including email and telephone.
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Text version
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.
| Solicitation Number: |
| undefined_9: |
| PrimeSubcontractor Name: |
| undefined_10: |
| Street: |
| State: |
| Zip: |
| City: |
| Street_2: |
| City_2: |
| State_2: |
| Zip_2: |
| undefined_11: |
| DESCRIPTION OF WORK SERVICE OR MATERIALS SUPPLIED TO BE PERFORMED ON THIS CONTRACTRow1: |
| ONLY LIST APPLICABLE NAICS CODES 6 DIGITS FOR LISTED WORK TO BE PERFORMEDRow1: |
| DESCRIPTION OF WORK SERVICE OR MATERIALS SUPPLIED TO BE PERFORMED ON THIS CONTRACTRow2: |
| ONLY LIST APPLICABLE NAICS CODES 6 DIGITS FOR LISTED WORK TO BE PERFORMEDRow2: |
| DESCRIPTION OF WORK SERVICE OR MATERIALS SUPPLIED TO BE PERFORMED ON THIS CONTRACTRow3: |
| ONLY LIST APPLICABLE NAICS CODES 6 DIGITS FOR LISTED WORK TO BE PERFORMEDRow3: |
| PrimeSubcontractor Name_2: |
| DBE Business Name: |
| Date: |
| Date_2: |
| Typed or Printed Name of Signee: |
| Typed or Printed Name of Signee_2: |
| Title of Signee: |
| Title of Signee_2: |
| Email_2: |
| Email_3: |
| Telephone: |
| Telephone_2: |
| METRO_9: |
| DBE INSTR TO BIDDERSPROPOSERS FEDERAL_9: |
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