FORM 4 - SBE-DVBE AFFIRMATION.pdf

FORM 4 – SBE/DVBE AFFIRMATION

TO BE COMPLETED BY CONTRACTOR AND ALL SUBCONTRACTORS (SBE/DVBE AND NON-

SBE/DVBE) THAT WILL SUBCONTRACT TO A DBE BUSINESS

INSTRUCTIONS:

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

ADDITIONAL INSTRUCTIONS TO CONTRACTOR ONLY:

1. In addition to completing and signing this SBE/DVBE Affirmation on your behalf, obtain all completed and signed

SBE/DVBE Affirmations from all Subcontractors (SBE/DVBE and Non-SBE/DVBE) of any tier that will subcontract to an SBE/DVBE business and verify that the information provided in the SBE/DVBE Affirmations are consistent with Form 1 and its Attachments.

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

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

1. Contract Number: ______________________________________________________________________________

2. Project Name: _____________________________________________________________________________

3. Contractor/Subcontractor Name: ________________________________________________________________

4. Contractor/Subcontractor Business Address: _______________________________________________________ (Street) (City) (State) (Zip)

5. Name of Proposed SBE/DVBE Business: _________________________________________________________

6. SBE/DVBE Business Address: _________________________________________________________________ (Street) (City) (State) (Zip)

7. Financial Description: Total $ Amount listed for this SBE/DVBE business is: $____________________________

1. 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 OR SERVICE TO BE

PERFORMED, OR MATERIALS SUPPLIED ON

THIS CONTRACT

ONLY LIST APPLICABLE NAICS CODE(S)

OR UNSPSC CODE(S) FOR WORK TO BE

PERFORMED

Affirmation:

Signatures of the authorized representatives of the Contractor/Subcontractor and of the SBE business below represent the commitment by both parties to enter into a formal subcontract agreement.

(Contractor/Subcontractor Name) (SBE/DVBE 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 Contractor/Subcontractor to which the DBE business will report to directly.