FORM 5 - DBE AFFIRMATION.pdf

EXHIBIT 1

FORM 5 - DBE AFFIRMATION

TO BE COMPLETED BY PRIME AND ALL SUBCONTRACTORS THAT WILL SUBCONTRACT TO A DBE BUSINESS.

Prime and subcontractor(s) at any tier level that will subcontract work to a DBE business are required to complete this form to affirm that it will utilize the DBE businesses listed on Form 1 or Form 4. This form must be signed by the DBE business acknowledging that it has submitted a written quote to the respective Prime or Subcontractor, and has been listed to perform work on this contract.

1. IFB/RFP/RFIQ Number: _________________________________________________________________________________

2. Project Name: _________________________________________________________________________________________

3. Prime Name: __________________________________________________________________________________________

4. Prime 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: $___________________________________________ (Amount should match $ Amount listed for this business on Form 1 or Form 4)

8. Technical Description - Identify the scope of work that will be performed by this DBE business. Please provide applicable Northern America Industry Classification System (NAICS) code(s) only.

Description of Work, Service, or Material Supplied DBE NAICS (6 digits)

Affirmation:

Signatures of the authorized representatives of this Contractor and of the DBE business below represent the commitment by both parties to enter into a formal subcontract agreement for the work and any terms or conditions described above and in the accompanying attachments, conditioned on the Bidder/Proposer being awarded this Contract.

(Prime Name)

(DBE Business Name)

(Authorized Signature of Business)1

(Authorized Signature of Business)

(Typed or Printed Name of Signee)

(Title of Signee)

(Typed or Printed Name of Signee)

(Title of Signee)

(Telephone)

(Telephone)

(Email)

(Email)

(Date)

(Date)