ITB_CIP260231_Construction_of_Union_Station_Restroom_with_Ticketing_Kiosk_-_Exhibit_D_-_DBE_Utilization_Form.pdf

DISADVANTAGED BUSINESS ENTERPRISE (DBE) AND NON-DBE

SUBCONTRACTOR UTILIZATION FORM

1 DBE and Non-DBE Subcontractor U�liza�on Form

This form is intended to capture the prime contractor’s actual and/or anticipated use of certified Disadvantaged Business Enterprises1 (DBEs) as subcontractors and the estimated dollar amount of each subcontract. Prime contractors are to complete this form and include it with their bid or proposal package. Prime contractors should also maintain a copy of this form on file.

Solicitation Number

Project Name

Name of Prime Contractor

Mailing Address

Telephone Number Fax Number E-Mail Address

The prime contractor shall make assertive good faith efforts to utilize as many DBEs as possible and, to this end, the prime contractor shall inform each subcontractor of this requirement. Please select the appropriate option below as it relates to the prime contractor’s ability or inability to satisfy the DBE requirements on this contract:

OPTION 1. The Bidder/Offeror cannot commit to any DBEs since the work will not be subcontracted.

OPTION 2. The Bidder/Offeror is committed to a minimum of 2.55% DBE utilization on this contract.

OPTION 3. The Bidder/Offeror is unable to meet the 2.55% DBE utilization goal and has submitted documentation demonstrating its good faith efforts to do so (i.e. copies of each DBE and non-DBE subcontractor quote submitted; description of the information provided to targeted DBEs regarding the specifications for the related portions of work; names, addresses, and phone numbers of DBEs contacted, etc.)

1 A DBE is a for-profit small business that is at least 51% owned (or, if a corpora�on, the 51% of the stock is owned) and whose management and daily business opera�ons are controlled by an individual who is a ci�zen (or lawfully admited permanent resident) of the United States and who has been subjected to racial or ethnic prejudice or cultural bias within American society because of his or her iden�ty as members of any of the following groups: Black Americans, Hispanic Americans, Na�ve Americans, Asian-Pacific Americans, Subcon�nent Asian Americans, Women, and any addi�onal groups whose members are designated as socially and economically disadvantaged by the United States Small Business Administra�on. All DBE firms must be cer�fied by the Unified Cer�fica�on Program to be counted on this form.

2 DBE and Non-DBE Subcontractor U�liza�on Form

Please provide the following information for ALL participating subcontractors (both DBE and non-DBE subcontractors) for the above referenced project, if applicable. You may use additional sheets if necessary.

NAME AND ADDRESS OF

SUBCONTRACTOR PERFORMING WORK

DBE STATUS DESCRIPTION OF COMMODITY,

MATERIAL, OR SERVICE TO BE

PROVIDED

PRICE AGREED TO BE

PAID TO

SUBCONTRACTOR DBE2 Non-DBE

2 All DBEs must be cer�fied by the Unified Cer�fica�on Program in order to be counted as DBE subcontractors. If not cer�fied, select Non-DBE.

3 DBE and Non-DBE Subcontractor U�liza�on Form

Dollar Amount of Work to be Completed by Non-DBE Subcontractors

Dollar Amount of Work to be Completed by Certified DBE Subcontractors

Total (This amount shall equal the amount proposed in your Bid proposal)

BIDDER’S/OFFEROR’S CERTIFICATION: The above information is true and complete, to the best of my knowledge and belief. The undersigned understands and agrees that if awarded the contract, this Utilization Form shall be attached thereto and become a part thereof. Failure to provide accurate information or exercise positive, good faith efforts (as defined by the City of Ocala’s DBE Program) may result in being considered non-responsive to the City’s solicitation requirements. The City Contracting Officer reserves the right to recommend an audit to verify the information submitted.

Signature of Authorized Representative Title of Authorized Representative

Printed Name of Authorized Representative Date