L27 Addendum C111 Forms 6.2024_signed.pdf

DEPARTMENT OF TRANSPORTATION

1401 EAST BROAD STREET

RICHMOND, VIRGINIA 23219-2000

Stephen C. Brich, P.E.

Commissioner

June 14, 2024

Order No.: All

Project: All

FHWA: All

District: All

County: All

Route: All

Bids: June 26, 2024

July 24, 2024

To Holders of Bid Proposals:

Order Number: L27 _______

Please replace the current C-111 form with the following in your copy of any bid proposal currently advertised as of today’s date.

BID PROPOSAL

Please find attached the updated C-111 with the current goal. Please remember to utilize for your bid preparation accordingly. A completed C-111 must be submitted in order to be considered responsive.

The updated special provision and forms will be reflected in the final executed contract.

The updated C-111 must be submitted as a paper copy for the June 26, 2024, and July 24, 2024, along with all over forms for the lettings while the BidX program is being updated.

David B. Coaker, PE, CCM

State Contract Engineer

Construction Division

Enclosures www.VirginiaDOT.org

WE KEEP VIRGINIA MOVING

James L. Swanson, P.E. for

ORDER NO.:

CONTRACT ID. NO.:

Form C-111

Rev. 06-10-24

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

MINIMUM DBE REQUIREMENTS

PROJECT NO: _____________________ Contract ID No.: _____________________

Order No.: _________________________

FHWA NO: _____________________

* * * I N S T R U C T I O N S * * *

LIST THE DBE(S) WHO WILL PARTICIPATE IN THE CONTRACT, INDICATE THE WORK THEY WILL PERFORM, THEIR VENDOR ID AND DBE CERTIFICATION NUMBERS, AND THE DOLLAR AMOUNT OF PARTICIPATION, REDUCED AS NEEDED FOR REGULAR DEALERS (60%), DISTRIBUTORS (40%), AND BROKERS (FEES/COMMISSIONS). COUNT 100% FOR SUBCONTRACTORS AND MANUFACTURERS, AND FOR HAULERS THAT DELIVER MATERIALS AND SUPPLIES TO THE PROJECT SITE (EXCLUDING COST

OF THE MATERIALS AND SUPPLIES.

% X $ = $

DBE GOAL TOTAL CONTRACT VALUE MINIMUM DBE PARTICIPATION

DBE SUMMARY

DBE PARTICIPATION ATTAINED TOTAL: $ ____________

DBE PARTICIPATION ATTAINED PERCENTAGE: ___________%

I/WE CERTIFY THAT THE LISTED DBES WILL BE USED ON THIS CONTRACT AS STATED HEREIN AND THAT IN THE PERFORMANCE OF THE CONTRACT I/WE WILL MAKE GOOD FAITH EFFORTS TO MEET OR EXCEED THE DBE GOAL

ESTABLISHED FOR THE CONTRACT.

BY:

BIDDER'S NAME SIGNATURE DATE

Title:

NAME OF DBE

SUBCONTRACTOR

VENDOR

ID NO.

DBE

CERTIFICATION

NO.

SUBCONTRACT

VALUE

DBE USED AS

DOLLAR AMT

DBE CREDIT

SUBCONTR. (S)

MNFR. (M)

HAULER (H)

REG. DLR. (R)

DISTR. (D)

BROKER (B)

100%

100%

100%

60%

40%

Fees/Com

L27

L27

3%

9999-963-653, N501

STP-BR03(348)

C0000122996N01

C0000122996N01

ORDER NO.:

CONTRACT ID. NO.:

Form C-111 Rev. 06-10-24

DBE ITEMS ENTRY

Instructions: For each DBE listed in the Summary on page 1, complete a DBE Item Entry form.

NOTE: To count toward the DBE goal, DBEs must be certified in NAICS codes applicable to kind of work they perform. A DBE's Certification number and NAICS Codes are shown in the DBE's listing in the DSBD DBE Directory at: https://directory.sbsd.virginia.gov/#/executiveExport

Full DBE Name: ______________________________________________

DBE Vendor ID No.: ___________ (DBE's number can be found on VDOT's List of Prequalified Vendors)

DBE Certification. No.: ____________________

DBE NAICS Code(s): _____________________________________________________________________

DBE Used As:

_______ Subcontractor (S) Eligible for 100% of Subcontract Value

_______ Manufacturer (M) Eligible for 100% of Subcontract Value

_______ Hauler (H) Eligible for 100% of Subcontract Value Excluding Materials

________ Regular Dealer (R) Eligible for 60%of Subcontract or PO Value

________ Distributor (D) Eligible for 40% of Subcontract or PO Value

________ Broker (B) Eligible for Fees / Commissions Only

WORK ASSIGNED TO DBE

Contract Bid Items Description Of Work QTY Unit DBE's Price Applicable

Dollar Amt

DBE Credit

DBE Credit Total: $ _______________________

BY:

BIDDER'S NAME SIGNATURE DATE

Title:

[ATTACH ADDITIONAL SHEETS AS NECESSARY, EACH OF WHICH MUST BE SIGNED AND DATED.]

L27 C0000122996N01 https://directory.sbsd.virginia.gov/#/executiveExport