July 23, 2015
Local Assistance Procedures Manual Exhibit 17-F
Final Report-Utilization of Disadvantaged Business Enterprises (DBE) and First-Tier Subcontractors Exhibit 17-F: Final Report-Utilization of Disadvantaged Business Enterprises (DBE) and First-Tier Subcontractors
1. Local Agency Contract Number 2. Federal-Aid Project Number 3. Local Agency T 4. Contract Acceptance Date
5. Contractor/Consultant 16. Business Address 7. Final Contract Amount
8. Contract 9. Description of Work, Service, or Certicaton 12. Contract Payments 13. Date 14. Date of Item 10. Company Name and Work Final
Materials Supplied Business Address Non-DBE DBE
Number Number Completed Payment
15. ORIGINAL DBE COMMITMENT AMOUNT $ 16. TOTAL
List all first-tier subcontractors/subconsultants and DBEs regardless of tier whether or not the firms were originally listed for goal credit. If actual DBE utilization (or item of work) was different than that approved at the time of award, provide comments on an additional page. List actual amount paid to each entity. If no subcontractors/subconsultants were used on the contract, indicate on the form.
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT
17. Contractor/Consultant Representative's Signature 18. Contractor/Consultant Representative's Name 19. Phone
I CERTIFY THAT THE CONTRACTING RECORDS AND ON-SITE PERFORMANCE OF THE DE(S) HAVE BEEN MONITORED
21. Local Agency Representative's Signature 22. Local Agency Representative's Name 24. Date DISTRIBUTION: Original - Local Agency, Copy - Caltrans District Local Assistance Engineer. Include with Final Report of Expenditures
January 2023
Local Assistance Procedures Manual Exhibit 17-F
Final Report-Utilization of Disadvantaged Business Enterprises (DBE) and First-Tier Subcontractors
INSTRUCTIONS - FINAL REPORT-UTILIZATION OF DISADVANTAGED BUSINESS ENTERPRISES (DBE) AND
FIRST-TIER SUBCONTRACTORS
1. Local Agency Contract Number - Enter the Local Agency contract number or identifier.
2. Federal-Aid Project Number - Enter the Federal-Aid Project Number.
3. Local Agency - Enter the name of the local or regional agency that is funding the contract.
4. Contract Acceptance Date - Enter the date the contract was accepted by the Local Agency.
5. Contractor/Consultant - Enter the contractor/consultant's firm name.
6. Business Address - Enter the contractor/consultant's business address.
7. Final Contract Amount - Enter the total final amount for the contract.
8. Contract Item Number - Enter contract item for work, services, or materials supplied provided. Not applicable for consultant contracts.
9. Description of Work, Services, or Materials Supplied - Enter description of work, services, or materials provided. Indicate all work to be performed by DBEs including work performed by the prime contractor/consultant's own forces, if the prime is a DBE. If 100% of the item is not to be performed or furnished by the DBE, describe the exact portion to be performed or furnished by the DBE. See LAPM Chapter 9 to determine how to count the participation of DBE firms.
10. Company Name and Business Address - Enter the name, address, and phone number of all subcontracted contractors/consultants. Also, enter the prime contractor/consultant's name and phone number, if the prime is a DBE.
11. DBE Certification Number - Enter the DBE's Certification Identification Number. Leave blank if subcontractor is not a DBE.
12. Contract Payments - Enter the subcontracted dollar amount of the work performed or service provided.
Include the prime contractor/consultant if the prime is a DBE. If the materials or supplies are obtained from a DBE manufacturer, count 100% of the cost of the materials or supplies toward DBE goals. If the materials or supplies are purchased from a DBE regular dealer/supplier, count 60% of the cost of the materials or supplies toward DBE goals. The Non-DBE column is used to enter the dollar value of work performed by firms that are not certified DBE or for work after a DBE becomes decertified.
13. Date Work Completed - Enter the date the subcontractor/subconsultant's item work was completed.
14. Date of Final Payment - Enter the date when the prime contractor/consultant made the final payment to the subcontractor/subconsultant for the portion of work listed as being completed
15. Original DBE Commitment Amount - Enter the "Total Claimed DBE Participation Dollars" from Exhibits 15-G or 10-02 for the contract.
16. Total - Enter the sum of the "Contract Payments" Non-DBE and DBE columns.
17. Contractor/Consultant Representative's Signature - The person completing the form on behalf of the contractor/consultant's firm must sign their name.
18. Contractor/Consultant Representative's Name - Enter the name of the person preparing and signing the form.
19. Phone - Enter the area code and telephone number of the person signing the form.
20. Date - Enter the date the form is signed by the contractor's preparer.
21. Local Agency Representative's Signature - A Local Agency Representative must sign their name to certify that the contracting records and on-site performance of the DBE(s) has been monitored
22. Local Agency Representative's Name - Enter the name of the Local Agency Representative signing the form.
23. Phone - Enter the area code and telephone number of the person signing the form.
24. Date - Enter the date the form is signed by the Local Agency Representative.
January 2023
Local Assistance Procedures Manual Exhibit 17-0
Disadvantaged Business Enterprises (DBE) Certification Status Change EXHIBIT 17-O DISADVANTAGED BUSINESS ENTERPRISES (DBE) CERTIFICATION STATUS CHANGE
1. Local Agency Contract Number 2. Federal-Aid Project Number 3. Local Agency 4. Contract Completion Date
5. Contractor/Consultant 6. Business Address | 7. Final Contract Amount
8. Contract 10. DBE 12. Certification/
1. Amount Paic Decertification
Item 9. DBE Contact Information Certification 13. Comments Number Number While Certified Date
(Letter Attached)
If there were no changes in the DBE certification of subcontractors/subconsultants, indicate on the form.
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT
14. Contractor/Consultant Representative's Signature 15. Contractor/Consultant Representative's Name 16. Phone 17. Date
I CERTIFY THAT THE CONTRACTING RECORDS AND ON-SITE PERFORMANCE OF THE DBES) HAS BEEN MONITORE
18. Local Agency Representative's Signature 9. Local Agency Representative's Nam 20. Phone T 21. Date DISTRIBUTION: Original - Local Agency, Copy - Caltrans District Local Assistance Engineer. Include with Final Report of Expenditures ADA NOTICE: For individuals with sensory disabilties, this document is available in altemate formats. For information, call (916) 445-1233, Local Assistance Procedures Manual TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
July 23, 2015
Local Assistance Procedures Manual Exhibit 17-0
Disadvantaged Business Enterprises (DBE) Certification Status Change
INSTRUCTIONS -DISADVANTAGED BUSINESS ENTERPRISES (DBE)
CERTIFICATION STATUS CHANGE
1. Local Agency Contract Number - Enter the Local Agency contract number or identifier.
2. Federal-Aid Project Number - Enter the Federal-Aid Project Number.
3. Local Agency - Enter the name of the local or regional agency that is funding the contract.
4. Contract Completion Date - Enter the date the contract was completed.
5. Contractor/Consultant - Enter the contractor/consultant's firm name.
6. Business Address - Enter the contractor/consultant's business address.
7. Final Contract Amount - Enter the total final amount for the contract.
8. Contract Item Number - Enter contract item for work, services, or materials supplied provided. Not applicable for consultant contracts.
9. DBE Contact Information - Enter the name, address, and phone number of all DBE subcontracted contractors/consultants.
10. DBE Certification Number - Enter the DBE's Certification Identification Number.
11. Amount Paid While Certified - Enter the actual dollar value of the work performed by those subcontractors/subconsultants during the time period they are certified as a DBE.
12. Certification/Decertification Date (Letter Attached) - Enter either the date of the Decertification Letter sent out by the Office of Business and Economic Opportunity (OBEO) or the date of the Certification Certificate mailed out by OBEO.
13. Comments - If needed, provide any additional information in this section regarding any of the above certification status changes.
14. Contractor/Consultant Representative's Signature - The person completing the form on behalf of the contractor/consultant's firm must sign their name.
15. Contractor/Consultant Representative's Name - Enter the name of the person preparing and signing the form.
16. Phone - Enter the area code and telephone number of the person signing the form.
17. Date - Enter the date the form is signed by the contractor's preparer.
18. Local Agency Representative's Signature - A Local Agency Representative must sign their name to certify
that the contracting records and on-site performance of the DBE(s) has been monitored.
19. Local Agency Representative's Name - Enter the name of the Local Agency Representative signing the form.
20. Phone - Enter the area code and telephone number of the person signing the form.
21. Date - Enter the date the form is signed by the Local Agency Representative.
July 23, 2015