39 186
Cost Proposal
Specific Rate of Compensation for State/Federally Funded Projects Consultant: Contract Amount:
Project No.: Date:
Quantity Unit Unit Cost Total
Notes:
Subconsultant 2:
Subconsultant 3:
Description of Item
Permit Fees
Plan Sheets
Test
Subconsultant 1:
List other direct cost items with estimated costs. These costs should be competitive in their respective industries and supported with appropriate documentation.
Proposed ODC items should be consistently billed regardless of client and contract type.
Items when incurred for the same purpose, in like circumstance, should not be included in any indirect cost pool or in the overhead rate.
Items such as special tooling, will be reimbursed at actual cost with supporting documentation (invoice).
Items listed above that would be considered "tools of the trade" are not reimbursable as other direct cost.
Travel related costs should be pre-approved by the contracting agency and shall not exceed current State Department of Personnel Administration rules.
If mileage is claimed, the rate should be properly supported by the consultant's calculation of their actual costs for company vehicles. In addition, the miles claimed should be supported by mileage logs.
If a consultant proposes rental costs for a vehicle, the company must demonstrate that this is its standard procedure for all of their contracts and that they do not own any vehicles that could be used for the same purpose.
The cost proposal format shall not be amended. All costs must comply with the Federal cost principles.
Subconsultants must provide their own cost proposals.
1. 2.
3. 4.
5. 6.
7. 8.
9. 10.
Other:
Vehicle
Other:
Other:
Other:
Mileage Costs
Equipment Rental and Supplies
Schedule of Other Direct Cost Items (Add additional pages as necessary) Page __ of __
40 187
Cost Proposal
Specific Rate of Compensation for State/Federally Funded Projects Consultant: Contract Amount:
Project No.: Date:
Actual or Avg. % or $
Straight OT (1.5x) OT (2x) Hourly Rate Increase
- -
-
- -
-
- -
-
- -
-
- -
-
- -
-
- -
-
- -
-
- -
-
- -
-
(Add pages as necessary. See Additional Sheet.)
Name & Job Title / Classification Hourly Billing Rates Effective Year of Hourly Rate
Hourly Range
(Classifications Only)
Page _ of __
41 188
Cost Proposal with Prevailing Wages
Specific Rate of Compensation for State/Federally Funded Projects Page __ of __
Consultant: Prime or Subconsultant Date:
Project No.:
Home Office Personnel: Fringe Benefit % Overhead % Combined % NORMAL + + = 0.00%
OVERTIME + + = 0.00%
Field Office Personnel: Fringe Benefit % Overhead % Combined % NORMAL + + = 0.00%
OVERTIME + + = 0.00%
=
=
=
Non Exempt Employee Loaded Billing Rates
Exempt Employee Loaded Billing Rates
Notes:
Applicable Multiplier Fringe (Field)
General Administration %
General Administration %
0.00%
0.00%
Fee
Applicable Multiplier Delta Base (Field)
Loaded Rate Calculation
A) Straight Time = Actual Hourly Rate * (1 + Field O.H.) * (1 + Fee) + Delta Base * (Applicable Multiplier Delta Base) + Delta Fringe * (Applicable Multiplier Delta Fringe) B) 1.5X or 2.0X Overtime = (Actual Hourly Rate) * (1 + Field O.H.) * (1 + Fee) +.5X or 1.0X (Actual Hourly Rate) + Delta Base * (Applicable Multiplier Delta Base) + Delta Fringe * (Applicable Multiplier Delta Fringe)
C) Straight Time or 1.5X or 2.0X Overtime = Actual Hourly Rate * (1 + Field O.H.) * (1 + Fee) + Delta Base * (Applicable Multiplier Delta Base) + Delta Fringe * (Applicable Multiplier Delta Fringe)
The PW differentials Delta Base and Delta Fringe shown in the formulas above for Loaded Billing Rates are applicable only when performing services covered under DIR determinations.
The PW differentials Delta Base and Delta Fringe shown in the formulas above for Loaded Billing Rates are applicable only when performing services covered under DIR determinations.
1. Prevailing Wages specified are based on current DIR determination. Any future DIR escalation of prevailing wage rates will be reflected in the loaded rates.
2. "NC" denotes No Charge for work more than 8 hours per day and for weekends and holidays for this contract only.
3. The billing rates shown in this cost proposal for field staff entitled for PW rates are calculated with estimated fringe benefits of the staff. The actual billing rates to be used in the invoices will be calculated by using the actual PW fringe benefits of the individual staff in accordance with the certified benefits statement submitted with each invoice.
4. The employees' actual hourly rates shown in this cost proposal are the rates that were effective on xx/xx/xx. Contract Manager's pre-approval is required for addition of staff not previously listed on the cost proposal. The billing rates for these employees, including those that fall under general classifications, will be calculated and reimbursed based on their actual hourly rates on xx/xx/xx. Hourly rates for new employees hired after the date of this cost proposal will not exceed (or shall be in line with) the rates of similar personnel listed on this cost proposal having similar experience.
5. Travel Time Charges: For Managers: On weekdays up to a maximum of 8 hours will be charged for work time, travel time or any combination of travel and work time. Billing Rate = Loaded Rate Formula "C" above. For Exempt staff: During regular work day, actual travel time not to exceed 8 hours in any one day or one way travel will be billed as follow: Billing rate for travel time = Loaded Rate Formula "C" above. All travel time, outside of the regular work day, will be billed without the application of overhead rate as follow: Billing Rate = (Actual Hourly Rate) (1+ Fee) + (Delta Base + Delta Fringe). For Non-Exempt Employees: During regular work day, actual travel time not to exceed 8 hours in any one day or one way travel will be billed at full normal overhead rate (i.e. without the application of the 1.5X or 2.0X multiplier for overtime as follow) 42 189
Cost Proposal with Prevailing Wages
Specific Rate of Compensation for State/Federally Funded Projects Page __ of __
Consultant: Project No.:
Straight
1.5 OT
2.0 OT
Straight
1.5 OT
2.0 OT
Straight
1.5 OT
2.0 OT
Straight
1.5 OT
2.0 OT
Straight
1.5 OT
2.0 OT
Straight
1.5 OT
2.0 OT
Straight
1.5 OT
2.0 OT
Straight
1.5 OT
2.0 OT
Straight
OT (1.5x)
OT (2x)
Name/Classification
Prevailing Wage work - Exempt or Non-Exempt
Home or Field Office Personnel
Fringe Benefits
Total Base Salary +
Fringe Benefits
Employee Actual Rate
(fringe benefits vary
year over year)
Base Salary
Estimate Fringe
Total = Base +
Fringe
% Escalation Increase
Actual Hourly Rate and/or Average Hourly Rate
Hourly Range for Class
(Add pages as necessary)
DELTA (TOTAL) =
Employee Total Rate - DIR Rate
Applicable DELTA (TOTAL) =
Employee Total - DIR Total
DELTA (BASE) =
Employee Base - DIR Base
Applicable DELTA Base =
DIR Rate - Employee Base Rate
Applicable DELTA FRINGE =
DELTA TOTAL - DELTA BASE
(Employee - DIR)
Loaded Hourly Billing Rates
Effective Year of Hourly Rate
Prevailing Wage Rate
established by State DIR
(only applicable for
prevailing wage work)
Base Salary
43 190
Cost Proposal with Prevailing Wages (EXAMPLE)
Specific Rate of Compensation for State/Federally Funded Projects Page __ of __
Consultant: Prime or Subconsultant:
Project No.: Date:
Home Office Personnel: Fringe Benefit % Overhead % Combined % NORMAL 60.00% + 60.00% + = 180.00%
OVERTIME 60.00% + 60.00% + = 180.00%
Field Office Personnel: Fringe Benefit % Overhead % Combined % NORMAL 50.00% + 50.00% + = 150.00%
OVERTIME 50.00% + 50.00% + = 150.00%
= 6%
= 1.00
= 0.00
Non Exempt Employee Loaded Billing Rates
Exempt Employee Loaded Billing Rates
Notes:
50.00%
XX-XX-XXXX
General Administration %
60.00%
60.00%
General Administration %
5. Travel Time Charges: For Managers: On weekdays up to a maximum of 8 hours will be charged for work time, travel time or any combination of travel and work time. Billing Rate = Loaded Rate Formula "C" above. For Exempt staff: During regular work day, actual travel time not to exceed 8 hours in any one day or one way travel will be billed as follow: Billing rate for travel time = Loaded Rate Formula "C" above. All travel time, outside of the regular work day, will be billed without the application of overhead rate as follow: Billing Rate = (Actual Hourly Rate) (1+ Fee) + (Delta Base + Delta Fringe). For Non-Exempt Employees: During regular work day, actual travel time not to exceed 8 hours in any one day or one way travel will be billed at full normal overhead rate (i.e. without the application of the 1.5X or 2.0X multiplier for overtime as follow) C) Straight Time or 1.5X or 2.0X Overtime = Actual Hourly Rate * (1 + Field O.H.) * (1 + Fee) + Delta Base * (Applicable Multiplier Delta Base) + Delta Fringe * (Applicable Multiplier Delta Fringe)
City of Simi Valley
PW XX-XX
Fee
Loaded Rate Calculation
Prime
50.00%
Applicable Multiplier Delta Base (Field)
Applicable Multiplier Fringe (Field)
A) Straight Time = Actual Hourly Rate * (1 + Field O.H.) * (1 + Fee) + Delta Base * (Applicable Multiplier Delta Base) + Delta Fringe * (Applicable Multiplier Delta Fringe) B) 1.5X or 2.0X Overtime = (Actual Hourly Rate) * (1 + Field O.H.) * (1 + Fee) +.5X or 1.0X (Actual Hourly Rate) + Delta Base * (Applicable Multiplier Delta Base) + Delta Fringe * (Applicable Multiplier Delta Fringe)
The PW differentials Delta Base and Delta Fringe shown in the formulas above for Loaded Billing Rates are applicable only when performing services covered under DIR determinations.
The PW differentials Delta Base and Delta Fringe shown in the formulas above for Loaded Billing Rates are applicable only when performing services covered under DIR determinations.
1. Prevailing Wages specified are based on current DIR determination. Any future DIR escalation of prevailing wage rates will be reflected in the loaded rates.
2. "NC" denotes No Charge for work more than 8 hours per day and for weekends and holidays for this contract only.
3. The billing rates shown in this cost proposal for field staff entitled for PW rates are calculated with estimated fringe benefits of the staff. The actual billing rates to be used in the invoices will be calculated by using the actual PW fringe benefits of the individual staff in accordance with the certified benefits statement submitted with each invoice.
4. The employees' actual hourly rates shown in this cost proposal are the rates that were effective on xx/xx/xx. Contract Manager's pre-approval is required for addition of staff not previously listed on the cost proposal. The billing rates for these employees, including those that fall under general classifications, will be calculated and reimbursed based on their actual hourly rates on xx/xx/xx. Hourly rates for new employees hired after the date of this cost proposal will not exceed (or shall be in line with) the rates of similar personnel listed on this cost proposal having similar experience.
44 191
Cost Proposal with Prevailing Wages (EXAMPLE)
Specific Rate of Compensation for State/Federally Funded Projects Page __ of __
Consultant: Project No.:
10/01/2023 -
9/30/2024
10/01/2024 -
9/30/2025
10/01/2023 -
9/30/2024
10/01/2024 -
9/30/2025
10/01/2023 -
9/30/2024
10/01/2024 -
9/30/2025
Straight 34.21$ 34.21$ 34.21$ 34.21$
1.5 OT 51.32$ 51.32$ 51.32$ 51.32$
2.0 OT 68.42$ 68.42$ 68.42$ 68.42$
15.41$ 15.41$ 15.41$ 15.41$ Straight 49.62$ 49.62$ 49.62$ 49.62$
1.5 OT 66.73$ 66.73$ 66.73$ 66.73$
2.0 OT 83.83$ 83.83$ 83.83$ 83.83$ Straight 42.17$ 43.44$ 45.00$ 46.35$ 42.17$ 43.44$
1.5 OT 63.26$ 65.16$ 45.00$ 46.35$
2.0 OT 84.34$ 86.88$ 45.00$ 46.35$
11.49$ 11.49$ 11.49$ 11.49$ Straight 53.66$ 54.93$ 56.49$ 57.84$
1.5 OT 74.75$ 76.65$ 56.49$ 57.84$
2.0 OT 95.83$ 98.37$ 56.49$ 57.84$ Straight 4.04$ 5.31$ 6.87$ 8.22$
1.5 OT 8.02$ 9.93$ (10.24)$ (8.88)$
2.0 OT 12.00$ 14.54$ (27.34)$ (25.99)$ Straight - $ - $ - $ - $
1.5 OT 11.94$ 13.85$ (6.32)$ (4.97)$
2.0 OT 15.92$ 18.46$ (23.42)$ (22.07)$ Straight - $ - $ - $ - $
1.5 OT - $ - $ (6.32)$ (4.97)$
2.0 OT - $ - $ (23.42)$ (22.07)$ Straight -$ -$ -$ -$
1.5 OT -$ -$ (3.92)$ (3.92)$
2.0 OT -$ -$ (3.92)$ (3.92)$ Straight 111.75$ 115.12$ 119.25$ 122.83$ 111.75$ 115.12$ OT (1.5x) 132.84$ 136.84$ 125.57$ 127.79$ 132.84$ 136.84$ OT (2x) 153.92$ 158.56$ 142.67$ 144.90$ 153.92$ 158.56$ 3% 3% 3%
42.17$ 43.44$ 45.00$ 46.35$ 42.17$ 43.44$
N/A N/A
Exempt Non-Exempt
Home or Field Office Personnel Field Field Field
Base Salary
Estimate Fringe
Total = Base +
Fringe
Prevailing Wage work - Exempt or Non-Exempt Non-Exempt
% Escalation Increase
Actual Hourly Rate and/or Average Hourly Rate
Hourly Range for Class
DELTA (TOTAL) =
Employee Total Rate - DIR Rate
Applicable DELTA (TOTAL) =
Employee Total - DIR Total
DELTA (BASE) =
Employee Base - DIR Base
Applicable DELTA Base =
DIR Rate - Employee Base Rate
Applicable DELTA FRINGE =
DELTA TOTAL - DELTA BASE
(Employee - DIR)
Loaded Hourly Billing Rates
Effective Dates of Hourly Rate
Prevailing Wage Rate
established by State DIR
(only applicable for
prevailing wage work)
Base Salary
Fringe Benefits
Total Base Salary +
Fringe Benefits
Employee Actual Rate
(fringe benefits vary
year over year)
Prevailing Wage Work Prevailing Wage Work Non-Prevailing Wage Work Name/Classification Inspector I Inspector II Inspector
(Add pages as necessary)
45 192
Certification of Direct Costs:
I, the undersigned, certify to the best of my knowledge and belief that all direct costs identified on the cost proposal(s) in this contract are actual, reasonable, allowable, and allocable to the contract in accordance with the contract terms and the following requirements:
1. Generally Accepted Accounting Principles (GAAP)
2. Terms and conditions of the contract
3. Title 23 United States Code Section 112 - Letting of Contracts
4. 48 Code of Federal Regulations Part 31 - Contract Cost Principles and Procedures
5. 23 Code of Federal Regulations Part 172 - Procurement, Management, and Administration of Engineering and Design Related Service
6. 48 Code of Federal Regulations Part 9904 - Cost Accounting Standards Board (when applicable) A
ll costs must be applied consistently and fairly to all contracts. All documentation of compliance must be retained in the project files and be in compliance with applicable federal and state requirements.
Costs that are noncompliant with the federal and state requirements are not eligible for reimbursement.
Prime Consultant or Subconsultant Certifying:
N
ame: Title*:
Signature: Date of Certification:
Email: Phone Number:
Address:
* An individual executive or financial officer of the consultant's or subconsultant's organization at a
level no lower than a Vice President or a Chief Financial Officer, or equivalent, who has authority to represent the financial information utilized to establish the cost proposal for the contract.
List of Services the consultant is providing under the proposed contract:
46 193
APPENDIX D
Additional Caltrans LAPM Forms
47 194
Local Assistance Procedures Manual Exhibit 9-F
DBE Running Tally of Payments
(11) Amount Paid to Prime To Date ($)
(14) DBE Cert.
Number
(15) Contract
Type
(16) Date of
Payment
(17) Amount of
This Payment
(18) Amount
Paid To Date
(19) Amount
Committed To
This DBE
Totals $0 $0 $0
COPY DISTRIBUTION: Original - Prime Contractor/Consultant, Copy - E-mail: [email protected]; Copy: Local Administering Agency List all DBEs regardless of tier, whether or not the firms were originally listed in Exhibit 10-O2 or 15-G as a DBE commitment. If the actual DBE utilization was different than that approved at the time of award, provide comments in box (20). All payments reported, including payments to contractor/consultant, are for the date listed. Select the most appropriate contract type (Agent, Consultant, Joint Venture, Manufacturer, Prime, Regular Dealer, Subcontractor, Truck/Haul, Service Provider) for the DBE from dropdown list.
By executing this 9-F, Contractor/Consultant represents and warrants, under penalty of perjury, that:
Contractor/Consultant contracted with the Disadvantaged Business Enterprise companies (DBEs) as set forth in their awarded bid on Contract number ____________________________ Contractor/Consultant paid the full amounts listed on their 9-F to the DBEs set forth in Contractor’s awarded bid, without reduction or offset. (21) Prime Contractor/Consultant Manager's Name (Print) (22) Business Phone Number (23) Date (13) DBE Subcontractor/Subconsultant
Name (20) Comments
(9) Business Name (10) Amount Prime Invoiced This Period ($) (12) Prime Certified DBE? (5) Contract Number (6) Total Contract Award Amount ($) (7) DBE Goal Percentage (%) (8) DBE Committed Percentage (%) EXHIBIT 9-F: DISADVANTAGED BUSINESS ENTERPRISE (DBE) RUNNING TALLY OF PAYMENTS Save this form using the following naming convention, [9 digit Federal Aid number]-[yyyymm]-[ss].xlsx. [yyyymm] is the reporting period. [ss] is two digit sequential numbering, applicable when consultant or contractor has more than one 9-F form to complete per pay period. For example, a valid saved file could read: 1234(567)-202207-01.xlsx. Prime contractors/consultants are required to submit this form no later than the 10th of the following month, after submitting an invoice for reimbursement that includes a payment to a DBE. If no payments have been made, do not submit the form. Email this form to [email protected] with a copy to their local administering agencies. Do not submit this form with the invoice, it will not be processed.
(1) Reporting Period (mm-yyyy) (2) Federal Aid Project Number (3) Caltrans District (4) Local Agency
January 2023
48 195
I I
Local Assistance Procedures Manual Exhibit 10-G
Individual A&E Task Order DBE Tracking Sheet
Exhibit 10-G: INDIVIDUAL A&E TASK ORDER DBE TRACKING SHEET Please fill out form in order
CONSULTANT NAME CONTRACT NUMBER FEDERAL PROJECT NUMBER TASK ORDER NUMBER
ADDRESS
CONSULTANT CONTRACT ADMINISTRATOR NAME PHONE NUMBER E-MAIL PROJECT TITLE:
PROJECT LOCATION:
SCOPE OF WORK
TOTAL MASTER CONTRACT AMOUNT: END OF CONTRACT DATE:
TASK ORDER AMOUNT: TASK ORDER BEGIN DATE: TASK ORDER END DATE:
TOTAL DBE CONTRACT ESTIMATE OF THIS TASK ORDER
CONSULTANT / SUBCONSULTANT DESCRIPTION OF WORK AMOUNT
(NON-DBE)
AMOUNT
(DBE) % OF DBE
SUBTOTAL
TOTAL TASK ORDER AMOUNT
COMMENTS ON DBE UTILIZATION DEFICIENCIES (COMMITTED VERSUS MET) AND PLANS TO MEET COMMITTED PERCENTAGES:
(If percent less than task order DBE goal, briefly state why in 1-2 sentences).
The consultant acknowledges the DBE listed in the DBE Task Order Utilization section above must be used, unless authorized by the Local Agency.
Approved By:
CONSULTANT CONTRACT MANAGERS SIGNATURE DATE LOCAL AGENCY ADMIN SIGNATURE DATE
January 2023
49 196
50 Local Assistance Procedures Manual Exhibit 10-02
Consultant Contract DBE Commitment
EXHIBIT 10-02 CONSULTANT CONTRACT DBE COMMITMENT
1. Local Agency: City of Simi Valley 2. Contract DBE Goal: 0% _...;;___________________ -------- ------
3. Project Description : On-Call Inspection Services
4. Project Location : Various ------- ------------ ---- ---- - --------- -----
5. Consultant's Name: 6. Prime Certified DBE: D 7 . Total Contract Award Amount: $500,000.00
8. Total Dollar Amount for ALL Subconsultants : 9. Total Number of ALL Subconsultants :
10. Description of Work, Service, or Materials 11. DBE 13. DBE Certification 12. DBE Contact Information Dollar Supplied Number Amount Local Agency to Complete this Section
$ 20. Local Agency Contract
N11mh,::::i,r· 14. TOTAL CLAIMED DBE PARTICIPATION
21. Federal-Aid Project Number :
22. Contract Execution %
n .. t.,.·
Local Agency certifies that all DBE certifications are valid and information on IMPORTANT : Identify all DBE firms being claimed for credit , this form is complete and accurate. regardless of tier. Written confirmation of each listed DBE is required.
23. Local Agency Representative's Signature 24. Date 15. Preparer's Signature 16. Date
25. Local Agency Representative's Name 26. Phone 17. Preparer's Name 18. Phone
27. Local Agency Representative's Title 19. Preparer's Title DISTRIBUTION : 1. Original - Local Agency
2. Copy - Caltrans District Local Assistance Engineer (DLAE). Failure to submit to DLAE within 30 days of contract execution may result in de-obligation of federal funds on contract.
ADA Notice: For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) 654- 3880 or write Records and Forms Management, 1120 N Street, MS-89, Sacramento , CA 95814.
July 23, 2015
197
51 Local Assistance Procedures Manual Exhibit I 0-02
Consultant Contract DBE Commitment
INSTRUCTIONS - CONSULTANT CONTRACT DBE COMMITMENT
CONSUL TANT SECTION
1. Local Agency- Enter the name of the local or regional agency that is funding the contract.
2. Contract DBE Goal - Enter the contract DBE goal percentage as it appears on the project advertisement.
3. Project Description - Enter the project description as it appears on the project advertisement (Bridge Rehab, Seismic Rehab, Overlay, Widening, etc).
4. Project Location - Enter the project location as it appears on the project advertisement.
5. Consultant's Name - Enter the consultant's firm name.
6. Prime Certified DBE - Check box if prime contractor is a certified DBE .
7. Total Contract Award Amount - Enter the total contract award dollar amount for the prime consultant.
8. Total Dollar Amount for ALL Subconsultants - Enter the total dollar amount for all subcontracted consultants.
SUM= (DBEs + all Non-DBEs). Do not include the prime consultant information in this count.
9. Total number of ALL subconsultants - Enter the total number of all subcontracted consultants. SUM = (DBEs + all Non-DBEs). Do not include the prime consultant information in this count.
10. Description of Work, Services, or Materials Supplied - Enter description of work, services , or materials to be provided . Indicate all work to be performed by DBEs including work performed by the prime 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.
11. DBE Certification Number - Enter the DBE's Certification Identification Number . All DBEs must be certified on the date bids are opened.
12. DBE Contact Information - Enter the name, address, and phone number of all DBE subcontracted consultants.
Also, enter the prime consultant's name and phone number, if the prime is a DBE.
13. DBE Dollar Amount - Enter the subcontracted dollar amount of the work to be performed or service to be provided. Include the prime consultant if the prime is a DBE. See LAPM Chapter 9 for how to count full/partial participation.
14. Total Claimed DBE Participation - $: Enter the total dollar amounts entered in the "DBE Dollar Amount " c olumn. %: Enter the total DBE participation claimed ("Total Participati on Dollars Claimed " divided by item "Total Contract .
Award Amount "). If the total% claimed is less than item "Contract DBE Goal," an adequately document ed Good Faith Effort (GFE) is required (see Exhibit 15-H DBE Information - Good Faith Efforts of the LAPM) .
15. Preparer's Signature - The person completing the DBE commitment form on behalf of the consultant's firm must sign their name.
16. Date - Enter the date the DBE commitment form is signed by the consultant's preparer.
17. Preparer's Name - Enter the name of the person preparing and signing the consultant's DBE commitment form.
18. Phone - Enter the are a code and phone number of the person signing the consult ant's DBE commitm ent form.
19. Preparer's Title - Enter the position/title of the person signin g the consult ant's DBE commitment form.
LOCAL AGENCY SECTION
20. Local Agency Contract Number - Enter the Local Agency contract number or identifier.
21. Federal-Aid Project Number - Enter the Federal-Aid Project Number.
22. Contract Execution Date - Enter the date the contract was executed.
23. Local Agency Representative's Signature - The person compl eting this section of the form for the Local Agency must sign their nam e to certify that the information in this and the Consult ant S ection of this form is complet e and accurate .
24. Date - Enter the date the DBE c ommitment form is signed by the Local Agency Representative.
25. Local Agency Representative's Name - Enter the name of the Local Agency Representa tive certifying the consultant's DBE commitment form.
26. Phone - Enter the are a code and phone numb er of the person sign ing the consult ant's DBE commitm ent form.
27. Local Agency Representative Title - Enter the position/titl e of the Loc al A gency Repres entative cert ifying the consultant 's DBE commitm ent form.
July 23, 2015
198
Local Assistance Procedures Manual Exhibit 10-S
Consultant Performance Evaluation
Exhibit 10-S Consultant Performance Evaluation
1. PROJECT DATA 2. CONSULTANT DATA
1a. Project (include title, location, and Activity/CIP No.) 2a. Consultant Name and Address 1b. Brief Description of Project (design, study, etc.) 2b. Consultant's Manager 1c. Budget Cost for Project: $_____________ 2c. Phone:
3a. Department (include section and division) 3b. Agency Project Manager (name & phone) 4a. Contract No.: Termination date: Base Fee: $
Agreement date: Date terminated: Contingency: $
4b. Amendment $ / # $ / #
(Total Value) (Initiated by Agency) (Total Value) (Initiated by Agency) 4c. Change Order $ / # $ / #
(Total Value) (Initiated by Agency) (Total Value) (Initiated by Agency) 4d. Total Fee per Agreement (4a. + 4b. + 4c.) $ Total Fee Paid $ (Do not include Contingency Listed in 4a.)
4e.
Preliminary 30% 70% 90% 100% Final
Per Agreement
Delivery Date
Acceptance Date
4j. Reasons for Change Orders: (Indicate total for each reason) 4g. Notice To Proceed (date) Errors/Omissions $ % of Base Fee Unforeseen Conditions $ % of Base Fee
4h. Number of Days (number) Changed Scope $ % of Base Fee Changed Quantities $ % of Base Fee
4i. Actual Number of Days (number) Program Task Options $ % of Base Fee
5.OVERALL RATING (Complete Section II on reverse, include comments as appropriate.) Outstanding Above
Average Average Below
Average Poor N/A
5a.
5b.
5c.
5d.
6a. Agency Design Team Leader Date:
6b. Agency Project Manager Date:
6c. Agency Public Works Manager Date:
6d. Consultant Representative Date:
6. AUTHORIZING SIGNATURES
4f. Historical Record of Key Submittal Dates (enter date or n/a if not applicable) Type of Services
(Design, study,
etc.)
3. AGENCY DEPARTMENT/SECTION RESPONSIBLE
4. CONTRACT DATA (Engineering Services)
Plans/Specifications accuracy
Consistency with budget
Responsiveness to Agency Staff
Overall Rating
See Reverse Side
LPP 13-01 May 8, 2013
52 199
Local Assistance Procedures Manual Exhibit 10-S
Consultant Performance Evaluation
PLANS/SPECIFICATIONS
ACCURACY
Outstanding Above
Avg.
Avg. Below
Avg.
Poor N/A Responsiveness
To Staff
Outstanding Above
Avg.
Avg. Below
Avg.
Poor N/A
Plans Specifications
clear and concise
Timely Responses
Plans/Specs
Coordination
Attitude toward Client and
review bodies
Plans/Specs
properly formatted
Follows directions and
Chain of responsibility
Code Requirements
covered
Work product delivered
on time
Adhered to Agency
Standard Drawings/Specs
Timeliness in notifying
Agency of major problems
Drawings reflect
existing conditions
Resolution of field
Problems
As-Built Drawings Consistency with
budget
Quality Design Reasonable Agreement
negotiation
Change Orders due to design
deficiencies are minimized
Adherence to fee schedule
Adherence to project
Budget
Section III EXPLANATIONS AND SUPPLEMENTAL INFORMATION
(Attach additional documentation as needed)
Item __________: _______________________________________________________________________ _______________________________________________________________________ Item __________: _______________________________________________________________________ _______________________________________________________________________ Item __________: _______________________________________________________________________ Item __________: _______________________________________________________________________ _______________________________________________________________________ Item __________: _______________________________________________________________________ _______________________________________________________________________ Item __________: _______________________________________________________________________ _______________________________________________________________________ *Indicates supporting documentation attached.
LPP 13-01 May 8, 2013
53 200
Local Assistance Procedures Manual Exhibit 15-H
Proposer/Contractor Good Faith Effort
EXHIBIT 15-H: PROPOSER/CONTRACTOR GOOD FAITH EFFORTS
Cost Proposal Due Date ___________________ PE/CE
Federal-aid Project No(s). _____________________ Bid Opening Date ___________________ CON The established a Disadvantaged Business Enterprise (DBE) goal of ______ for this contract. The information provided herein shows the required good faith efforts to meet or exceed the DBE contract goal.
Proposers or bidders submit the following information to document their good faith efforts within five (5) calendar days from cost proposal due date or bid opening. Proposers and bidders are recommended to submit the following information even if the Exhibit 10-O1: Consultant Proposal DBE Commitments or Exhibit 15-G:
Construction Contract DBE Commitment indicate that the proposer or bidder has met the DBE goal. This form protects the proposer’s or bidder’s eligibility for award of the contract if the administering agency determines that the bidder failed to meet the goal for various reasons, e.g., a DBE firm was not certified at bid opening, or the bidder made a mathematical error.
The following items are listed in the Section entitled “Submission of DBE Commitment” of the Special Provisions, please attach additional sheets as needed:
A. The names and dates of each publication in which a request for DBE participation for this project was placed by the bidder (please attach copies of advertisements or proofs of publication):
Publications Dates of Advertisement
B. The names and dates of written notices sent to certified DBEs soliciting bids for this project and the dates and methods used for following up initial solicitations to determine with certainty whether the DBEs were interested (please attach copies of solicitations, telephone records, fax confirmations, etc.):
Names of DBEs Solicited Date of Initial Solicitation Follow Up Methods and Dates
May 2020
54 201
Local Assistance Procedures Manual Exhibit 15-H
Proposer/Contractor Good Faith Effort
C. The items of work made available to DBE firms including those unbundled contract work items into economically feasible units to facilitate DBE participation. It is the bidder's responsibility to demonstrate that sufficient work to facilitate DBE participation in order to meet or exceed the DBE contract goal.
Items of Proposer or Bidder Breakdown of Amount Percentage Work Normally Performs Item Items ($) Of
(Y/N) Contract
D. The names, addresses and phone numbers of rejected DBE firms, the reasons for the bidder's rejection of the DBEs, the firms selected for that work (please attach copies of quotes from the firms involved), and the price difference for each DBE if the selected firm is not a DBE:
Names, addresses and phone numbers of rejected DBEs and the reasons for the bidder's rejection of the DBEs:
Names, addresses and phone numbers of firms selected for the work above:
E. Efforts (e.g. in advertisements and solicitations) made to assist interested DBEs in obtaining information related to the plans, specifications and requirements for the work which was provided to DBEs:
May 2020
55 202
Local Assistance Procedures Manual Exhibit 15-H
Proposer/Contractor Good Faith Effort
F. Efforts (e.g. in advertisements and solicitations) made to assist interested DBEs in obtaining bonding, lines of credit or insurance, necessary equipment, supplies, materials, or related assistance or services, excluding supplies and equipment the DBE subcontractor purchases or leases from the prime contractor or its affiliate:
G. The names of agencies, organizations or groups contacted to provide assistance in contacting, recruiting and using DBE firms (please attach copies of requests to agencies and any responses received, i.e., lists, Internet page download, etc.):
Name of Agency/Organization Method/Date of Contact Results H. Any additional data to support a demonstration of good faith efforts:
May 2020
56 203
Local Assistance Procedures Manual Exhibit 17-F1 A&E On-Call Final Report-Utilization of Disadvantaged Business Enterprises (DBE) for On-Call Contracts Cert. #
16. TOTAL for Task Orders: $0.00
DISTRIBUTION: Original – Local Agency, Copy – Caltrans District Local Assistance Engineer, include with Final Report of Expenditures.
3. Caltrans District 4. Contract Completion Date1. Local Agency Contract Number
9. Task
Order
Number
$0.00 $0.00
23. Local Agency Representative’s Signature 24. Local Agency Representative’s Name 25. Phone 26. Date
17. ORIGINAL DBE COMMITMENT AMOUNT:
List actual amount paid to all DBEs and non-DBEs for all task orders. If actual DBE utilization percentage (or item of work) was less than that approved at the time of award, provide comments in Explanation Box.
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT
18. Explaination Box:
Estimate from 10-O2.
20. Consultant Representative’s Name 22. Date21. Phone19. Consultant Representative’s Signature
I CERTIFY THAT THE CONTRACTING RECORDS OF THE DBE(S) HAS BEEN MONITORED
13. Contract Payments ($) 14. Date Work
CompletedDBE
2. Local Public Agency
EXHIBIT 17-F1: FINAL REPORT-UTILIZATION OF DISADVANTAGED BUSINESS ENTERPRISES (DBE) FOR A&E ON-CALL CONTRACTS
15. Date of Final
Payment
6. Business Address 7. Orig. Contract Amount ($)5. Consultant 8. Final Contract Amount ($) Non-DBE
10. Federal
Project
Number
12. Task Order Description
11. Task Order DBE Firm
Name
January 2023
57 204
I I I
I I
I I I
I I I
Local Assistance Procedures Manual Exhibit 17-O
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
Item
Number
9. DBE Contact Information
10. DBE
Certification
Number
11. Amount Paid
While Certified
12. Certification/
Decertification
Date
(Letter Attached)
13. Comments
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 DBE(S) HAS BEEN MONITORED
18. Local Agency Representative’s Signature 19. Local Agency Representative’s Name 20. Phone 21. Date DISTRIBUTION: Original – Local Agency, Copy – Caltrans District Local Assistance Engineer. Include with Final Report of Expenditures ADA NOTICE: For individuals with sensory disabilities, this document is available in alternate 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
58 205
Local Assistance Procedures Manual Exhibit 17-O
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 89
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