Item 13 - Safe Mobility Santa Ana Planning and Engineering Services

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Local Assistance Procedures Manual Exhibit 10-O2 Consultant Contract DBE Commitment INSTRUCTIONS – CONSULTANT CONTRACT DBE COMMITMENT CONSULTANT 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” column. %: Enter the total DBE participation claimed (“Total Participation Dollars Claimed” divided by item “Total Contract Award Amount”). If the total % claimed is less than item “Contract DBE Goal,” an adequately documented 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 area code and phone number of the person signing the consultant’s DBE commitment form. 19. Preparer’s Title -Enter the position/title of the person signing the consultant’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 completing this section of the form for the Local Agency must sign their name to certify that the information in this and the Consultant Section of this form is complete and accurate. 24. Date -Enter the date the DBE commitment form is signed by the Local Agency Representative. 25. Local Agency Representative’s Name -Enter the name of the Local Agency Representative certifying the consultant’s DBE commitment form. 26. Phone -Enter the area code and phone number of the person signing the consultant’s DBE commitment form. 27. Local Agency Representative Title -Enter the position/title of the Local Agency Representative certifying the consultant’s DBE commitment form. Page 2 of 2 July 23, 2015 EXHIBIT 1