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Enclosure 4b Page 1 of 2 <br />NOTE: PLEASE REFER TO INSTRUCTIONS ON THE REVERSE SIDE OF THIS FORM <br />AGENCY: LOCATION: PROJECT <br />DESCRIPTION: TOTAL CONTRACT <br />AMOUNT:$ PROPOSAL <br />DATE: PROPOSER'S <br />NAME: <br />CONTRACT <br />ITEM NO. DESCRIPTION OR SERVICES TO <br />BE SUBCONTRACTED DBE Cert. No. AND <br />EXPIRATION DATE NAME OF DBEs (Must be <br />certified on the date bids are <br />opened - include DBE address <br />PERCENTAGE OF DBE <br /> and hone number <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />For Local Agency to Complete: Local Agency Contract Number: Total Claimed Participation <br />Federal Aid Project Number: <br />Federal Share: <br />Contract Award <br />Date: Local Agency $ <br />certifies that the DBE certification(s) has been verified and all information is <br />complete and accurate. % <br />Print Name Signature Date Local <br />Agency Representative Area Code) Telephone Number: <br /> <br />For Caltrans Review: <br />Signature of Proposer <br />Print Name Date <br />Signature Date Caltrans District Loc (Area Code) Tel. No. <br />al Assistance Engineer Local <br /> Agency Bidder - DBE Commitment(Rev 3/09) <br />Distribution: (1) Copy - Fax or scan a copy to the Caltrans District Local Assistance Engineer (DLAE) within 15 days of contract <br />execution. Failure to send a copy to the DLAE within 15 days of contract execution may result in de-obligation of funds for this <br />project. (2) Original - Local agency files <br />Page 45 of 48 <br />19H-49