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INSTRUCTIONS - LOCAL AGENCY PROPOSER DBE INFORMATION <br />SUCCESSFUL PROPOSER: <br />The form requires specific information regarding the consultant contract: Agency, Location, <br />Project Description, Federal Aid Project Number (assigned by Caltrans-Local Assistance), <br />Proposal Date, and Successful Proposer's Name. <br />The form has a column for the Description or Services to be Subcontracted by DBEs. The DBE <br />should provide a certification number to the prime consultant. The form has a column for the <br />Names of DBE certified consultants to perform the work (must be certified on the date the <br />proposal is received and include DBE address and phone number). Enter DBE prime <br />consultant's and subconsultants' certification numbers. The prime consultant shall indicate all <br />work to be performed by DBEs including, if the prime consultant is a DBE, work performed by its <br />own forces. <br />Enter the Total Claimed DBE Participation percentage of items of work in the total DBE Dollar <br />Amount column. (If 100% of item is not to be performed by the DBE, describe the exact portion of <br />time to be performed by the DBE.) See Notice to Proposers/Bidders Disadvantaged Business <br />Enterprise Information to determine how to count the participation of DBE firms. <br />Exhibit H-2 must be signed and dated by the successful proposer at contract execution. Also <br />list a phone number in the space provided and print the name of the person to contact. <br />For the successful proposer, local agencies should complete the Contract Award Date <br />and Federal Share fields and verify that all information is complete and accurate before <br />signing and sending a copy of the form to the District Local Assistance Engineer within 15 <br />days of contract execution. Failure to submit a completed and accurate form within the 15- <br />day time period may result in the de-obligation of funds on this project. <br />District DBE Coordinator should verify that all information is complete and accurate. <br />Once the information has been verified, the District Local Assistance Engineer signs and <br />dates the form. <br />Page 46 of 48 <br />19H-50