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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. <br />DESCRIPTION OR SERVICES TO <br />BE SUBCONTRACTED <br />DBE Cert. No. AND <br />EXPIRATION DATE <br />NAME OF DBEs (Must be <br />certified on the date bids are <br />opened - include DBE address <br />PERCENTAGE OF DBE <br />and phone number <br />For Local Agency to Complete: Local Agency Contract Number: <br />Total Claimed Participation <br />Federal Aid Project Number: <br />Federal Share: <br />Contract Award <br />Date: Local Agency <br />$ <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 />Signature of Proposer <br />For Caltrans Review: <br />Print Name <br />Date <br />Signature Date Caltrans District Loc <br />(Area Code) Tel. No. <br />al Assistance Engineer <br />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 />iam. ■ e, <br />P � <br />