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Local Assistance Procedures Manual EXHIBIT 10 -02 <br />Local Agency Proposer DBE Information (Consultant Contracts) <br />EXHIBIT 10 -02 Local Agency Proposer DBE Information (Consultant Contracts) <br />NOTE: PLEASE REFER TO INSTRUCTIONS ON THE REVERSE SIDE OF THIS FORM <br />LOCAL AGENCY: LOCATION: <br />PROJECT DESCRIPTION: <br />TOTAL CONTRACT AMOUNT ($): <br />PROPOSER' S NAME: <br />WORK <br />ITEM NO. <br />DESCRIPTION OR SERVICES TO BE <br />SUBCONTRACTED (or contracted if <br />the proposer is a DBE) <br />DBE CERT NO. <br />AND EXPIRATION <br />DATE <br />NAME OF EACH DBE <br />(Must be certified at the time <br />proposals are due - include DBE <br />address and phone number) <br />DOLLAR AMOUN T OF <br />EACH DBE <br />For Local Agency to Complete: <br />Local Agency Contract Number: <br />Federal -Aid Project Number: <br />Federal Share: <br />Total Claimed DBE <br />Participation <br />% <br />Contarct Award: <br />Local Agency certifies that the DBE certifications have been verified and all <br />informations is complete and accurate. <br />Print Name Signature Date <br />Local Agency Representative <br />(Area Code) Telephone Number: <br />Signature of Proposer <br />Date (Area Code) Tel. No. <br />Person to Contact (Please Type or Print) <br />Local Agency Proposer DBE Information (Consultant Conttarcts) <br />(Rev 6/27/09) <br />For Caltrans Review: <br />Print Name Signature Date <br />Caltrans District Local Assistance Engineer <br />Distribution: (1) Copy - Fax or scan a copy to the Caltrans District Local Assistance Engineer (DLAE) within 15 days after contract execution. <br />Failure to send a copy to the DLAE within 15 days after contract execution may result in deobligation of funds for this project. <br />(2) Original - Local agency files <br />Page 10 -74a <br />LPP 09 -02 July 31, 2009 <br />