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<br /> <br /> Local Assistance Procedures Manual EXHIBIT 10-02 <br /> Local Agency Proposer DBE Information (Consultant Contracts) <br /> <br /> <br /> EXHIBIT 10-02 Local Agency Proposer DBE Information (Consultant Contracts) <br /> <br /> NOTE: PLEASE REFER TO INSTRUCTIONS ON THE REVERSE SIDE OF THIS FORM <br /> LOCAL AGENCY: LOCATION: <br /> PROJECT DESCRIPTION: <br /> <br /> TOTAL CONTRACT AMOUNT <br /> PROPOSER'S NAME: <br /> <br /> WORK DESCRIPTION OR SERVICES TO BE DBE CERT N0. NAME OF EACH DBE DOLLAR AMOUN T OF <br /> ITEM N0. SUBCONTRACTED (or contracted if AND EXPIRATION (Must be certified at the time EACH DBE <br /> the proposer is a DBE) DATE proposals are due -include DBE <br /> address and phone number) <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> For Local Agency to Complete: <br /> Total Claimed DBE <br /> Local Agency Contract Number: Participation <br /> Federal-Aid Project Number: % <br /> Federal Share: <br /> Contaact Award: <br /> Local Agency certifies that the DBE certifications have been verified and all <br /> informations is complete and accurate. <br /> Signature of Proposer <br /> <br /> Print Name Signature Date Date (Area Code) Tel. No. <br /> Local Agency Representative <br /> (Area Code) Telephone Number: <br /> <br /> FOr CaltrallS ReVIeW: Person to Contact (Please Type or Print) <br /> <br /> <br /> <br /> Print Name Signature Date Local Agency Proposer DBE Information (Consultant Conttarcts) <br /> Caltrans District Local Assistance Engineer (Rev 6127109) <br /> <br /> Distribution: (I) 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 /> <br /> <br /> Page 10-74a <br /> LPP 09-02 ~ July 31, 2009 <br />