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COOPERATIVE AGREEMENT NO. C- 5.3583 <br />EXHIBIT D <br />The Form 103 must include the following information: <br />A. General Contract Information — Including Contract Number and Name, Prime <br />Consultant and the following: <br />1. Original Contract Amount <br />2. Running Total of Change Order Amount <br />3. Current Contract Amount <br />4. Amount Paid to Consultant during Month <br />5. Amount Paid to Consultant from Inception to Date <br />6. DBE Contract Goal <br />7. Total Dollar Amount of DBE Commitment <br />8. DBE Commitment as Percentage of Current Contract Amount <br />Listed and /Proposed Consultant /Subconsultant Information — For All DBE <br />participation being claimed either Race Neutrally or Race Consciously, <br />regardless of tier: <br />1. DBE Firm Name, Address, Phone Number, DBE Type of Operation, <br />Certification Type and Certification Number. <br />2. DBE Firm Contract Value Information: <br />Original contract amount, running total of change order amount, Current <br />contract amount, Amount paid to Consultant during month and Amount paid <br />to Consultant to date. <br />1 Consultant Assurance of Full Compliance with Prompt Payment Provisions <br />Consultant to sign the prompt payment assurance statement of compliance <br />contained within the Form 103. Consultant is to further maintain and submit at the <br />request of Authority a detailed running tally of related invoices submitted by DBE(s) <br />and Non DBE(s), including dates of invoice submission, dates accepted and <br />corresponding dates and amount of payments made. The Payment and Retention <br />Reporting tally must also include: <br />DBE(s) and Non DBE(s) Invoice Number, Invoice Amount, Invoice Date, <br />Prime Consultant's Invoice Number that incorporated the corresponding DBE and <br />Non DBE invoice(s) for billing purposes, Date of Invoice submission to Authority, <br />Date and amount Authority paid on Prime Consultant's Invoice. The report must also <br />reflect a breakout of retention withheld (including retention as specified in <br />subcontract agreement(s) and disputed invoice retention) and retention payments <br />made, check number and date paid to DBE and Non DBE. <br />Consultant is advised not to report the participation of DBE(s) toward the <br />Consultant's DBE attainment until the amount being claimed has been paid to the <br />DBE, Verification of payments and /or a signed Verification of Payment by the <br />applicable DBE or Non DBE must be submitted with Form 103 to authenticate <br />reported payments. <br />3. DBE Subcontract Agreements <br />Exhibit D <br />Page 8 <br />25F -51 <br />