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Local Assistance Procedures (Manual Exhibit 10-0I <br />Consultant Proposal DBE Commitment <br />INSTRUCTIONS — CONSULTANT PROPOSAL DISE COMMITMENT <br />CONSULTANT SECTION <br />1. Local Agency - Enter the name of the local or regional agency that is funding the contract. <br />2. Contract DBE Goal - Enter the contract DBE goal percentage as it appears on the project advertisement. <br />3. Project Description - Enter the project description as it appears on the project advertisement (Bridge Rehab, <br />Seismic Rehab, Overlay, Widening, etc.). <br />4. Project Location - Enter the project location as it appears on the project advertisement, <br />5. Consultant's Name - Enter the consultant's firm name. <br />6. Prime Certified DBE - Check box i f prime contractor is a certified DBE. <br />7. Description of Work, Services, or Materials Supplied - Enter description of work, services, or materials to be <br />provided. Indicate all work to be performed by DBEs including work performed by the prime consultant's own <br />forces, if the prime is a DBE. If 100% of the item is not to be performed or furnished by the DBE, describe the <br />exact portion to be performed or furnished by the DBE. See LAPM Chapter 9 to determine how to count the <br />participation of DBE firms. <br />S. DBE Certification Number - Enter the DBE's Certification Identification Number. All DBEs must be certified <br />on the date bids are opened. <br />9. DBE Contact Information - Enter the name, address, and phone number of all DBE subcontracted consultants. <br />Also, enter the prime consultant's name and phone number, if the prime is a DBE. <br />10. DBE % - Percent participation of work to be performed or service provided by a DBE. Include the prime <br />consultant if the prime is a DBE. See LAPM Chapter 9 for how to count full/partial participation. <br />11. Total Claimed DBE Participation "k, - Enter the total DBE participation claimed. If the total % claimed is <br />less than item "Contract DBE Goal," an adequately documented Good Faith Effort (GTE) is required (see Exhibit <br />I5 -H DBE, Information - Good Faith Efforts of the LAPM). <br />12, Preparer's Signature - The person completing the DBE commitment form on behalf ofthe consultant's firm <br />must sign their name. <br />13. Date - Enter the date the DBE commitment form is signed by the consultant's preparer. <br />14. Preparer's Name - Enter the name of the person preparing and signing the consultant's DBE commitment <br />force. <br />15. Phone - Enter the area code and phone number of the person signing the consultant's DBE commitment 'form. <br />16. Preparer's Title - Enter the position/titic of the person signing the consultant's DBE commitment form. <br />LOCAL AGENCY SECTION <br />17. Local Agency Contract Number - Enter the Local Agency contract number or identifier. <br />18. Federal -Aid Project Number - Enter the Federal -Aid Project Number. <br />19. Proposed Contract Execution Date - Enter the proposed contract execution date. <br />20. Local Agency Representative's Signature - The person completing this section of the form for the Local <br />Agency must sign their name to certify that the information in this and the Consultant Section of this form is <br />complete and accurate. <br />2L Date - Enter the date the DBE commitment form is signed by the Local Agency Representative. <br />22. Local Agency Representative's Name - Enter the name of the Local Agency Representative certifying the <br />consultant's DBE commitment form. <br />23. Phone - Enter the area code and phone number of the person signing the consultant's DBE commitment form. <br />24. Local Agency Representative Title - Enter the position/title of the Local Agency Representative certifying <br />the consultant's DBE commitment form. <br />Page 2 of 2 <br />July 23, 2015 <br />