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CITY OF SANTA ANA PROPOSAL PROJECT NO.: 15-6831 CROSSWALK UPGRADES - PHASE I FEDERAL PROJECT NO: HSIPL 5063(155) INSTRUCTIONS — CONSTRUCTION CONTRACT DBE COMMITMENT 1. Local Agency -Enter the name of the local or regional agency that is funding the contract 2. Contract DBE Goal - Enter the contract DBE goal percentage as it appears on the project advertisement. 3. Project Location -Enter the project location as it appears on the project advertisement 4. Project Description - Enter the project description as it appears on the project advertisement (Bridge Rehab, Seismic Rehab, Overlay, Widening, etc). 5. Bidder's Name - Enter the contractor's firm name. 6. Prime Certified DBE - Check box if prime contractor is a certified DBE. 7. Bid Amount - Enter the total contract bid dollar amount for dte prime contractor. 8. Total Dollar Amount for LL Subcontractors —Enter the total dollar amount for all subcontracted contractors. SUM = (DBEs + all Non - DBEs). Do not include the prime contractor information in this count. 9. Total number of ALL subcontractors —Enter the total number of all subcontracted contractors. SUM = (DBEs + all Non - DBEs). Do not include the prime contractor information in this count. 10. Bid Item Number - Enter bid item number for work, services, or materials supplied to be provided. 11. Description of Work, Services, or Materials Supplied - Enter description of work, services, or materials to be provided. Indicate all work to be performed by DBEs including work performed by the prime contractor's own forces, if the prime is a DBE. If 100% of the item is not to be performed or famished by the DBE, describe the exact portion to be performed or furnished by the DBE. See LAPM Chapter 9 to determine how to count the participation of DBE firms. 12. DBE Certification Number - Enter the DBE's Certification Identification Number. All DBEs must be certified on the date bids are opened. 13. DBE Contact Information - Enter the name, address, and phone number of all DBE subcontracted contractors. Also, enter the prime contractor's name mid phone number, if the prime is a DBE. 14. DBE Dollar Amount - Enter the subcontracted dollar amount of the work to be performed or service to be provided- Include the prime contractor if the prime is aDBE. See LAPM Chapter 9 for how to count full/partial participation. 15. Total Claimed DBE Participation - S: Enter the total dollar amounts entered in the "DBE Dollar Amounf' column. %: Enter the total DBE participation claimed ("Total Claimed DBE Participation Dollars" divided by item "Bid Amount "). If the total % claimed is less than item "Contract DBE Goal," an adequately documented Good Faith Effort (GFE) is required (see Exhibit 15- H DBE Information - Good Faith Efforts of the LAPM), 16. Preparer's Signature - The person completing the DBE commitment form on behalf of the contractor's firm must sign their name. 17. Date - Enter the date the DBE commitment form is signed by the contractor's prepmer. 18. Preparers Name - Enter the name of the person preparing and signing the contractor's DBE commitment form. 19. Phone - Enter the area code and phone number of the person signing the contractor's DBE commitment form. 20. Preparers Title -Enter the position/title of die person signing the contractor's DBE commitment form. LOCAL AGENCY SECTION 21. Local Agency Contract Number - Enter the Local Agency contract number or identifier. 22. Federal -Aid Project Number - Enter the Federal -Aid Project Number. 23. Bid Opening Date - Enter the date contract bids were opened. 24. Contract Award Date - Enter the date the contract was executed. 25. Local Agency Representative's Signature - The person completing this section of the form for the Local Agency must sign their name to certify that the information in this and the Contractor Section of this form is complete mid accurate. 26. Date - Enter the date the DBE commitment form is signed by the Local Agency Representative. 27. Local Agency Representative's Name - Enter the name of the Local Agency Representative certifying the contractor's DBE commitment farm. 28. Phone - Enter the area code and phone number of the person signing the contractor's DBE commitment form. 29. Local Agency Representative Title - Enter the position/title of the Local Agency Representative certifying the contractor's DBE commitment form. P -28 of P -40 23A -39