Disadvantagedbusiness Enterprise (DBE)Programdbe Subcontractor Utilizationform

DisadvantagedBusiness Enterprise (DBE)ProgramDBE Subcontractor UtilizationForm

Thisform isintendedtocapturetheprimecontractor’sactualand/oranticipateduse of identifiedcertifiedDBE1subcontractors2and theestimateddollaramountofeachsubcontract.An EPA FinancialAssistanceAgreementRecipientmust requireitsprimecontractorstocompletethisformandinclude itin thebid or proposalpackage.Primecontractorsshouldalsomaintain a copy of thisformon file.

Prime ContractorNameClick here to enter text. / Project NameClick here to enter text.
Bid/ProposalNo.Click here to enter text. / AssistanceAgreement IDNo. (ifknown)Click here to enter text. / Point of ContactClick here to enter text.
AddressClick here to enter text.
TelephoneNo.Click here to enter text. / EmailAddressClick here to enter text.
Issuing/Funding EntityDepartment of Ecology
I have identifiedpotentialDBEcertifiedsubcontractors ☐YES ☐NO
Ifyes,pleasecompletethetablebelow. Ifno,pleaseexplain: Click here to enter text.
Subcontractor Name/CompanyName / CompanyAddress/Phone/ Email / Estimated DollarAmount / CurrentlyDBE
Certified?
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.

Add more lines if needed

1ADBE isa Disadvantaged,Minority, orWomanBusinessEnterprisethathasbeencertifiedby anentityfrom whichEPA acceptscertificationsasdescribedin40CFR33.204-33.205orcertifiedbyEPA.EPAaccepts certificationsfromentitiesthat meetorexceedEPAcertification standardsasdescribedin40 CFR33.202.

2Subcontractorisdefinedasacompany,firm,jointventure,orindividualwhoentersintoanagreementwithacontractortoprovideservicespursuanttoanEPAawardoffinancialassistance.

FORM6100-4(DBESubcontractorUtilizationForm)

DisadvantagedBusiness Enterprise (DBE)ProgramDBE Subcontractor UtilizationForm

I certify under penalty of perjury that the forgoingstatementsare trueand correct.Signing thisformdoesnotsignify acommitment to utilize thesubcontractorsabove.I amaware of thatin the event of a replacement of asubcontractor, I will adhere to the replacement requirementsset forthin 40CFR Part 33 Section 33.302 (c).

Prime Contractor Signature / PrintName
Title / Date
Click here to enter text. / Click here to enter text.

FORM6100-4(DBESubcontractorUtilizationForm)