Request No. / Airport Name
Subcontractor Registration #, Prequalification #
IL Project No.
(Subcontractor) 1st Tier 2nd Tier DBE / Fed Project No.
Street or P.O. Box / Contract No.
City / State / Zip Code / County
Telephone Number / FEIN Number / Letting Date
Est. Starting Date / Est. Completion Date / Date
Item No. / * / Item / Approximate
Quantity / Contract Unit
Price / Amount
* Indicates Specialty Items
Value of above specialty items / $ / Value of above subcontract...... / $
Value of all work sublet previously (include specialty items)...... / $
Specialty items to date / $ / Total of all work sublet to date (less specialty items sublet to date) / $
Total value of contract (less specialty items sublet to date)...... / $
51% of total contract value (less specialty items sublet to date)...... / $ 0.00
49% of total contract value (maximum allowable sub-contracted percentage)...... / $ 0.00
The Contractor certifies that a subcontract exists in writing between the prime contractor, or 1st tier subcontractor and the above named subcontractor, that it describes the scope of the services and that the actual dollar amount of the subcontract is / $
The undersigned contractor certifies that the subcontract along with all subcontractor disclosures (if required) have been submitted to the Department………………..…………………………………….…………………………………………………...…... / Yes
The subcontract documents physically incorporate all pertinent provisions and requirements of the prime contract including Equal Employment Opportunity provisions and the minimum wage for labor as stated in the contract shall apply to labor performed on all work sublet. The subcontract will in no way hinder the above-named subcontractor from maintaining his/her progress on any other work under the supervision of the Department of Transportation on which he/she is either a subcontractor or prime contractor. This request is made with the understanding that the prime contractor is not under any circumstances relieved of his/her liabilities and obligations and is responsible for organization, performance and quality of work obtained.
The undersigned certifies that affirmative action was taken to seek out and consider disadvantaged business enterprises as potential subcontractors.
Required for DBE Subcontractors only.
This form serves as a confirmation and/or addition to the DBE Utilization Plan. / 1st Tier Subcontractor If Applicable
Contractor
Reviewed for Compliance:
Date EEO Labor Compliance Signature / Street or P.O. Box
City / State / Zip Code
Note: Contractor should send one signed copy of request to the ConstructionEngineer. / By
Signature / Title
Approved
Chief Airport Construction & Materials EngineerDate
Printed 1/18/2019AER 260A(Rev. 01/22/15)