CDOT Form 17 "Contractor Dbe Payment Certification" - Colorado

What Is CDOT Form 17?

This is a legal form that was released by the Colorado Department of Transportation - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2006;
  • The latest edition provided by the Colorado Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of CDOT Form 17 by clicking the link below or browse more documents and templates provided by the Colorado Department of Transportation.

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Download CDOT Form 17 "Contractor Dbe Payment Certification" - Colorado

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Project No
.:
COLORADO DEPARTMENT OF TRANSPORTATION
CONTRACTOR DBE PAYMENT CERTIFICATION
Project Code (SA#):
Section I.
Prime Contractor:
List the DBE firms and the amount you have paid or will pay for work performed and materials used on this project
Return both copies to the Project Engineer.
Retain supporting documentation for a minimum of seven years from the project acceptance date.
The contractor is required to provide written explanation(s) for final pay amounts that are less than the amount
committed on CDOT Form 715 when the difference is 10% or greater. Use space below in Section II.
DBE FIRM NAME
AMOUNT
TIER
Section II.
Explain why your company paid less to the project’s DBE(s) subcontractors than was shown on CDOT Form 715:
I declare under penalty of perjury in the second degree, and any other applicable state or federal laws, that the
statements made in this document are true and complete to the best of my knowledge.
Prime Contractor’s Name:
Date:
/
/
Authorized Representative’s Signature and Title:
Distribution: Contracts and Market Analysis Branch (original)
CDOT Form 17
05/06
Project Engineer
Region EEO Manager
Previous editions may be used until supplies are exhausted
Project No
.:
COLORADO DEPARTMENT OF TRANSPORTATION
CONTRACTOR DBE PAYMENT CERTIFICATION
Project Code (SA#):
Section I.
Prime Contractor:
List the DBE firms and the amount you have paid or will pay for work performed and materials used on this project
Return both copies to the Project Engineer.
Retain supporting documentation for a minimum of seven years from the project acceptance date.
The contractor is required to provide written explanation(s) for final pay amounts that are less than the amount
committed on CDOT Form 715 when the difference is 10% or greater. Use space below in Section II.
DBE FIRM NAME
AMOUNT
TIER
Section II.
Explain why your company paid less to the project’s DBE(s) subcontractors than was shown on CDOT Form 715:
I declare under penalty of perjury in the second degree, and any other applicable state or federal laws, that the
statements made in this document are true and complete to the best of my knowledge.
Prime Contractor’s Name:
Date:
/
/
Authorized Representative’s Signature and Title:
Distribution: Contracts and Market Analysis Branch (original)
CDOT Form 17
05/06
Project Engineer
Region EEO Manager
Previous editions may be used until supplies are exhausted