"Pre-award Dbe Commitment Approval Request" - Connecticut

Pre-award Dbe Commitment Approval Request is a legal document that was released by the Connecticut Department of Transportation - a government authority operating within Connecticut.

Form Details:

  • Released on July 1, 2015;
  • The latest edition currently provided by the Connecticut Department of Transportation;
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Download "Pre-award Dbe Commitment Approval Request" - Connecticut

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CONNECTICUT DEPARTMENT OF TRANSPORTATION (CTDOT)
Rev 07/2015
PRE-AWARD DBE COMMITMENT APPROVAL REQUEST
TO BE SUBMITTED WITHIN THE TIME FRAME INDICATED IN THE BID DOCUMENTS
Only certified DBE firms and only for work which they have been certified for will be approved by CDOT toward the goal. Department's DBE directory is available on CTDOT's website or by calling 860-594-2171
Sheet
of
CDOT Project Number (s):
DBE Subcontractor:
Town(s) of:
NAICS Code (s) associated with this submission:
Submitted By (Prime):
Address:
Original Bid ($):
Is this DBE firm a 1st or 2nd tier subcontractor?
1st
2nd*
Dollar amount subcontracted to this DBE firm ($):
*
The CDOT prefers 1st tier subcontractors; however, credit for 2nd tier DBE firms will be approved provided this page is
**
Dollar amount requested for CREDIT for this DBE Firm ($):
signed by both the prime and the DBE firm, the 1st tier subcontractor is identified, the extent of the 2nd tier work is clearly
**
Please be advised that by submitting this form you (the prime) agree that the total Credited amount will be the amount
identified, and the prime makes the assertion that regardless of its arrangement with the 1st tier subcontractor, this DBE firm
of commitment and will be measured by the Commercially Useful Function the Subcontractor performs.
will be used and its replacement is subject to the conditions of the DBE specification and contract requirements.
Is This
Unit
Total item prices
Firm Type
item
Quantity bid
Contract
Quantity
Subcontract
Total Item price
Item Number & Description
of
credited to the
***
Partial
Code
by Prime
Unit Price
Subcontracted
Unit Price
subcontracted****
Item
subcontractor
*****
Yes No
N
$ 0.00
N
$ 0.00
$ 0.00
N
$ 0.00
N
$ 0.00
N
$ 0.00
N
$ 0.00
N
If any of the items above are checked Yes as to Partial, please use the space provided or use an attachment to offer
an explanation of the work involved. Also please identify who is responsible for the remainder of the partial items.
***
Firm Type Code: S (subcontractor), M (manufacturer), P (supplier), T (trucking), V (services)
Any DBE Trucking firm (T) nominated on this form must self-perform not less than 30% of their contract value.
****
In instances where the Prime is paying the Subcontractor a higher unit price than the bid, by submitting this form the Prime agrees to the higher subcontracted price without additional costs to the Department.
*****
The credited amount includes adjustments for supply items (60%) or items further subcontracted to NON-DBE firms.
****
Is this DBE Purchasing any Material or Leasing any Equipment from the Prime or any of the Prime's Affiliates?
YES
If YES, state the amount and DO NOT include the
Amount: $ ________________________
NO
amount in the amount toward the goal.
Signature of Prime Contractor, Title
Date
Signature of Subcontractor, Title
Date
After this submittal is approved by the Department, any proposed changes to it must be submitted to the Department for approval.
CONNECTICUT DEPARTMENT OF TRANSPORTATION (CTDOT)
Rev 07/2015
PRE-AWARD DBE COMMITMENT APPROVAL REQUEST
TO BE SUBMITTED WITHIN THE TIME FRAME INDICATED IN THE BID DOCUMENTS
Only certified DBE firms and only for work which they have been certified for will be approved by CDOT toward the goal. Department's DBE directory is available on CTDOT's website or by calling 860-594-2171
Sheet
of
CDOT Project Number (s):
DBE Subcontractor:
Town(s) of:
NAICS Code (s) associated with this submission:
Submitted By (Prime):
Address:
Original Bid ($):
Is this DBE firm a 1st or 2nd tier subcontractor?
1st
2nd*
Dollar amount subcontracted to this DBE firm ($):
*
The CDOT prefers 1st tier subcontractors; however, credit for 2nd tier DBE firms will be approved provided this page is
**
Dollar amount requested for CREDIT for this DBE Firm ($):
signed by both the prime and the DBE firm, the 1st tier subcontractor is identified, the extent of the 2nd tier work is clearly
**
Please be advised that by submitting this form you (the prime) agree that the total Credited amount will be the amount
identified, and the prime makes the assertion that regardless of its arrangement with the 1st tier subcontractor, this DBE firm
of commitment and will be measured by the Commercially Useful Function the Subcontractor performs.
will be used and its replacement is subject to the conditions of the DBE specification and contract requirements.
Is This
Unit
Total item prices
Firm Type
item
Quantity bid
Contract
Quantity
Subcontract
Total Item price
Item Number & Description
of
credited to the
***
Partial
Code
by Prime
Unit Price
Subcontracted
Unit Price
subcontracted****
Item
subcontractor
*****
Yes No
N
$ 0.00
N
$ 0.00
$ 0.00
N
$ 0.00
N
$ 0.00
N
$ 0.00
N
$ 0.00
N
If any of the items above are checked Yes as to Partial, please use the space provided or use an attachment to offer
an explanation of the work involved. Also please identify who is responsible for the remainder of the partial items.
***
Firm Type Code: S (subcontractor), M (manufacturer), P (supplier), T (trucking), V (services)
Any DBE Trucking firm (T) nominated on this form must self-perform not less than 30% of their contract value.
****
In instances where the Prime is paying the Subcontractor a higher unit price than the bid, by submitting this form the Prime agrees to the higher subcontracted price without additional costs to the Department.
*****
The credited amount includes adjustments for supply items (60%) or items further subcontracted to NON-DBE firms.
****
Is this DBE Purchasing any Material or Leasing any Equipment from the Prime or any of the Prime's Affiliates?
YES
If YES, state the amount and DO NOT include the
Amount: $ ________________________
NO
amount in the amount toward the goal.
Signature of Prime Contractor, Title
Date
Signature of Subcontractor, Title
Date
After this submittal is approved by the Department, any proposed changes to it must be submitted to the Department for approval.