Form CEM-2403F "Disadvantaged Business Enterprises (Dbe) Certification Status Change" - California

What Is Form CEM-2403F?

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

Form Details:

  • Released on July 1, 2012;
  • The latest edition provided by the California 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 fillable version of Form CEM-2403F by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-2403F "Disadvantaged Business Enterprises (Dbe) Certification Status Change" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
ADA Notice
DISADVANTAGED BUSINESS ENTERPRISES (DBE)
For individuals with sensory disabilities, this document is available in alternate
CERTIFICATION STATUS CHANGE
formats.
For information call (916) 654-6410 or TDD (916) 654-3880 or write
Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
CEM-2403F (REV 7/2012)
CONTRACT NUMBER
COUNTY
ROUTE
POST MILES
ADMINISTERING AGENCY
CONTRACT COMPLETION DATE
PRIME CONTRACTOR
BUSINESS ADDRESS
ESTIMATED CONTRACT AMOUNT
$
The Contractor: List all DBE's with change in certification status (certified/decertified) while in your employ, whether or not firms were originally listed for goal credit. Attach DBE certification/decertification letter in
accordance with the Special Provisions.
CERTIFICATION/
CONTRACT
FIRM NAME
AMOUNT PAID WHILE
DECERTIFICATION DATE
BUSINESS PHONE
CERTIFICATION NUMBER
ITEM NO.
AND BUSINESS ADDRESS
CERTIFIED
Letter attached
COMMENTS:
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT
CONTRACTOR REPRESENTATIVE'S SIGNATURE
TITLE
BUSINESS PHONE NUMBER
DATE
TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS COMPLETE AND CORRECT
RESIDENT ENGINEERING'S SIGNATURE
BUSINESS PHONE NUMBER
DATE
COPY DISTRIBUTION:
Original - OBEO - email smallbusinessadvocate@dot.ca.gov or FAX to (916) 324-1949
Copy - Contractor
Copy - District Construction
Copy - Resident Engineer
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
ADA Notice
DISADVANTAGED BUSINESS ENTERPRISES (DBE)
For individuals with sensory disabilities, this document is available in alternate
CERTIFICATION STATUS CHANGE
formats.
For information call (916) 654-6410 or TDD (916) 654-3880 or write
Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
CEM-2403F (REV 7/2012)
CONTRACT NUMBER
COUNTY
ROUTE
POST MILES
ADMINISTERING AGENCY
CONTRACT COMPLETION DATE
PRIME CONTRACTOR
BUSINESS ADDRESS
ESTIMATED CONTRACT AMOUNT
$
The Contractor: List all DBE's with change in certification status (certified/decertified) while in your employ, whether or not firms were originally listed for goal credit. Attach DBE certification/decertification letter in
accordance with the Special Provisions.
CERTIFICATION/
CONTRACT
FIRM NAME
AMOUNT PAID WHILE
DECERTIFICATION DATE
BUSINESS PHONE
CERTIFICATION NUMBER
ITEM NO.
AND BUSINESS ADDRESS
CERTIFIED
Letter attached
COMMENTS:
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT
CONTRACTOR REPRESENTATIVE'S SIGNATURE
TITLE
BUSINESS PHONE NUMBER
DATE
TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS COMPLETE AND CORRECT
RESIDENT ENGINEERING'S SIGNATURE
BUSINESS PHONE NUMBER
DATE
COPY DISTRIBUTION:
Original - OBEO - email smallbusinessadvocate@dot.ca.gov or FAX to (916) 324-1949
Copy - Contractor
Copy - District Construction
Copy - Resident Engineer
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
DISADVANTAGED BUSINESS ENTERPRISES (DBE)
CERTIFICATION STATUS CHANGE
CEM-2403F (REV 7/2012
The top of the form requires specific information regarding the construction project: Contract Number, County, Route,
Post Miles, the Administering Agency (Caltrans), the Contract Completion Date and the Estimated Contract Amount. It
requires the prime contractor name and business address. The focus of the form is to substantiate and verify the actual
DBE dollar amount paid to contractors on federally funded projects that had a change in certification status during the
course of the completion of the contract. The two situations that are being addressed by CEM 2403F are if a firm
certified as a DBE and doing construction work on the contract during the course of the project becomes decertified, and
if a non-DBE firm doing work on the contract during the course of the project becomes certified as a DBE.
The form has a column to enter the Contract Item No. (or Item No's), as well as a column for the Subcontractor name
and Business Address, Business Phone and contractor's Certification Number.
The column entitled Amount Paid While Certified will be used to enter the actual dollar value of the work performed by
those contractors who meet the conditions as outlined above during the time period they are certified as a DBE. This
column on the CEM-2403(F) should only reflect the dollar value of work performed while the firm was certified as a DBE.
The column called Certification/Decertification Date (Letter attached) will reflect either the date of the Decertification
Letter sent out by the Civil Rights or the date of the Certification Certificate mailed out by the Civil Rights. There is a box
to check that support documentation is attached to the CEM-2403(F) form.
There is a comments section for any additional information that may need to be provided regarding any of the above
transactions.
The CEM-2403(F) has an area at the bottom where the contractor and the resident engineer sign and date that the
information provided is complete and correct.
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