Form CEM-2404F "Monthly Dbe/Udbe Trucking Verification" - California

What Is Form CEM-2404F?

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-2404F 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-2404F "Monthly Dbe/Udbe Trucking Verification" - California

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MONTHLY DBE/UDBE TRUCKING VERIFICATION
CEM-2404F (REV 7/2012)
CONTRACT NO.
MONTH
YEAR
Trucking Company
DBE
Company
Truck No.
CA No.
Amount paid to
Amount paid to DBE
Date
Transportation
or
Cert. No.
Name and Address
DBE
and UDBE for lease
Paid
Arrangement
Owner Operator
(if certified)
Telephone Number
and UDBE
arrangement
(
all that apply)
Truckers
with non-DBE
and UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
0.00
0.00
$
$
TOTAL AMOUNT PAID
PRIME CONTRACTOR
BUSINESS ADDRESS
BUSINESS PHONE NUMBER
* Upon request all lease agreements must be made available, in accordance with the special provisions.
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT
CONTRACTOR REPRESENTATIVE'S SIGNATURE
TITLE
DATE
COPY - OBEO - smallbusinessadvocate@dot.ca.gov or FAX to (916) 324-1949
COPY DISTRIBUTION:
ORIGINAL - RESIDENT ENGINEER
For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) 654-3880 or
ADA Notice
write Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
MONTHLY DBE/UDBE TRUCKING VERIFICATION
CEM-2404F (REV 7/2012)
CONTRACT NO.
MONTH
YEAR
Trucking Company
DBE
Company
Truck No.
CA No.
Amount paid to
Amount paid to DBE
Date
Transportation
or
Cert. No.
Name and Address
DBE
and UDBE for lease
Paid
Arrangement
Owner Operator
(if certified)
Telephone Number
and UDBE
arrangement
(
all that apply)
Truckers
with non-DBE
and UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
Lease
$
$
Non-DBE
DBE
UDBE
0.00
0.00
$
$
TOTAL AMOUNT PAID
PRIME CONTRACTOR
BUSINESS ADDRESS
BUSINESS PHONE NUMBER
* Upon request all lease agreements must be made available, in accordance with the special provisions.
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT
CONTRACTOR REPRESENTATIVE'S SIGNATURE
TITLE
DATE
COPY - OBEO - smallbusinessadvocate@dot.ca.gov or FAX to (916) 324-1949
COPY DISTRIBUTION:
ORIGINAL - RESIDENT ENGINEER
For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) 654-3880 or
ADA Notice
write Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
MONTHLY DBE/UDBE TRUCKING VERIFICATION
CEM-2404F (REV 7/2012)
Instructions
Contracts advertised on or before June 15, 2012 may contain UDBE contract goals. UDBE trucking
participation must be reported on contracts with UDBE goals only. All other trucking participation
must be reported as DBE or non-DBE.
In the "Amount paid to DBE and UDBE Truckers" column, the contractor must show the dollar amount paid
to:
1. DBE and UDBE trucking companies using trucks it owns, insures and operates. Include 100 percent of
the amount paid to DBE and UDBE for trucking services provided.
2. DBE and UDBE trucking companies who lease from other UDBE and DBE trucking companies or owner
operators. Include 100 percent of the amount paid to DBE and UDBE for trucking services provided.
To ensure proper crediting of participation on contracts advertised on or before June 15, 2012, identify the
firm as a DBE or UDBE in the "Transportation Arrangement" column.
show the dollar amount paid to the DBE and UDBE who leases trucks from non-DBE firms. Include only the
amount for the fee or commission received as a result of the lease arrangement.
for all DBE trucking participation on contracts advertised after June 15, 2012.
The prime contractor or its representative must sign, including the individual's title and the date, certifying
that the information provided on the form is complete and accurate.
th
The form must be submitted to the Department of Transportation before the 15 of each month.
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