Form 4101 "Disadvantaged Business Enterprise (Dbe) Heavy Construction Trucking Credit Worksheet" - Michigan

What Is Form 4101?

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

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Michigan 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 4101 by clicking the link below or browse more documents and templates provided by the Michigan Department of Transportation.

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Download Form 4101 "Disadvantaged Business Enterprise (Dbe) Heavy Construction Trucking Credit Worksheet" - Michigan

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DISADVANTAGED BUSINESS ENTERPRISE (DBE)
Michigan Department
Clear Form
of Transportation
HEAVY CONSTRUCTION TRUCKING
4101 (06/18)
CREDIT WORKSHEET
Information listed below must be complete and in compliance with the DBE CUF requirements under 49 CFR Part 26.55. This form is only used
for DBE Trucking work (MDOT Code RJ). Worksheet must accompany MDOT’s DBE Participation Form 0178.
MDOT CONTRACT IDENTIFICATION NUMBER
CONTRACT LOCATION
DBE TRUCKER
PRIME CONTRACTOR
EXPECTED START DATE
EXPECTED COMPLETION DATE
NAME OF CONTRACTOR PAYING YOUR FIRM
TOTAL NUMBER OF TRUCKS BEING USED ON THIS CONTRACT
TOTAL DOLLAR VALUE OF YOUR TRUCKING COMMITMENT FOR
THIS CONTRACT $ ______________________________________
(OWNED + LEASED)
_________ Trucks Total
TYPE OF MATERIAL BEING HAULED
COST PER UNIT FOR HAULING
$_______________________ PER
HOUR
or
TON
TRUCKS YOU WILL USE ON THIS CONTRACT
TRUCKS OWNED BY YOUR FIRM
Number of owned trucks that
What Type(s) of Trailers are you
Do you own the trailers?
Yes or
No
Total Dollar Value of Work
you will use on this contract
using on this contract?
If not, who owns them?
for your firm
$
________ Trucks
TRUCKS LEASED FROM ADDITIONAL DBEs
NUMBER OF TRUCKS
TOTAL DOLLAR VALUE
NAME OF ADDITIONAL DBEs THAT YOU WILL
BEING LEASED PER
OF WORK FOR EACH
USE ON THIS CONTRACT
DBE FIRM
ADDITIONAL DBE FIRM
________ Trucks
TOTALS
$
TRUCKS LEASED* FROM NON-DBEs
NUMBER OF TRUCKS
TOTAL DOLLAR
NAME OF NON-DBEs THAT YOU WILL
BEING LEASED PER
VALUE OF WORK FOR
USE ON THIS CONTRACT
EACH NON-DBE FIRM
NON-DBE FIRM
TOTALS
________ Trucks
$
%
What is YOUR TRANSPORTATION FEE / COMMISSION FOR EACH LEASED NON-DBE TRUCK (percentage)?
*
Lease agreement(s) must be on file with the Office of Business Development (OBD) for the Non-DBEs listed above. Failure to
provide lease(s) for the above firms in accordance with the MDOT's DBE Program Procedures will result in delay of approval.
If there are any changes to this form, once approved by MDOT, a revised form must be submitted to OBD within two weeks of
the change. If you need additional information or have questions regarding the completion of this form or submittal of this
information, please contact OBD via email at mdot-dbe@michigan.gov or by phone 1-866-DBE-1264.
False statements on this form or fraudulent documentation provided could result in sanctions by federal authorities
and/or MDOT. All signatures must be handwritten or digital. Rubber stamped not accepted.
DBE FIRM AUTHORIZED SIGNATURE
DATE
FOR MDOT INTERNAL USE ONLY
TOTAL NUMBER OF TRUCKS FOR DBE CREDIT
TOTAL # OF NON-DBE TRUCKS
TOTAL # OF DBE TRUCKS
TOTAL CREDIT FOR TRUCKING
NON-DBE
DBE
$
$
$
MDOT REVIEWER APPROVAL SIGNATURE
DATE
DISADVANTAGED BUSINESS ENTERPRISE (DBE)
Michigan Department
Clear Form
of Transportation
HEAVY CONSTRUCTION TRUCKING
4101 (06/18)
CREDIT WORKSHEET
Information listed below must be complete and in compliance with the DBE CUF requirements under 49 CFR Part 26.55. This form is only used
for DBE Trucking work (MDOT Code RJ). Worksheet must accompany MDOT’s DBE Participation Form 0178.
MDOT CONTRACT IDENTIFICATION NUMBER
CONTRACT LOCATION
DBE TRUCKER
PRIME CONTRACTOR
EXPECTED START DATE
EXPECTED COMPLETION DATE
NAME OF CONTRACTOR PAYING YOUR FIRM
TOTAL NUMBER OF TRUCKS BEING USED ON THIS CONTRACT
TOTAL DOLLAR VALUE OF YOUR TRUCKING COMMITMENT FOR
THIS CONTRACT $ ______________________________________
(OWNED + LEASED)
_________ Trucks Total
TYPE OF MATERIAL BEING HAULED
COST PER UNIT FOR HAULING
$_______________________ PER
HOUR
or
TON
TRUCKS YOU WILL USE ON THIS CONTRACT
TRUCKS OWNED BY YOUR FIRM
Number of owned trucks that
What Type(s) of Trailers are you
Do you own the trailers?
Yes or
No
Total Dollar Value of Work
you will use on this contract
using on this contract?
If not, who owns them?
for your firm
$
________ Trucks
TRUCKS LEASED FROM ADDITIONAL DBEs
NUMBER OF TRUCKS
TOTAL DOLLAR VALUE
NAME OF ADDITIONAL DBEs THAT YOU WILL
BEING LEASED PER
OF WORK FOR EACH
USE ON THIS CONTRACT
DBE FIRM
ADDITIONAL DBE FIRM
________ Trucks
TOTALS
$
TRUCKS LEASED* FROM NON-DBEs
NUMBER OF TRUCKS
TOTAL DOLLAR
NAME OF NON-DBEs THAT YOU WILL
BEING LEASED PER
VALUE OF WORK FOR
USE ON THIS CONTRACT
EACH NON-DBE FIRM
NON-DBE FIRM
TOTALS
________ Trucks
$
%
What is YOUR TRANSPORTATION FEE / COMMISSION FOR EACH LEASED NON-DBE TRUCK (percentage)?
*
Lease agreement(s) must be on file with the Office of Business Development (OBD) for the Non-DBEs listed above. Failure to
provide lease(s) for the above firms in accordance with the MDOT's DBE Program Procedures will result in delay of approval.
If there are any changes to this form, once approved by MDOT, a revised form must be submitted to OBD within two weeks of
the change. If you need additional information or have questions regarding the completion of this form or submittal of this
information, please contact OBD via email at mdot-dbe@michigan.gov or by phone 1-866-DBE-1264.
False statements on this form or fraudulent documentation provided could result in sanctions by federal authorities
and/or MDOT. All signatures must be handwritten or digital. Rubber stamped not accepted.
DBE FIRM AUTHORIZED SIGNATURE
DATE
FOR MDOT INTERNAL USE ONLY
TOTAL NUMBER OF TRUCKS FOR DBE CREDIT
TOTAL # OF NON-DBE TRUCKS
TOTAL # OF DBE TRUCKS
TOTAL CREDIT FOR TRUCKING
NON-DBE
DBE
$
$
$
MDOT REVIEWER APPROVAL SIGNATURE
DATE