Form 25A-336 "Monthly Summary of Disadvantaged Business Enterprise Participation" - Alaska

What Is Form 25A-336?

This is a legal form that was released by the Alaska Department of Transportation and Public Facilities - a government authority operating within Alaska. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on March 1, 2012;
  • The latest edition provided by the Alaska Department of Transportation and Public Facilities;
  • 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 Form 25A-336 by clicking the link below or browse more documents and templates provided by the Alaska Department of Transportation and Public Facilities.

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Download Form 25A-336 "Monthly Summary of Disadvantaged Business Enterprise Participation" - Alaska

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MONTLY SUMMARY OF DISADVANTAGED BUSINESS
FOR PAYMENTS MADE IN:
ENTERPRISE PARTICIPATION
MONTH
YEAR
Federal-Aid Contracts
State of Alaska DOT & PF Civil Rights Office ● 2200 E 42nd Ave. ● Anchorage, AK 99519-6900
Please read instructions before completing this form.
Submit this form to the CRO by the 15th of he month following the reporting month. (i.e.: Work performed in January will be paid in February; the summary report for
January must be submitted to the CRO by March 15).
1. PROJECT NAME
Project Number
4. PRIME CONTRACTOR NAME
The undersigned affirms that the information that they are providing to the Alaska Department of Transportation and Public Facilities, Civil Rights Office is accurate and complete to the best of their knowledge.
Further, the undersigned authorizes the Alaska Department of Transportation and Public Facilities, Civil Rights Office to verify the accuracy of the information provided. Please note that the Alaska Department of
Transportation and Public Facilities, Civil Rights Office, is required to report to the Department of Transportation any false, fraudulent, or dishonest conduct in connection with the program, so that DOT can take
steps (e.g. referral to the Department of Justice for criminal prosecution, referral to the DOT Inspector General, action under suspension and debarment or Program Fraud and Civil Penalties rules) provided in
§26.109. The Alaska Department of Transportation and Public Facilities, Civil Rights Office, will consider similar action under our own legal authorities, including responsibility determinations in future contracts.
13. DATE
10. NAME OF PERSON PREPARING REPORT
11. TITLE
12. SIGNATURE
SUBCONTRACTORS
14. FIRM (DBE) NAME
15. BID ITEMS PAID
16. AGREED
17. AMOUNT PAID
18. AMOUNT
19. % OF WORK
20. FINAL PAYMENT
(LIST SEPARATELY)
PRICE
THIS PERIOD
PAID TO DATE
COMPLETED TO
DATE
YES
NO
1
2
3
4
5
If more spaces are required, use as many copies of the second page of this form as necessary. The contractor must sign each sheet to certify its content and completion.
YES
NO
Are additional pages attached?
10. NAME OF PERSON PREPARING REPORT
11. TITLE
12. SIGNATURE
13. DATE (mm/dd/yyyy)
Page __ of __
Form 25A-336 (3/12)
MONTLY SUMMARY OF DISADVANTAGED BUSINESS
FOR PAYMENTS MADE IN:
ENTERPRISE PARTICIPATION
MONTH
YEAR
Federal-Aid Contracts
State of Alaska DOT & PF Civil Rights Office ● 2200 E 42nd Ave. ● Anchorage, AK 99519-6900
Please read instructions before completing this form.
Submit this form to the CRO by the 15th of he month following the reporting month. (i.e.: Work performed in January will be paid in February; the summary report for
January must be submitted to the CRO by March 15).
1. PROJECT NAME
Project Number
4. PRIME CONTRACTOR NAME
The undersigned affirms that the information that they are providing to the Alaska Department of Transportation and Public Facilities, Civil Rights Office is accurate and complete to the best of their knowledge.
Further, the undersigned authorizes the Alaska Department of Transportation and Public Facilities, Civil Rights Office to verify the accuracy of the information provided. Please note that the Alaska Department of
Transportation and Public Facilities, Civil Rights Office, is required to report to the Department of Transportation any false, fraudulent, or dishonest conduct in connection with the program, so that DOT can take
steps (e.g. referral to the Department of Justice for criminal prosecution, referral to the DOT Inspector General, action under suspension and debarment or Program Fraud and Civil Penalties rules) provided in
§26.109. The Alaska Department of Transportation and Public Facilities, Civil Rights Office, will consider similar action under our own legal authorities, including responsibility determinations in future contracts.
13. DATE
10. NAME OF PERSON PREPARING REPORT
11. TITLE
12. SIGNATURE
SUBCONTRACTORS
14. FIRM (DBE) NAME
15. BID ITEMS PAID
16. AGREED
17. AMOUNT PAID
18. AMOUNT
19. % OF WORK
20. FINAL PAYMENT
(LIST SEPARATELY)
PRICE
THIS PERIOD
PAID TO DATE
COMPLETED TO
DATE
YES
NO
1
2
3
4
5
If more spaces are required, use as many copies of the second page of this form as necessary. The contractor must sign each sheet to certify its content and completion.
YES
NO
Are additional pages attached?
10. NAME OF PERSON PREPARING REPORT
11. TITLE
12. SIGNATURE
13. DATE (mm/dd/yyyy)
Page __ of __
Form 25A-336 (3/12)
SUBCONTRACTORS CONTINUED
14. FIRM (DBE) NAME
15. BID ITEMS PAID
16. AGREED
17. AMOUNT PAID
18. AMOUNT
19. % OF WORK
20. FINAL PAYMENT
(LIST SEPARATELY)
PRICE
THIS PERIOD
PAID TO DATE
COMPLETED TO
DATE
YES
NO
If more spaces are required, use as many copies of the second page of this form as necessary. The contractor must sign each sheet to certify its content and completion.
YES
NO
Are additional pages attached?
10. NAME OF PERSON PREPARING REPORT
11. TITLE
12. SIGNATURE
13. DATE (mm/dd/yyyy)
Page __ of __
Form 25A-336 (3/12)
MANUFACTURERS (100 % DBE Credit)
21. FIRM (DBE MANUFACTURER) NAME
22. PRODUCT
23. AMOUNT PAID
24. AMOUNT PAID TO
20. FINAL PAYMENT
MANUFACTURED
THIS PERIOD
DATE
YES
NO
1
2
3
4
5
6
7
BROKERS (5% DBE Credit for brokerage fee)
25. FIRM (DBE BROKER) NAME
26. PRODUCT/
27. DBE BROKERAGE FEE
28. AMOUNT PAID
29. AMOUNT PAID TO
20. FINAL PAYMENT
SERVICE
THIS PERIOD
DATE
YES
NO
1
$
-
$
-
2
$
-
3
$
-
4
$
-
5
$
-
6
REGULAR DEALERS (60% DBE Credit)
30. FIRM (DBE REGULAR DEALER) NAME
31. MATERIALS
32. AMOUNT PAID THIS
33. AMOUNT PAID
34. AMOUNT PAID TO
20. FINAL PAYMENT
SUPPLIED
PERIOD
THIS PERIOD (60%)
DATE
YES
NO
$
-
1
$
-
2
$
-
3
$
-
4
$
-
5
$
-
6
If more spaces are required, use as many copies of the second page of this form as necessary. The contractor must sign each sheet to certify its content and completion.
YES
NO
Are additional pages attached?
Page __ of __
Form 25A-336 (3/12)
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