Form TC18-12 "Notice of Voluntary Withdrawal' " - Kentucky

What Is Form TC18-12?

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

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Kentucky Transportation Cabinet;
  • 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 TC18-12 by clicking the link below or browse more documents and templates provided by the Kentucky Transportation Cabinet.

ADVERTISEMENT
ADVERTISEMENT

Download Form TC18-12 "Notice of Voluntary Withdrawal' " - Kentucky

Download PDF

Fill PDF online

Rate (4.3 / 5) 33 votes
Page background image
TC 18-12
KENTUCKY TRANSPORTATION CABINET
Rev. 08/2017
Office for Civil Rights and Small Business Development
Page 1 of 1
NOTICE OF VOLUNTARY WITHDRAWAL
SECTION 1: DISADVANTAGED OWNER(S) INFORMATION
FIRST NAME
MI LAST NAME
PHONE
EMAIL ADDRESS
1
2
3
4
SECTION 2: FIRM INFORMATION
FIRM NAME
MAILING ADDRESS
CITY
STATE ZIP
(street)
SECTION 3: VOLUNTARY WITHDRAWAL STATEMENT
After careful consideration, I, the undersigned disadvantaged business enterprise (DBE) owner or authorized designee,
have elected not to apply or continue the firm’s participation as a DBE at this time. This notice serves to inform the
Kentucky Transportation Cabinet (KYTC) DBE program office of this decision.
Mark the explanation that best describes your reason for voluntarily withdrawing the firm from the DBE/ACDBE
program:
Personal Net Worth exceeds $1.32 million
No benefit in being a certified KYTC DBE/ACDBE program
Change of firm’s ownership
Not interested in continuing participation in the KYTC
Sale of business
DBE/ACDBE program
Business dissolved
Other
(Provide brief explanation in comments section below.)
Comments:
(Text limited for accurate printing.)
SECTION 4: SIGNATURES
DBE APPLICANT
DBE APPLICANT SIGNATURE
DATE
(Print name)
WITNESS
WITNESS SIGNATURE
DATE
(Print name)
WITNESS
WITNESS SIGNATURE
DATE
(Print name)
Return completed form to: KYTC Office for Civil Rights and Small Business Development, 200 Mero Street, Frankfort, KY
40602. DBE applicant and two witness signatures are required.
Whoever knowingly makes false statements or false representation as to a material fact in any statement, certificate, or report
submitted pursuant to the provisions of the Federal-Aid Road Act approved July 11, 1916 (39 Stat. 355), as amended and
supplemented, shall be fined under this title or imprisoned not more than five years or both.
TC 18-12
KENTUCKY TRANSPORTATION CABINET
Rev. 08/2017
Office for Civil Rights and Small Business Development
Page 1 of 1
NOTICE OF VOLUNTARY WITHDRAWAL
SECTION 1: DISADVANTAGED OWNER(S) INFORMATION
FIRST NAME
MI LAST NAME
PHONE
EMAIL ADDRESS
1
2
3
4
SECTION 2: FIRM INFORMATION
FIRM NAME
MAILING ADDRESS
CITY
STATE ZIP
(street)
SECTION 3: VOLUNTARY WITHDRAWAL STATEMENT
After careful consideration, I, the undersigned disadvantaged business enterprise (DBE) owner or authorized designee,
have elected not to apply or continue the firm’s participation as a DBE at this time. This notice serves to inform the
Kentucky Transportation Cabinet (KYTC) DBE program office of this decision.
Mark the explanation that best describes your reason for voluntarily withdrawing the firm from the DBE/ACDBE
program:
Personal Net Worth exceeds $1.32 million
No benefit in being a certified KYTC DBE/ACDBE program
Change of firm’s ownership
Not interested in continuing participation in the KYTC
Sale of business
DBE/ACDBE program
Business dissolved
Other
(Provide brief explanation in comments section below.)
Comments:
(Text limited for accurate printing.)
SECTION 4: SIGNATURES
DBE APPLICANT
DBE APPLICANT SIGNATURE
DATE
(Print name)
WITNESS
WITNESS SIGNATURE
DATE
(Print name)
WITNESS
WITNESS SIGNATURE
DATE
(Print name)
Return completed form to: KYTC Office for Civil Rights and Small Business Development, 200 Mero Street, Frankfort, KY
40602. DBE applicant and two witness signatures are required.
Whoever knowingly makes false statements or false representation as to a material fact in any statement, certificate, or report
submitted pursuant to the provisions of the Federal-Aid Road Act approved July 11, 1916 (39 Stat. 355), as amended and
supplemented, shall be fined under this title or imprisoned not more than five years or both.