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JOB NUMBER: FAP NUMBER: RESIDENT ENGINEER:

CONTRACTOR: CONTRACT AMOUNT:

REPORT NO.: EST. END DATE:

DBE GOAL AMOUNT:

DBE GOAL %:

ARKANSAS STATE HIGHWAY AND TRANSPORTATION DEPARTMENT

NON-DBE PRIME / SUB CONTRACTOR PAYMENT LOG TO DISADVANTAGED BUSINESS ENTERPRISE FIRMS

AMOUNT PAID

AMOUNT PAID

THIS PERIOD

TO DATE

RETAINAGE

HELD PAID

NAME OF DBE FIRM (any DBE providing services or supplies on project)

DATE PAID

Rev. 4-10-00

Figure 107-14

ARKANSAS STATE HIGHWAY AND TRANSPORTATION DEPARTMENT

7-01-03

Page 100-74

Date

Date

The Contractor certifies that the above amounts have been paid to the listed DBEs and that documentation of these payments is available for inspection upon request.

Authorized Signature Typed/Printed Name Title

Must be received from Contractor within 30 calendar days of following end of each estimate period..

DEPARTMENT USE ONLY Reviewed By

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