EST. END DATE:
DBE GOAL AMOUNT:
DBE GOAL %:
DBE PRIME CONTRACTOR PAYMENT LOG TO DBE and NON-DBE FIRMS
NAME OF FIRM (any firm providing subcontracting work or services on project)
The Contractor certifies that the above amounts have been paid to those listed firms 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 following the end of the estimate period..
DEPARTMENT USE ONLY Reviewed By
ARKANSAS STATE HIGHWAY AND TRANSPORTATION DEPARTMENT Page 100-75