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JOB NUMBER:

CONTRACTOR:

REPORT NO.:

FAP NUMBER:

CONTRACT AMOUNT:

EST. END DATE:

RESIDENT ENGINEER:

DBE GOAL AMOUNT:

DBE GOAL %:

DBE SUBCONTRACTOR WITH 2ND TIER SUBS/TRUCKERS PAYMENT LOG TO DBE and NON-DBE FIRMS

DBE

DATE

AMOUNT

AMOUNT RETAINAGE

FIRM

PAID

PAID THIS

PAID TO

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

(check here)

PERIOD

DATE

HELD

PAID

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

Authorized Signature Typed/Printed Name Title

Date

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

DEPARTMENT USE ONLY: Reviewed By

Date

Rev. 4-10-00

Figure 107-16

7-01-03

Page 100-76

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