EST. END DATE:
DBE GOAL AMOUNT:
DBE GOAL %:
DBE SUBCONTRACTOR WITH 2ND TIER SUBS/TRUCKERS PAYMENT LOG TO DBE and NON-DBE FIRMS
NAME OF FIRM (any firm providing services or supplies on project)
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
Must be received from Contractor within 30 calendar days following the end of each estimate period.
DEPARTMENT USE ONLY: Reviewed By