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4 <br /> am, mir Washington State Underutilized Disadvantaged Business <br /> Department of Transportation <br /> Enterprise Utilization Certification <br /> To be eligible for Award of this Contract the Bidder shall fill out and submit, as a supplement to its sealed Bid Proposal, an <br /> Underutilized Disadvantaged Business Enterprise (UDBE) Utilization Certification. The Contracting Agency shall consider as <br /> I non-responsive and shall reject any Bid Proposal that does not contain a UDBE Utilization Certification which properly <br /> demonstrates that the Bidder will meet the UDBE participation requirements in one of the manners provided for in the <br /> proposed Contract. Refer to the instructions on Page 2 when filling out this form or the Bid may be rejected.An <br /> I example form has been provided on Page 3.The successful Bidder's UDBE Utilization Certification shall be deemed a <br /> part of the resulting Contract. <br /> Box 1: certifies that the UDBE firms listed below have been contacted <br /> regarding participation on this project. If this Bidder is successful on this project and is awarded the Contract, it shall <br /> I assure that subcontracts or supply agreements are executed with named UDBEs. (If necessary, use additional sheets.) <br /> Box 2: <br /> IColumn 1 Column 2 Column 3 Column 4 Column 5 <br /> Name of UDBE Project Role Description of Work Dollar Amount Dollar Amount <br /> (See instructions) (See instructions) (See instructions) Subcontracted to be Applied <br /> I to UDBE Towards Goal <br /> (See instructions) (See instructions) <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I <br /> IUnderutilized Disadvantaged Business Total UDBE Commitment Dollar Amount <br /> Enterprise Condition of Award Contract Goal Box 3 Box 4 <br /> I5 ❑ By checking Box 5 the Bidder is stating that their attempts to solicit sufficient UDBE participation to meet <br /> the COA Contract goal has been unsuccessful and good faith effort will be submitted in accordance with <br /> Section 1-02.9 of the Contract <br /> IDOT Form 272-056U <br /> Revised 02/2018 <br /> IMAPLE HEIGHTS BRIDGE SEISMIC RETROFIT PAGE 11 OF 15 BID PROPOSAL—UDBE CERTIFICATION—Addendum 1 <br /> WORK ORDER#3693 MAY 4,2020,2020 FEDERAL AID#BHM-2776(008) <br />