HM Pacific Northwest Inc. 5/18/2023

Instructions for Disadvantaged Business Enterprise Utilization Certification Form Box 1: Name of Bidder(Proposal holder)submitting Bid. Box 2: Name of the Project. Column 1:Name of the Disadvantaged Business Enterprise(DBE).DBE firms can be found using the Diversity Management and Compliance System web page:)tttps:ltwsdot.diversitycompliance.com. Repeat the name of the DBE for each Project Role that will be performed. Column 2:The Project Role that the DBE will be performing as follows; • Prime Contractor • Subcontractor • Subcontractor(Force Account) • Work sublet as Force Account must be listed separately. • Manufacturer • Regular Dealer • Work sublet to a Regular Dealer must be listed separately. • Regular Dealer status must be approved prior to Bid submittal by the Office of Equal Opportunity, Washington State Department of Transportation,on each Contract. • Broker • Work sublet to a Broker must be listed separately. List each project role to be performed by a single DBE individually on a separate row.The role is used to determine what portion of the amount to be subcontracted(Column 4)may be applied toward meeting the goal (column 5). Column 3:Provide a description of work to be performed by the DBE.The work to be performed must be consistent with the Certified Business Description of the DBE provided at the Diversity Management and Compliance System web page httasJ/wsdoldiversitycomoiiance.com • A Bidder subletting a portion of a bid item shall slate"Partial"and describe the Work that is included. • For example:"Electrical(Partial)—Trenching". • "Mobilization"will not be accepted as a description of Work. • Column 4:List the total amount to be subcontracted to each DBE for each Project Role they are performing. Column 5:This is the dollar amount for each line listed in the certification that the prime intends to apply towards meeting the COA Contract goal.It may be that only a portion of the amount subcontracted to a DBE in Column 4 is eligible to be credited toward meeting the goal See Note 1,Note 2,Note 3.The Contracting Agency will utilize the sum of this column(Box 4)to determine whether or not the bidder has met the goal. In the event of an arithmetic error in summing column 5 or an error in making appropriate reductions in the amounts in column four,See Note 1,Note 2,Note 3, then the mathematics will be corrected and the total(Box 4)will be revised accordingly. Note 1:For Work sublet as Force Account the bidder may only claim 50%of the amount subcontracted(Column 4) towards meeting the goal(Column 5). This information will be used to demonstrate that the DBE contract goal Is met at the time that the bidder submits their bid. For example;amount sublet as force account=$100,000 (Column 4)equates to($100,000 X 50%)_$50,000(Column 5)to be applied towards the goal. Note 2:For Work sublet to a Regular Dealer the bidder may only claim 60%of the cost of the materials or supplies (Column 4)towards meeting the goal(Column 5). For example;Material cost=$100,000(Column 4)equates to($100,000 X 60%)_$60,000(Column 5)to be applied towards the goal Note 3:For Work sublet to a Broker the bidder may only claim the fees paid to a Broker towards meeting the goal(Column 4). For example;amount sublet to a broker=$100,000(Column 4)equates to($100,000 X reasonable fee%)=$(Column 5)to be applied towards the goal. Box 3: Box 3 is the COA Contract goal which is the minimum required DBE participation.The goal stated in the Contract will be in terms of a dollar amount or a percentage in the Contract. When expressed as a percentage you must multiply the percentage times the sum total of all bid items as submitted in the Bidder's Proposal to determine the dollar goal and write it in Box 3.In the event of an error in this box,the Contracting Agency will revise the amount accordingly. Box 4: Box 4 is the sum of the values in column 5.This value must equal or exceed the COA Contract goal amount written in Box 3 or; Box 5: Check Box 5 if insufficient DBE Participation has been achieved and a good faith effort is required.Refer to the subsection titled,Selection of Successful Bidder/Good Faith Efforts(GFE)in the Contract. See the Disadvantaged Business Enterprise Participation specification In the Contract for more information. DOT Form 272-056 Revised 10f2019 2023 FEDERAL OVERLAY , FEDERAL AIDtt STBGUL-2715(011) W083788 March 2,2023 128 Provided to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com - Always Verify Scal