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I <br /> Submit this form to in accordance with section 1-02.9 of the Contract. <br /> Instruction to Bidder:The Bidder shall complete and submit the Disadvantaged Business Enterprise(DBE)Trucking Credit <br /> Form in accordance with Section 1-02,9 of the Contract. <br /> INSTRUCTIONS <br /> Please note—All Fields are required <br /> PART A:TO BE COMPLETED BY THE BIDDER <br /> Federal Aid:Include the project federal-aid number. <br /> County:Specify the County where the project will take place. <br /> Contract#:Specify the Project Contract Number which can be found in the Engineer's estimate bid check report. <br /> Bid Item:Provide the Bid Item Number(as It appears in the engineer's estimate bid check report)for which trucking <br /> services will be utilized. <br /> Item Description:Provide description of the bid item(as it appears in the engineer's estimate bid check report)for which <br /> trucking will be utilized. <br /> Bidder: In this section,provide the bidder's legal name,title,Business address,Phone and email. <br /> The bidder's representative signature is required In addition to the date the form was signed. <br /> PART B:TO BE COMPLETED BY THE DBE TRUCKING FIRM ' <br /> Question 1:Specify type of material that will be hauled(i.e.Sand,HMA,gravel) <br /> Question 2:Specify the total number of operational trucks that will be used on the project. <br /> Question 3:Specify the total number of operational trucks and trailers owned by the DBE that will be used on the project. <br /> Question 4:Specify the total number of operational trucks and trailers leased by the DBE that will be used on the project. <br /> DBE Firm:In this section,provide the DBE Firm's legal name,DBE Firm's representative legal name and title,certification <br /> Number(Found in the firms OMWBE Profile page in the OMWBE directory),Business address, Phone,fax and email. <br /> The DBE Firm's representative signature is required in addition to the date the form was signed. <br /> I <br /> I <br /> I <br /> DOT Form 272-058 111 <br /> Revised 09/2020 <br /> 1 <br /> 2023 FEDERAL OVERLAY <br /> FEDERAL AID#STBGUL-2715(011) <br /> WO#3788 March 2,2023 134 <br /> Provided to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com - Always Verify Scal <br />