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<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />regardi <br />Washington State <br />Department of Transportation Disadvantaged BusinessEnterprise 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, <br />a Disadvantaged Business Enterprise (DBE) Utilization Certification. The Contracting Agency shall consider as non- <br />responsive and shall reject any Bid Proposal that does not contain a DBE Utilization Certification which properly <br />demonstrates that the Bidder will meet the DBE 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 />example form has been provided on Page 3. The successful Bidder’s DBE Utilization Certification shall be deemed a <br />part of the resulting Contract. <br />Box 1: certifies that the DBE firms listed below have been contacted ng participation on this project. If this Bidder is successful on this project and is awarded the Contract, it shallassure that subcontracts or supply agreements are executed with named DBEs. (If necessary, use additional sheets.) <br />Box 2: <br />Column 1 <br />Name of DBE <br />(See instructions) <br />Column 2 <br />Project Role <br />(See instructions) <br />Column 3 <br />Description of Work <br />(See instructions) <br />Column 4 <br />Dollar Amount <br />Subcontracted <br />to DBE <br />(See instructions) <br />Column 5 <br />Dollar Amount <br />to be Applied <br />Towards Goal <br />(See instructions) <br />Disadvantaged Business Enterprise <br />Condition of Award Contract Goal Box 3 <br />Total DBE Commitment Dollar Amount <br />Box 4 <br />5 By checking Box 5 the Bidder is stating that their attempts to solicit sufficient DBE 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 />DOT Form 272-056 <br />Revised 03/2018 C