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Disadvantaged Business Enterprise (DBE) <br />Written Confirmation Document <br />See Contract Provisions: DBE Document Submittal Requirements <br />Disadvantaged Business Enterprise Participation <br />THIS FORM SHALL ONLY BE SUBMITTED TO A DBE THAT IS LISTED ON THE CONTRACTOR’S <br />DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION CERTIFICATION. <br />THE CONTRACTOR SHALL COMPLETE PART A PRIOR TO SENDING TO THE DBE. <br />PART A: To be completed by the bidder <br />The entries below shall be consistent with what is shown on the Bidder’s Disadvantaged Business Enterprise <br />Utilization Certification. Failure to do so will result in Bid rejection. <br />Contract Title: <br />Bidder’s Business Name: <br />DBE’s Business Name: <br />Description of DBE’s Work: <br />Dollar Amount to be Applied Towards DBE Goal: <br />Dollar Amount to be Subcontracted to DBE*: <br />*Optional Field <br />PART B: To be completed by the Disadvantaged Business Enterprise <br />As an authorized representative of the Disadvantaged Business Enterprise, I confirm that we have been <br />contacted by the Bidder with regard to the referenced project for the purpose of performing the Work described <br />above. If the Bidder is awarded the Contract, we will enter into an agreement with the Bidder to participate in <br />the project consistent with the information provided in Part A of this form. <br />Name (printed): <br />Signature: <br />Title: <br />Address: Date: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />DOT Form 422-031 <br />Revised 07/2016