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DOT Form 272-058Revised 09/2020 <br />Disadvantaged Business Enterprise <br />(DBE)Trucking Credit Form <br />PART A: TO BE COMPLETED BY THE BIDDER <br />This form is in support of the trucking commitment identified on the DBE Utilization Certification Form submitted with the proposal. <br />Please note that DBE’s must be certified prior to time of submittal. <br />Federal Aid #Contract #Project Name <br />If listing items by hours, or by lump sum amounts, please provide calculations to substantiate the quantities listed. <br />Bid Item Item Description <br />Use additional sheets as necessary. <br />Bidder Name/Title (please print) <br />Phone Fax Signature <br />Address <br />I certify that the above information is complete and accurate. <br />Email Date <br />PART B: TO BE COMPLETED BY THE DBE TRUCKING FIRM <br />Note: DBE trucking firm participation may only be credited as DBE participation for the value of the hauling services, not for the <br />materials being hauled unless the trucking firm is also recognized as a supplier of the materials used on the project and approved <br />for this project as a regular dealer. <br />Tractor/trailers: Dump trucks: <br />Tractor/trailers: Dump trucks: <br />1.Type of Material expected to be <br />hauled? <br />2.Number of fully operational trucks <br />expected to be used on this project? <br />3.Number of trucks and trailers owned by <br />the DBE that will be used on this <br />project? <br />4.Number of trucks and trailers leased by <br />the DBE that will be used on this <br />project? <br />Tractor/trailers: Dump trucks: <br />DBE Firm Name Name/Title (please print) <br />Certification Number <br />Phone Fax Signature <br />Address <br />I certify that the above information is complete and accurate. <br />Email Date