Earthwork Solutions, LLC 1/30/2025

Revised 09/2020 Submit this form to in accordance with section 1-02.9 of the Contract. Instruction to Bidder: The Bidder shall complete and submit the Disadvantaged Business Enterprise (DBE) Trucking Credit Form in accordance with Section 1-02.9 of the Contract. INSTRUCTIONS Please note – All Fields are required PART A: TO BE COMPLETED BY THE BIDDER Federal Aid: Include the project federal-aid number. County: Specify the County where the project will take place. Contract #: Specify the Project Contract Number which can be found in the Engineer’s estimate bid check report. Bid Item: Provide the Bid Item Number (as it appears in the engineer’s estimate bid check report) for which trucking services will be utilized. Item Description: Provide description of the bid item (as it appears in the engineer ’s estimate bid check report) for which trucking will be utilized. Bidder: In this section, provide the bidder’s legal name, title, Business address, Phone and email. The bidder’s representative signature is required in addition to the date the form was signed. PART B: TO BE COMPLETED BY THE DBE TRUCKING FIRM Question 1: Specify type of material that will be hauled (i.e. Sand, HMA, gravel) Question 2: Specify the total number of operational trucks that will be used on the project. Question 3: Specify the total number of operational trucks and trailers owned by the DBE that will be used on the project. Question 4: Specify the total number of operational trucks and trailers leased by the DBE that will be used on the project. DBE Firm: In this section, provide the DBE Firm’s legal name, DBE Firm’s representative legal name and title, certification Number (Found in the firm’s OMWBE Profile page in the OMWBE directory), Business address, Phone, fax and email. The DBE Firm’s representative signature is required in addition to the date the form was signed. DOT Form 272-058