Non-Construction DBE Payment Agreement Subcontractor Prime Contractor Name Name Address Address Telephone Telephone Subject Contract number Amount originally committed This agreement is to verify the work completed and the amount paid to the DBE Subcontractor on the above captioned contract. Under penalty of law for perjury or falsification, the undersigned certifies that the work reported herein was executed by the DBE, that the DBE actually performed, managed and supervised the work and that the work reported herein conforms to the work reported in the approved Utilization Plan together with any amendments approved by the Department. Role Hours Worked Rate $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Total $ Amount for Work Completed $0.00 Payment Received Balance Due (if any) Signature and title of DBE Subcontractor Date Signature and title of Prime Contractor Date Note: Submittal of this agreement shall be deemed as concurring with the payment amount specified above. The Department of Transportation is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the state and federal law. Disclosure of this information is REQUIRED.
Non-Construction DBE Payment Agreement Subcontractor Prime Contractor Name Name Address Address Telephone Telephone Subject Contract number Amount originally committed This agreement is to verify the work completed and the amount paid to the DBE Subcontractor on the above captioned contract. Under penalty of law for perjury or falsification, the undersigned certifies that the work reported herein was executed by the DBE, that the DBE actually performed, managed and supervised the work and that the work reported herein conforms to the work reported in the approved Utilization Plan together with any amendments approved by the Department. Role Hours Worked Rate $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Total $ Amount $0.00 for Work Completed Payment Received Balance Due (if any) Signature and title of DBE Subcontractor Date Signature and title of Prime Contractor Date Note: Submittal of this agreement shall be deemed as concurring with the payment amount specified above. The Department of Transportation is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the state and federal law. Disclosure of this information is REQUIRED.
SBE%202115-NC.docx