17-O BUSINESS ENTERPRISES (DBE) CERTIFICATION STATUS CHANGE 1. Local Agency Contract Number 2. Federal-Aid Project Number 3. Local Agency 4. Contract Completion Date 5. Contractor/Consultant 6. Business Address 7. Final Contract Amount 12. Certification/ 10. DBE 8. Contract 11. Amount Paid Decertification 9. DBE Contact Information Certification 13. Comments Item While Certified Date Number Number (Letter Attached) If there were no changes in the DBE certification of subcontractors/subconsultants, indicate on the form. I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT 14. Contractor/Consultant Representative’s Signature 15. Contractor/Consultant Representative’s Name 16. Phone 17. Date I CERTIFY THAT THE CONTRACTING RECORDS AND ON-SITE PERFORMANCE OF THE DBE(S) HAS BEEN MONITORED 18. Local Agency Representative’s Signature 19. Local Agency Representative’s Name 20. 21. Date DISTRIBUTION: Original Local Agency, Copy Caltrans District Local Assistance Engineer. Include with Final Report of Expenditures – – ADA NOTICE: For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233, Local Assistance Procedures Manual TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
17-O (DBE) 1. Local Agency Contract Number 2. Federal-Aid Project Number 3. Local Agency 4. Contract Completion Date 5. Contractor/Consultant 6. Business Address 7. Final Contract Amount 8. Contract Item Number 9. DBE Contact Information 10. DBE Certification Number 11. Amount Paid While Certified 12. Certification/ Decertification Date (Letter Attached) 13. Comments If there were no changes in the DBE certification of subcontractors/subconsultants, indicate on the form. I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT 14. Contractor/Consultant Representative’s Signature 15. Contractor/Consultant Representative’s Name 16. Phone 17. Date I CERTIFY THAT THE CONTRACTING RECORDS AND ON-SITE PERFORMANCE OF THE DBE(S) HAS BEEN MONITORED 18. Local Agency Representative’s Signature 19. Local Agency Representative’s Name 20. 21. Date DISTRIBUTION: Original – Local Agency, Copy – Caltrans District Local Assistance Engineer. Include with Final Report of Expenditures ADA NOTICE: For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233, Local Assistance Procedures Manual TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814. BUSINESS ENTERPRISES CERTIFICATION STATUS CHANGE
CalT.Exhibit.17O.V.07232015.docx