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..., . STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 275-030,11 A EQUAL OPPORTUNITY OFFICE 04/05 r"'"J . ANTICIPATED DBE PARTICIPATION STATEMENT '1 . Financial Project Number: Contract Number: r, . Federal Aid Project Number (if applicable): ~ Prime Contractor Name: . Contract Dollar Amount: ,.., . Is the prime contractor a Florida Department of Transportation Certified Disadvantaged Business Enterprise (DBE)? (yes 0 ) (no 0) ,., Expected amount of contract dollars to be subcontracted to DBE(s): $ . " . It is our intent to subcontract sub-contractors: % of the contract dollars to DBE(s), Listed below are the proposed DBE DBE (s) Name Tvpe of Work/Specialtv Dollar Amount/Percentaqe t'j . .., . .., . .., . n . Submitted by: Title: E-mail Address: Telephone Number: .., . Fax Number: Date: .., Note: This information is used to track and report anticipated DBE participation in all state and federally funded FOOT contracts. The anticipated DBE amount will not become a part of the contractual terms. . ..., This form must be submitted at the pre-construction or pre-work conference. DOT staff must forward this to the Equal Opportunity Office, 605 Suwannee Street, MS 65 Tallahassee, FL 32399-0450 or fax to (850) 414-4879. If you have any questions, please contact the EOO at (850) 414-4747. . ~ . .... - February 2007 00404-6 03-4122.0. .., .