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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION ANTICIPATED DBE PARTICIPATION STATEMENT 275-030-11 EQUAL OPPORTUNITY OFFICE 03111 Page 2 of B 1. FINANCIAL PROJECT NO. 13, 2. FAP NO. 15. TITLE OF SUBMITTER 3. CONTRACT NO. 4. COUNTY(IES) 5. DISTRICT 17. FAX NUMBER 18. PHONE NUMBER 1 wt Y � S2 - ` 19 9 �1 ;? - c - 7 tui c -VL. THE FOLLOWING SECTIONS ARE FOR FDOT USE 6. PRIME CONTRACTOR NAME 19 .PROCESSED BY 7. FFEI/D NUMBER 21. LETTING DATE 22. EXECUTED DATE 23. PRECON CONF DATE we 8. CONTRACT DO LAR AMOUNT 9. REVISION? IF YES, REVISION NUMBER: 10. IS THE PRIME CONTRACTOR A FLORIDA—/ CERTIFIED "DBE"? (DISADVANTAGED BUSINESS ENTERPRISE) LIr' NO ❑ YES 11. IS THE WORK OF THIS CONTRACT CONSTRUCTION ❑ OR MAINTENANCE P07 12. ANTICIPATED DBE SUBCONTRACTS: EO25.lNCLUDED IN DBE PARTICIPATION REPORT OF MIDIY DBE SUBCONTRACTOR or SUPPLIER TYPE OF WORK/SPECIALTY DOLLAR AMOUNT PERCENT OF CONTRACT DOLLARS A B C D E 12F TOTAL DOLLARS TO DBE's 12G TOTAL PERCENT OF CONTRACT $0400 0.00% SUBMITTED BY 14 .DATE 15. TITLE OF SUBMITTER jb 16. EMAIL ADDREA, S OF SUBMITTER 17. FAX NUMBER 18. PHONE NUMBER 1 wt Y � S2 - ` 19 9 �1 ;? - c - 7 tui NOTE: THIS INFORMATION IS USED TO TRACK AND REPORT ANTICIPATED DBE PARTICIPATION IN ALL STATE AND FEDERALLY FUNDED FDOT CONTRACTS. THE ANTICIPATED DBE AMOUNT IS VOLUNTARY AND WILL NOT BECOME A PART OF THE CONTRACTUAL TERMS, THIS FORM MUST BE SUBMITTED AT THE PRE CONSTRUCTION OR PRE WORK CONFERENCE. FOOT STAFF FORWARDS THE FORM TO THE EQUAL OPPORTUNITY OFFICE. THE FOLLOWING SECTIONS ARE FOR FDOT USE 19 .PROCESSED BY 20. DATE TO EO OFFICE 21. LETTING DATE 22. EXECUTED DATE 23. PRECON CONF DATE DIST 24 .SUBMITTED TO EO BY ❑ FAX ❑ EMAIL ❑ SHARED FOLDER EO25.lNCLUDED IN DBE PARTICIPATION REPORT OF MIDIY OFC 470-2