Proposed ACDBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
Who Must Complete this Form?
A Proposed ACDBE Credit Form must be completed for each ACDBE firm for which the Prime Contractor intends to
claim ACDBE credit, including the Prime and/or any first tier AND lower tier (i.e., second tier, third tier, etc.) firm. This
credit would be for the anticipated ACDBE firm’s work performed or materials provided as part of the Prime Contractor’s
“good faith efforts” to meet the ACDBE goal for the Prime contract. Note: In order to receive ACDBE credit for work
performed or materials provided by an ACDBE firm, the ACDBE firm must be certified as an ACDBE in the state of
Michigan by the bid or proposal deadline.
If the Prime Contractor will not claim, as ACDBE credit, any work performed or materials provided by a ACDBE firm
towards meeting the ACDBE goal for the Prime contract, then completion of this form is not required.
All fields on the form must be completed; no fields should be left blank. If appropriate, complete a field with “not
applicable” or “N/A”. Ensuring accurate completion of the Proposed ACDBE Credit Form is the responsibility of the
prospective Prime Contractor. Failure to timely arrange for prospective ACDBE firm to complete this form as part
of the Prime Contractor’s bid or proposal may result in its bid or proposal being deemed Nonresponsive. Both
the Prime Contractor and ACDBE firm must sign the certification at the end of this form. For further guidance on the
completion of this form, carefully review the attached instructions. Duplicate as needed.
What type of Contract is this? (check one)


Concession - Any future reference to “firm” means Concession: Subcontractor; or Joint Venture Partner; or
Supplier.
Management Services - Any future reference to “firm” means Subconsultant or Joint Venture Partner.
What Type of ACDBE Firm are you? (check one)

Services Subcontractor (subcontractor) is defined as a firm that performs services at the direction and
discretion of the Prime contractor and for which is paid for the performance of this work. The value of the work
performed by a subcontractor is 100 percent creditable toward a contracted ACDBE commitment.

Joint Venture Partner is defined as a person or firm that participates in a contract with one or more other firms
to carry out a single for profit business enterprise, and to which contributes property, capital, efforts, skills, and
knowledge, and in which is responsible for a distinct, clearly defined portion of the work of the contract
(commercially useful function) and shares in the capital, contribution, control, management, risks, and profits of
the joint venture commensurate with its ownership interest. The value of the work performed by a Joint Venture
Partner is 100 percent creditable toward a contracted ACDBE commitment.

Supplier (includes Manufacturer, Regular Dealer (Supplier), and Broker)
A Manufacturer is defined as a firm that operates, or maintains a factory or establishment that produces on the
premises the materials or supplies obtained by the contractor. The value of the materials provided by a
Manufacturer is 100 percent creditable toward a contracted ACDBE commitment.
A Regular Dealer is defined as firm that owns, operates or maintains a store, warehouse or other establishment
in which the materials or supplies required for the performance of the contract are bought, kept in stock, and
regularly sold in the usual course of business. The firm must engage in, as its principal business, and in its own
name, the purchase and sale of the products in question. Bulk items such as steel, cement, gravel, stone, and
petroleum products need not be kept in stock, if it owns or operates distribution equipment. The value of the
materials provided by a Regular Dealer is 60 percent creditable toward a contracted ACDBE commitment.
A Broker is defined as a firm that arranges or expedites transactions. Only those costs associated with the
arranging or expediting of such transactions can be applied as ACDBE creditable.
 If you are a Services Subcontractor then only complete sections A thru E, and K of this form.
 If you are a Joint Venture Partner then only complete sections A, F, G, and K of this form.
 If you are a Supplier then only complete sections A, and H thru K of this form.
Any future reference to “firm” means Services Subcontractor or Joint Venture Partner or Supplier.
Revised 12/2010
Proposed ACDBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 1 of 6
Proposed ACDBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
A. Description of Prime Contract
(1) Project Name
(2) Airport Authority Control (Solicitation) Number
(3) Prime Contractor Name
B. Description of ACDBE Services Subcontractor Work/Participation**
(1) ACDBE Services Subcontractor Name.
___________________________________________________________________________________________
(2) Describe in detail the distinct, clearly defined commercially useful function that the ACDBE Services
Subcontractor will perform on the Prime contract with its own forces:
___________________________________________________________________________________________
(3) Will the ACDBE Services Subcontractor purchase or lease any supplies or equipment from the Prime
Contractor?
Yes
No
If yes, then also describe the supplies and/or equipment the ACDBE Services Subcontractor will purchase or
lease from the Prime Contractor and provide the dollar value of the supplies/equipment to be leased from the
Prime Contractor.
**Note: A copy of the ACDBE Services Subcontractor’s agreement or purchase order must be submitted upon request of the Airport Authority.
C. Value of ACDBE Services Subcontractor Work/Participation
(1) Provide the total dollar value of the ACDBE Services Subcontractor’s $
work/participation on the Prime contract, including any work to be performed by
Non-ACDBEs or other ACDBE’s.
(2) Provide the percentage of the Prime contract value to be performed by the
ACDBE Services Subcontractor. For this section, “Prime contract value” means
the total cost of work awarded by the Airport Authority. [Insert Basis for
Determining Low Bid]
Revised 12/2010
%
Proposed ACDBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 2 of 6
Proposed ACDBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
D. Description of ACDBE Services Subcontractor Work/Participation to be Performed by Other Firms
(1) If any ACDBE Services Subcontractor work will be performed by any NON-ACDBE firms, then provide the
following for each NON-ACDBE (include any NON-ACDBE suppliers, including brokers and attach additional
pages if needed):
a) Non-ACDBE
Phone Number Email Address Contact
(b) Description of Work
(c) Total Dollar
Name and
Person Name
to be Performed or
Value of
Address
Supplies/Equipment
NONto be Provided by
ACDBE Work
NON-ACDBE Firm
(2) If any ACDBE Services Subcontractor work will be performed by other ACDBE firms, then provide the
following for each ACDBE firm (includes any ACDBE suppliers, including brokers and attach additional pages
if needed):
a) Name and
Phone
Email
Contact
(b) Description of work (c) Dollar
(d) Total Dollar
Address
Number
Address
Person
to be Performed
Value of
Value to
Name
or Supplies/
ACDBE
be claimed
Equipment to be
Work
as ACDBE
Provided by
Credit
ACDBE Firm
E. Breakdown of Value of ACDBE Credit for Services Subcontractor Work/Participation
(1) Total dollar value of the ACDBE Services Subcontractor’s work/
participation [This is the same dollar value provided in Section C(1)
above].
$____________
(2) Total dollar value of ACDBE Services Subcontractor’s work/participation
that will be performed by NON-ACDBE firms. [This is the same Grand
Total Dollar Value provided in Section D.(1)(d) above.]
$____________
(3) Total dollar value of ACDBE Services Subcontractor’s work/ participation
that can count as ACDBE Credit [Subtract line E.(2) from line E.(1)]
Grand Total of ACDBE Credit
Revised 12/2010
$____________
Proposed ACDBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 3 of 6
Proposed ACDBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
F. Description of ACDBE Joint Venture Partner’s Participation**
(1) ACDBE Joint Venture Partner Name.
(2) Describe in detail the distinct, clearly defined commercially useful function1 that the ACDBE Partner will
perform on the Prime contract with its own forces:
*Note: A copy of the ACDBE Partner’s joint venture agreement must be submitted upon request of the Airport Authority.
G. Value of ACDBE Joint Venture Partner Participation
(1) Provide the total dollar value of the ACDBE partner’s participation on the
Prime contract.
(2) Provide the percentage of the Prime contract value to be performed by the
ACDBE partner. For this section, “Prime contract value” means [Insert Basis
for Determining Low Bid.]
$
%
Useful Function is explained at 49 CFR § 26.55 as follows: “A DBE performs a commercially useful
function when it is responsible for execution of the work of the contract and is carrying out its responsibilities by actually
performing, managing, and supervising the work involved. To perform a commercially useful function, the DBE must also
be responsible, with respect to materials and supplies used on the contract, for negotiating price, determining quality and
quantity, ordering the material, and installing (where applicable) and paying for the material itself.” For further guidance
please see the explanation at the beginning of this section entitled Airport Concession Disadvantaged Business
Enterprise (ACDBE) Program or refer to 49 CFR Parts 23 and 26.
1Commercially
Revised 12/2010
Proposed ACDBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 4 of 6
Proposed ACDBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
H. Description of ACDBE Supplier Participation
(1) ACDBE Supplier Name
____________________________________________________________________________________________
(2) Describe all of the supplies and/or equipment the ACDBE Supplier will provide under the subcontract.
____________________________________________________________________________________________
(3) Based upon the definitions included in 49 CFR §26.55(e), identify below the type of “supplier” the ACDBE
Supplier is certified as in the Michigan Unified Certification Program (MUCP) and will operate as under this
subcontract (Check the appropriate box):
____________________ Manufacturer
 Regular Dealer (Supplier)
 Broker___________________
(4) Is the ACDBE supplier certified by the Michigan Unified Certification Program (MUCP) as the type of “supplier”
identified immediately above?
 Yes
 No
NOTE: If your response to H.(4) above is “no”, then this work cannot be counted towards meeting the ACDBE goal.
I. Value of ACDBE Supplier Participation
(1) Provide the total dollar value of the ACDBE Supplier’s subcontract.
$
(2) Provide only the total dollar value and percentage value of the commission,
transportation charges for the delivery of supplies/equipment or other fees the $_______________
ACDBE supplier will charge. Note: For the percentage value, use a percent that
is based upon the total dollar value of the supplies/equipment to be provided by
AND
the ACDBE Supplier under the subcontract (i.e., provide a percent of the dollar
value provided in I. (1) immediately above).
______________%
(3) Provide only the cost of the supplies/equipment to be provided by the ACDBE $
Supplier under the subcontract.
J. Value of ACDBE Credit for ACDBE Supplier
In the applicable ACDBE Supplier category below, state (in dollars and percent) what portion of the ACDBE
Supplier’s subcontract value identified in Section I.(1) above, can count as ACDBE Credit towards meeting the
ACDBE goal for the Prime contract. If the ACDBE Supplier is certified and will operate in only one category, then
note $0 for the other categories.
Additionally, if the ACDBE Supplier is certified, and will operate under its subcontract, in more than one “supplier”
category for different types of supplies/equipment, then note the countable ACDBE Credit for each area of
participation and provide the total for all categories on Line 4 below.
(1) ACDBE Manufacturer Credit
$__________________________
_____% of Total Subcontract Value
(2) ACDBE Regular Dealer Credit
$__________________________
_____% of Total Subcontract Value
(3) ACDBE Broker Credit
$__________________________
_____% of Total Subcontract Value
(4) Total ACDBE Credit [Add lines J(1) thru J(3) above]
$__________________________
_____% of Total Subcontract Value
Revised 12/2010
Proposed ACDBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 5 of 6
Proposed ACDBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
K. Certification and Signatures
Under penalty of perjury, I certify that:
(1)
I am authorized to execute this form on behalf of my firm;
(2)
I have conducted reasonable due diligence in collecting the information to be submitted on or
with this form;
(3)
I understand that this form contains material statements relied upon by the Airport Authority
as a part of their decision-making process, and, based on my knowledge, the foregoing form
does not contain any untrue information or omit any material fact necessary to make the
information contained herein true and complete;
(4)
I have read and understand the rules, regulations, and policies applicable to the Airport
Authority’s ACDBE program;
(5)
I, and the organization I represent, are in compliance with the rules, regulations, and policies
applicable to the Airport Authority’s ACDBE program; and
(6)
I understand that if the Airport Authority determines that any information provided on this
form, or any other document submitted to the Airport Authority in connection with the subject
solicitation, is intentionally false or misleading, the Airport Authority may pursue any and all
remedies at law or in equity, including without limitation termination of any and all contracts
with my firm, designating my firm as non-responsible on future bid opportunities, debarment
of my firm from doing business with the Airport Authority, as well as referral of my firm to the
appropriate certifying and law enforcement agency(ies).
Printed Name and Title of Prime Contractor
Representative
Signature of Prime Contractor
Representative
Date
/
/
Printed Name and Title of ACDBE Firm
Representative
Signature of ACDBE Firm
Representative
Date
/
/
Revised 12/2010
Proposed ACDBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
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