Proposed DBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
Who Must Complete this Form?
A Proposed DBE Credit Form must be completed for each DBE firm for which the Prime Contractor intends to claim
DBE 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 DBE firm’s work performed or materials provided as part of the Prime Contractor’s “good faith
efforts” to meet the DBE goal for the Prime contract. Note: In order to receive DBE credit for work performed or materials
provided by a DBE firm, the DBE firm must be certified as a DBE in the state of Michigan by the bid or proposal
deadline.
If the Prime Contractor will not claim, as DBE credit, any work performed or materials provided by a DBE firm towards
meeting the DBE 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 DBE Credit Form is the responsibility of the
prospective Prime Contractor. Failure to timely arrange for prospective DBE 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 DBE 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)


Contractor - Any future reference to “firm” means Concession: Subcontractor; or Joint Venture Partner; or
Supplier.
Professional Services - Any future reference to “firm” means Subconsultant or Joint Venture Partner.
What Type of DBE 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 DBE 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 DBE 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 DBE 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 DBE 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 DBE 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 2/2011
Proposed DBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 1 of 6
Proposed DBE 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 DBE Services Subcontractor Work/Participation**
(1) DBE Services Subcontractor Name.
___________________________________________________________________________________________
(2) Describe in detail the distinct, clearly defined commercially useful function that the DBE Services
Subcontractor will perform on the Prime contract with its own forces:
___________________________________________________________________________________________
(3) Will the DBE 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 DBE 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 DBE Services Subcontractor’s agreement or purchase order must be submitted upon request of the Airport Authority.
C. Value of DBE Services Subcontractor Work/Participation
(1) Provide the total dollar value of the DBE Services Subcontractor’s $
work/participation on the Prime contract, including any work to be performed by
Non-DBEs or other DBE’s.
(2) Provide the percentage of the Prime contract value to be performed by the
DBE 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 2/2011
%
Proposed DBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 2 of 6
Proposed DBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
D. Description of DBE Services Subcontractor Work/Participation to be Performed by Other Firms
(1) If any DBE Services Subcontractor work will be performed by any NON-DBE firms, then provide the following
for each NON-DBE (include any NON-DBE suppliers, including brokers and attach additional pages if
needed):
a) Non-DBE
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
DBE Work
NON-DBE Firm
(2) If any DBE Services Subcontractor work will be performed by other DBE firms, then provide the following for
each DBE firm (includes any DBE 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/
DBE
be claimed
Equipment to be
Work
as DBE
Provided by
Credit
DBE Firm
E. Breakdown of Value of DBE Credit for Services Subcontractor Work/Participation
(1) Total dollar value of the DBE Services Subcontractor’s work/
participation [This is the same dollar value provided in Section C(1)
above].
(2) Total dollar value of DBE Services Subcontractor’s work/participation that
will be performed by NON-DBE firms. [This is the same Grand Total Dollar
Value provided in Section D.(1)(d) above.]
$____________
$____________
(3) Total dollar value of DBE Services Subcontractor’s work/ participation that
can count as DBE Credit [Subtract line E.(2) from line E.(1)]
Grand Total of DBE Credit
Revised 2/2011
$____________
Proposed DBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 3 of 6
Proposed DBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
F. Description of DBE Joint Venture Partner’s Participation**
(1) DBE Joint Venture Partner Name.
(2) Describe in detail the distinct, clearly defined commercially useful function1 that the DBE Partner will perform
on the Prime contract with its own forces:
*Note: A copy of the DBE Partner’s joint venture agreement must be submitted upon request of the Airport Authority.
G. Value of DBE Joint Venture Partner Participation
(1) Provide the total dollar value of the DBE partner’s participation on the Prime
contract.
(2) Provide the percentage of the Prime contract value to be performed by the
DBE 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 Disadvantaged Business Enterprise (DBE) Program
or refer to 49 CFR Parts 23 and 26.
1Commercially
Revised 2/2011
Proposed DBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 4 of 6
Proposed DBE Credit Form –
Services Subcontractor/Joint Venture
Partner/Supplier
H. Description of DBE Supplier Participation
(1) DBE Supplier Name
____________________________________________________________________________________________
(2) Describe all of the supplies and/or equipment the DBE 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 DBE 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 DBE 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 DBE goal.
I. Value of DBE Supplier Participation
(1) Provide the total dollar value of the DBE 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 $_______________
DBE 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 DBE 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 DBE $
Supplier under the subcontract.
J. Value of DBE Credit for DBE Supplier
In the applicable DBE Supplier category below, state (in dollars and percent) what portion of the DBE Supplier’s
subcontract value identified in Section I.(1) above, can count as DBE Credit towards meeting the DBE goal for the
Prime contract. If the DBE Supplier is certified and will operate in only one category, then note $0 for the other
categories.
Additionally, if the DBE 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 DBE Credit for each area of
participation and provide the total for all categories on Line 4 below.
(1) DBE Manufacturer Credit
$__________________________
_____% of Total Subcontract Value
(2) DBE Regular Dealer Credit
$__________________________
_____% of Total Subcontract Value
(3) DBE Broker Credit
$__________________________
_____% of Total Subcontract Value
(4) Total DBE Credit [Add lines J(1) thru J(3) above]
$__________________________
_____% of Total Subcontract Value
Revised 2/2011
Proposed DBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
Page 5 of 6
Proposed DBE 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 DBE program;
(5)
I, and the organization I represent, are in compliance with the rules, regulations, and policies
applicable to the Airport Authority’s DBE 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 DBE Firm Representative
Signature of DBE Firm Representative
Date
/
/
Revised 2/2011
Proposed DBE Credit Form –
Services Subcontractor/Joint
Venture Partner/Supplier
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