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Local Assistance Procedures Manual Exhibit 17-F Final Report-Utilization of Disadvantaged Business Enterprises (DBE) and First-Tier Subcontractors INSTRUCTIONS — FINAL REPORT-UTILIZATION OF DISADVANTAGED BUSINESS ENTERPRISES (DBE) AND FIRST-TIER SUBCONTRACTORS 1. Local Agency Contract Number - Enter the Local Agency contract number or identifier. 2. Federal-Aid Project Number - Enter the Federal-Aid Project Number. 3. Local Agency - Enter the name of the local or regional agency that is funding the contract. 4. Contract Completion Date - Enter the date the contract was completed. 5. Contractor/Consultant - Enter the contractor/consultant's firm name. 6. Business Address - Enter the contractor/consultant's business address. 7. Final Contract Amount - Enter the total final amount for the contract. 8. Contract Item Number - Enter contract item for work, services, or materials supplied provided. Not applicable for consultant contracts. 9. Description of Work, Services, or Materials Supplied - Enter description of work, services, or materials provided. Indicate all work to be performed by DBEs including work performed by the prime contractor/consultant's own forces, if the prime is a DBE. If 100% of the item is not to be performed or furnished by the DBE, describe the exact portion to be performed or furnished by the DBE. See LAPM Chapter 9 to determine how to count the participation of DBE firms. 10. Company Name and Business Address - Enter the name, address, and phone number of all subcontracted contractors/consultants. Also, enter the prime contractor/consultant's name and phone number, if the prime is a DBE. 11. DBE Certification Number - Enter the DBE's Certification Identification Number. Leave blank if subcontractor is not a DBE. 12. Contract Payments - Enter the subcontracted dollar amount of the work performed or service provided. Include the prime contractor/consultant if the prime is a DBE. The Non-DBE column is used to enter the dollar value of work performed by firms that are not certified DBE or for work after a DBE becomes decertified. 13. Date Work Completed - Enter the date the subcontractor/subconsultant's item work was completed. 14. Date of Final Payment - Enter the date when the prime contractor/consultant made the final payment to the subcontractor/subconsultant for the portion of work listed as being completed. 15. Original DBE Commitment Amount - Enter the "Total Claimed DBE Participation Dollars" from Exhibits 15-G or 10-02 for the contract. 16. Total - Enter the sum of the "Contract Payments" Non-DBE and DBE columns. 17. Contractor/Consultant Representative's Signature - The person completing the form on behalf of the contractor/consultant's firm must sign their name. 18. Contractor/Consultant Representative's Name - Enter the name of the person preparing and signing the form. 19. Phone - Enter the area code and telephone number of the person signing the form. 20. Date - Enter the date the form is signed by the contractor's preparer. 21. Local Agency Representative's Signature - A Local Agency Representative must sign their name to certify that the contracting records and on-site performance of the DBE(s) has been monitored. 22. Local Agency Representative's Name - Enter the name of the Local Agency Representative signing the form. 23. Phone - Enter the area code and telephone number of the person signing the form. 24. Date - Enter the date the form is signed by the Local Agency Representative. Page 2 of 2 ATTY/AGR.2016.053/CDM Smith July 23, 2015