Common use of Iran Divestment Act Compliance Clause in Contracts

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this Contract in accordance with §102-12 of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by New York State Department of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate and enter below the name of a Disadvantaged Business Enterprise Officer that will have the responsibility for and is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who must be assigned adequate authority and responsibility to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BID.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public ARTICLE 6 BID SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this Contract in accordance with §102-12 of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by New York State Department of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate and enter below the name of a Disadvantaged Business Enterprise Officer that will have the responsibility for and is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who must be assigned adequate authority and responsibility to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BID.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public FILLABLE FORM ARTICLE 6 BID SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this Contract in accordance with §102-12 of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by New York State Department of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ xxxxx://xxxxxx.xxxxxxxxxxxxxx.xxx or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New YorkXxx Xxxx, NY XX 00000 (000212) 000839-0000 9411 Disadvantaged Business Enterprise Officer The Bidder shall designate and enter below the name of a Disadvantaged Business Enterprise Officer that will have the responsibility for and is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who must be assigned adequate authority and responsibility to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/1408/16) RETURN THIS PAGE WITH BID.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID APT E- See Footer Tax ID #: PIN #: SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract in accordance with §102-12 of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by New York State Overview APT E- Pin # See Footer FMS Project ID#: Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEsBuildings Agency Address 000 Xxxxxxxx, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 0xx Xxxxx Xxxx Xxx Xxxx Xxxxx XX Xxx Code 10007 Contact Person Xxxxxx New York, NY 00000 (X. Wong Title Deputy Agency Chief Contracting Officer Telephone # 000) -000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate Email xxxxxx@xxxxxxxxx.xxx.xxx Project Description (attach additional pages if necessary) M/WBE Participation Goals for Services Enter the percentage amount for each group or for an unspecified goal. Please note that there are no goals for Asian Americans in Professional Services. Prime Contract Industry: Group Percentage Unspecified N/A% or Black American N/A% Hispanic American N/A% Asian American N/A% Women N/A% Total Participation Goals See Schedule A% Line 1 APT E- See Footer Tax ID #: PIN #: SCHEDULE B - Part II: M/WBE Participation Plan Part II to be completed by the bidder/proposer. Please note: For Non-M/WBE Prime Contractors who will NOT subcontract any services and enter below will self-perform the name of entire contract, you must obtain a Disadvantaged Business Enterprise Officer that will have FULL waiver by completing the responsibility for Waiver Application on pages 5 and 6 and timely submitting it to the contracting agency pursuant to the Notice to Prospective Contractors. Once a FULL WAIVER is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who granted, it must be assigned adequate authority included with your bid or proposal and responsibility you do not have to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BIDcomplete or submit this form with your bid or proposal.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established B – M/WBE Utilization Plan‌ M/WBE Participation Goals for Services Enter the following Disadvantaged Business Enterprise percentage amount for each category or for an unspecified Goal. Prime Contract Industry: Category and Breakdown: Unspecified % Black American % Hispanic American % Asian American % Women % Total Participation Goals % Line 1 Part 1: M/WBE Participation Goals Contract Overview (DBETo be completed by contracting agency) utilization goal for this APT E-Pin# See Footer FMS Project ID# See Contract in accordance with §102-12 Cover Page Project Title See Footer Agency PIN# See Footer Contracting Agency Department of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by Transportation Bid/Proposal Response Date See Article 1 Agency Address New York City New York State Department NY ZIP 10041 Contact Person Xxxxxx Xxxxxx Title Director of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 M/WBE Program & Oversight Telephone (000) 000-0000 Disadvantaged Business Enterprise Officer The Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4 Bidder shall designate or proposer  is required OR  is not required to specifically identify the contact information of all M/WBE firms they intend to use as a subcontractor on this contract, including the M/WBE vendor name, address and enter telephone number in the space provided below in Part 2 Section 4. Section 2: M/WBE Utilization Goal Calculation Prime Contractor Adopting Agency Participation Goals For Prime Contractors (including Qualified Joint Ventures and M/WBE firms) adopting Agency M/WBE Participation Goals. Total Bid/Proposal Value $ multiplied by x Total Participation Goals % (Line 1 above) Calculated M/WBE Participation Amount $ Line 2 OR Prime Contractor With Partial Waiver Approval Adopting Revised Participation Goals For Prime Contractors (including Qualified Joint Ventures and M/WBE firms) adopting Revised M/WBE Participation Goals. Total Bid/Proposal Value $ multiplied by x Total Revised Participation Goals % Calculated M/WBE Participation Amount $ Line 3 Part 2: M/WBE Participation Plan (To be completed by the name of bidder/proposer unless granted a Disadvantaged Business Enterprise Officer that will have the responsibility for and is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who full waiver, which must be assigned adequate authority and responsibility to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BID.submitted with the bid/proposal in lieu of this form)

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this Contract in accordance with §102-12 of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by New York State Department of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate and enter below the name of a Disadvantaged Business Enterprise Officer that will have the responsibility for and is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who must be assigned adequate authority and responsibility to do so. _______________________________________________ Designated DBE Officer: (Name, Title) ________________________________________ Telephone: (Revised 08/14) RETURN THIS PAGE WITH BID.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public ARTICLE 6 BID SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this Contract in accordance with §102-12 of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by New York State Department of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx 55 Water Street New York, NY 00000 (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate and enter below the name of a Disadvantaged Business Enterprise Officer that will have the responsibility for and is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who must be assigned adequate authority and responsibility to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BID.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID Tax ID #: SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency 000035 APT E-PIN #: See Footer Contract in accordance with §102-12 Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Part A, Article A Contracting Agency Department of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by Transportation Agency Address New York City New York State Department NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 M/WBE Program & Oversight Telephone # (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Part D Article D M/WBE Participation Goals for Services Enter the percentage amount for each group or for an unspecified goal. Please note that there are no goals for Asian Americans in Professional Services. Prime Contract Industry: See Contract Cover Page Group Percentage Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Total Participation Goals See Schedule A for % Line 1 SCHEDULE B - Part II: M/WBE Participation Plan Tax ID #: Part II to be completed by the bidder/proposer. PIN #: Please note: For Non-M/WBE Prime Contractors who will NOT subcontract any services and enter below will self-perform the name of entire contract, you must obtain a Disadvantaged Business Enterprise Officer that will have FULL waiver by completing the responsibility for Waiver Application on pages 5 and 6 and timely submitting it to the contracting agency pursuant to the Notice to Prospective Contractors. Once a FULL WAIVER is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who granted, it must be assigned adequate authority included with your bid or proposal and responsibility you do not have to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BIDcomplete or submit this form with your bid or proposal.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public FILLABLE FORM BID SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this Contract in accordance with §102-12 of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by New York State Department of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate and enter below the name of a Disadvantaged Business Enterprise Officer that will have the responsibility for and is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who must be assigned adequate authority and responsibility to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BID.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID Tax ID #: SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency 000028 APT E-PIN #: See Footer Contract in accordance with §102-12 Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Part A, Article A Contracting Agency Department of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by Transportation Agency Address New York City New York State Department NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 M/WBE Program & Oversight Telephone # (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Part D Article D M/WBE Participation Goals for Services Enter the percentage amount for each group or for an unspecified goal. Please note that there are no goals for Asian Americans in Professional Services. Prime Contract Industry: See Contract Cover Page Group Percentage Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Total Participation Goals See Schedule A for % Line 1 SCHEDULE B - Part II: M/WBE Participation Plan Part II to be completed by the bidder/proposer. Please note: For Non-M/WBE Prime Contractors who will NOT subcontract any services and enter below will self-perform the name of entire contract, you must obtain a Disadvantaged Business Enterprise Officer that will have FULL waiver by completing the responsibility for Waiver Application on pages 5 and 6 and timely submitting it to the contracting agency pursuant to the Notice to Prospective Contractors. Once a FULL WAIVER is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who granted, it must be assigned adequate authority included with your bid or proposal and responsibility you do not have to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BIDcomplete or submit this form with your bid or proposal.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID Tax ID #: APT E-PIN #: See Footer SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract in accordance with §102-12 Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by Transportation Agency Address New York City New York State Department NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 M/WBE Program & Oversight Telephone # (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4 M/WBE Participation Goals for Services Enter the percentage amount for each group or for an unspecified goal. Please note that there are no goals for Asian Americans in Professional Services. Prime Contract Industry: See Contract Cover Page Group Percentage Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Total Participation Goals See Schedule A for % Line 1 SCHEDULE B - Part II: M/WBE Participation Plan Tax ID #: Part II to be completed by the bidder/proposer. APT E- PIN #: Please note: For Non-M/WBE Prime Contractors who will NOT subcontract any services and enter below will self-perform the name of entire contract, you must obtain a Disadvantaged Business Enterprise Officer that will have FULL waiver by completing the responsibility for Waiver Application on pages 5 and 6 and timely submitting it to the contracting agency pursuant to the Notice to Prospective Contractors. Once a FULL WAIVER is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who granted, it must be assigned adequate authority included with your bid or proposal and responsibility you do not have to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BIDcomplete or submit this form with your bid or proposal.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID Tax ID #: SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency 000060 APT E-PIN #: See Footer Contract in accordance with §102-12 Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by Transportation Agency Address New York City New York State Department NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 M/WBE Program & Oversight Telephone # (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4 M/WBE Participation Goals for Services Enter the percentage amount for each group or for an unspecified goal. Please note that there are no goals for Asian Americans in Professional Services. Prime Contract Industry: See Contract Cover Page Group Percentage Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Total Participation Goals See Schedule A for % Line 1 SCHEDULE B - Part II: M/WBE Participation Plan Part II to be completed by the bidder/proposer. Please note: For Non-M/WBE Prime Contractors who will NOT subcontract any services and enter below will self-perform the name of entire contract, you must obtain a Disadvantaged Business Enterprise Officer that will have FULL waiver by completing the responsibility for Waiver Application on pages 5 and 6 and timely submitting it to the contracting agency pursuant to the Notice to Prospective Contractors. Once a FULL WAIVER is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who granted, it must be assigned adequate authority included with your bid or proposal and responsibility you do not have to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BIDcomplete or submit this form with your bid or proposal.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID Tax ID #: M/WBE UTILIZATION FORMS FILLABLE FORM APT E-PIN #: See Footer SCHEDULE DBE UTILIZATION GOAL FORM DISADVANTAGED BUSINESSS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract in accordance with §102-12 Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Price. It is the Contractor’s responsibility to secure utilization of the Work, in the Contract, by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by Transportation Agency Address New York City New York State Department NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of Transportation Equal Opportunity Development and Compliance (“EODC”) for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price for the Work. Disadvantaged Business Enterprise Utilization Goal: See Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or upon written request from: NYC Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New York, NY 00000 M/WBE Program & Oversight Telephone # (000) 000-0000 Disadvantaged Business Enterprise Officer The Bidder shall designate Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4 M/WBE Participation Goals for Services Enter the percentage amount for each group or for an unspecified goal. Please note that there are no goals for Asian Americans in Professional Services. Prime Contract Industry: See Contract Cover Page Group Percentage Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Total Participation Goals See Schedule A for % Line 1 SCHEDULE B - Part II: M/WBE Participation Plan Tax ID #: Part II to be completed by the bidder/proposer. APT E- PIN #: FILLABLE FORM See Footer Please note: For Non-M/WBE Prime Contractors who will NOT subcontract any services and enter below will self-perform the name of entire contract, you must obtain a Disadvantaged Business Enterprise Officer that will have FULL waiver by completing the responsibility for Waiver Application on pages 5 and 6 and timely submitting it to the contracting agency pursuant to the Notice to Prospective Contractors. Once a FULL WAIVER is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who granted, it must be assigned adequate authority included with your bid or proposal and responsibility you do not have to do so. Designated DBE Officer: (Name, Title) Telephone: (Revised 08/14) RETURN THIS PAGE WITH BIDcomplete or submit this form with your bid or proposal.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public BID SCHEDULE DBE UTILIZATION GOAL FORM "H" DISADVANTAGED BUSINESSS BUSINESS ENTERPRISE UTILIZATION NEW YORK CITY DEPARTMENT OF TRANSPORTATION DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION REQUIREMENTS NYCDOT The Department has established the following Disadvantaged Business Enterprise (DBE) utilization goal for this Contract contract in accordance with §102-12 of the NYSDOT Standard Specifications. This goal is expressed as a percentage of the Total Bid Pricetotal contract bid price. It is the Contractor’s 's responsibility to secure utilization in the work of the Work, in the Contract, contract by DBEs in satisfaction of the goal, and to document satisfactory good-faith efforts taken to fulfill the goal. DBE firms must be certified by New York State Department of Transportation Equal Opportunity Development and Compliance (“"EODC”") for all items to be performed. Utilization is measured as the amount actually paid to DBEs, not the Total Bid Price contract bid price for the Workwork. Disadvantaged Business Enterprise Utilization Goal: See Part E - Schedule A % Disadvantaged Business Enterprise Registry A current listing of certified DBEs is available at xxxx://xxxxxx.xxxxxx.xxx/ or available, upon written request from: NYC New York City Department of Transportation Office of Contract Compliance 00 Xxxxx Xxxxxx New YorkXxxxxx, NY 0XX Xxxxx Xxx Xxxx, XX 00000 (000212) 000-0000 839- 9411 Disadvantaged Business Enterprise Officer The Bidder shall designate and enter below the name of a Disadvantaged Business Enterprise Officer that will have the responsibility for and is capable of effectively administering and promoting an active Disadvantaged Business Enterprise Program and who must be assigned adequate authority and responsibility to do so. Bidder-Designated DBE Officer: (Name, Title) Telephone: (Revised 08/1404/04/03) RETURN THIS PAGE WITH BID.