Common use of Local Agency Name Clause in Contracts

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 T-29972.015/ 1258410 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 T-29972.011/ 1258460 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 1258454/T-29972.023 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 T-29972.018/ 1246116 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 1258461/T-29972.005 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION2014

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 E- 10 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 1258456/T-29972.001 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 T-29972.009/ 1258480 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 E- 10 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 T-29972.004/ 1258502 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 T-29972.017/ 1258414 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION

Local Agency Name. 2. Project Location: 3. Project Description: 4. Total Contract Award Amount: $ 5. Consultant Name: 6. Contract DBE Goal %: 0.0% 7. Total Dollar Amount for all Sub-consultants: $ 8. Total Number of all Sub-consultants: Award DBE/DBE Information 9. Description of Services to be Provided 10. DBE/DBE Firm Contact 11.DBE Cert. 12. DBE Dollar Amount Local Agency to Complete this Section 13. Total Dollars Claimed 14. Total % Claimed $ 0 0.0% % 20. Local Agency Contract Number: 21. Federal-aid Project Number: 22. Contract Execution Date: Local Agency certifies that all DBE certifications are valid and the information on this form is complete and accurate: 23. Local Agency Representative Name (Print) 24. Local Agency Representative Signature 25. Date 26. Local Agency Representative Title 27. (Area Code) Tel. No. 15. Preparer’s Signature 16. Preparer’s Name (Print) 17. Preparer’s Title 18. Date 19. (Area Code) Tel. No. Caltrans to Complete this Section Caltrans District Local Assistance Engineer (DLAE) certifies that this form has been reviewed for completeness: 28. DLAE Name (Print) 29. DLAE Signature 30. Date Page X- 00 E - of 12 Form Name: Master City of San Xxxx Consultant Agreement Exhibit E – Disadvantaged Business Enterprise Participation Form/FileNo.: T-29972.020/ 1258442 T-29972.021/ 1258407 City Attorney Approval Date: September, 2014 INSTRUCTIONS - CONSULTANT CONTRACT AWARD DBE INFORMATION