Form DOT F 4504 DOT F 4504 ARRA Application For Reimbursement of Bond Fees

U.S. Department of Transportation
Disadvantaged Business Enterprise American Reinvestment and Recovery Act
of 2009 Bonding Assistance Reimbursable Fee Program

OMB Control Number: 2105-xxxx
Expiration Date: mm/dd/yyyy
Form DOT F4504

Application For Reimbursement of Bond Fees
Public Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information
subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this
information collection is 2105-XXXX. Public reporting for this collection of information is estimated to be approximately 2 hours per response, including the time for reviewing instructions,
gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of
Transportation, Office Of Small and Disadvantaged Business Utilization, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

1.

Full Legal Name of Company:

3.

Full Street Address of Primary Business Location:

6.

PART B – BOND INFORMATION
Bond Information (One Bond Per Application)

2.
4. Dun & Bradstreet
(DUNS) #:

TIN (Federal Tax ID No):

Registered in Central Contractor
Registration (ccr.gov) with Bank
Information:

□ Yes

7.

8.

a.

Surety Bond Number:

______________________

Date of Issue:

b.

Name of Surety Company: ____________________________________________________________________________

c.

Type of Bond:

Performance __________

d.

Bond Amount:

____________

Payment __________

____________________________
Bid/Proposal _______________

Total Bond Fees _______________________________________________

Enclose a copy of your bond, invoice(s)s for premium(s)/fee(s), and proof of payment with your application
PART C – TRANSPORTATION-RELATED CONTRACT BEING BONDED
Transportation-related Contract Information
a.

Contract Awarder (Agency/Prime/Subcontractor): __________________________________________________________

b.

Contract Number:

c.

Federal Project No. and Name on Contract:

d.

Contract Amount:

______________________________________________________________________

e.

Contract Start Date:

______________________

______________________________________________________________________
_____________________________________________________________
Estimated Completion Date : ____________________

Enclose documentation from the federal, state or local transportation authority indicating the federal project number and a
copy of the contract for which you are receiving the bond with your application
PART D – DISADVANTAGED BUSINESS ENTERPRISE (DBE) CERTIFICATION
DBE Certification

The definition of a Disadvantaged Business Enterprise, which includes woman-owned businesses and minority-owned businesses, are
set forth in 49 Code of Federal Regulations Part 26.
The applicant, ___________________________________________ certifies that it is a DBE and that the contract bonded is a
transportation-related contract receiving funding pursuant to the ARRA.
a.

Name of Agency which Certified your Business as a DBE: ____________________________________________________

b.

State: _______________ Certification Expiration/Renewal Date: __________ Current Annual Affidavit Date: __________

Enclose a copy of your certification and your annual affidavit, if applicable, with your application
PART E – SIGNATURES AND CONTACT INFORMATION
By signing this application, the DBE certifies: the DBE has not sought reimbursement for the bond fee(s) related to this bond from a
third party; will not seek reimbursement from a third party in the event the DBE receives reimbursement from the U.S. Department
of Transportation; and provides consent for the U.S. DOT to contact the agency/prime/subcontractor to confirm non-reimbursement
of the bond fee(s).
Signature of Applicant :
Name: ______________________________________

Title: ______________________ Date: ____________________

Type or Print Name: _________________________________

Phone #: _____________ Email: ___________________

PART F – FOR GOVERNMENT USE ONLY
OSDBU Approval for Bonding Fee Reimbursement:
Name: ______________________________________

Title: ______________________ Date: ___________________

U.S. Department of Transportation
Disadvantaged Business Enterprise American Reinvestment and Recovery Act of 2009 Bonding Assistance
Reimbursable Fee Program
Instructions for Application For Reimbursement of Bond Fees

General Instructions
Purpose of Form
Use form Application for Reimbursement of Surety Bond Fees,
OMB Control Number 2105-xxxx, to apply for

reimbursement of the Contractor Fee paid to the surety
company and if applicable, the U.S. Small Business
Administration (SBA) in return for a surety bond.

Who is Eligible for the Reimbursement?
To be eligible, you must:
 Be A Disadvantaged Business Enterprise (DBE),
which includes woman-owned businesses and
minority-owned businesses, certified under 49 Code
of Federal Regulations Parts 26.
 Have obtained a performance, payment, or
bid/proposal surety bond during the period [Insert
date of Federal Register Notice-Notice of Funds]
and September 8, 2010 for a contract for a
transportation project receiving American
Reinvestment and Recovery Act of 2009 funding
from the U.S. Department of Transportation (DOT).
 Have paid a surety premium to the surety company
and if applicable, a small business concern
(principal) fee to SBA
 Have a Dun & Bradstreet Number (DUNS#) and
have registered your DUNS# with Central Contractor
Registration (CCR) at www.ccr.gov. Your bank
information must be completed in your profile on
ccr.gov to receive payment.

How do I Obtain More Information?
You can contact the U.S. Department of Transportation,
Office of the Secretary, Office of Small and
Disadvantaged Business Utilization for further
information:
Email. [email protected] .
Voice. 1-800-532-1169 or 202-366-1930. A longdistance charge to callers located outside of the local
calling area will apply when calling the 202-366-1930
number.
Internet Guidance. [Location of guidance on OST
Recovery Website]

How to Apply
You can apply for reimbursement by email or by mail.
Use only one method per application. Applications must
be received on or before September 8, 2010.
Regardless, the applicant is advised to request delivery
confirmation for mail submissions or return receipt for
email submissions. Awards will be made in the order of
application receipt until funding is fully expended or the
program closes on September 8, 2010. In the event

funding is fully expended prior to September 8, 2010,
OSDBU will cease to accept new applications.
Applications submitted by mail may be delayed due to
mail screening security requirements. For faster
reimbursement, submit your application electronically by
email.
Email. Scan your signed application and all supporting
documentation to a .pdf document and email to
[email protected] .
Mail. Mail your signed application and all supporting
documentation to the following address:
U.S. Department of Transportation (DOT)
Office of Small and Disadvantaged Business Utilization
(OSDBU)
1200 New Jersey Ave., SE, W56-448
Washington, DC 20590

How to assemble your application
Submitted Applications must contain in the following
order:
 A completed and signed application
 A copy of the bond
 A copy of the contract
 DBE certification letter from the DBE certification
office in their state and a current annual affidavit. A
current annual affidavit is not required in the event
the DBE is certified less than one (1) year.
 Whether the DBE is a prime contractor or a
subcontractor, a letter from the federal, state or local
transportation authority, on their letterhead,
indicating the DBE is a prime contractor and the
federal project number. In the event the DBE is
already in possession of other documentation from
the federal, state or local transportation authority
indicating the federal project number, that
documentation may be submitted in lieu of the letter.
 A copy of their invoice(s) from the surety company
and if applicable, SBA and cancelled checks or other
proof of payment of the bond fees in support of the
total amount claimed for reimbursement.
 Certificate Regarding Lobbying in compliance with
49 CFR Part 20
 Certification stating that the DBE will comply with the
requirements of subchapter IV of chapter 31 of title
40, United States Code (Federal wage rate
requirements), as required by the Recovery Act.
 Certification Regarding Debarment, Suspension in
compliance with 29 CFR Part 98

U.S. Department of Transportation
Disadvantaged Business Enterprise American Reinvestment and Recovery Act of 2009 Bonding Assistance
Reimbursable Fee Program
Instructions for Application For Reimbursement of Bond Fees

Specific Instructions
Print or type all entries on the Application for
Reimbursement of Surety Bond Fees, OMB Control
Number 2105-xxxx. The application is an electronically
fillable application form. We strongly suggest applicants
utilize the electronically fillable form to complete the
application entries. Illegible applications will delay
processing time. Follow the instructions for each line to
expedite processing and to avoid unnecessary requests
for additional information.
Line 1. Full Legal Name of Company applying for
reimbursement. Enter the company name as it appears
on the legal document creating it.
Line 2. TIN (Federal Tax ID No). Enter your Employer
Identification Number (EIN) exactly as it appears on the
document provided by the Internal Revenue Service
(IRS).
Line 3. Full Street Address of Primary Business
Location. Enter the mailing address for the entity’s
primary physical location. Do not enter a P.O. Box here.
Line 4. Dun & Bradstreet (DUNS#). Enter your
company’s DUNS# exactly as it appears on the
document provided by Dun & Bradstreet. If you are not
registered, you can register online at
http://fedgov.dnb.com/webform .
Line 5. Registered in Central Contractor Registration
(ccr.gov) with Bank Information. Check “Yes” to
indicate that you: 1) have a DUNS #; 2) have registered
your DUNS# at www.ccr.gov; and 3) and you have
populated your financial information for electronic
payment (bank information) in your profile on ccr.gov.
Instructions may be found in on-line help at
www.ccr.gov.
Line 6a. Surety Bond Number and Date of Issue.
Enter the Surety’s bond number exactly as it appears on
your Surety Bond. Enter the date of issue on your
Surety Bond. A separate application must be submitted
for each bond for which the applicant is seeking
reimbursement of the bond premiums and fees paid by
the applicant.
Line 6b. Name of Surety Company. Enter the name of
the surety company exactly as it appears on your Surety
Bond.
Line 6c. Type of Bond. Check the type of bond that
corresponds to the type of bond denoted on your Surety
Bond. Only premiums and fees for performance,
payment, or bid/proposal bonds are eligible for
reimbursement.
Line 6d. Bond Amount, Bond Number and Bond
Fee(s). Enter the bond amount exactly as it appears on
your Surety Bond. Enter the sum total of the bond fee(s)
exactly as they appear on your cancelled check(s) or
other form of proof of payment. You must add together
all of the premium(s) and fee(s) you paid for the bond
and place the total amount for which you are seeking
reimbursement in this field.

Enclose a copy of your bond and your cancelled
check(s), or other proof of payment documentation,
with your application
Line 7a. Contract Awarder
(Agency/Prime/Subcontractor). Enter the contract
awarder exactly as it appears on your contract. Your
contract awarder may be a federal, state or local agency,
a prime contractor, or another subcontractor.
Line 7b. Contract Number. Enter the contract number
exactly as it appears on your contract.
Enclose a copy of the contract that was bonded.
Line 7c. Federal Project No. on Contract. Enter the
federal project number exactly as it appears on the letter
from the federal, state or local transportation authority or
other documentation provided by the federal, state or
local transportation authority indicating the federal
project number.
Enclose a letter from the federal, state or local
transportation authority indicating the federal
project number or other documentation indicating
the federal project number provided by the federal,
state or local transportation authority with your
application.
Line 7d. Contract Amount. Enter the contract amount
exactly as it appears on your contract.
Line 7e. Contract Start Date and Estimated
Completion Date. Enter the period of performance
/contract start date and contract completion date exactly
as it appears on your contract.
Line 8. DBE Certification. Enter the applicant name
exactly as it appears on the legal document creating it.
Line 8a. Name of DBE Certifying Agency. Enter the
name of the agency granting your DBE certification
exactly as it appears on the document informing your
company that it has been certified as a DBE.
Line 8b. State, Certification Expiration/Renewal Date
and Affidavit Date. Enter the state of certification and
the certification expiration date exactly as it appears on
your document granting DBE certification. If applicable,
enter the date of your annual affidavit exactly as it
appears on the document. A current annual affidavit is
not required in the event the DBE is certified less than
one (1) year.
Enclose a copy of your certification and your
affidavit, if applicable, with your application
Sign and date the application. Print your name, title
and contact information. You will not receive email
confirmation of receipt unless an email address is
provided on your application.

U.S. Department of Transportation
Disadvantaged Business Enterprise American Reinvestment and Recovery Act of 2009 Bonding Assistance
Reimbursable Fee Program
Instructions for Application For Reimbursement of Bond Fees

Enclose the following certifications with your
application:
 Certificate Regarding Lobbying in compliance
with 49 CFR Part 20
 Certification stating that the DBE will comply
with the requirements of subchapter IV of
chapter 31 of title 40, United States Code
(Federal wage rate requirements), as required by
the Recovery Act.
 Certification Regarding Debarment, Suspension
in compliance with 29 CFR Part 98

U.S. Department of Transportation
Disadvantaged Business Enterprise American Reinvestment and Recovery Act of 2009 Bonding Assistance
Reimbursable Fee Program
Sample Letter From the Federal, State or Local Transportation Authority Indicating the Federal Project
Number

STATE OR LOCAL TRANSPORTATION
AUTHORITY LETTERHEAD

Today’s Date
(contact information of individual writing the letter)
Name
Address
City, State, Zip
Telephone number
DOT/OSDBU
1200 New Jersey Avenue, SE.
Suite W56-497
Washington, DC 20590
Attn: DBE ARRA BAP
Dear DOT/OSDBU:
[Insert name of DBE] is a [Insert prime contractor or subcontractor] providing services on federal project
[Insert federal project number and name] receiving funding pursuant to the American Recovery and
Reinvestment Act of 2009.
I certify that the information presented in this letter is true and correct.
Sincerely,
Signature (of individual writing the letter)
Printed Name
Job Title or Position