DBE uniform Report Template

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Overview

burden statement
Uniform Report
DBE List for Uniform Report Mod

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Sheet 1: burden statement

OMB CONTROL NUMBER: 2105-0586 

EXPIRATION DATE: (pending) 

Paperwork Reduction Act 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 currently valid OMB Control Number.  The OMB Control Number for this information collection is 2105-0586.  Public reporting for this collection of information is estimated to be approximately 317 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.  

All responses to this collection of information are mandatory under 49 CFR § 26.11; the nature and extent of confidentiality to be provided, if any under 49 CFR §§ 26.109(b). 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, (your agency name and address), Washington, D.C. 20590. 

Privacy Act Statement (5 U.S.C. § 552a, as amended):   

AUTHORITY: 42 U.S.C. 2000d et seq., § 12101 et seq., 42 U.S.C. 6101 et seq.; 29 U.S.C. 794, 749d; 49 U.S.C. 47113; 42 U.S.C. 12101; 49 CFR Part 23; 49 CFR Part 26, and Executive Order 13160. 

PURPOSE(S):  DOT will use the information collected to respond to Disadvantaged Business Enterprise (DBE) and Airport Concession Disadvantaged Business Enterprise (ACDBE) inquiries and adjudicate appeals. 

ROUTINE USE(S):  In accordance with DOT’s system of records notice, DOT/ALL–24 Departmental Office of Civil Rights System, 76 FR 71108 (Nov. 16, 2011), the information provided may be disclosed to the U. S. Department of Justice, including United States Attorney’s Offices, or other Federal agency conducting litigation or in proceedings before any court, adjudicative or administrative body, when it is necessary to the litigation and one of the following is a party to the litigation or has an interest in such litigation.  A comprehensive list of routine uses can be found in DOT/ALL 24 and DOT’s General Statement of Routine uses, 75 FR 82138 (Dec. 29, 2010). 77 FR 42796 (July 20, 2012), 84 FR 55222 (Oct. 15, 2019). 

DISCLOSURE: Provision of the requested information is voluntary; however, failure to furnish the requested information may result in the denial of a DBE or ACDBE application and an inability of the Department to process an appeal or inquiry from any party. 

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Sheet 2: Uniform Report

UNIFORM REPORT OF DBE COMMITMENTS/AWARDS AND PAYMENTS
**Please refer to the instruction sheet for directions on filling out this form**
1	Submitted to (check only one)	[ ] FHWA	[ ] FAA	[ ] FTA - Recipient ID Number
2	AIP Numbers (FAA Recipients); Grant Number (FTA Recipients):
3	Federal Fiscal year in which reporting period falls	FY 20XX			4. Date This Report Submitted:
5	Reporting Period	[ ] Report due June 1 (for period Oct 1-Mar 31)			[ ] Report due Dec 1 (for period April 1-Sep 30)			[ ] FAA annual report due Dec 1
6	Name and address of Recipient:
7	Annual DBE Goal(s):	Race Conscious Projection:			Race Neutral Projection:			OVERALL Goal:
Awards/Commitments this Reporting Period
		A	B	C	D	E	F	G	H	I
A	AWARDS/COMMITMENTS MADE DURING THIS REPORTING PERIOD (Total contracts and subcontracts committed during this reporting period)	Total Dollars	Total Number	Total to DBEs (dollars)	Total to DBEs (number)	Total to DBEs/Race Conscious (dollars)	Total to DBEs/Race Conscious (number)	Total to DBEs/Race Neutral (dollars)	Total to DBEs/Race Neutral (number)	Percentage of total dollars to DBEs
8	Prime contracts awarded this period	$-	0	$-	0			$-	0	#DIV/0!
9	Subcontracts awarded/committed this period	$-	0	$-	0	$-	0	$-	0	#DIV/0!
10	TOTAL			$-	0	$-	0	$-	0	#DIV/0!
B	BREAKDOWN BY ETHNICITY & GENDER
		A	B	C	D	E	F
		Total to DBE (dollar amount)			Total to DBE (number)
		Women	Men	Total	Women	Men	Total
11	Black American	$-	$-	$-	0	0	0
12	Hispanic American	$-	$-	$-	0	0	0
13	Native American	$-	$-	$-	0	0	0
14	Asian-Pacific American	$-	$-	$-	0	0	0
15	Subcontinent Asian Americans	$-	$-	$-	0	0	0
16	Non-Minority	$-	$-	$-	0	0	0
17	TOTAL	$-	$-	$-	0	0	0
Payments Made this Period
		A	B		C	D		E		F
C	PAYMENTS ON ONGOING CONTRACTS	Total Number Prime Contracts	Total Dollars Paid		Total Number of Prime and Subontracts with DBEs	Total Payments to DBE firms		Total Number of DBE firms Paid		Percent to DBEs
18	Prime and subcontracts currently in progress	0	$-		0	$-		0		#DIV/0!
		A		B		C		D		E
D	TOTAL PAYMENTS ON CONTRACTS COMPLETED THIS REPORTING PERIOD	Number of Contracts Completed		Total Dollar Value of Contracts Completed		DBE Participation Needed to Meet Goal (Dollars)		Total DBE Participation (Dollars)		Percent to DBEs
19	Race Conscious	0		$-		$-		$-		#DIV/0!
20	Race Neutral	0		$-				$-		#DIV/0!
21	Totals	0		$-				$-		#DIV/0!
22	Submitted by:			23. Signature:				24. Phone Number:

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Sheet 3: DBE List for Uniform Report Mod

Data Entry Form Template: Certified DBE Contractors Used ON [FAA/FHWA/FTA]-Assisted Contracts (Award/Committed and Closed):
Enter the firms and information for all data entered in Sections A, B, & D of the DBE Uniform Form for the fiscal year being reported.
#	DBE Firm	Street Address	City	State	Zip	Contact Email Address	Contact Phone Number	Type of Work	NAICS	Awarded Dollar Amount of Contract if for Section A	Final Dollar Amount of Completed Contract if for Section D	Contract Number	Disadvantaged Group (from list)	Gender (female/male)
	Name of the DBE firm	Street number, street name, suite number (if applicable)		2 digit format	5 digit format		10 digit format	Short description of the work performed by the DBE firm on the contract	6 digit NAICS code related to the work performed by the DBE firm on the contract	Numeric format	Numeric format		Enter one of: Black American Hispanic American Native American Subcontinent Asian American Asian-Pacific American Non-Minority Other	Enter one of: Female Male
	Required	Required	Required	Required	Required	Required	Recommended	Required	Required	Required if for Section A	Required if for Section D	Required	Recommended	Recommended
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