USDOT Regular Dealer/Distributor Affirmation Form

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OMB APPROVAL NO: 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 45 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 voluntary, required to obtain or retain a
benefit under 49 CFR §§ 26.53 and 26.55, 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: [email protected]
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.

DBE Regular Dealer/Distributor
Affirmation Form

U.S. Department of
Transportation

Bidder Name:
Contract Name/Number:

Sections 26.53(c)(1) of Title 49 Code of Federal Regulations requires recipients to make a preliminary counting determination for each DBE listed as a regular dealer or
distributor to assess its eligibility for 60 or 40 percent credit, respectively, of the cost of materials and supplies based on its demonstrated capacity and intent to perform as a
regular dealer or distributor, as defined in section 26.55(e)(2)(iv)(A),(B),(C), and (3) under the contract at issue. The regulation requires the recipient's preliminary
determination to be made based on the DBE’s written responses to relevant questions and its affirmation that its subsequent performance of a commercially useful function will
be consistent with the preliminary counting of such participation. The U.S. Department of Transportation is providing this form as a tool for recipients, prime contractors,
regular dealers, and distributors to use to carry out their respective responsibilities under this regulation. The form may be used by each DBE supplier whose participation is
submitted by a bidder for regular dealer or distributor credit on a federally-assisted contract with a DBE participation goal. The form may also be used by prime contractors in
connection with DBE regular dealer or distributor participation submitted after a contract has been awarded provided such participation is subject to the recipient's prior
evaluation and approval. If this form is used, it should be accompanied by the bidder's commitment, contract, or purchase order showing the materials the DBE regular dealer or
distributor is supplying. Use of this tool is not mandatory. If a recipient chooses a different method for complying with Section 26.53(c)(1), it must include that method in its
DBE Program Plan.
DBE Name:

Total Subcontract/Purchase Order Amount:

Authorized DBE Representative (Name and Title):

NAICS Code(s) Related to the Items to be Sold/Leased:

1. Will all items sold or leased be provided from the on-hand inventory at your establishment?

YES

NO

(If "YES," you have indicated that your performance will satisfy the regular dealer requirements and may
be counted at 60%. STOP here. Read and sign the affirmation below. If "NO" Continue.)

a) Are you selling bulk items (e.g., petroleum products, steel, concrete, concrete products, sand, gravel, asphalt, etc.) or items not
typically stocked due to their unique characterisics (aka specialty items)?
YES
NO (If "YES," Go to Question 2. If "NO" Continue.)
b) Will at least 51% of the items you are selling be provided from the inventory maintained at your establishment, and will the minor
quantities of items delivered from and by other sources be of the general character as those provided from your inventory?
YES

NO*

(If "YES," you have indicated that your performance will satisfy the regular dealer requirements and

may be counted at 60%. STOP here. Read and sign the affirmation below.
*If 1.,1.a), and 1. b) above are "NO," your performance on the whole will not satisfy the regular dealer requirements;
therefore, only the value of items to be sold or leased from inventory can be counted at 60%. (Go to Question 3. to
determine if the items delivered from and by other sources are eligible for Distributor credit.)

2. Will you deliver all bulk or specialty items using distribution equipment you own (or under a long-term lease) and operate?
YES

NO1

(If "YES," you have indicated that your performance will satisfy the requirements for a regular dealer of bulk items and may be
counted at 60%. STOP here. Read and sign the affirmation below.)
1 If "NO," your performance will not satisfy the requirements for a regular dealer of bulk items; the value of items to
be sold or leased cannot be counted at 60%. (Go to Question 3.)

3. Will the written terms of your purchase order or bill of lading from a third party transfer responsibility, including risk for loss or
NO3
YES2
damage, to your company at the point of origin (e.g. a manufacture's facility) ?
a) Will you be using sources other than the manufacturer (or other seller) to deliver or arrange delivery of the items
sold or leased ?
NO3
YES2
2 If your responses to 3 and 3.a) are "YES," you have indicated that your performance will satisfy the requirements of a distributor;

therefore, the value of items sold or leased may be counted at 40%.
3 If you responded "NO" to either 3 or 3.a), counting of your participation is limited to the reasonable cost of fees or commissions

charged, including transportation charges for the delivery of materials or supplies; the cost of materials or supplies may not be counted.

I affirm that the information that I provided above is true and correct and that my company's subsequent performance of a commercially useful function will
be consistent with the above responses. I further affirm that my company will independently negotiate price, order specified quantities, and pay for the
items listed in the bidder's commitment. This includes my company's responsibility for the quality of such items in terms of necessary repairs, exchanges, or
processing of any warranty claims for damaged or defective materials.
Printed Name and Signature of DBE Owner/Authorized Representative:

The bidder acknowledges its responsibility for verifying the information provided by the DBE named above and ensuring that the
counting of the DBE's participation is accurate. Any shortfall caused by errors in counting are the responsibility of the bidder.

Printed Name and Signature of Bidder's Authorized Representative: