Form DOT Form 4630 DOT Form 4630 Uniform Report of DBE Awards/Commitments and Payments

OMB Cont rol No: 2 1 0 5 -0 5 1 0
Expirat ion Dat e: xx/ xx/ xxx

UNIFORM REPORT OF DBE AWARDS OR COMMITMENTS AND PAYMENTS
Paperwork Reduction Act 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 the Control Number issued by the Office of Management and Budget is displayed. The Control number for this information collection is 2105-0510. Public reporting for this collection of
information is estimated to be approximately one hour per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are
voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: U.S. Department of Transportation, Office of the Secretary,
Office of Small and Disadvantaged Business Utilization, 1200 New Jersey Avenue SE, Suite W94-302, Washington, DC 20590.
* * Please ref er t o t he Inst ruct ions sheet f or direct ions on f illing out t his f orm* *
1 . Submit t ed t o ( check only one) :

[

] FHWA

[

] FAA

[

] FTA--Vendor Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2 . AIP Numbers ( FAA Recipient s Only) :

3 . Federal f iscal year in which report ing period f alls:
5 . Report ing Period

FY _ _ _ _ _ _ _ _ _ _ _ _
[

4 . Dat e This Report Submit t ed:

[

] Report due June 1 ( f or period Oct . 1 -Mar. 3 1 )

] Report due Dec. 1 ( f or period April 1 -Sept . 3 0 )

6 . Name of Recipient :
7 . Annual DBE Goal( s) :

Race Conscious Goal _ _ _ _ _ _ _ _ _ %
A

AWARDS/ COMMITMENTS MADE DURING THIS
REPORTING PERIOD
( t ot al

B

Tot al Dollars

Race Neut ral Goal _ _ _ _ _ _ _ _ _ %
C

D

OVERALL Goal _ _ _ _ _ _ _ _ _ _ %

E

Tot al Number Tot al t o DBEs Tot al t o DBEs Tot al t o DBEs
( dollars)
( number)
/ Race
Conscious
( dollars)

cont ract s and subcont ract s awarded or commit t ed
during t his report ing period)

F

G

H

I

Tot al t o
DBEs/ Race
Conscious
( number)

Tot al t o
DBEs/ Race
Neut ral
( dollars)

Tot al t o
DBEs/ Race
Neut ral
( number)

Percent age of
t ot al dollars
t o DBEs

F

G

H

I

Non-Minorit y
Women

Ot her
( i.e. not of
any ot her
group list ed
here)

TOTALS
( f or t his
report ing
period only)

Year-End
TOTALS

8 . Prime cont ract s awarded t his period
9 . Subcont ract s awarded/ commit t ed t his period
TOTAL
A

DBE AWARDS/ COMMITMENTS THIS
REPORTING PERIOD-BREAKDOWN BY
ETHNICITY & GENDER

B

Black
American

Hispanic
American

C

D

Subcont .
Asian
American

Nat ive
American

E

Asian-Pacif ic
American

1 0 . Tot al Number of Cont ract s ( Prime and Sub)
1 1 . Tot al Dollar Value

ACTUAL PAYMENTS ON CONTRACTS
COMPLETED THIS REPORTING PERIOD

A

B

C

D

E

Number of Prime Cont ract s
Complet ed

Tot al Dollar Value of Prime
Cont ract s Complet ed

DBE Part icipat ion Needed t o
Meet Goal ( Dollars)

Tot al DBE Part icipat ion
( Dollars)

Percent age of
Tot al DBE
Part icipat ion

1 2 . Race Conscious
1 3 . Race Neut ral
1 4 . Tot als

1 5 . Submit t ed by ( Print Name of Aut horized Represent at ive)

1 6 . Signat ure of Aut horized Represent at ive

1 7 . Phone Number:

1 8 . Fax Number:

DOT Form 4 6 3 0