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(Rev. 03/28/2016) <br />Request for Proposal Number: ___________ <br />RFP Item Description: ___________________________________ <br />Affirmative Action Certification (AAC) for Disadvantaged Business Enterprises (DBE) <br />I hereby certify that my company intends to affirmatively seek out and consider Disadvantaged Business <br />Enterprises (DBEs) certified in the State of Indiana to participate as part of this proposal. I acknowledge that <br />this certification is to be made an integral part of this proposal. I understand and agree that the submission of a <br />blank certification may cause the proposal to be rejected. I certify that I have consulted the following DBE <br />website to confirm that the firms listed below are currently certified DBEs: <br />http://www.in.gov/indot/2732.htm. <br />I certify that I have contacted the certified DBEs listed below, and if my company becomes the <br />CONSULTANT, these DBEs have tentatively agreed to perform the services as indicated. I understand that <br />neither my company nor I will be penalized for DBE utilization that exceeds the goal. After contract award, any <br />change to the firms listed in this Affirmative Action Certification to be applied toward the DBE goal must have <br />prior approval by INDOT’s Economic Opportunity Division. <br />I.DBE Subconsultants to be applied toward DBE goal for the RFP item: <br />II.DBE Subconsultants to be utilized beyond the advertised DBE goal for the RFP item: <br />Certified DBE Name to DBE Service Planned Estimated Percentage to be Paid* <br />% <br />% <br />% <br />% <br />Certified DBE Name to DBE Service Planned Estimated Percentage to be Paid* <br />% <br />% <br />% <br />% <br />Estimated Total Percentage Credited toward DBE Goal: __________ <br />Estimated Percentage of Voluntary DBE Work Anticipated over DBE Goal: <br />Company Name:_________________________________________________________________________ <br />Signature: ____________________________________________ Date: <br />_____________________________ *It is understood that these individual firm percentages are estimates only and that percentages paid may be greater or less as a result of <br />negotiation of the contract scope of work. My firm will use good faith efforts to meet the overall DBE goal through the use of these or other <br />certified and approved DBE firms.