DBE PARTICIPATION STATEMENT

**FOR FAA-ASSISTED CONTRACTING ACTIVITY**

**(Provide the following information for each prime contract.)**

<table>
<colgroup>
<col style="width: 9%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 27%" />
<col style="width: 2%" />
<col style="width: 15%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 11%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="6">Name of Airport:</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="9">FY Approved Overall Goal:</td>
<td colspan="2"><strong>     </strong>%</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="7"><h1 id="section"></h1></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4">AIP No:</td>
<td colspan="2"></td>
<td><strong>     </strong></td>
<td></td>
<td colspan="7"><h1 id="contract-funds">Contract Funds</h1></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4">AIP Grant $:</td>
<td colspan="2">$</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="7">AIP Federal</td>
<td>$</td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="7">AIP Local Match</td>
<td>$</td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="7">PFC</td>
<td>$</td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="6">Contact Name:</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="8">Date of Contract Award:</td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="6">Phone Number:</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="2">(Mo/Day/Yr)</td>
<td colspan="9"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="7"><strong><u>Prime Contractor Name &amp;
Address</u></strong></td>
<td></td>
<td colspan="10"><strong><u>Contract Type</u></strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="10">Construction</td>
<td></td>
</tr>
<tr class="even">
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="10">Professional Services</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="10">Equipment Purchase</td>
<td></td>
</tr>
<tr class="even">
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td></td>
<td colspan="11">Contract Goal <strong><u>     </u></strong>% DBE</td>
</tr>
<tr class="even">
<td colspan="7"></td>
<td></td>
<td colspan="11">Contract $<strong><u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="7"><h1 id="dbe-subcontract-no.-1">DBE Subcontract No.
1</h1></td>
<td><h1 id="section-1"></h1></td>
<td colspan="11"><h1 id="section-2"></h1></td>
</tr>
<tr class="odd">
<td>Name:</td>
<td colspan="6"><strong>     </strong></td>
<td></td>
<td colspan="4">Subcontract $:</td>
<td colspan="7"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2">Address:</td>
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="4">Subcontract %:</td>
<td colspan="7"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="5">Phone Number:</td>
<td colspan="2"><strong>     </strong></td>
<td></td>
<td colspan="4">*DBE Category:</td>
<td colspan="7"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="4">Work Items:</td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="7"><h1 id="section-3"></h1></td>
<td><h1 id="section-4"></h1></td>
<td colspan="11"><h1 id="section-5"></h1></td>
</tr>
<tr class="odd">
<td colspan="7"><h1 id="dbe-subcontract-no.-2">DBE Subcontract No.
2</h1></td>
<td><h1 id="section-6"></h1></td>
<td colspan="11"><h1 id="section-7"></h1></td>
</tr>
<tr class="even">
<td>Name:</td>
<td colspan="6"><strong>     </strong></td>
<td></td>
<td colspan="5">Subcontract $:</td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2">Address:</td>
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="5">Subcontract %:</td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="5"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="5">Phone Number:</td>
<td colspan="2"><strong>     </strong></td>
<td></td>
<td colspan="5">*DBE Category:</td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="7"></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="4">Work Items:</td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="7"><strong>     </strong></td>
<td></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td></td>
<td colspan="3"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="7">(Use page 2 for additional DBE’s.)</td>
<td></td>
<td colspan="3">TOTAL DBE $</td>
<td colspan="8"><strong><u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td></td>
<td colspan="3">DBE %</td>
<td colspan="8"><strong><u>     </u></strong></td>
</tr>
<tr class="even">
<td colspan="19">I certify that the above information is accurate:</td>
</tr>
<tr class="odd">
<td colspan="3">Signature</td>
<td colspan="6"></td>
<td colspan="5">Date</td>
<td colspan="5"><strong>     </strong></td>
</tr>
</tbody>
</table>

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  Title   **     **

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\* DBE Category refers to specific minority group (e.g., Hispanic,
Native American, Black, Asian-Indian, Asian-Pacific), woman-owned, SBA
8(a), or other socially and economically disadvantaged individual.

Rev. 10/95

**(Use for additional DBE's.)**

<table>
<colgroup>
<col style="width: 9%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 28%" />
<col style="width: 2%" />
<col style="width: 18%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 29%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><h1 id="dbe-subcontract-no.-3">DBE Subcontract No.
3</h1></td>
<td><h1 id="section-8"></h1></td>
<td colspan="4"><h1 id="section-9"></h1></td>
</tr>
<tr class="even">
<td>Name:</td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td colspan="2">Subcontract $:</td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2">Address:</td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td colspan="2">Subcontract %:</td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4">Phone Number:</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="2">*DBE Category:</td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="3">Work Items:</td>
<td colspan="2"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5"><h1 id="section-10"></h1></td>
<td><h1 id="section-11"></h1></td>
<td colspan="4"><h1 id="section-12"></h1></td>
</tr>
<tr class="even">
<td colspan="5"><h1 id="dbe-subcontract-no.-4">DBE Subcontract No.
4</h1></td>
<td><h1 id="section-13"></h1></td>
<td colspan="4"><h1 id="section-14"></h1></td>
</tr>
<tr class="odd">
<td>Name:</td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td colspan="3">Subcontract $:</td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2">Address:</td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td colspan="3">Subcontract %:</td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">Phone Number:</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="3">*DBE Category:</td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="3">Work Items:</td>
<td colspan="2"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="5"><h1 id="dbe-subcontract-no.-5">DBE Subcontract No.
5</h1></td>
<td><h1 id="section-15"></h1></td>
<td colspan="4"><h1 id="section-16"></h1></td>
</tr>
<tr class="even">
<td>Name:</td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td colspan="2">Subcontract $:</td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2">Address:</td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td colspan="2">Subcontract %:</td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4">Phone Number:</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="2">*DBE Category:</td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="3">Work Items:</td>
<td colspan="2"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5"><h1 id="section-17"></h1></td>
<td><h1 id="section-18"></h1></td>
<td colspan="4"><h1 id="section-19"></h1></td>
</tr>
<tr class="even">
<td colspan="5"><h1 id="dbe-subcontract-no.-6">DBE Subcontract No.
6</h1></td>
<td><h1 id="section-20"></h1></td>
<td colspan="4"><h1 id="section-21"></h1></td>
</tr>
<tr class="odd">
<td>Name:</td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td colspan="3">Subcontract $:</td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2">Address:</td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td colspan="3">Subcontract %:</td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">Phone Number:</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="3">*DBE Category:</td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="3">Work Items:</td>
<td colspan="2"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="5"><h1 id="dbe-subcontract-no.-7">DBE Subcontract No.
7</h1></td>
<td><h1 id="section-22"></h1></td>
<td colspan="4"><h1 id="section-23"></h1></td>
</tr>
<tr class="even">
<td>Name:</td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td colspan="3">Subcontract $:</td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2">Address:</td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td colspan="3">Subcontract %:</td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">Phone Number:</td>
<td><strong>     </strong></td>
<td></td>
<td colspan="3">*DBE Category:</td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="3">Work Items:</td>
<td colspan="2"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>     </strong></td>
<td></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td></td>
<td></td>
<td colspan="3"></td>
</tr>
</tbody>
</table>

  --------------------------------- -- ------------- -------------------------
                                       TOTAL DBE \$  **[     ]{.underline}**

                                       DBE %         **[     ]{.underline}**
  --------------------------------- -- ------------- -------------------------