Form 4630 Report of DBE Awards and Commitments

UNIFORM REPORT OF DBE AWARDS OR COMMITMENTS AND PAYMENTS
**Please refer to the Instructions sheet for directions on filling out this form**
[X] FTA--Vendor Number 1812 _______________________

1. Submitted to (check only one):
2. AIP Numbers (FAA Recipients Only): N/A

3. Federal fiscal year in which reporting period falls: FY2004

5. Reporting Period

[ X ] Report due June 1 (for period Oct. 1-Mar. 31)

[ ] Report due Dec. 1 (for period April 1-Sept. 30)

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

Race Conscious Goal 0.1%
A

AWARDS/COMMITMENTS MADE
DURING THIS REPORTING PERIOD

B

Total
Dollars

Total
Number

(total contracts and subcontracts awarded or
committed during this reporting period)

Race Neutral Goal 0.6%
C

D

Total to
DBEs

Total to
DBEs

(dollars)

(number)

OVERALL Goal 0.7%

E

F

G

H

I

Total to
Total to
Total to
Total to Percentage
DBEs
DBEs/Race DBEs/Race DBEs/Race of total
/Race
dollars to
Conscious
Neutral
Neutral
(number)
(dollars)
(number)
Conscious
DBEs
(dollars)

8. Prime contracts awarded this period
9. Subcontracts awarded/committed this period
TOTAL
A

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

B

C

Black
Hispanic
Native
American American American

D

E

F

NonMinority
Women

AsianSubcont.
Pacific
Asian
American American

G

H

I

TOTALS
Other (i.e.
Year-End
(for this
not of any
other group reporting
TOTALS
listed here) period only)

10. Total Number of Contracts (Prime and Sub)
11. Total Dollar Value

ACTUAL PAYMENTS ON CONTRACTS
COMPLETED THIS REPORTING
PERIOD

A

B

C

Number of Prime
Contracts Completed

Total Dollar Value of
Prime Contracts
Completed

DBE Participation
Needed to Meet Goal
(Dollars)

12. Race Conscious
13. Race Neutral
14. Totals
15. Submitted by (Print Name of
Authorized Representative)

16. Signature of Authorized
Representative

17. Phone Number:

18. Fax Number:

D

E

Total DBE Participation Percentage
(Dollars)
of Total DBE

Participation