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Form A-644 DBE E REV. 05/22 Monthly Prime Contractor or Consultant Payment Information Subcontractor/Supplier Work Description or Item DBE? Yes No DBE % Commitment* Actual Payments this period to DBEs and non-DBE Subcontractors *IF ANY FIRM LISTED ABOVE IS A MATERIAL SUPPLIER, BUT NOT THE MANUFACTURER, THE CONTRACTOR MAY CREDIT ONLY 60% OF THE EXPENDITURE TO THE SUPPLIER FOR FINAL PAYMENT. Project Name: Project No: Prime Contractor/Consultant: DBE Contract Goal %: Reporting Period: ____________ thru ____________ Monthly Estimate No: Original Contract Amount: Total $ Paid to Date: % Paid to Date: % Time Used: % of Construction Completed (consultants only) Summary of Payment Information a. Previous actual payments to DBEs: g. Previous actual payments to non-DBEs b. Actual payments to DBEs this period: h. Actual payments to non-DBEs this period c. Total actual payments to DBEs to date: i. Total actual payments to non- DBEs to date d. Total actual payments to Prime to date: j. % of actual payments to non- DBEs to date e. Total % of actual payments to DBEs to date: k. Total % of actual payments to non DBEs to date. f. Total actual payments to Prime less Subs to date l. Total actual payments to all Subs. Form A- 644 DBE REV. 05/2022 Summary of Payments Withheld Prime Contractor/Consultant Certification: I swear or affirm that the above named prime contractor paid all subcontractors within ten (10) days of receipt of payment from VIDPW and that the prime contractor ensured prompt payment of lower tier subcontractors, if any. I further certify that retainage, if any, was returned to any subcontractor within thirty (30) days of completing the subcontracted work. Name of Prime Representative: Title of Prime Representative: ____________________________________________________________________________________ __________________________________________________________________ Signature: ______________________________________________ Date: _________________ Below this line for VIDPW staff only Project Manager Monitoring Certification: (To be completed monthly by Project Manager) I reviewed the work site and related documents associated with this Form A-644 and find it accurate and complete. Payments withheld from/by subcontractors, if any, appear to be for cause and not the result of failure to promptly pay. Name of Project Manager: Signature of Project Manager: Date: __________________________________________________________ ____________________________________________________________ ___________________ DBELO Monitoring Certification: (To be completed by DBELO on the final project A-644) I certify that both the project site and related documents were monitored for compliance with 49 CFR Part 26 and all other applicable regulations. All subcontractors have been paid and retainage, if any, returned. Name of DBELO: Signature of DBELO Date: _______________________________________________________ ____________________________________________________________________ ______________________ Subcontractor/Supplier DBE? Tier Reason for Withholding Payment