Missouri Department of Transportation
Patrick K. McKenna, Director
1.888.ASK MODOT (275.6636)
Our mission is to provide a world-class transportation system that is safe,
innovative, reliable and dedicated to a prosperous Missouri.
www.modot.org
MODOT INTERSTATE DISADVANTAGED
BUSINESS ENTERPRISE (DBE) AFFIDAVIT
Name of Firm _________________________________________________________________________
I affirm, as evidenced by my signature below, I have provided all information required by 49 CFR
26.85(c) to MoDOT for inspection and review to determine eligibility for DBE certification in Missouri.
I affirm the information is complete and, in the case of the information required by §26.85(c)(1), is an
identical copy of the information submitted to _______________________________________________
(home state agency).
I further affirm all information and statements I have provided are true and correct.
_____________________________ ________________________________
Printed Name of Eligible Applicant Signature of Eligible Applicant
_____________________________ ________________________________
Email Address Phone Number
Subscribed and sworn before me, the undersigned notary public, on this date:
__________________________________ __________________________
Notary Public Signature/Seal Date
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