MassDOT Form AD4D Page 1 of 1 Last Modified: March 23, 2018 (A)
Project Expenditure Report
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Disadvantaged Business Enterprise (DBE)
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Participation
(For Federally-sponsored Projects)
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PROJECT __________________________________________________________________________________________________
DBE CONTRACTOR _________________________________________________________________________________________
MASSDOT PAYMENT VOUCHER (PV) NO. _________________ TOTAL DBE CONTRACTOR PARTICIPATION $_____________
PERCENTAGE OF CONTRACT __________________________
Contract
Item No.
Description of Work to be Performed by DBE Contractor
Estimated
Quantity
Unit Price
Item
Amount
Total amount requested by DBE contractor this invoice (add item amounts): TOTAL $
Total amount previously requested by DBE contractor: $
Total amount requested by DBE contractor to date: $
The undersigned certifies that the DBE Contractor has successfully completed the above referenced work associated with this
project and further assures that said DBE Contractor will be paid in full for the amount indicated above for said services.
Prime Contractor
Authorized Signature
Date
DBE Contractor
Authorized Signature
Date
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Form must be submitted with each PV. Separate forms for each DBE contractor.
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Must be register with the MA Supplier Diversity Office (SDO) and must be listed as a DBE with a valid certification when
work is completed.
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For projects with any federal participation.
