SUPERIOR COURT OF CALIFORNIA,
SANTA CLARA COUNTY
DVBE POST-CONTRACT REPORT
Agreement number:
Contractor name:
The contractor identified above (Contractor) entered into the agreement identified above
(Agreement) with the JBE. Pursuant to Military and Veterans Code section 999.5(d), Contractor
must provide and certify the information below. Please return this form to the JBE within
sixty (60) days of receiving final payment under the Agreement. Failure to return this form
as required constitutes a breach of the Agreement.
Total amount of money Contractor
received under the Agreement
Name and address of each disabled
veteran business enterprise (DVBE)
subcontractor to which Contractor
subcontracted work in connection with the
Agreement
Amount each DVBE subcontractor
received from Contractor in connection
with the Agreement
Contractor certifies that (i) the information above is accurate, and (ii) all payments
under the Agreement have been made to the applicable DVBE subcontractor(s).
Contractor (Printed) Date Executed
By (Authorized Signature)
Printed Name and Title of Person Signing
Send completed form to: Superior Court of California, Santa Clara County
Attn: Procurement Division
191 North First Street
San Jose, CA 95113
GS-043 REV 2/4/14
