Form 4101 - Heavy Construction Trucking Credit Worksheet
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1DISADVANTAGED BUSINESS ENTERPRISE
Michigan Department
(DBE) HEAVY CONSTRUCTION TRUCKING
Of Transportation
4101 (07/15)
CREDIT WORKSHEET
Information listed below must be complete and in compliance with the DBE CUF requirements under 49 CFR Part 26.55. This form is only used for
DBE Trucking work (MDOT Code RJ). Worksheet must accompany MDOT’s DBE Participation Form 0178.
MDOT CONTRACT IDENTIFICATION NUMBER
CONTRACT LOCATION
DBE TRUCKER
PRIME CONTRACTOR
EXPECTED START DATE
EXPECTED COMPLETION DATE
NAME OF CONTRACTOR PAYING YOUR FIRM
TOTAL NUMBER OF TRUCKS BEING USED ON THIS CONTRACT
TOTAL DOLLAR VALUE OF YOUR TRUCKING COMMITMENT FOR
$ _______________
(OWNED + LEASED)
________ Trucks Total
THIS CONTRACT
TYPE OF MATERIAL BEING HAULED
COST PER UNIT FOR HAULING
$_______________________ PER
____ HOUR
or
____ TON
TRUCKS YOU WILL USE ON THIS CONTRACT
TRUCKS OWNED BY YOUR FIRM
Number of owned trucks that
Do you own the trailers?
___ Yes or ___ No
Total Dollar Value of Work
What Type(s) of Trailers are you
If not, who owns them?
you will use on this contract
using on this contract?
for your firm
________ Trucks
$
TRUCKS LEASED FROM ADDITIONAL DBEs
Number of trucks being
Name of additional DBEs that you will use on this contract
Total Dollar Value of Work
leased per DBE firm
for each additional DBE firm
TOTALS
________ Trucks
$
TRUCKS LEASED* FROM NON-DBEs
Number of trucks being
Name of Non-DBEs that you will use on this contract
Total Dollar Value of Work
leased per Non-DBE firm
for each Non-DBE firm
TOTALS
________ Trucks
$
What is YOUR TRANSPORTATION FEE/COMMISSION FOR EACH LEASED NON-DBE TRUCK (percentage)? _________%
*Lease agreement(s) must be on file with the Office of Business Development (OBD) for the Non-DBEs listed above. Failure to
provide lease(s) for the above firms in accordance with the MDOT's DBE Program Procedures will result in delay of approval.
If there are any changes to this form, once approved by MDOT, a revised form must be submitted to OBD within two weeks of
the change. f you need additional information or have questions regarding the completion of this form or submittal of this information
False statements on this form or fraudulent documentation provided could result in sanctions by federal authorities
and/or MDOT.
DBE FIRM AUTHORIZED SIGNATURE
DATE
FOR MDOT INTERNAL USE ONLY
TOTAL NUMBER OF TRUCKS FOR DBE CREDIT
TOTAL # OF DBE TRUCKS
TOTAL # OF NON-DBE TRUCKS
TOTAL CREDIT FOR TRUCKING $
DBE $
NON-DBE $
MDOT REVIEWER APPROVAL SIGNATURE
DATE
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