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Minnesota Department of Transportation Office of Ci vil Rights Page of Contractor Payme nt Form State Project Numbe r Payment Reporting Pe riod 1 st Tier SubContractor Prime Contractor From To Instructions All Contractors making payments to Contractors/Subcontractors/Suppliers/Service Providers regardless of their tier or DBE status are required to complete and submit this form to the Mn/DOT Office of Civil Rights OCR each time payments are made to sub-contractors until final payment is made. Submit one copy of this form to the Mn/DOT OCR and one copy to the Project Engineer no later than ten 10 days after receiving payment from Mn/DOT. Contractor Information Original Contract Amount Committe d DBE Actual DBE to Date Name Address Phone DBE Check if Yes Name of Subcontractor/Supplier Description of Work Subcontract Amount Amount of Current Payment Total Sub-Contractor Payment-To-Date Paid to date Final Payment Yes/No Company Officials Signature Title Date Signed Title Name Title of Individual Comple ting Re port Type or Print Clearly Fax DBE Page 6. Failure to comply with this form and Minnesota s prompt payment law may cause progr ess payments to be withheld. Submit one copy of this form to the Mn/DOT OCR and one copy to the Project Engineer no later than ten 10 days after receiving payment from Mn/DOT. Contractor Information Original Contract Amount Committe d DBE Actual DBE to Date Name Address Phone DBE Check if Yes Name of Subcontractor/Supplier Description of Work Subcontract Amount Amount of Current Payment Total Sub-Contractor Payment-To-Date Paid to date Final Payment Yes/No Company Officials Signature Title Date Signed Title Name Title of Individual Comple ting Re port Type or Print Clearly Fax DBE Page 6. Failure to comply with this form and Minnesota s prompt payment law may cause progr ess payments to be withheld. Submit one copy of this form to the Mn/DOT OCR and one copy to the Project Engineer no later than ten 10 days after receiving payment from Mn/DOT.

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