DOT 202

Project no. PCN
County Date
Type of work

Request to sublet work to
Firm name
Firm ID no.
(Federal S.S. number used on employer’s quarterly federal tax return)
Address
Phone Proposed start date Completion date

List the contract items to be sublet when completing this form. Use contract bid unit prices and quantities for each sublet item. Show portions of a sublet item as a partial quantity or an adjusted unit price amount, then state which portion of the partial line item is being sublet. Examples: crushing, hauling, sawing and sealing.

Contract item no.	Contract Quantity	Description	Contract unit price	Amount

TOTAL
I certify that I have contacted all potential minority subcontractors and did not discriminate in selection and retention of the subcontractor. In accordance with provisions of the specifications, I certify that the subcontract agreement is in writing and that the subcontract agreement contains all the requirements and pertinent provisions of the prime contract.

Prime Contractor
___________________________________________
Signature

Company address
Email Address
Phone no.

Print this form, sign it and convert it to a PDF, then email it
as an attachment to: DOTOperationsSupport@state.sd.us
or regular mail to: CONSTRUCTION ENGINEER
SD DEPT. OF TRANSPORTATION
700 E. BROADWAY AVE.
PIERRE, SD 57501-2586

$ sublet _______________ % sublet _______________

$ contract _____________ % contract ______________