Form A-644  
                                                  DBE E  
                                                             Page 1 of 2  
                                                              REV. 05/22  
 
Monthly Prime Contractor or Consultant Payment Information  
Subcontractor/Supplier  
Work Description or Item  
DBE? 
Yes    No 
DBE %  
Commitment* 
Actual Payments this period  
to DBEs and non-DBE 
Subcontractors  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*IF ANY FIRM LISTED ABOVE IS A MATERIAL SUPPLIER, BUT NOT THE MANUFACTURER, THE CONTRACTOR MAY CREDIT ONLY 60% 
OF THE EXPENDITURE TO THE SUPPLIER FOR FINAL PAYMENT.  
Project Name: 
Project No: 
Prime Contractor/Consultant: 
DBE Contract Goal %: 
Reporting Period:  ____________ thru ____________ 
 
Monthly Estimate No: 
Original Contract Amount: 
Total $ Paid to Date: 
% Paid to Date: 
% Time Used:      
% of Construction Completed 
 
   (consultants only) 
Summary of Payment Information 
 
 
a. Previous actual payments to DBEs: 
 g. Previous actual payments to  
    non-DBEs 
 
b. Actual payments to DBEs this  
    period: 
 h. Actual payments to non-DBEs  
   this period 
 
c. Total actual payments to DBEs to  
    date: 
 i. Total actual payments to non- 
    DBEs to date 
 
d.  Total actual payments to Prime    
     to date: 
 
 j. % of actual payments to non- 
    DBEs to date 
 
e. Total % of actual payments to DBEs  
    to date: 
 k.  Total % of actual payments to  
     non DBEs to date. 
 
f.  Total actual payments to Prime less  
    Subs to date 
 l.  Total actual payments to all  
    Subs. 
 
                                                                                                                                          Form A-
644                                                                                                                                       
      DBE  
 
   Page 2 of 2  
 
      REV. 05/2022  
Summary of Payments Withheld 
 
 
                 
 
 Prime Contractor/Consultant Certification:   
I swear or affirm that the above named prime contractor paid all subcontractors within ten (10) days of receipt of payment 
from VIDPW and that the prime contractor ensured prompt payment of lower tier subcontractors, if any.  I further certify that 
retainage, if any, was returned to any subcontractor within thirty (30) days of completing the subcontracted work.   
  
  
Name of Prime Representative:   
 
 
 
     
Title of Prime Representative:   
  
____________________________________________________________________________________ 
 
__________________________________________________________________ 
  
 Signature: ______________________________________________   
  
Date: _________________ 
 
Below this line for VIDPW staff only   
  
 
Project Manager Monitoring Certification: (To be completed monthly by Project Manager)  
I reviewed the work site and related documents associated with this Form A-644 and find it accurate and complete.  
Payments withheld from/by subcontractors, if any, appear to be for cause and not the result of failure to promptly pay.   
  
Name of Project Manager:                                   Signature of Project Manager:  
Date:   
  
__________________________________________________________ 
____________________________________________________________ 
                ___________________ 
   
 DBELO Monitoring Certification: (To be completed by DBELO on the final project A-644)   
I certify that both the project site and related documents were monitored for compliance with 49 CFR Part 26 and all 
other applicable regulations.   All subcontractors have been paid and retainage, if any, returned.    
  
 
Name of DBELO:                                              Signature of DBELO  
Date:   
  
_______________________________________________________             ____________________________________________________________________                 ______________________ 
  
Subcontractor/Supplier  DBE?  
Tier  
Reason for Withholding Payment