Santa Clara — GS-043*

Source: https://santaclara.courts.ca.gov/system/files/forms/gs-043_rem.pdf

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