PRODUCT NAME: PRODUCT NUMBER:IS THE PRODUCT CURRENTLY ON THE QPL? IF YES, QPL TRACKING NUMBER:PAY ITEM NUMBER OR CATEGORY: DATE:DOMESTIC MATERIALS SOURCE (NAME AND ADDRESS) TO INCLUDE SUPPLIER, FABRICATOR, AND MANUFACTURER

DOMESTIC MATERIALS DESCRIPTION

DOMESTIC ENTITIES INVOLVED IN OTHER MANUFACTURING PROCESSES (I.E. GALVANIZATION, EPOXY COATING, WELDING, BENDING, ETC.)

MATERIALS OF UNKOWN ORIGIN OR FOREIGN MATERIALS

Company Name and Address Authorized RepresentativeName:Title:Signature:Date:

FORM MDT-3 Revised: 1/21

This certification is made for the purpose of establishing the materials acceptance under the Buy America Certification (23CFR 635.410). All iron and steel manufacturing processes, including protective coating, for the domestic materials described above occurred in the United States of America.Manufacturer's certificates verifying the origin above described in the domestic materials will be kept on file as long as the product is on the QPL. ODOT has the right to verify at any time the material source. Copies will be provided to ODOT once per calendar year and upon request: I declare under the penalty of perjury under the Oklahoma and Federal Laws that the foregoing is true and correct.

ODOT CERTIFICATE OF MATERIALS ORIGINNote: This form is for products on Traffic Engineering Division's Qualified Products List (QPL) which contain steel or iron, and is necessary to comply with the Buy America requirements.

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