00 21 13-1 Owner Minority, Women and Other DBE Forms.pdf

00 21 13 Owner Minority, Women and Other Disadvantaged Business Enterprise Forms Cover Sheet

Exhibit 1 – MBE/WBE/DBE Solicitation and Commitment Statement Exhibit 2 – Standard Form of CRW’s Letter to Prime Contractor After Award of Contract

Exhibit 3 – Standard Form of Prime Contractor’s Letter to Subcontractors After Notice of Award to Prime Contractors

Exhibit 4 – Prime Contractor MBE/WBE/DBE Monthly Reporting Form Summarizing Payments Made

Exhibit 5 – Subcontractor MBE/WBE/DBE Monthly Reporting Form Summarizing Payments Received Exhibit 6 – CRW’s Monthly MBE/WBE/DBE Business Utilization Report

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Disadvantaged Business Enterprise Plan.docx

Minority/Women/Disadvantaged Business Enterprise Plan Exhibit 1

MBE/WBE/DBE Solicitation and

Commitment Statement

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Minority/Women/Disadvantaged Business Enterprise Plan – Exhibit 1

MBE/WBE/DBE Solicitation and Commitment Statement

Owner / Prime Bidder’s Firm Name (1) Project Name (2)

Address Bid Opening Date Contract Award Date

Telephone Number Contact Person

* (3) (3) (4) (4) (4) (4) (5) (6) * (7)

Company Name

EIN/SSN

Telephone Number

Date Of

Solicitation MBE WBE DBE

Certification

Program and

Number

Type Of Work to

Be Performed and/or Material to Be Supplied

Total

Dollar Amount of Quote

Received

Total

Commitment

Dollar Amount

*(8) Note: List those certified minority and/or women owned businesses from whom you solicited quotes or who contacted you and gave you quotes in regard to this Invitation to Bid. Contact with MBE/WBE/DBE subcontractors should be at least equivalent to the notice given to other subcontractor proposers.

(9) Prepared By (Please Print) Telephone Number E-Mail

* Use additional sheets if necessary

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MBE/WBE/DBE SOLICITATION AND COMMITMENT STATEMENT

Instructions and Explanation of Columns

Project owners and all prime bidders will complete this form to document all businesses solicited and all businesses that provided solicited or unsolicited quotes for project-related contracts.

(1) Provide your (project owner’s or prime bidder’s) company name, address, telephone number.

(2) Provide the project name, project number, bid opening date, contract award date, and a contact person’s name.

(3) For each business solicited and each quote/bid received, enter the firm name, Employer

Identification Number (EIN) or Social Security Number (SSN) for a sole proprietorship, telephone number with area code, and email address. Only the company’s name is a mandatory item. Add the date of the Solicitation.

(4) Indicate whether or not the firm is a MBE, WBE business or other DBE business. Place a check mark in only one of the appropriate MBE, WBE or DBE columns, add the identity of the certifying entity and the MBE’s/WBE’s/DBE’s certification number.

(5) Indicate the type of work to be performed and/or material to be supplied.

(6) Enter the total dollar amount of the quote received.

(7) Enter the total dollar ($) amount of the commitment which you have made to the MBE, WBE or other DBE business. If no amount is provided in this space, it will be presumed that your firm made no commitment to the MBE, WBE or other DBE business.

(8) NOTE: You must include information on both solicited and unsolicited quotes. Failure to include a firm providing solicited or unsolicited quotes may result in the rejection of the bid or a determination that you are not a responsible contractor. Adequate time equivalent to that provided to other subcontractor proposers must be provided for MBE/WBE/DBE subcontractors and suppliers to respond to bids. You should include a description of any barriers or impediments encountered in the effort to assure MBE, WBE or other DBE participation.

(9) For the proposals of MBE/WBE/DBE firms that are not selected, indicate in an attachment the majority Subcontractor or Subcontractors whom Bidder intends to use instead, and the reasons for the selection of the majority Subcontractors.

(10) Indicate the name, telephone number and e-mail address of the person(s) who prepared the form.

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Exhibit 2

Exhibit 2

Standard Form of CRW’s Letter to

Prime Contractor After Award of Contract

Capital Region Water | Administrative Offices

3003 North Front Street, Harrisburg, PA 17110 | 888-510-0606 capitalregionwater.com

(Date)

(Contractor’s Name and Address)

Re: (Name of Project, Project Number, Contract Type)

Dear Sir/Madam:

Congratulations on being awarded the above referenced contract. In the bid, a binding commitment was made by your firm to the following MBE, WBE or other DBE firms – [List Names of MBE/WBE/DBE firms here].

Please prepare letters and forward to your Subcontractors, using the Standard Form of Prime Contractor’s Letter to Subcontractors After Notice of Award to Prime Contractors (Exhibit 3).

Please complete the enclosed Prime Contractor’s Monthly Business Utilization Report (Exhibit 4) and return it to ___________________________________ (Name of CRW’s representative) at ______________________ (insert address) each month with your payment requisitions. The information requested on this form will, among other things, be used to determine the actual dollar amount paid to MBE/WBE/DBE Subcontractors to which your firm made commitments during the bidding process.

Also, please provide the enclosed MBE/WBE/DBE Monthly Reporting Form for Subcontractors Summarizing Payments Received, so that your Subcontractors may submit their monthly reports. Please coordinate with your Subcontractors on the periods covered.

If you have any questions regarding the above, please contact (Name of CRW’s representative) at ________________________ (insert phone number) or at _____________ (insert email address).

Very truly yours, Signature

Name Title

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Exhibit 3

Standard Form of Prime Contractor’s

Letter to Subcontractors

After Notice of Award to Prime Contractors

(On Prime Contractor’s Letterhead)

(Date)

MBE/WBE/DBE Subcontractor’s Name and Address

Re: (Name of Project, Project Number, Contract Type)

Dear _____________:

The above referenced contract has been awarded to ______________________ (Name of Prime

Contractor). In the contract, a binding commitment was made to your firm of

___________________________________ (dollar amount of commitment). Per page 10 of CRW’s MWDBE plan, your subcontract should include the requirement that you not be replaced without the express, written consent of CRW, which consent shall not be unreasonably withheld.

Please verify the above committed amount with this office within five (5) days after receipt of this letter. If you do not respond, we will presume that your firm is in agreement with the committed amount.

In order that we may track this amount accurately, we ask that the attached Subcontractor

MBE/WBE/DBE Monthly Reporting Form Summarizing Payments Received (Exhibit 5) be completed and returned to _____________________________ (Name of Prime Contractor’s representative), with a copy to _____________________________ (Name of CRW’s representative) within ten (10) working days after the end of each month and at final project completion, covering checks issued, cash transferred on or after _________________ date thru and including ___________ date (insert beginning and end of periods).

Should you have any questions regarding this letter, please contact _________________ (Name of Prime

Contractor’s representative) at ________________________ (insert phone number) or at _____________

(insert email address).

Very truly yours, Signature

Name

Title

Attachment cc: (CRW’s Representative)

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Exhibit 4

Exhibit 4

Prime Contractor MBE/WBE/DBE

Monthly Reporting Form

Summarizing Payments Made

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Minority/Women/Disadvantaged Business Enterprise Plan – Exhibit 4

Mandatory Form. Submit Monthly. (Page 1 of 2)

PRIME CONTRACTOR Monthly MBE/WBE/DBE Payment Report

Name of Project ___________________________________________________________

Prime Original Contract Value: ____________________________________________

Change Orders (Overall Add/Deduct): _____________________________________

Total Contract Amount to Date: ___________________________________________

Total Payments Issued from ____________ to ___________ (date)

Contract No.: ______________________________________________________________

Report for the Month of: __________________________________________________

Notice to Proceed Date: ___________________________________________________

Project Mgr. Name: _______________________________________________________

Assigned MBE/WBE/DBE Goal %: _____________

Name of

MBE/WBE/DBE

Subcontractor

Work Task

Performed

Original

Contract

Amount

Change

Order

Amount

Amount of

Invoice

Received this Month

Date of

Invoice

Received in this

Month

Payments

Made to

MBE/

WBE/DBE

in this

Month ($)

Date(s)

Payments

Made this

Month

Total

MBE/WBE/DBE

Payments Made to Date in $

Overall

Work

Finished

Final

Payment

(Y/N)

Total(s) →

$ $ $ Total(s)

$ Total(s)

Itemize payments/invoices and dates if paid/received more than one payment/invoice between the 1st and 31st of this Month.

Prime Contractor Information:

Prime Firm Name: ______________________________________

Address: ________________________________________________

Telephone No.: _____________________Date: ______________

Project Director Name: ___________________________________

Project Director Signature: _______________________________

EIN # / TIN # _______________________________

Prime’s Past Due Invoice Information: List any invoice more than ______ days past due from the date submitted to _______ at the time you complete this form.

Invoice # Invoice Date Invoice Amount ($) No. of Days Past Due Comments

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Minority/Women/Disadvantaged Business Enterprise Plan – Exhibit 4

Mandatory Form. Submit Monthly. (Page 2 of 2)

Prime Contractor MBE/WBE/DBE Payment Certification

1. Have all MBE/WBE/DBE subcontractors with executed subcontracts been paid amounts due from previous progress payments?

□ If Yes, skip the next section and go to Number 3.

□ If No, please complete fields in box below (use additional paper, if necessary)

Subcontractor Name

Amount Withheld from Invoice ($)

Total of Invoice

Amount ($) Invoice No. Invoice Date Specific Reason for Withholding

2. Have you notified the MBE/WBE/DBE subcontractor(s) that you are withholding payment and the reason(s) why?

□ If Yes, provide a copy of written notification to the MBE/WBE/DBE subcontractor with this form, indicating the date of notification which includes an explanation as to why payment was withheld.

□ If No, lack of prior written notification to the MBE(s)/WBE(s)/DBE(s) that you are withholding payment may violate the prompt payment clause guidelines.

Please contact the MBE/WBE/DBE immediately, and provide a copy of written notification to the subcontractor with this form.

3. By signing this form, I certify that all of the above represent true and accurate information.

Project Director Name (Print) Project Director (Signature) Date

Additional Reasons/Comments for Withholding Payment:

DO NOT WRITE BELOW This Form is Due on the ______________ of each Month.

Please forward to: ____________________________________

□ Approved

□ Denied

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Minority/Women/Disadvantaged Business Enterprise Plan Exhibit 5

Exhibit 5

Subcontractor MBE/WBE/DBE Monthly

Reporting Form

Summarizing Payments Received

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Minority/Women/Disadvantaged Business Enterprise Plan – Exhibit 5

Mandatory Form. COMPLETE & SUBMIT BY MBE/WBE/DBE ONLY.

SUBCONTRACTOR Monthly Payment Report

Name of MBE/WBE/DBE Firm: ___________________________________________

MBE/WBE/DBE EIN: _______________________________________________________

MBE/WBE/DBE Address: __________________________________________________

MBE/WBE/DBE Telephone No.: ___________________________________________

Report payments issued from ______________ (date) to _______________ (date)

Contract No.: _______________________________________________________________

Contract Name: ____________________________________________________________

MBE/WBE/DBE Contract Start Date: ________________________________________

Prime Contractor’s Information:

Name of Prime: _____________________________________ Address: __________________________________________________________ Telephone #: _________________________

MBE/WBE/DBE PAYMENT INFO: Itemize payments/invoices and dates if received/submitted more than one payment/invoice between the 1st and 31st of THIS Month.

Work Task

Performed

Original

Subcontract

Amount

Change

Order

Amount

Invoice #’s

Submitted in this

Month

Dollar

Amount of each Invoice

Submitted this Month

Date of

Invoice(s)

Submitted this Month

Total Payments

Received by

MBE/WBE/DBE

this Month ($)

Date(s)

Payments

Received in this

Month

Total

Payments

Received by

MBE/WBE/DBE

to Date ($)

Total %

Work

To

Date

Final

Payment

(Y/N)

Total(s) → $ $ Total(s) → $ Total(s) → $ Total(s) → $

Is retainage held on your subcontract? Yes or No (circle one) If yes, how much? $_______________. Did your final payment include retainage? Yes or No (circle one)

Past Due Invoice(s) Information: List any invoice more than ______ days past due from date submitted to prime at the time you complete this form.

Invoice # Invoice Date Invoice Amount ($) No. of Days Past Due Comments

Name: ____________________________________ Signature: ___________________________________ Title: ______________________________________________ Date: ________________

THIS FORM IS DUE ON THE ___________ OF EACH MONTH IMMEDIATELY Please forward to: ______________________________________

FOLLOWING MBE’s/WBE’s/DBE’s SUBCONTRACT START DATE, EVEN IF PAYMENT ______________________________________

IS NOT RECEIVED ______________________________________

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Minority/Women/Disadvantaged Business Enterprise Plan Exhibit 6

Exhibit 6

CRW’s Monthly MBE/WBE/DBE Business

Utilization Report

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Minority/Women/Disadvantaged Business Enterprise Plan – Exhibit 6

Contractor Name, Address, and Telephone Project Name and Number Prime Contract

Value

MBE/WBE/DBE Exhibit 1 Project Participation Level:

MBE/WBE/DBE Exhibit 1 Total Commitment Dollar Amount:

Munis Project Code

Subcontractor/Supplier Name, Address, Telephone Number

MBE Final

Subcontract Amounts

WBE Final

Subcontract Amounts

DBE Final

Subcontract Amounts

Final Total Value

All M/W/DBE Subcontractor/Supplier Contracts

Total Dollar Value Difference from Awarded Amount in Exhibit 1 (+/-)

MBE/WBE/DBE Participation Level % Change from

Exhibit 1 Commitment (+/-)

Final MBE/WBE/DBE Participation Level %

NOTES (include an explanation of any variance between the M/W/DBE Commitment Amount reflected in Exhibit 1 and the Final Commitment

Amount awarded):