11._SC_Federal_MBE_Form.pdf
PDF 138 KB Posted
- Attached to
- Bottled Water & Bagged Ice (Disaster) State and local contract opportunity
- Solicitation number
- 0021-24-ITB
- Issued by
- Lee County, Fort Lauderdale City, Florida
About this file
This document is a Schedule of Subcontracting and Affidavit of Compliance form related to federal procurement requirements, specifically aligned with 2 CFR §200.321 and 45 C.F.R. §75.330 for federal funding. The form is designed to ensure prime contractors take affirmative steps to engage small and minority-owned businesses, women's business enterprises, and labor surplus area firms in subcontracting opportunities.
The affidavit requires the prime contractor to affirm several commitments, including placing qualified small and minority businesses on solicitation lists, actively soliciting these businesses as potential sources, dividing project requirements into smaller tasks to maximize their participation, establishing delivery schedules that encourage their involvement, and utilizing resources like the Small Business Administration and Minority Business Development Agency. The document warns that false statements may result in criminal prosecution, and failure to provide documentation of compliance could render a bid non-responsive. The form includes a section for listing subcontractors, their addresses, types of work, and the percentage and dollar amount of the contract to be subcontracted, though this section is blank in the provided document.
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Text version
NOTE: SMALL AND MINORITY-OWNED, WOMEN-OWNED BUSINESS ENTERPRISES, AND LABOR SURPLUS AREA FIRMS SHALL NOT BE EXEMPT FROM COMPLYING WITH THE
AFFIRMATIVE STEPS OUTLINED IN 2 CFR §200.321 (OR 45 C.F.R. §75.330 FOR HEALTH AND HUMAN SERVICES FUNDS) FOR SUB-CONTRACTING.
SCHEDULE OF SUBCONTRACTING AND AFFIDAVIT OF COMPLIANCE WITH 2 CFR §200.321 REQUIREMENTS
(OR 45 C.F.R. §75.330 FOR HEALTH AND HUMAN SERVICES FUNDS)
I, , in my capacity as , am authorized to sign on behalf of, and fully bind, (First and Last Name) (Company Title/Position)
(the “Prime Contractor”). Accordingly, on behalf of the Prime Contractor, I swear to, and affirm the following:
(Company Name)
✓ Qualified small and minority businesses, and women’s business enterprises were, and will continue to be, placed on all of the Prime Contractor’s solicitation lists.
✓ The Prime Contractor solicited, and will continue to solicit, small and minority businesses, and women’s business enterprises, when they were/are potential sources.
✓ Based on the Prime Contractor’s experience and expertise, the total requirements of the project were, and will continue to be, divided when economically feasible into smaller tasks or quantities to permit maximum participation by small and minority businesses, and women’s business enterprises.
✓ The Prime Contractor has and/or will establish delivery schedules that will encourage participation of small and minority business, and women’s business enterprises.
✓ The Prime Contractor has and/or will use the services and assistance, as appropriate, of such organizations as the Small Business Administration and the Minority Business Development Agency of the Department of Commerce.
✓ I understand that failure to present documentation validating compliance upon request of the County may result in this bid being deemed non-responsive.
✓ I understand that, should the Prime Contractor be the awarded the contract that this affidavit will continue to be considered binding for the duration of the project.
Name of Subcontractor (attach additional pages as necessary)
Address Type of Work to be Performed Percent and dollar amount of Contract
Amount to be Subcontracted
I understand that false statements on this Affidavit of Compliance may result in criminal prosecution for a felony of the third degree as provide for in §92.525(3), Florida Statutes.
NOTE: SMALL AND MINORITY-OWNED, WOMEN-OWNED BUSINESS ENTERPRISES, AND LABOR SURPLUS AREA FIRMS SHALL NOT BE EXEMPT FROM COMPLYING WITH THE
AFFIRMATIVE STEPS OUTLINED IN 2 CFR §200.321 (OR 45 C.F.R. §75.330 FOR HEALTH AND HUMAN SERVICES FUNDS) FOR SUB-CONTRACTING.
SCHEDULE OF SUBCONTRACTING AND AFFIDAVIT OF COMPLIANCE WITH 2 CFR §200.321 REQUIREMENTS
(OR 45 C.F.R. §75.330 FOR HEALTH AND HUMAN SERVICES FUNDS)
Y##- -
SIGNATURE PRINTED NAME OFFICIAL TITLE DATE
STATE OF FLORIDA )
) ss:
COUNTY OF ______________ )
The foregoing instrument was acknowledged before me by means of ☐ physical presence, or ☐ online notarization, this _____ day of ________________, 20__, by
__________________________________ [NAME OF PERSON], as ______________________________________ [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for _____________________________[NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED].
☐ Personally Known; OR
☐ Produced Identification. Type of identification produced:____________________________.
[CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05]
Notary Public My Commission Expires:
(Printed, typed or stamped commissioned name of Notary Public)
File details come from the government source that posted it. Updated .