15-Appendix Small Business Form 106711.docx
DOCX document 82 KB Posted
- Solicitation number
- 26-0149
- Issued by
- Tarrant County, Fort Worth City, Texas
About this file
This is a Small Business Utilization Form for the City of Fort Worth, Texas, related to Water Main Replacements - Contract 2026 (ITB 106711). The form requires prime bidders and offerors to identify all subcontractors and suppliers, whether certified small businesses or not, and to document their commitment to meeting the City's 30 percent small business utilization goal. The work involves extensions, replacements, and relocations of water mains, service lines, and related construction to upgrade existing water infrastructure or provide water service to customers and developers. Certified small business firms must be physically located within the City's marketplace, defined as Denton, Parker, Wise, Tarrant, and Johnson counties, and must hold certification from an approved certifying agency including the North Central Texas Regional Certification Agency, Women's Business Council - Southwest, Dallas/Fort Worth Business Council, Texas HUB Program, Texas Unified Certification Program, or TxDOT SBE Directory.
Prime bidders and offerors must list all contractors and suppliers with their business classification, NAICS codes, services or supplies provided, addresses, contact information, and dollar amounts on the utilization form. Certified small business prime contractors may count their self-performance toward meeting the contract goal if certified within the appropriate NAICS codes for their work. The form requires submission of complete certification documentation with the bid and prohibits any additions, deletions, or substitutions to the listed subcontractors without prior City approval. Failure to complete the form entirely or submit it with the bid may render the bid non-responsive. Prime bidders must agree to provide complete and accurate information regarding actual work performed, permit City audits and examinations of company records, and allow authorized City representatives to conduct interviews with relevant parties. Intentional or knowing misrepresentation of material facts may result in debarment for a period of not less than one year.
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Text version
Small Business Utilization Form
PRIME BIDDER/OFFEROR
COMPANY NAME:
PROJECT NAME:
PROJECT NUMBER:
| City’s Small Business Goal |
| Bidder/Offeror’s Commitment |
BID DATE:
| 30 % |
| ___ % |
| Check applicable box to describe Prime Bidder/Offeror | |
| ☐ | Not Small Business |
| ☐ | Small Business |
ALL SMALL BUSINESS FIRMS MUST BE CERTIFIED BEFORE BID
DOCUMENTATION FROM AN APPROVED CERTIFYING AGENCY MUST BE PROVIDED WITH THIS FORM.
Failure to complete this form in its entirety and submit it with the Bid/Offer may result in the bid being considered non-responsive.
Should the City of Fort Worth determine that the Prime Bidder/Offeror is qualified for award of contract, upon execution of said contract, the undersigned Prime Bidder/Offeror shall enter into a formal agreement with the Small Business firm(s) listed in this utilization schedule.
Small Business firms listed toward meeting the project goal must be physically located in the City's marketplace at the time of bid.
The marketplace is Denton, Parker, Wise, Tarrant, and Johnson counties.
Certified means those small business firms that have been certified as Small Businesses by one of the following Certifying Agencies: North Central Texas Regional Certification Agency (NCTRCA), Women’s Business Council – Southwest (WBCS), Dallas/Fort Worth Business Council (DFW BC), Texas Historically Underutilized Business (HUB) Program and Texas Unified Certification Program (TUP) DBE/ACDBE and Texas Department of Transportation (TXDOT) SBE Directory.
Prime Bidders/Offerors are required to identify ALL subcontractors/suppliers, regardless of status.
Certified Small Business Prime/Bidder/Offeror Contractors, counting their self-performance towards meeting the contract goal, must be certified within those NAICS codes for the work it intends to perform.
The Prime Bidder/Offeror will not make additions, deletions, or substitutions to this list without the prior approval of the City of Fort Worth. Any unjustified change or deletion shall be a material breach of contract and may result in debarment.
Check this box if certified Prime Contractor services will be counted towards the Small Business contracting goal. ☐ List Prime Contractor first and Prime Contractor’s participation, expressed in dollars. Next, list certified Small Business firm names, including DBAs, as shown on their certification. Last, list non-small business firms.
| NAMES AND ADDRESSES OF CONTRACTORS/SUPPLIERS |
| TYPE OF SERVICES/SUPPLIES PROVIDED (NAICS Required) |
Business Name:
Small Business ☐ Not Small Business ☐
Address (including County):
Type of Services/Supplies:
Phone:
Email:
NAICS Code:
Contact Person:
$ AMOUNT:
| NAMES AND ADDRESSES OF CONTRACTORS/SUPPLIERS |
| TYPE OF SERVICES/SUPPLIES PROVIDED (NAICS Required) |
Business Name:
Small Business ☐ Not Small Business ☐
Address (including County):
Type of Services/Supplies:
Phone:
Email:
NAICS Code:
Contact Person:
$ AMOUNT:
| NAMES AND ADDRESSES OF CONTRACTORS/SUPPLIERS |
| TYPE OF SERVICES/SUPPLIES PROVIDED (NAICS Required) |
Business Name:
Small Business ☐ Not Small Business ☐
Address (including County):
Type of Services/Supplies:
Phone:
Email:
NAICS Code:
Contact Person:
$ AMOUNT:
| NAMES AND ADDRESSES OF CONTRACTORS/SUPPLIERS |
| TYPE OF SERVICES/SUPPLIES PROVIDED (NAICS Required) |
Business Name:
Small Business ☐ Not Small Business ☐
Address (including County):
Type of Services/Supplies:
Phone:
Email:
NAICS Code:
Contact Person:
$ AMOUNT:
| NAMES AND ADDRESSES OF CONTRACTORS/SUPPLIERS |
| TYPE OF SERVICES/SUPPLIES PROVIDED (NAICS Required) |
Business Name:
Small Business ☐ Not Small Business ☐
Address (including County):
Type of Services/Supplies:
Phone:
Email:
NAICS Code:
Contact Person:
$ AMOUNT:
Please include additional copies of this page if needed to list all subcontractors and suppliers.
| Total Dollar Amount of Certified Prime Bidder/Offeror Services towards contract goal |
| $ |
| Total Dollar Amount of Small Business Subcontractors/Suppliers |
| $ |
| Total Dollar Amount of Non-Small Business Subcontractors/Suppliers |
| $ |
| TOTAL AMOUNT BID |
| $ |
By affixing a signature to this form, the Prime Bidder/Offeror agrees to provide, directly to the City upon request, complete and accurate information regarding actual work performed by all subcontractors. The Prime Bidder/Offeror also agrees to allow an audit and/or examination of any books, records and files held by their company. The Prime Bidder/Offeror agrees to allow an authorized officer or employee of the City to conduct interviews with owners, principals, officers, employees and applicable subcontractors/suppliers participating on the contract to substantiate the actual work performed by the Small Business firms on this contract. A Prime Bidder/Offeror who intentionally and/or knowingly misrepresents material facts shall be debarred for a period of time of not less than one year.
Authorized Signature
Printed Signature
Title
Contact Name and Title (if different)
Company Name
Phone Number
Address
Email Address
City/State/Zip Code
Date
| Page 1 of 2 | |
| Revised 11.06.25 | Page 2 of 5 |
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