20-015R-JM OEBO Schedules 1-4.pdf

REVISED 02/28/2019

OEBO SCHEDULE 1

LIST OF PROPOSED CONTRACTOR/CONSULTANT AND SUBCONTRACTOR/SUBCONSULTANT PARTICIPATION

SOLICITATION/PROJECT/BID NAME: _________________________________________ SOLICITATION/PROJECT/BID No.: ______________________________________

NAME OF PRIME RESPONDENT/BIDDER: ADDRESS: _________________________________________________________

CONTACT PERSON: _______________________________________________________ PHONE NO.: ___________________________ E-MAIL:______________________

SOLICITATION OPENING/SUBMITTAL DATE: ___________________________________ DEPARTMENT: ______________________________________________________

PLEASE LIST THE DOLLAR AMOUNT OR PERCENTAGE OF WORK TO BE COMPLETED BY THE PRIME CONTRACTOR/CONSULTANT ON THIS PROJECT.

PLEASE ALSO LIST THE DOLLAR AMOUNT OR PERCENTAGE OF WORK TO BE COMPLETED BY ALL SUBCONTRACTORS/SUBCONSULTANTS ON THE

PROJECT.

(Check all Applicable Categories) Non-SBE M/WBE SBE DOLLAR AMOUNT OR PERCENTAGE OF WORK

Name, Address and Phone Number Minority/Women Small

Business Business Black Hispanic Women Caucasian Other (Please Specify)

1.

2.

3.

4.

5.

(Please use additional sheets if necessary) Total ___ _____ __ ______ _________ _________ _________

Total Bid Price $________________________________________ Total SBE - M/WBE Participation _____________

I hereby certify that the above information is accurate to the best of my knowledge: ____________________________________________________________ ______________________________________ Signature Title

Note: 1. The amount listed on this form for a Subcontractor/subconsultant must be supported by price or percentage listed on the properly executed Schedule 2 or attached signed proposal.

2. Firms may be certified by Palm Beach County as an SBE and/or an M/WBE. If firms are certified as both an SBE and/or M/WBE, please indicate the dollar amount under the appropriate category.

3. Modification of this form is not permitted and will be rejected upon submittal.

OEBO LETTER OF INTENT – SCHEDULE 2

Revised 09/17/2019

A completed Schedule 2 is a binding document between the Prime Contractor/consultant and a Subcontractor/subconsultant (for any tier) and should be treated as such. The Schedule 2 shall contain bolded language indicating that by signing the Schedule 2, both parties recognize this Schedule as a binding document. All Subcontractors/subconsultants, including any tiered Subcontractors/subconsultants, must properly execute this document. Each properly executed Schedule 2 must be submitted with the bid/proposal.

SOLICITATION/PROJECT NUMBER: ________________________________________________________________________________

SOLICITATION/PROJECT NAME: __________________________________________________________________________________

Prime Contractor: ___________________________________________Subcontractor:______________________________________ (Check box(s) that apply) � SBE � WBE � MBE � M/WBE � Non-S/M/WBE Date of Palm Beach County Certification (if applicable):_______________.

The undersigned affirms they are the following (select one from each column if applicable):

Column 1 Column 2 Column 3

� Male � Female � African-American/Black � Asian American � Caucasian American � Supplier � Hispanic American � Native American

S/M/WBE PARTICIPATION – S/M/WBE Primes must document all work to be performed by their own work force on this form. Failure to submit a properly executed Schedule 2 for any S/M/WBE participation may result in that participation not being counted. Specify in detail, the scope of work to be performed or items supplied with the dollar amount and/or percentage for each work item. S/M/WBE credit will only be given for the areas in which the S/M/WBE is certified. A detailed proposal may be attached to a properly executed Schedule 2.

Line Item

Item Description Unit Price Quantity/ Units

Contingencies/ Allowances

Total Price/Percentage

The undersigned Subcontractor/subconsultant is prepared to self-perform the above-described work in conjunction with the aforementioned project at the following total price or percentage:

Print Name of Prime Print Name of Subcontractor/subconsultant

By: _____________________________________________ By: ________________________________________________

Authorized Signature Authorized Signature

Print Name Print Name

Title Title

Date: ___________________________________________ Date: ______________________________________________

If the undersigned intends to subcontract any portion of this work to another Subcontractor/subconsultant, please list the business name and the amount below accompanied by a separate properly executed Schedule 2.

Price or Percentage:

Name of 2nd/3rd tier Subcontractor/subconsultant

Revised 02/28/2019

OEBO SCHEDULE 3

SUBCONTRACTOR ACTIVITY FORM

SUBCONTRACTOR ACTIVITY FOR MONTH ENDING PROJECT #:

PROJECT NAME

PRIME CONTRACTOR NAME

PROJECT SUPERVISOR

Schedule 3 is used to show the monthly payment activity for work performed by each Subcontractor on the project and in conformity with the Subcontractor(s) submitted on Schedule 2. It also shows approved change orders as they impact all Subcontractors. Schedule 3 is to be submitted by the Prime Contractor with each payment request to Palm Beach County. In the Subcontracting Information section, list the name(s) of each Subcontractor, including each S/M/WBE subcontractor on the project and the total contracted amount for each Subcontractor on the project. As the project proceeds, please complete each column under the Subcontractor Information section. If a subcontractor is an S/M/WBE, please check the appropriate categories applicable.

I hereby certify that the above information is accurate to the best of my knowledge (Signature) (Title)

Additional Sheets May Be Used As Necessary

NOTE: Firms may be certified as an SBE and/or an M/WBE. If firms are certified as both an SBE and M/WBE, the dollar amount will not be counted twice.

SUBCONTRACTING INFORMATION Subcontractor Category (check all applicable)

Name of Subcontractor(s)

Total Contract Amount

Approved Change Orders

Revised Contract Amount

Amount drawn for Sub this Period

Amount drawn for

Sub to Date

Amount Paid to Date for

Subcontractor

Actual Starting Date

Minority/ Women

Business

Small Business

Black

Hispanic

Women

Caucasian

Other (Please Specify)

Revised 12/31/2019

OEBO SCHEDULE 4 – SUBCONTRACTOR/SUBCONSULTANT PAYMENT CERTIFICATION

A properly executed Schedule 4 shall be submitted for each Subcontractor/subconsultant after receipt of payment from the Prime. The Prime shall submit this form with each payment application or invoice submitted to the County when the COUNTY has paid the Prime on the previous payment application for services provided by a Subcontractor/subconsultant. All named Subcontractors/subconsultants on this form must also complete and submit a separate Schedule 4 after receipt of payment. If the Prime is an S/M/WBE, completion of a Schedule 4 is also required to document all portions of work performed by their work force. A completed release of lien form can be submitted in lieu of a Schedule 4.

This is to certify that received a (Subcontractor/subconsultant Name)

(Monthly) or (Final) payment of $ _____________________________ from _____

(Prime Contractor Name)

On _______/_________/____________ for my ________________________ Invoice for labor and/or materials supplied MM DD YYYY Month

On ___________________________________ / (Project Name) (Project No.)

DEPT.: ______________ TASK ORDER/WORK ORDER/DELIVERY ORDER/PURCHASE ORDER/ NO.: ____________________________

PRIME CONTRACTOR/CONSULTANT VENDOR CODE: ____________________________________________________________

SUBCONTRACTOR/SUBCONSULTANT VENDOR CODE: ____________________________________________________________

By:

(Signature of Subcontractor/subconsultant) (Name & Title of Person executing on behalf of Subcontractor/ subconsultant)

STATE OF FLORIDA

COUNTY OF

The foregoing instrument was acknowledged before me by means of � physical presence or � online notarization, this ____________ day of __________________, ____________(year), by ____________________________________________________(name of person acknowledging).

Notary Public, State of Florida

Print, Type or Stamp Commissioned Name of Notary

Personally Known ____ OR Produced Identification Type of Identification

If the undersigned intends to distribute any portion of this payment to another Subcontractor/subconsultant, please list the business name and the amount below accompanied by a separate properly executed Schedule 4.

_______________________________________________ Price or Percentage: _________________________________ Name of 2nd/3rd tier Subcontractor/subconsultant