2026-570_Attachment_A-_First_Tier_Subcontractors_List.pdf

ATTACHMENT A

FIRST-TIER SUBCONTRACTORS LIST

THIS FORM MUST BE COMPLETED PRIOR TO CONTRACT EXECUTION

PROJECT NUMBER 2026-570

PROJECT NAME Forest Lake #2 PWA – Parking Lot Reclaim and Repave

FIRST TIER SUBCONTRACTOR NAMES

(Legal name of company as registered with the Secretary of State)

Name of city where company home office is located

% of value of Contract

*Is the First Tier Subcontractor a

TG/ED/VO?

Attach additional sheets as needed for submission of all first-tier subcontractors.

*TG/ED/ VO = Certified Targeted Group Business, Economically Disadvantaged Business, and Veteran-Owned Business

I certify by signing this form under oath that I am an owner or officer of the company, and that:

All first-tier subcontractors listed above have verified through a signed statement under oath by an owner or officer that they meet the minimum criteria to be a responsible contractor as defined in Minn. Stat. § 16C.285. A prime contractor shall submit to the contracting authority upon request copies of the signed verifications of compliance from all subcontractors of any tier and motor carriers, pursuant to subdivision 3, clause (7).

Authorized Signature of Owner or Officer Company Name

Print Name Date

Title