4-03. MBE Attachment A.pdf

PROJECT: _____________________________________________

PSC#: _______________________________________________

Attachment A (page 1 of 2)

CERTIFIED MINORITY BUSINESS ENTERPRISE

UTILIZATION AND FAIR SOLICITATION AFFIDAVIT

NOTE: You must include this document with your bid or offer. If you do not submit the form with your bid or offer, the procurement officer shall deem your bid non-responsive or your offer not reasonably susceptible of being selected for award.

Part I.

I acknowledge the:

• Overall certified MBE subcontract participation goal of __%. and

• The subgoals, if applicable, of:

• _ _ % for certified African American-owned businesses and

• _ _ % for certified Women-owned businesses.

I have made a good-faith effort to achieve this goal. If awarded the contract, I will continue to attempt to increase MBE participation during the project.

Part II.

Check ONE Box

NOTE: FAILURE TO CHECK ONE OF BOXES 1, 2, or 3 BELOW WILL RENDER A BID

NON-RESPONSIVE OR AN OFFER NOT REASONABLY SUSCEPTIBLE OF BEING

SELECTED FOR AWARD

NOTE: INCONSISTENCY BETWEEN THE ASSERTIONS ON THIS FORM AND THE

INFORMATION PROVIDED ON THE MBE PARTICIPATION SCHEDULE

(ATTACHMENT B) MAY RENDER A BID NON-RESPONSIVE OR AN OFFER NOT

REASONABLY SUSCEPTIBLE OF BEING SELECTED FOR AWARD

1 I have met the overall MBE goal and MBE subgoals for this project. I submit with this Affidavit [Attachment A] the MBE Participation Schedule [Attachment B], which details how I will reach that goal.

or 2 After having made a good-faith effort to achieve the overall MBE goal and MBE subgoals for this project, I can achieve partial success only. I submit with this Affidavit [Attachment A] the MBE Participation Schedule [Attachment B], which details the MBE participation I have achieved.

I request a partial waiver as follows:

• Waiver of overall MBE subcontract participation goal: ____ %

• Waiver of MBE subcontract participation subgoals, if applicable:

• ____ % for certified African American-owned businesses and

• ____ % for certified Woman-owned businesses.

Within 10 days of being informed that I am the apparent awardee, I will submit MBE Waiver Documentation [Attachment F] (with supporting documentation).

Attachment A (page 2 of 2) or

3 After having made a good faith effort to achieve the overall MBE goal and MBE subgoals for this project, I am unable to achieve any portion of the goal or subgoals. I submit with this Affidavit [Attachment A] the MBE Participation Schedule [Attachment B].

I request a full waiver.

Within 10 days of being informed that I am the apparent awardee, I will submit MBE Waiver Documentation [Attachment F] (with supporting documentation).

Part III.

I understand that if I am the apparent awardee or conditional awardee, I must submit within 10 working days after receiving notice of the potential award or within 10 days after the date of conditional award – whichever is earlier – the:

• Outreach Efforts Compliance Statement (Attachment C)

• Subcontractor Project Participation Statement (Attachment D)

• Minority Subcontractors Unavailability Certificate (Attachment E) (if applicable)

• Any other documentation the Procurement Officer requires to ascertain my responsibility in connection with the MBE participation goal and subgoals

I acknowledge that if I fail to timely return complete documents, the Procurement Officer may determine that I am not responsible and therefore not eligible for contract award. If the contract has been awarded, the award is voidable.

I acknowledge that the MBE subcontractors/suppliers listed in the MBE Participation Schedule and any additional MBE subcontractor/suppliers identified in the Subcontractor Project Participation Statement will be used to accomplish the percentage of MBE participation that I intend to achieve.

In the solicitation of subcontract quotations or offers, MBE subcontractors were provided the same information and amount of time to respond as were non-MBE subcontractors.

The solicitation process was conducted in such a manner so as to not place MBE subcontractors at a competitive disadvantage to non-MBE subcontractors.

I solemnly affirm under the penalties of perjury that this Affidavit is true to the best of my knowledge, information, and belief.

Bidder/Offeror Name Affiant Signature Address Printed Name & Title Address (continued) Date

October 2017