4-RFP-05-Small Business Utilization Form.pdf

City of Fort Worth Small Business Utilization Form

10.1.2025-V1

The City of Fort Worth has set a Small Business Goal of 30% for this procurement. That goal may be met by self-performance by a prime contractor that is a certified Small Business, utilization of one or more subcontractors that are certified Small Businesses, or a combination of both.

ALL BIDDERS MUST COMPLETE THIS FORM.

ALL SMALL BUSINESS FIRMS MUST BE CERTIFIED PRIOR TO SUBMITTING A BID SUBMISSION.

A Small Business means a business entity that is located in Tarrant, Wise, Johnson, Parker or Denton County and that holds current certification as a small business from an organization approved by the City Manager for each commodity and service code listed. A copy of the current certification for each Small Business (including Bidder, if a Small Business seeking credit for self-performance) must be submitted with the bid.

Failure to (i) complete this form in its entirety or (ii) submit a current valid certification for all Small Businesses to be used with this Bid/Offer may result in zero points being awarded with respect to the Small Business Goal criteria during bid evaluation and with the bid being awarded points based solely on the remaining best value criteria.

If the undersigned Bidder is awarded a contract for this procurement, the Bidder must execute a formal agreement with each Small Business that Bidder uses as a subcontractor or supplier that is listed on this form.

Please list all subcontractors and suppliers being utilized to meet the Small Business Goal for this procurement.

Please list certified Small Business firm names as listed on their certification, including DBA names.

Contractors/Suppliers Legal Name

Address Contact information:

Name/Phone/Email

Types of Services

NAICS

Code(s)

$ Amount Certifying Agency

Address Contact information:

Name/Phone/Email

Types of Services

NAICS

Address Contact information:

Name/Phone/Email

Types of Services

NAICS

BIDDER LEGAL NAME:

Bid Name: Bid Number:

Certifying Agency:

City’s Small Business Goal is 30% if Bidder would like to commit to a higher percentage, please provide % Are you a certified Small Business Enterprise

(SBE)?

Yes No

City of Fort Worth Small Business Utilization Form

10.1.2025-V1

By affixing a signature to this form, Bidder further agrees to provide, directly to the City upon request, complete and accurate information regarding actual work performed by all subcontractors. The Bidder also agrees to allow an audit and/or examination of any books, records, and files held by their company related to the job being bid and/or the subcontractors being utilized. The Bidder agrees to allow and facilitate interviews by an authorized officer or employee of the City with owners, principals, officers, employees, and applicable subcontractors/suppliers participating on the contract in order to substantiate the actual work performed by the Small Business(es) under this contract.

A Bidder who intentionally and/or knowingly misrepresents material facts may no longer be considered a responsible bidder and therefore disqualified from consideration with respect to future City bids.

Legal Company Name: ___________________________________________________

Authorized Signature: ____________________________________________________

Printed Name: __________________________________________________________

Title: __________________________________________________________________

Address (Street, City, State, Zip): ____________________________________________

Phone Number: __________________________________________________________

Email address: ___________________________________________________________

Total Dollar Amount of Bidder Services towards small business goal

Total Dollar Amount of Small Business Subcontractors $

Total Dollar Amount of Non-Small Business Subcontractors $

TOTAL DOLLAR AMOUNT $