6-Small Business Utilization Form.pdf

Small Business Utilization Form Page 1 of 5

Revised 9/01/2025

PRIME BIDDER/OFFEROR

COMPANY NAME:

PROJECT NAME:

PROJECT NUMBER: City’s Small Business Goal

Bidder/Offeror’s Commitment

BID DATE: 30 % ___ %

Check all applicable boxes to describe Prime Contractor Bidder/Offeror Owner's Classification:

☒ Not Certified

☐ Small Business

Certifying Agency: ☒ NCTRA ☐ WBCS ☐ MSDC ☐ TXDOT

ALL SMALL BUSINESS FIRMS MUST BE CERTIFIED BEFORE BID

Failure to complete this form in its entirety and submit it with the Bid/Offer will result in the bid being considered non-responsive to bid specifications.

The undersigned Prime Bidder/Offeror agrees to enter into a formal agreement with the Small Business firm(s) listed in this utilization schedule, conditioned the City of Fort Worth upon execution of a contract with the intentional and/or knowing misrepresentation of facts is grounds for consideration of disqualification and will result in the bid being considered non-responsive to bid specifications.

Small Business firms listed toward meeting the project goal must be 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, located in the marketplace, that have been determined to be bona fide 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 Minority Supplier Development Council (MSDC), and Texas Department of Transportation (TXDOT).

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Please note that only certified Small Business firms will be counted to meet the Small Business goal. 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 commodity codes with a certifying agency acceptable by the City of Fort Worth. Certified Small Business Prime/Bidder/Offeror, counting self-performing services towards the goal, the service(s) to be performed should be listed first on the Utilization form.

Check this box if certified Prime Contractor services will be counted towards the Small Business contracting goal. ☒

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

NAMES AND ADDRESSES OF

CONTRACTORS/SUPPLIERS

TYPE OF SERVICES/SUPPLIES PROVIDED

(NAICS Required)

Specify Tier

Certification Agency

Business Name: Type of Services/Supplies: Certified by:

Address: ☐ NCTRCA

Phone: ☐ WBCS

Email: NAICS Code: ☐ MSDC

Contact Person: $ AMOUNT: ☐ TXDOT

NAMES AND ADDRESSES OF

CONTRACTORS/SUPPLIERS

TYPE OF SERVICES/SUPPLIES PROVIDED

(NAICS Required)

Specify Tier

Certification Agency

Business Name: Type of Services/Supplies: Certified by:

Address: ☐ NCTRCA

Phone: ☐ WBCS

Email: NAICS Code: ☐ MSDC

Contact Person: $ AMOUNT: ☐ TXDOT

Small Business Utilization Form Page 3 of 5

Please include multiple copies of this page if needed to list all contractors and suppliers.

NAMES AND ADDRESSES OF

CONTRACTORS/SUPPLIERS

TYPE OF SERVICES/SUPPLIES PROVIDED

(NAISC Required)

Specify Tier

Certification Agency

Business Name: Type of Services/Supplies: Certified by:

Address: ☐ NCTRCA

Phone: ☐ WBCS

Email: NAICS Code: ☒ TXDOT

Contact Person: $ AMOUNT: ☐

NAMES AND ADDRESSES OF

CONTRACTORS/SUPPLIERS

TYPE OF SERVICES/SUPPLIES PROVIDED

(NAICS Required)

Specify Tier

Certification Agency

Business Name: Type of Services/Supplies: Certified by:

Address: ☐ NCTRCA

Phone: ☐ WBCS

Email: NAICS Code: ☒ TXDOT

Contact Person: $ AMOUNT: ☐

NAMES AND ADDRESSES OF

CONTRACTORS/SUPPLIERS

TYPE OF SERVICES/SUPPLIES PROVIDED

(NAISC Required)

Specify Tier

Certification Agency

Business Name: Type of Services/Supplies: Certified by:

Address: ☐ NCTRCA

Phone: ☐ WBCS

Email: NAICS Code: ☒ TXDOT

Contact Person: $ AMOUNT: ☐

Small Business Utilization Form Page 4 of 5

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 DOLLAR AMOUNT OF PRIME/ALL SUBCONTRACTORS/SUPPLIERS $

The Prime Bidder/Offeror will not make additions, deletions, or substitutions to this certified 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.

By affixing a signature to this form, the Prime Bidder/Offeror further 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 the transmission of interviews with owners, principals, officers, employees and applicable subcontractors/suppliers participating on the contract that will substantiate the actual work performed by the Small Business firms on this contract, by an authorized officer or employee of the City. A Prime Bidder/Offerer who intentionally and/or knowingly misrepresents material facts shall be debarred for a period of time of not less than one (1) years.

Authorized Signature Printed Signature

Title Contact Name and Title (if different)

Company Name Phone Number

Address Email Address

City/State/Zip Code Date

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