Appendix MWBE-4.pdf

MWBE 100 (01/18) Page 1 of 1

Purchase and Contracts, MWBE Administrator Harriman State Office Campus, Building 12, Room 465

Albany, NY 12240 Phone: (518) 474-2678 | Fax: (518) 457-0620

Labor.sm.MWBEAdmin@labor.ny.gov

MWBE Utilization Plan Contract No.:

This form must be submitted with any bid, proposal, or response to request for qualifications or proposed negotiated contract or within a reasonable time thereafter. It must be submitted prior to contract award. This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (MWBE) under the contract. Utilization of certified Minority and Women-owned Business Enterprises for non-commercially useful functions may not be counted toward utilization of certified Minority and Women-owned Business Enterprises as identified in this Utilization Plan.

Attach additional sheets if necessary.

Contractor’s Name, Address and Telephone No.

Federal Identification No.

Contract Description Location (Region) MWBE Goals in Contract

MBE %

WBE %

Certified M/WBE Subcontractors/Suppliers Name, Address, Telephone No, Email Address

Federal ID.

No.

NYS ESD Certified Detailed Description of Work (Attach additional sheets, if necessary)

Dollar Value of subcontracts/ supplies/services and intended performance dates of each component of the contract MBE WBE

Phone: ( ) - Email:

Phone: ( ) - Email:

Phone: ( ) - Email:

If unable to fully meet the MBE and WBE goals set forth in the contract, the contractor must submit an Application for Waiver of MWBE Participation Goal (MWBE 101) Submission of this form constitutes the contractor’s acknowledgement and agreement to comply with the M/WBE requirements set forth under NYS Executive Law, Article 15-A and 5 NYCRR Part 142. Failure to submit completed and accurate information may result in a finding of noncompliance or rejection of the bid/proposal and/or suspension or termination of the contract.

Prepared By (Signature) Email Address:

Name and Title of Preparer (Print or Type) Telephone Phone: ( ) - Date

FOR MWBE USE ONLY

Reviewed By Date

Utilization Plan Approved Yes No Date

Contract No. Project No. (If applicable) Contract Award Date Estimated Completion Date Contract Amount Obligated

Notice of Deficiency Issued Yes No Date Description of Work

Notice of Acceptance Issued Yes No Date

Appendix MWBE-4