Appendix MWBE-5.pdf

MWBE 101 (01/18) Page 1 of 2

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

Application for Waiver of MWBE Participation Goal

Section 1: Basic Information

Contractor’s Name: Federal Identification No.:

Street Address: Contract No.:

City, State, Zip Code :

MWBE Contract Goals

E-mail address: MBE % WBE %

Telephone No.: ( ) -

Section 2: Type of MWBE Waiver Requested

MBE Waiver: Total Partial If partial waiver, please enter the revised MBE percentage:

WBE Waiver: Total Partial If partial waiver, please enter the revised WBE percentage:

Please explain the reason for the waiver request:

Text field will expand as you type.

Section 3: Supporting Documentation

Provide the following documentation as evidence of your good faith efforts to meet the MWBE goals set forth in the contract and in support of your waiver application:

Attachment A. List of the general circulation, trade and MWBE-oriented publications and dates of publications soliciting for certified MWBE participation as a subcontractor/supplier and copies of such solicitation.

Attachment B. List of the certified MWBEs appearing in the Empire State Development MWBE directory that were solicited for this contract. Provide proof of dates or copies of the solicitations and copies of the responses made by the certified MWBEs. Describe specific reasons that responding certified MWBEs were not selected.

Attachment C. Descriptions of the contract documents/plans/specifications made available to certified MWBEs by the contractor when soliciting their participation and steps taken to structure the scope of work for the purpose of subcontracting with or obtaining supplies from certified MWBEs.

Attachment D. Description of the negotiations between the contractor and certified MWBEs for the purposes of complying with the MWBE goals of this contract.

Attachment E. Identify dates of any pre-bid, pre-award or other meetings attended by contractor, if any, scheduled by NYSDOL with certified MWBEs whom the NYSDOL determined were capable of fulfilling the MWBE goals set in the contract

Attachment F. Other information deemed relevant to the request.

Section 4: Signature and contract Information

By signing and submitting this form, the contractor certifies that a good faith effort has been made to promote MWBE participation pursuant to the MWBE requirements set forth under the contract. Failure to submit complete and accurate information may result in a finding of noncompliance, non-responsibility, and a suspension or termination of the contract.

Prepared by (signature): Date:

Name and title of preparer (print):

Appendix MWBE-5 mailto:Labor.sm.MWBEAdmin@labor.ny.gov

MWBE 101 (01/18) Page 2 of 2

Instructions for Completing and Submitting an Application for a Waiver of MWBE Utilization Goals

Article 15-A of the New York State Executive Law, and 5 NYCRR 140-145, require state agencies to set goals for participation by Minority and Women-owned Business Enterprises (MWBE) on many types of State contracts. Prior to the contract award, separate goals are established for MBE and WBE utilization, expressed as a percentage of payments made under the contract. The regulations allow agencies to impose penalties if contractors fail to meet the MWBE utilization goals established for the contract and also allow agencies to grant waivers of MWBE utilization goals, either prior to a contract award or after the award has been made, provided the contractor demonstrates an inability to solicit MWBE participation despite good faith efforts to that end. In order for a waiver to be granted, the contractor must submit a completed “Application for Waiver of MWBE Utilization Goals” form, along with the required supporting documentation.

Section 1: Basic Information

Enter the contractor’s name, address, federal identification number, and the contract number in the spaces provided.

Enter the MBE and WBE utilization goals set forth in the solicitation or assigned contract.

Section 2: Type of Waiver Request

Check the type(s) of waiver requested. You may request a total or partial waiver of the MBE goals and/or a total or partial waiver of the WBE goals. If you request a partial waiver of either the MBE or WBE goal, enter the revised goal for participation in the box provided. Use the space provided to provide a rationale for your waiver request. You may attach additional sheets, if necessary.

Section 3: Supporting Documentation

Extensive documentation is required to demonstrate good faith efforts to comply with the MWBE goals. See the form for details on the required documentation.

Section 4: Signature and Contact Information

The waiver application must be signed by someone authorized to discuss the waiver with Purchase and MWBE Administrator. By signing the waiver application, the contractor certifies that a good faith effort has been made to promote MWBE participation pursuant to the MWBE requirements set forth under the contract. Failure to submit complete and accurate information may result in a finding of non-compliance, non-responsibility, and a suspension or termination of the contract.

Note: Unless total waivers for both MBE and WBE participation have been granted, the contractor is required to submit all reports and documents – including MWBE compliance reports – pursuant to the provisions set forth in the contract, to evidence compliance with the MWBE goals.