Appendix MWBE-6.pdf

MWBE 105 (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

MWBE Quarterly Compliance Report Contract No.

The following information indicates the payment amounts made by the grantee/contractor to the NYS Certified M/WBE subcontractor on this project.

The payments as shown made are in compliance with contract documents for the above referenced project. Submit the completed form to the address above.

Prepared By (signature): Telephone No.:

E-Mail Address: Date:

Name and Title of Preparer (print):

Failure to submit this form will result in non-compliance *See Reverse Side for Product Codes

Contractors Name and Address Federal ID# Goals/$ Amt.

MBE %=$

WBE %=$

Contract Type Paid to Contractor This Quarter Total Paid to Contractor To Date

Project Completion Date: Work Location: Reporting Period:

1st Quarter (4/1-6/30) 3rd Quarter (10/1-12/31) 2nd Quarter (7/1-9/30) 4th Quarter (1/1-3/31)

M/WBE Subcontractor/Vendor Product Code*

Work Status This Report

Total Subcontractor Contract Amount Payments this Quarter Previous Payments Total Payment Made to

Date

MBE WBE MBE WBE MBE WBE MBE WBE

Name:

FED ID#

Active Inactive Complete

Name:

FED ID#

Active Inactive Complete

Name:

FED ID#

Active Inactive Complete

Name:

FED ID#

Active Inactive Complete

Total

Appendix MWBE-6

MWBE 105 (01/18) Page 2 of 2

Product Key Code

A = Agriculture/ Landscaping (e.g., all forms of landscaping services) B = Mining (e.g., geological investigations) C = Construction C15 = Building Construction – General Contractors C16 = Heavy Construction (e.g., highway, pipe laying) C17 = Special Trade Contractors (e.g., plumbing, heating, electrical, carpentry) D = Manufacturing E = Transportation, Communication and Sanitary Services (e.g., delivery services, warehousing, broadcasting and cable systems) F/G = Wholesale/Retail Goods (e.g. hospital supplies and equipment, food stores, computer stores, office supplies G52 = Construction Materials (e.g., lumber, paint, law supplies) H = Financial, Insurance and Real Estate Services I = Services I73 = Business Services (e.g., copying, advertising, secretarial, janitorial, rental services of equipment, computer programming, security services) I81 = Legal Services I82 = Education Services (e.g., AIDS education, automobile safety, tutoring, public speaking) I83 = Social Services (Counselors, vocational training, child care) I87 = Engineering, architectural, accounting, research, management and related services