Appendix SDVOB-2 - SDVOB 101 SDVOB Monthly Compliance Report4.pdf

SDVOB 101 (01/18) Page 1 of 1

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

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

Labor.sm.SDVOBAdmin@labor.ny.gov

SDVOB Monthly Compliance Report Contract No.

The SDVOB Monthly Compliance Report is due on the 10th day of each month for the preceding month’s activity as evidence towards achievement of the SDVOB goals on the contract. Submit the completed form to the address above.

Contractor/Vendor Name, Address and Phone No.:

Contractor/Vendor Federal ID No.: SDVOB Goals Reporting Period Description of Project:

Month Year

Firm Name, Address and Phone Number (List All Firms)

Description of Work or Supplies Provided Designation Payment This Month Contract Amount

SDVOB

Sub Broker Joint Venture Written Contract

Supplier Team Other No Written Contract

Federal ID No.: No Payment This Month

SDVOB

Sub Broker Joint Venture Written Contract

Supplier Team Other No Written Contract

Federal ID No.: No Payment This Month

SDVOB

Sub Broker Joint Venture Written Contract

Supplier Team Other No Written Contract

Federal ID No.: No Payment This Month

Signature Print Name and Title Date Submission of this form constitutes the Contractor’s acknowledgement as to the accuracy of the information contained herein. Failure to submit complete and accurate information may result in a finding of noncompliance, non-responsibility, suspension and/or termination of the Contract.

For Department of Labor Use Only Reviewed By: Date:

Appendix SDVOB-2