ATT B - Subcontractor Acknowledgment Form.pdf

Subcontractor Acknowledgment Form (Non-Federally Funded Contract)

Are there any subcontractors and/or SBE suppliers to be utilized under this contract?

WCAA Subcontractor Acknowledgment Form 5/18/2017

Yes - A separate Subcontractor Form must be completed for each subcontractor and/or SBE supplier intended to be used on the contract, regardless of tier.*

*Subcontractor Forms must be provided at the time the response is submitted and/or prior to the Response Deadline.

ATTACHMENTWAYNE COUNTY AIRPORT AUTHORITY

WCAA Subcontractor Acknowledgment Form (Non-Federally Funded) - Revised 11/1/2018

Prime Contractor

Authorized Representative - Printed Name Title Signature Date

Certification & Signature Under penalty of perjury, I certify that:

1) I am authorized to execute this form on behalf of my firm;

2) I have conducted reasonable due diligence in collecting the information to be submitted on or with this form;

and

3) I understand that this form contains material statements relied upon by the Airport Authority as a part of their decision-making process, and, based on my knowledge, the foregoing form does not contain any untrue information or omit any material fact necessary to make the information contained herein true and complete.

No - Complete only this "Subcontractor Acknowledgment Form" Page

This form is intended to be used to identify solicitation responses that anticipate using subcontractors in the completion of the proposed contract. For purposes of this solicitation, SBE suppliers are considered as subcontractors and must have a completed form to be able to count SBE participation towards the SBE commitment (if applicable).

Ensuring the accurate completion of this Subcontractor Acknowledgment Form is the responsibility of the prospective prime contractor. Failure to complete this form and/or provide the information requested may result in your response being deemed non-responsive and rejected without any further evaluation.

Joseph.Theis Inserted Text 25-01937

Subcontractor Form (Non-Federally Funded Contract)

A separate subcontractor form must be completed by the prime contractor for each subcontractor and/or SBE supplier that will be working or otherwise participating on the prime contract by performing all or part of the work, and/or providing goods or services. Ensuring accurate completion of this subcontractor form is the responsibility of the prospective prime contractor. Duplicate this form as needed.

All sections must be completed; no fields should be left blank. If appropriate, enter "not applicable" or "N/A"

Note: Both the prime and subcontractor authorized representatives must sign this form.

Project & Prime Contractor Information Project Title:

WCAA SBE Cert# _____________

Certification & Signature Under penalty of perjury, I certify that:

1) I am authorized to execute this form on behalf of my firm;

2) I have conducted reasonable due diligence in collecting the information to be submitted on or with this form; and

3) I understand that this form contains material statements relied upon by the Airport Authority as a part of their decision-making process, and, based on my knowledge, the foregoing form does not contain any untrue information or omit any material fact necessary to make the information contained herein true and complete.

(if known)

1. Prime Contractor Name:

2. Subcontractor Name & Address:

3. WCAA SBE Consideration:

4. Subcontractor Primary Contact Name/Title:

5. Subcontractor Primary Contact Phone Number:

6. Subcontractor Owners/Partners/Corporate Director/Principal Stockholders(>5% stock holdings):

7. State relationship, if any, between Prime Contractor & Subcontractor:

8. Detailed description of the work to be performed by the Subcontractor:

9. Subcontract amount: 10. Percent of total contract:

Prime Contractor Authorized Representative - Printed Name Title Signature Date Subcontractor (First Tier) Subcontractor Name (First Tier)

Authorized Representative - Printed Name Title Signature Date

Subcontractor (Second Tier) Subcontractor Name (Second Tier)

Authorized Representative - Printed Name WCAA Subcontractor Form (Non-Federally Funded) - Revised 11/1/2018

Title Signature Date

(if applicable)

ATTACHMENTWAYNE COUNTY AIRPORT AUTHORITY