Attachment-4.3-MWBE Subcontractors and Suppliers Notice-of-Intent-to-Participate.pdf

ATTACHMENT 4.3: MWBE SUBCONTRACTORS AND SUPPLIERS NOTICE OF INTENT TO PARTICIPATE

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES

INSTRUCTIONS: A separate Notice of Intent to Participate must be completed by each MWBE identified on the MWBE Utilization Plan (Form 4.2). Parts A & C must be completed by the Contractor and Part B must be completed by MBE and/or WBE subcontractors/suppliers. Signed and completed form(s) must be returned as part of your proposal.

PART A

Contractor Name: Federal Identification No.:

Address: Telephone No.:

City, State, Zip Code: Email Address:

PART B

THE UNDERSIGNED INTENDS TO PROVIDE SERVICES OR SUPPLIES IN CONNECTION WITH THE ABOVE PROCUREMENT:

Name of MWBE: Federal Identification No.:

Address: Telephone No.:

City, State, Zip Code: Email Address:

DESCRIPTION OF SERVICES OR SUPPLIES:

DESIGNATION: MBE Subcontractor WBE Subcontractor MBE Supplier WBE Supplier

PART C

WAIVER Requested: MBE: YES NO If YES, submit Attachment A-5.5. WBE: YES NO If YES, submit Attachment A-5.5.

THE QUALIFICATION OF THE UNDERSIGNED AS A MBE AND/OR WBE IS CONCONTRACTORED (CHECK ONE):

The undersigned is a certified MWBE by the New York State Department of Minority and Woman-Owned Business Development (MWBD) (copy of certifying letter attached).

The undersigned has applied to New York State’s Department of Minority and Woman-Owned Business Development (MWBD) for MWBE certification.

THE UNDERSIGNED IS PREPARED TO PROVIDE SERVICES OR SUPPLIES AS DESCRIBED ABOVE AND WILL ENTER INTO A FORMAL AGREEMENT WITH THE CONTRACTOR CONDITIONED UPON THE CONTRACTOR’S EXECUTION OF A CONTRACT WITH

THE DEPARTMENT OF THE BUDGET.

The estimated dollar amount of the agreement is: $

Signature of Authorized Representative of MWBE Contractor

Date:

Printed or Typed Name and Title of Authorized Representative of MWBE Contractor