Attachment A Subcontractor Form.pdf

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 if a subcontractor is being utilized.

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.

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

Prime Contractor

Title Signature DateAuthorized Representative - Printed Name 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 9/24/2025

Title Signature Date

(if applicable)

ATTACHMENTWAYNE COUNTY AIRPORT AUTHORITY

Yes

No

Fill out 3-10 of this section for each subcontractor

Skip to "Certification & Signature" section

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 & Applicable NAICS Code(s):

1. Prime Contractor

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

Description: NAICS Code(s):

3. Subcontractor is a WCAA Certified SBE:

4. Subcontractor Name & Address:

5. Subcontractor Primary Contact Name/Title/Phone:

YesNo

Joseph.Theis Line

Joseph.Theis Line