Attachment D - MBE FORMS.pdf

MDOT-OP 012-2 (9/11) (Revised 10/08/20)

MDOT MBE FORM A

STATE-FUNDED CONTRACTS

CERTIFIED MBE UTILIZATION AND FAIR SOLICITATION AFFIDAVIT

THIS AFFIDAVIT MUST BE INCLUDED WITH THE BID/PROPOSAL. IF THE BIDDER/OFFEROR FAILS TO ACCURATELY COMPLETE AND SUBMIT THIS AFFIDAVIT AS REQUIRED, THE BID SHALL BE DEEMED NOT

RESPONSIVE OR THE PROPOSAL NOT SUSCEPTIBLE OF BEING SELECTED FOR AWARD.

In connection with the bid/proposal submitted in response to Solicitation No. , I affirm the following:

1. MBE Participation (PLEASE CHECK ONLY ONE)

I have met the overall certified Minority Business Enterprise (MBE) participation goal of percent ( %) and the following subgoals, if applicable:

percent ( %) for African American-owned MBE firms percent ( %) for Hispanic American-owned MBE firms percent ( %) for Asian American-owned MBE firms percent ( %) for Women-owned MBE firms I agree that these percentages of the total dollar amount of the Contract, for the MBE goal and subgoals (if any), will be performed by certified MBE firms as set forth in the MBE Participation Schedule - Part 2 of the MDOT MBE Form B (State-Funded Contracts).

OR

I conclude that I am unable to achieve the MBE participation goal and/or subgoals. I hereby request a waiver, in whole or in part, of the overall goal and/or subgoals. Within 10 business days of receiving notice that our firm is the apparent awardee or as requested by the Procurement Officer, I will submit a written waiver request and all required documentation in accordance with COMAR

21.11.03.11. For a partial waiver request, I agree that certified MBE firms will be used to accomplish the percentages of the total dollar amount of the Contract, for the MBE goal and subgoals (if any), as set forth in the MBE Participation Schedule - Part 2 of the MDOT MBE Form B (State-Funded Contracts).

2. Additional MBE Documentation

I understand that if I am notified that I am the apparent awardee or as requested by the Procurement Officer, I must submit the following documentation within 10 business days of receiving such notice:

(a) Outreach Efforts Compliance Statement (MDOT MBE Form C - State-Funded Contracts);

(b) Subcontractor Project Participation Statement (MDOT MBE Form D - State-Funded Contracts);

(c) If waiver requested, MBE Waiver Request Documentation and Forms (MDOT MBE/DBE Form E – Good Faith Efforts Guidance and Documentation) per COMAR 21.11.03.11; and

(d) Any other documentation required by the Procurement Officer to ascertain bidder’s responsibility/ offeror’s susceptibility of being selected for award in connection with the certified MBE participation goal and subgoals, if any.

I acknowledge that if I fail to return each completed document (in 2 (a) through (d)) within the required time, the Procurement Officer may determine that I am not responsible and therefore not eligible for contract award or that the proposal is not susceptible of being selected for award.

MDOT-OP 012-2 (9/11) (Revised 10/08/20)

MDOT MBE FORM A

STATE-FUNDED CONTRACTS

CERTIFIED MBE UTILIZATION AND FAIR SOLICITATION AFFIDAVIT

3. Information Provided to MBE firms

In the solicitation of subcontract quotations or offers, MBE firms were provided not less than the same information and amount of time to respond as were non-MBE firms.

4. Products and Services Provided by MBE firms

I hereby affirm that the MBEs are only providing those products and services for which they are MDOT certified.

I solemnly affirm under the penalties of perjury that the information in this affidavit is true to the best of my knowledge, information and belief.

Company Name Signature of Representative

Address Printed Name and Title

City, State and Zip Code Date

MDOT-OP 013-2 (10/08/2020)

MDOT MBE FORM B

STATE-FUNDED CONTRACTS

PART 1 – INSTRUCTIONS FOR MBE PARTICIPATION SCHEDULE

PARTS 2 AND 3 MUST BE INCLUDED WITH THE BID/PROPOSAL. IF THE BIDDER/OFFEROR FAILS TO ACCURATELY COMPLETE AND SUBMIT PART 2 WITH THE BID/PROPOSAL AS REQUIRED, THE BID SHALL BE DEEMED NOT RESPONSIVE OR THE PROPOSAL SHALL BE DEEMED NOT SUSCEPTIBLE OF BEING SELECTED FOR AWARD.

PLEASE READ BEFORE COMPLETING THIS FORM

1. Please refer to the Maryland Department of Transportation (MDOT) MBE Directory at www.mdot.state.md.us to determine if a firm is certified for the appropriate North American Industry Classification System (“NAICS”) Code and the product/services description (specific product that a firm is certified to provide or specific areas of work that a firm is certified to perform). For more general information about NAICS, please visit www.naics.com. Only those specific products and/or services for which a prime or subcontractor is a certified MBE in the MDOT Directory can be used for purposes of achieving the MBE participation goals.

2. In order to be counted for purposes of achieving the MBE participation goals, the MBE firm (whether a prime or subcontractor) must be certified for that specific NAICS Code (“MBE” for State-funded projects designation after NAICS Code). WARNING: If the firm’s NAICS Code is in graduated status, such services/products will not be counted for purposes of achieving the MBE participation goals. Graduated status is clearly identified in the MDOT Directory (such graduated codes are designated with the word graduated after the appropriate NAICS Code).

3. Examining the NAICS Code is the first step in determining whether an MBE firm is certified and eligible to receive MBE participation credit for the specific products/services to be supplied or performed under the contract. The second step is to determine whether a firm’s Products/Services Description in the MBE Directory includes the products to be supplied and/or services to be performed that are being used to achieve the MBE participation goals. If you have any questions as to whether a firm is certified to perform the specific services or provide specific products, please contact MDOT’s Office of Minority Business Enterprise at 1-800-544-6056 or via email at mbe@mdot.state.md.us.

4. Complete the Part 2 – MBE Participation Schedule for all certified MBE firms (including primes and subcontractors) being used to achieve the MBE participation goal and subgoals, if any.

5. MBE Prime Self-Performance. When a certified MBE firm participates as a prime (independently or as part of a joint venture) on a contract, a procurement agency may count the distinct, clearly defined portion of the work of the contract that the certified MBE firm performs with its own forces toward fulfilling up to fifty-percent (50%) of the MBE participation goal (overall) and up to one hundred percent (100%) of not more than one of the MBE participation subgoals, if any, established for the contract. In order to receive credit for self-performance, an MBE prime must be (a) a certified MBE (see 1-3 above) and (b) listed in the Part 2 – MBE Participation Schedule with its certification number, the certification classification under which it will self-perform, and the percentage of the contract that can be counted as MBE self-performance. For the remaining portion of the overall goal and any subgoals, the MBE prime must also list, in the Part 2 – MBE Participation Schedule, other certified MBE firms used to meet those goals or, after making good faith efforts to obtain the participation of additional MBE firms, request a waiver. Note: A dually-certified MBE firm can use its own forces toward fulfilling ONLY ONE of the MBE subgoals for which it can be counted.

6. The Contractor’s subcontractors are considered second-tier subcontractors. Third-tier contracting used to meet an MBE goal is to be considered the exception and not the rule. The following two conditions must be met before MDOT, its Modal Administrations and the Maryland Transportation Authority may approve a third-tier contracting agreement: (a) the bidder/offeror must request in writing approval of each third-tier contract arrangement, and (b) the request must contain specifics as to why a third-tier contracting arrangement should be approved. These documents must be submitted with the bid/proposal in Part 2 of this MBE Participation Schedule.

7. For each MBE firm that is being used as a supplier/wholesaler/regular dealer/broker/manufacturer, please follow these instructions for calculating the amount of the subcontract for purposes of achieving the MBE participation goals:

A. Is the firm certified as a broker of the products/supplies? If the answer is YES, please continue to Item C. If the answer is NO, please continue to Item B.

B. Is the firm certified as a supplier, wholesaler, regular dealer, or manufacturer of such products/supplies? If the answer is

YES, continue to Item D. If the answer is NO, continue to Item C only if the MBE firm is certified to perform trucking/hauling services under NAICS Codes 484110, 484121, 484122, 484210, 484220 and 484230. If the answer is NO and the firm is not certified under these NAICS Codes, then no MBE participation credit will be given for the supply of these products.

http://www.mdot.state.md.us/ http://www.naics.com/

STATE-FUNDED CONTRACTS

C. For purposes of achieving the MBE participation goal, you may count only the amount of any reasonable fee that the MBE firm will receive for the provision of such products/supplies - not the total subcontract amount or the value (or a percentage thereof) of such products and/or supplies. For Column 3 of the MBE Participation Schedule, please divide the amount of any reasonable fee that the MBE firm will receive for the provision of such products/services by the total Contract value and insert the percentage in Line 3.1.

D. Is the firm certified as a manufacturer (refer to the firm’s NAICS Code and specific description of products/services) of the products/supplies to be provided? If the answer is NO, please continue to Item E. If the answer is YES, for purposes of achieving the MBE participation goal, you may count the total amount of the subcontract. For Column 3 of the MBE Participation Schedule, please divide the total amount of the subcontract by the total Contract value and insert the percentage in Line 3.1.

E. Is the firm certified as a supplier, wholesaler and/or regular dealer? If the answer is YES and the MBE firm is furnishing and installing the materials and is certified to perform these services, please divide the total subcontract amount (including full value of supplies) by the total Contract value and insert the percentage in Line 3.1. If the answer is YES and the MBE firm is only being used as a supplier, wholesaler and/or regular dealer or is not certified to install the supplies/materials, for purposes of achieving the MBE participation goal, you may only count sixty percent (60%) of the value of the subcontract for these supplies/products (60% Rule). To apply the 60% Rule, first divide the amount of the subcontract for these supplies/products only (not installation) by the total Contract value. Then, multiply the result by sixty percent (60%) and insert the percentage in Line 3.2.

8. For each MBE firm that is not being used as a supplier/wholesaler/regular dealer/broker/manufacturer, to calculate the amount of the subcontract for purposes of achieving the MBE participation goals, divide the total amount of the subcontract by the total Contract value and insert the percentage in Line 3.1.

Example: $ 2,500 (Total Subcontract Amount) ÷ $10,000 (Total Contract Value) x 100 = 25%

9. WARNING: The percentage of MBE participation, computed using the percentage amounts determined per Column 3 for all of the

MBE firms listed in Part 2, MUST at least equal the MBE participation goal and subgoals (if applicable) as set forth in MDOT MBE Form A – State-Funded Contracts for this solicitation. If a bidder/offeror is unable to achieve the MBE participation goal and/or any subgoals (if applicable), then the bidder/offeror must request a waiver in Form A or the bid will be deemed not responsive, or the proposal not susceptible of being selected for award. You may wish to use the attached Goal/Subgoal Worksheet to assist you in calculating the percentages and confirming that you have met the applicable MBE participation goal and subgoals (if any).

GOAL/SUBGOAL PARTICIPATION WORKSHEET

1. Complete the Part 2 – MBE Participation Schedule for each MBE being used to meet the MBE goal and any subgoals.

2. After completion of the Part 2 – MBE Participation Schedule, you may use the Goal/Subgoal Worksheet to calculate the total MBE participation commitment for the overall goal and any subgoals.

3. MBE Overall Goal Participation Boxes: Calculate the total percentage of MBE participation for each MBE classification by adding the percentages determined per Column 3 of the Part 2 – MBE Participation Schedule. Add the percentages determined in Lines

3.1 and 3.2 for the MBE subcontractor (subs) total. Add the overall participation percentages determined in Line 3.3 for the MBE prime total.

4. MBE Subgoal Participation Boxes: Calculate the total percentage of MBE participation for each MBE classification by adding the percentages determined per Column 3 of the Part 2 – MBE Participation Schedule. Add the percentages determined in Lines 3.1 and 3.2 for the MBE subcontractor (subs) total. Add the subgoal participation percentages determined in Line 3.3 for the MBE prime total.

5. The percentage amount for the MBE overall participation in the Total MBE Firm Participation Box F1 should be equal to the sum of the percentage amounts in Boxes A through E of the MBE Overall Goal Participation Column of the Worksheet.

6. The percentage amount for the MBE subgoal participation in the Total MBE Firm Participation Box L should be equal to the sum of the percentage amounts in Boxes A through E of the MBE Subgoal Participation Column of the Worksheet.

GOAL/SUBGOAL WORKSHEET

MBE Classification MBE Overall Goal Participation

MBE Subgoal Participation

(A) Total African American Firm Participation (Add percentages determined for African American-Owned Firms per Column 3 of MBE Participation Schedule)

_________%subs

_________%prime

_________%subs

_________%prime

(B) Total Hispanic American Firm Participation (Add percentages determined for Hispanic American-Owned Firms per Column 3 of MBE Participation Schedule)

_________%subs

_________%prime

_________%subs

_________%prime

(C) Total Asian American Firm Participation (Add percentages listed for Asian American-Owned Firms per Column 3 of MBE Participation Schedule)

_________%subs

_________%prime

_________%subs

_________%prime

(D) Total Women-Owned Firm Participation (Add percentages determined for Women-Owned Firms per Column 3 of MBE Participation Schedule)

_________%subs

_________%prime

_________%subs

_________%prime

(E) Total for all other MBE Firms (Add percentages for firms listed as Other MBE Classification per Column 3 of the MBE Participation Schedule)

_________%subs

_________%prime

_________%subs

_________%prime

Total MBE Firm Participation (Add total percentages determined for all MBE Firms in each column of the Worksheet)

(F1)__________% (F2)__________%

STATE-FUNDED CONTRACTS

PART 2 – MBE PARTICIPATION SCHEDULE

PAGE __ OF ___

PARTS 2 AND 3 MUST BE INCLUDED WITH THE BID/PROPOSAL. IF THE BIDDER/OFFEROR FAILS TO ACCURATELY COMPLETE AND SUBMIT PART 2 WITH THE BID/PROPOSAL AS REQUIRED, THE BID SHALL BE DEEMED NOT RESPONSIVE OR THE PROPOSAL SHALL BE DEEMED NOT SUSCEPTIBLE OF BEING SELECTED FOR AWARD.

Prime Contractor Project Description Solicitation Number

LIST INFORMATION FOR EACH CERTIFIED MBE PRIME OR MBE SUBCONTRACTOR YOU AGREE TO USE TO ACHIEVE THE MBE

PARTICIPATION GOAL AND SUBGOALS, IF ANY. NOTE INSTRUCTIONS IN EACH COLUMN.

COLUMN 1 COLUMN 2 COLUMN 3 Unless the bidder/offeror requested a waiver in MDOT MBE Form A – State Funded Contracts for this solicitation, the cumulative MBE participation for all MBE firms listed herein must equal at least the MBE participation goal and subgoals (if applicable) set forth in Form A.

NAME OF MBE PRIME

OR MBE

SUBCONTRACTOR

AND TIER

CERTIFICATION NO. AND

MBE CLASSIFICATION

FOR PURPOSES OF ACHIEVING THE MBE PARTICIPATION GOAL AND

SUBGOALS, refer to Sections 5 through 8 in Part 1 - Instructions. State the percentage amount of the products/services in Line 3.1, except for those products or services where the MBE firm is being used as a wholesaler, supplier, or regular dealer. For items of work where the MBE firm is being used as a supplier, wholesaler and/or regular dealer, complete Line 3.2 using the 60% Rule. For items of work where the MBE firm is the prime, complete Line 3.3.

MBE Name:

Check here if MBE firm is a subcontractor and complete in accordance with Sections 6, 7, & 8 of Part 1 - Instructions. If this box is checked, complete 3.1 or

3.2 in Column C, whichever is appropriate.

firm is the prime contractor, including a participant in a joint venture, and self-performance is being counted pursuant to Section 5 of Part 1 - Instructions. If this box is checked, complete 3.3 in Column C.

firm is a third-tier contractor (if applicable).

Please submit written documents in accordance with Section 6 of Part 1 - Instructions

Certification Number:

(If dually certified, check only one box.)

African American-Owned

Hispanic American- Owned

Asian American-Owned

Women-Owned

Other MBE Classification

3.1. TOTAL PERCENTAGE TO BE PAID TO THE SUBCONTRACTOR (STATE

THIS PERCENTAGE AS A PERCENTAGE OF THE TOTAL CONTRACT

VALUE- EXCLUDING PRODUCTS/SERVICES FROM SUPPLIERS,

WHOLESALERS OR REGULAR DEALERS).

__________% (Percentage for purposes of calculating achievement of MBE Participation goal and subgoals, if any)

3.2 TOTAL PERCENTAGE TO BE PAID TO THE SUBCONTRACTOR FOR

ITEMS OF WORK WHERE THE MBE FIRM IS BEING USED AS A SUPPLIER,

WHOLESALER AND/OR REGULAR DEALER) (STATE THE PERCENTAGE AS

A PERCENTAGE OF THE TOTAL CONTRACT VALUE AND THEN APPLY THE

60% RULE PER SECTION 7(E) IN PART 1 - INSTRUCTIONS).

_____________% Total percentage of Supplies/Products x _________60% (60% Rule)

__________% (Percentage for purposes of calculating achievement of MBE Participation goal and subgoals, if any)

3.3. TOTAL PERCENTAGE TO BE PAID TO MBE PRIME FOR WORK THAT

CAN BE COUNTED AS MBE SELF-PERFORMANCE (STATE THIS

PERCENTAGE AS A PERCENTAGE OF THE TOTAL CONTRACT VALUE)..

(a) ____________% Total percentage for self-performed items of work in which MBE is certified)

(b) ____________% (Insert 50% of MBE overall goal)

(c) ____________% (Insert subgoal for classification checked in Column 2, if applicable)

Percentages for purposes of calculating achievement of MBE Participation goals:

For MBE Overall goal – Use lesser of (a) or (b) For MBE Subgoal – Use lesser of (a) or (c) If MBE Prime is supplier, wholesaler and/or regular dealer, apply the 60% rule.

Check here if Continuation Sheets are attached.

STATE-FUNDED CONTRACTS

PART 2 – MBE PARTICIPATION SCHEDULE

CONTINUATION SHEET

PAGE __ OF ___

Prime Contractor Project Description Solicitation Number

LIST INFORMATION FOR EACH CERTIFIED MBE PRIME OR MBE SUBCONTRACTOR YOU AGREE TO USE TO ACHIEVE THE MBE

PARTICIPATION GOAL AND SUBGOALS, IF ANY. NOTE INSTRUCTIONS IN EACH COLUMN.

COLUMN 1 COLUMN 2 COLUMN 3 Unless the bidder/offeror requested a waiver in MDOT MBE Form A – State Funded Contracts for this solicitation, the cumulative MBE participation for all MBE firms listed herein must equal at least the MBE participation goal and subgoals (if applicable) set forth in Form A.

NAME OF MBE PRIME

OR MBE

SUBCONTRACTOR

AND TIER

CERTIFICATION NO. AND

MBE CLASSIFICATION

FOR PURPOSES OF ACHIEVING THE MBE PARTICIPATION GOAL AND

SUBGOALS, refer to Sections 5 through 8 in Part 1 - Instructions. State the percentage amount of the products/services in Line 3.1, except for those products or services where the MBE firm is being used as a wholesaler, supplier, or regular dealer. For items of work where the MBE firm is being used as a supplier, wholesaler and/or regular dealer, complete Line 3.2 using the 60% Rule. For items of work where the MBE firm is the prime, complete Line 3.3.

MBE Name:

firm is a subcontractor and complete in accordance with Sections 6, 7, & 8 of Part 1 - Instructions. If this box is checked, complete 3.1 or

3.2 in Column C, whichever is appropriate.

firm is the prime contractor, including a participant in a joint venture, and self-performance is being counted pursuant to Section 5 of Part 1 - Instructions. If this box is checked, complete 3.3 in Column C.

firm is a third-tier contractor (if applicable).

Please submit written documents in accordance with Section 6 of Part 1 - Instructions

Certification Number:

(If dually certified, check only one box.)

African American-Owned

Hispanic American- Owned

Asian American-Owned

Women-Owned

Other MBE Classification

3.1. TOTAL PERCENTAGE TO BE PAID TO THE SUBCONTRACTOR (STATE

THIS PERCENTAGE AS A PERCENTAGE OF THE TOTAL CONTRACT

VALUE- EXCLUDING PRODUCTS/SERVICES FROM SUPPLIERS,

WHOLESALERS OR REGULAR DEALERS).

__________% (Percentage for purposes of calculating achievement of MBE Participation goal and subgoals, if any)

3.2 TOTAL PERCENTAGE TO BE PAID TO THE SUBCONTRACTOR FOR

ITEMS OF WORK WHERE THE MBE FIRM IS BEING USED AS A SUPPLIER,

WHOLESALER AND/OR REGULAR DEALER) (STATE THE PERCENTAGE AS

A PERCENTAGE OF THE TOTAL CONTRACT VALUE AND THEN APPLY THE

60% RULE PER SECTION 7(E) IN PART 1 - INSTRUCTIONS).

_____________% Total percentage of Supplies/Products x _________60% (60% Rule)

__________% (Percentage for purposes of calculating achievement of MBE Participation goal and subgoals, if any)

3.3. TOTAL PERCENTAGE TO BE PAID TO MBE PRIME FOR WORK THAT

CAN BE COUNTED AS MBE SELF-PERFORMANCE (STATE THIS

PERCENTAGE AS A PERCENTAGE OF THE TOTAL CONTRACT VALUE)..

(a) ____________% Total percentage for self-performed items of work in which MBE is certified)

(b) ____________% (Insert 50% of MBE overall goal)

(c) ____________% (Insert subgoal for classification checked in Column 2, if applicable)

Percentages for purposes of calculating achievement of MBE Participation goals:

For MBE Overall goal – Use lesser of (a) or (b) For MBE Subgoal – Use lesser of (a) or (c) If MBE Prime is supplier, wholesaler and/or regular dealer, apply the 60% rule.

Check here if Continuation Sheets are attached.

PART 3 – CERTIFICATION FOR MBE PARTICIPATION SCHEDULE

PARTS 2 AND 3 MUST BE INCLUDED WITH THE BID/PROPOSAL

AS DIRECTED IN THE INVITATION TO BID/ REQUEST FOR PROPOSALS.

I hereby affirm that I have reviewed the Products and Services Description (specific product that a firm is certified to provide or areas of work that a firm is certified to perform) set forth in the MDOT MBE Directory for each of the MBE firms listed in Part 2 of this MBE Form B for purposes of achieving the MBE participation goals and subgoals that were identified in the MBE Form A that I submitted with this solicitation, and that the MBE firms listed are only performing those products/services/areas of work for which they are certified. I also hereby affirm that I have read and understand the form instructions set forth in Part 1 of this MBE Form B.

The undersigned Prime Contractor hereby certifies and agrees that they have fully complied with the State Minority Business Enterprise law, State Finance and Procurement Article §14-308(a)(2), Annotated Code of Maryland which provides that, except as otherwise provided by law, a contractor may not identify a certified minority business enterprise in a bid or proposal and:

(1) fail to request, receive, or otherwise obtain authorization from the certified minority business enterprise to identify the certified minority business enterprise in its bid or proposal;

(2) fail to notify the certified minority business enterprise before execution of the contract of its inclusion of the bid or proposal;

(3) fail to use the certified minority business enterprise in the performance of the contract; or

(4) pay the certified minority business enterprise solely for the use of its name in the bid or proposal.

I solemnly affirm under the penalties of perjury that the contents of Parts 2 and 3 of MDOT MBE Form B are true to the best of my knowledge, information and belief.

MDOT-OP 014-2 (10/08/2020)

MDOT MBE FORM C

STATE-FUNDED CONTRACTS

OUTREACH EFFORTS COMPLIANCE STATEMENT

In conjunction with the offer/proposal submitted in response to Solicitation No.___________, I state the following:

1. Bidder/Offeror took the following efforts to identify subcontracting opportunities in these specific work categories:

2. Attached to this form are copies of written solicitations (with bidding/proposal instructions) used to solicit certified MBE firms for these subcontract opportunities.

3. Bidder/Offeror made the following attempts to personally contact the solicited MBE firms:

4. Please Check One:

□ This project does not involve bonding requirements.

□ Bidder/Offeror assisted MBE firms to fulfill or seek waiver of bonding requirements. (DESCRIBE

EFFORTS)

5. Please Check One:

□ Bidder/Offeror did attend the pre-bid/pre-proposal meeting/conference.

□ No pre-bid/pre-proposal meeting/conference was held.

□ Bidder/Offeror did not attend the pre-bid/pre-proposal meeting/conference.

MDOT-OP 015-2 (10/08/2020)

MDOT MBE FORM D

STATE-FUNDED CONTRACTS

MBE SUBCONTRACTOR PROJECT PARTICIPATION AFFIDAVIT

IF THE BIDDER/OFFEROR FAILS TO RETURN THIS AFFIDAVIT WITHIN THE REQUIRED TIME, THE PROCUREMENT OFFICER MAY DETERMINE THAT THE BIDDER/OFFEROR IS NOT RESPONSIBLE AND THEREFORE NOT ELIGIBLE FOR CONTRACT AWARD OR THAT THE PROPOSAL IS NOT SUSCEPTIBLE OF BEING SELECTED FOR AWARD. SUBMIT ONE FORM FOR EACH CERTIFIED MBE FIRM LISTED IN THE MBE PARTICIPATION SCHEDULE. BIDDERS/OFFERORS

ARE HIGHLY ENCOURAGED TO SUBMIT FORM D PRIOR TO THE TEN (10) DAY DEADLINE.

Provided that _________________________________________________ (Prime Contractor’s Name) is awarded the Contract in conjunction with Solicitation No. _______________________, such Prime Contractor will enter into a subcontract with ____________________(Subcontractor’s Name) committing to participation by the MBE firm ___________________ (MBE Name) with MDOT Certification Number _______________ (if subcontractor previously listed is also the MBE firm, please restate name and provide MBE Certification Number) which will receive at least $___________ (Total Subcontract Amount) which is ___% (Percent) of the Total Contract Value, for performing the following products/services for the Contract:

NAICS CODE WORK ITEM, SPECIFICATION NUMBER,

LINE ITEMS OR WORK CATEGORIES (IF

APPLICABLE)

DESCRIPTION OF SPECIFIC PRODUCTS AND/OR

SERVICES

I solemnly affirm under the penalties of perjury that the information provided in this MBE Subcontractor Project Participation Affidavit is true to the best of my knowledge, information, and belief. I acknowledge that, for purposes of determining the accuracy of the information provided herein, the Procurement Officer may request additional information, including, without limitation, copies of the subcontract agreements and quotes.

PRIME CONTRACTOR

Signature of Representative:

Printed Name and Title: _______________

Firm’s Name: _______________________

Federal Identification Number: __________

Address: ___________________________

Telephone: _________________________

Date: _____________________________

SUBCONTRACTOR (SECOND-TIER)

Signature of Representative:

Printed Name and Title: _______________

Firm’s Name: ________________________

Federal Identification Number: __________

Address: ___________________________

Telephone: _________________________

Date: ______________________________

SUBCONTRACTOR (THIRD-TIER)

Signature of Representative:

Printed Name and Title: _______________

Firm’s Name: ________________________

Federal Identification Number: __________

Address: ___________________________

Telephone: _________________________

Date: ______________________________

IF MBE FIRM IS A THIRD-TIER SUBCONTRACTOR, THIS FORM MUST ALSO BE EXECUTED BY THE SECOND-TIER

SUBCONTRACTOR THAT HAS THE SUBCONTRACT AGREEMENT WITH THE MBE FIRM.