Attachment E Investin MA Form~25.pdf

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Invest in Massachusetts ejrobbins D:20110524123954- 04'00' D:20110525082154- 04'00'

INVEST IN MASSACHUSETTS DATA FORM

Instructions: Completing all parts of this form is mandatory unless directed otherwise.

Part I Respondent Information

Business Name:

Full Address: number, street, and apt. or suite no., city, state, zip

Contact Name:

Phone # ( ) -

Email address:

Part II Invest in Massachusetts Data (Please respond to the inquiries (1‐3) listed below. If you answer "No" to Inquiry #1 of this Part II, then you are not required to complete Part III of this IMD Form).

1.

Will at least 50% or more of the work‐hours performed as a result of a contract arising out of this proposal be performed in Massachusetts?

Yes

No 2.

If you responded "Yes" to Inquiry #1, how many of those jobs performed in Massachusetts will be created and/or preserved as a result of a contract arising out of this proposal?

3.

If you responded "Yes" to Inquiry #1, where in Massachusetts will those jobs be located?

Part III

Certification Based on your responses in Part II of the IMD Form, those Respondents who have answered "Yes" to Inquiry #1 are required to certify the Respondent's commitment that 50% or more of the work‐hours performed in connection with any contractarising out of the Respondent's RFR Response will be performed in Massachusetts. This certification must be signed by an individualauthorized to bind the Respondent firm. Additionally, this commitment will be an essential part of any contract awarded by the MSBAand will be written into any formal agreement.

I, , hereby certify that the information contained in this IMD Form is true and accurate and

I hereby certify on behalf of

[Respondent Name] that, if awarded the contract, 50% or more of the work‐hours performed in connection with any agreement arising out of the Respondent's RFR Response, will be performed in theCommonwealth of Massachusetts.

Signed under the pains and penalties of perjury.

Print Name

Title

Authorized Signature ________________________________

Date

Will at least 50% or more of the work-hours performed as a result ofa contract arising outof this proposal be performed in

ATTACHMENT E