ATTACHMENT E - MBE Forms.pdf

ATTACHMENT E - MBE Forms

E1 - MBE Utilization Affidavit

E2 - MBE Participation Schedule

E3 - Outreach Efforts Compliance Statement

E4 - Subcontractor Project Participation Statement

E5 - Prime Contractor Unpaid MBE Invoice Report

E6 - Subcontractor Paid/Unpaid MBE Invoice Report

MBE FORM E1

PRINCE GEORGE’S COMMUNITY COLLEGE

MINORITY BUSINESS ENTERPRISE UTILIZATION AFFIDAVIT

To Be Provided with the Bid

I hereby declare and affirm that I am the (Title) and the duly authorized representative of

(Name of Bidder)

1. I further declare and affirm that the Bidder acknowledges the Minority Business Enterprise participation goal of not less than percent of the total Contract amount and commits to make a good faith effort to achieve the goal.

Therefore, I will not be seeking a waiver pursuant to MBE provisions included in this solicitation.

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, I will submit all required waiver documentation in accordance with the provisions included in the solicitation or as requested by the College later.

2. If requested and/or required under this solicitation by PGCC to submit an MBE Participation Schedule with our firm’s Technical Proposal, I acknowledge that I will/have identified the MBE’s that meet the College’s MBE status and goal requirements, per the solicitation documents.

3. I understand that if I am notified that I am the apparent awardee, I must submit the following additional documentation within 10 working days of receiving notice of the potential award or from the date of conditional award, whichever is earlier.

(a) Outreach Efforts Compliance Statement (E-3 Form)

(b) Subcontractor Project Participation Statement (E-4Form)

(c) Any other documentation, including waiver documentation, if applicable, required by the Procurement Officer to ascertain bidder or offeror responsibility in connection with the certified MBE participation goal.

I understand that if I fail to return each completed document within the required time, the Procurement Officer may determine that I am not responsible and therefore not eligible for Contract award. If the Contract has already been awarded, the award is voidable.

4. In the solicitation of Subcontract quotations or offers, MBE Subcontractors were provided (or will be provided) not less than the same information and amount of time to respond as were (are) non-MBE Subcontractors.

5. I understand that my failure to comply with the requirements of this solicitation and the Contract may result in my being assessed liquidated damages as stated in the Contract issued with this solicitation.

6. I solemnly affirm under the penalties of perjury that the contents of this paper are true to the best of my knowledge, information, and belief.

Printed Name Signature

Firm Address

Date Date

SUBMIT THIS AFFIDAVIT WITH INITIAL BID

MBE FORM E2

MBE Participation Schedule

To Be Provided with the Price Proposal

This document must be included with the bid or Price Proposal offer. If the Offeror fails to submit this form with the bid or Price Proposal offer as required, the Procurement Officer shall deem the bid non-responsive or shall determine that the Offer is not reasonably susceptible of being selected for award.

Prime Contractor (Firm Name, Address, Phone Project Description

Project Number Total Contract Amount $

List Information For Each Certified MBE Subcontractor On This Project Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

USE THE ATTACHED CONTINUATION PAGE AS NEEDED

SUMMARY

TOTAL MBE PARTICIPATION: % $

TOTAL AFRICAN-AMERICAN MBE PARTICIPATION: % $

TOTAL ASIAN-AMERICAN MBE PARTICIPATION: % $

TOTAL HISPANIC-AMERICAN MBE PARTICIPATION: % $

TOTAL WOMAN-OWNED MBE PARTICIPATION: % $

TOTAL OTHER MBE PARTICIPATION: % $

Name: Title:

Document Prepared By: (print or type)

MBE Participation Schedule, continued

List Information For Each Certified MBE Subcontractor On This Project Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

Minority Firm Name MBE Certification Number

Work To Be Performed

Dollar Amount or Percentage of Total Contract

MBE FORMS E3 and E4

ARE TO BE

SUBMITTED ONLY IF THE FIRM PROGRESSES IN THE

PROCUREMENT PROCESS AS APPLICABLE.

IF OFFEROR IS NOTIFIED AS THE APPARENT AWARDEE:

MBE FORM E3

OUTREACH EFFORTS COMPLIANCE STATEMENT

Complete and submit this form within 10 working days of notification of apparent award or actual award, whichever is earlier, unless modified by the College, at a later date.

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

1. Bidder/Offeror identified 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 conference.

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

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

Company Name Signature of Representative

Address Printed Name and Title

City, State and Zip Code Date

IF BIDDER IS NOTIFIED AS THE APPARENT AWARDEE

MBE FORM E4

SUBCONTRACTOR PROJECT PARTICIPATION STATEMENT

Please complete and submit one form for each MBE listed in the Bid within 10 working days of notification of apparent award, unless modified by the College, at a later date.

Prime Contractor Address and Phone Project Description

Project Number Total Contract Amount $

Minority Firm Name MBE Certification Number

Description of MBE’s Work to Be Performed

Percentage of Total Contract

Type of Bonds Required of MBE, if any and amounts:

Provided that (Prime Contractor Name) is awarded the Contract in conjunction with the Solicitation described above , it and (Subcontractor Name) intend to enter into a Contract by which Subcontractor shall provide the services described above.

The undersigned Prime Contractor and Subcontractor hereby certify and agree that they have fully complied with the College’s Minority Business Enterprise requirements, which provides that, except as otherwise provided or modified by the College, a Contractor may not identify a minority business enterprise in a bid or proposal and:

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

(2) fail to notify the minority business enterprise before execution of the Contract of its inclusion of the bid o/r proposal;

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

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

Both parties signing below understand that failure to comply with the requirements of the College may result in both parties being assessed liquidated damages as stated in the Contract issued with the solicitation. Both parties affirm that this is a Contractual requirement for both the Prime Contractor and the MBE Subcontractor.

Prime Contractor Signature Subcontractor Signature

Print Title Print Title

Date: Date:

MBE FORMS E5 AND E6 THAT FOLLOW ARE TO BE USED

TO REPORT PAYMENTS/NON-PAYMENTS

MBE FORM E5 (Sample)

Minority Business Enterprise Participation Prime Contractor Unpaid MBE Invoice Report

Report #:

Reporting Period (Month/Year):

Report is due by the 15th of the following month, or as requested by the College.

Contracting Unit:

Contract Amount:

MBE Subcontract Amt:

Project Begin Date:

Project End Date:

Services Provided:

Prime Contractor: Contact Person:

Address:

City: State: ZIP:

Phone: FAX:

Subcontractor Name: Contact Person:

Phone: FAX:

Subcontractor Services Provided:

List all unpaid invoices over 30 days old received from the MBE Subcontractor named above:

1.

2.

3.

Total Dollars Unpaid: $

**If more than one MBE Subcontractor is used for this Contract, please use separate forms.

Return one copy (hard or electronic) of this form to the following address (electronic copy is preferred):

Signature: Date:

Contact person:

Dept:

E-mail:

MBE FORM E6 (Sample)

Minority Business Enterprise Participation Subcontractor Paid/Unpaid MBE Invoice Report

Report#:

Reporting Period (Month/Year):

Report is due by the 15th of the following month, or as requested by the College.

Contracting Unit:

Contract/PO Amount:

MBE Subcontract Amount:

Project Begin Date:

Project End Date:

Services Provided:

MBE Subcontractor Name:

MDOT Certification #:

Contact Person:

Address:

City: State: ZIP:

Phone: FAX:

Subcontractor Services Provided:

List all payments received from Prime Contractor List dates and amounts of any unpaid during reporting period indicated above. invoices over 30 days old.

1. 1.

2. 2.

3. 3.

Total Dollars Paid: $ Total Dollars Unpaid:

Prime Contractor: Contact Person:

Return one copy (hard or electronic) of this form to the following address (electronic copy is preferred):

Signature: Date

Contact Person:

Dept.:

E-mail: