Compliance Forms Appendix C.pdf

SCHEDULE FOR PARTICIPATION

BY MINORITY/WOMEN BUSINESS ENTERPRISES

DCAMM Project Number_____________________________ Project Location___________________________________________

Project Name ________________________________________________________________________________________________

A. Filed Sub-bidders utilizing MBE/WBE firms, and MBE/WBE Sub-bidders - attach to Filed Sub-bid.

B. General Contractor must submit to the Compliance Office within five (5) working days of the opening of General Bids.

BIDDER CERTIFICATION:

The Bidder agrees that if awarded the contract it will expend at least the amount of the contract set forth below for MBE/WBE participation. For purposes of this commitment, the MBE and WBE designation means that a business has been certified by SDO as either a MBE, WBE or M/WBE, see Article XIII of the Contract. The Bidder must indicate the MBE/WBE firms it intends to utilize on the project as follows (attach additional sheets if necessary):

Company Name & Address

MBE

or

WBE

Describe MBE/WBE Scopes of Work (clarify “Labor Only”, “Material Only” or “Labor and Material”)

If Supplier, Indicate Total Value of Supplies (10% of total counts toward Participation)

Total Dollar Value of Participation

1.

2.

3.

4.

5.

6.

7.

8.

MBE Goal: $_________________ Total Dollar Value of MBE Commitment: $_______________

WBE Goal: $_________________ Total Dollar Value of WBE Commitment: $_______________

The undersigned hereby certifies that he/she has read the terms and conditions of the contract with regard to MBE/WBE participation and is authorized to bind the Bidder to the commitment set forth above.

Name of Firm__________________________________________ Authorized Signature_________________________________

Business Address_______________________________________ Print Name_________________________________________

_____________________________________________________ Title______________________________________________

Telephone No.__________________ Fax No.________________ Date ______________________________________________

Schedule for Participation – Revised 04/16

LETTER OF INTENT

MINORITY/WOMEN BUSINESS ENTERPRISES PARTICIPATION

(To be completed by MBE/WBE, and submitted by the General Bidder to the DCAMM Compliance Office within five (5) working days of the opening of General Bids or by Filed Sub-bidder with its bid.)

DCAMM Project Number________________________________________________ Indicate SDO Certification:

Project Name ________________________________________________________ ____ MBE

Project Location______________________________________________________ ____ WBE

To__________________________________________________________________ ____ M/WBE Name of General Bidder/ Sub-bidder

1. This firm intends to perform work in connection with the above project.

2. This firm is currently certified by SDO to perform the work identified below, and has not changed its minority/women ownership, control, or management without notifying SDO within thirty (30) days of such a change.

3. This firm understands that if the General Bidder/Sub-bidder referenced above is awarded the contract, the Bidder intends to enter into an agreement with this firm to perform the activity described below for the prices indicated. This firm also understands that the above-referenced firm, as General Bidder/Sub-bidder, will make substitutions only as allowed by Article XIII of the Contract.

4. This firm understands that under the terms of Article XIII of the contract, only work actually performed by an MBE/WBE will be credited toward MBE/WBE participation goals, and this firm cannot assign or subcontract out any of its work without prior written approval of the DCAMM Compliance Office, and that any such assignment or subcontracting will not be credited toward MBE/WBE participation goals.

MBE/WBE PARTICIPATION

Section/Item Number (if applicable)

Describe MBE/WBE Scopes of Work (clarify “Labor Only”, “Material Only” or “Labor and Material”)

If Supplier, Indicate Total Value of Supplies (10% of total counts toward Participation)

Dollar Value of Participation

Total Dollar Value: $_________________________________

Name of MBE/WBE Firm______________________________ Authorized Signature_________________________________

Business Address_____________________________________ Print Name_________________________________________

___________________________________________________ Title______________________________________________

Telephone No________________ Fax No._________________ Date______________________________________________

Letter of Intent – Revised 04/16

Revised 4/16

CERTIFICATE OF COMPLETION

BY MINORITY/WOMEN BUSINESS ENTERPRISE

DCAMM Project Number_____________________________Project Location ____________________________________________

Project Name ________________________________________________________________________________________________

Name of MBE/WBE Firm________________________ Address_______________________________________________________

Name of General Contractor______________________ Address________________________________________________________

DESCRIPTION OF WORK SELF-PERFORMED BY MBE/WBE SUBCONTRACTOR/SUBCONSULTANT

AS SHOWN IN LETTER OF INTENT

Original Subcontract Amount $_______________________________ Adjusted Subcontract Amount (Change Orders, etc.) $_______________________________ Total Payments Received to Date From Prime Contractor $_______________________________ Total Amount/Balance Due From Prime Contractor $_______________________________

If the work performed is different from that listed on the Letter of Intent, please explain:

(If more space is needed, continue on back of sheet)

The individuals signing below hereby certify under the pains and penalties of perjury that all work listed on the Contract Letter of Intent (or approved changes thereto as explained above) was self-performed by the undersigned MBE/WBE subcontractor in accord with Article XIII of the General Conditions of the Contract on ______________________, 20_____ and the above amounts listed for these services are true and accurate.

FOR GENERAL CONTRACTOR/LEAD DESIGNER FOR MBE/WBE SUBCONTRACTOR/SUBCONSULTANT

Authorized Signature_________________________________ Authorized Signature_________________________________

Print Name ________________________________________ Print Name_________________________________________

Title______________________________________________ Title______________________________________________

Date________________ Telephone No.__________________ Date________________ Telephone No. _________________

NOTE: To be submitted to the DCAMM Compliance Office within ten (10) days after completion of work by MBE/WBE.

Division of Capital Asset Management and Maintenance Contract Compliance Office One Ashburton Place, 15th Floor Boston, MA 02108

INSTRUCTIONS FOR COMPLETING M/WBE

CERTIFICATES OF PAYMENT

Payments made to certified M/WBE subcontractors on all DCAMM projects must be submitted to the Compliance Office. If the project is complete or on hold, or your firm previously submitted a final certification of M/WBE payments for this project, please indicate that on the form. This information is due to DCAMM Compliance Office within the quarter upon commencement of the contract and no later than 10 business days after a quarter expires even if payments have not been made to an MBE/WBE and marked as such. THE COMPLIANCE

OFFICE WILL RETURN ANY CERTIFICATES OF PAYMENT THAT ARE INCOMPLETE.

• Include only M/WBE sub-contractors listed on the projects approved Schedule of Participation. Any change in

MBE/WBE participation must be pre-approved by the Compliance Office. A revised M/WBE Schedule of Participation will be required.

• Include a brief description of the work performed by each subcontractor. The description should match the M/WBE Letter of Intent and approved Schedule of Participation. M/WBEs must be certified by the Supplier Diversity Office (formerly known as SOMWBA) in the category of work performed. Attach a separate sheet if necessary.

• Include the subcontract amounts listed on the M/WBE Letters of Intent and approved Schedule of Participation. If the value of a M/WBE subcontract has decreased for any reason, you must contact the Compliance Officer immediately.

• Include the amount you paid the subcontractor, either directly or indirectly, for the month covered by this Certificate of Payment. If the amount paid was zero, please indicate that. Do not include payments from previous periods or estimated future payments. You may be required to submit copies of cancelled checks to verify the amounts reported.

• Include the total amount you paid the subcontractor to date for work performed. This amount should match all payments made during the period, as well as, all payments from previous periods. The Compliance Office will verify the total amount reported against any payments previously reported. To ensure accurate reporting, please review the prior Certificates of Payments you submitted for this project. If any mathematical or reporting errors occurred please correct them and submit revised Certificates of Payment.

• For your convenience you can either email (cop.dcam@state.ma.us), fax (617) 727-8284 or mail back to DCAMM’s Compliance Office at 1 Ashburton Place, 16th Floor, Boston, MA 02108.

THANK YOU FOR SUPPORTING THE COMMONWEALTH’S SUPPLIER

DIVERSITY PROGRAM.

mailto:cop.dcam@state.ma.us

NOTICE: Intentionally submitting false information in this document may subject the contractor/designer to criminal prosecution and/or debarment from public contracting revised: 1/2013

CONTRACTOR/DESIGNER CERTIFICATION OF PAYMENT TO

MINORITY & WOMEN BUSINESS ENTERPRISES

TO: Division of Capital Asset Management and Maintenance Reporting FY___ Qtr.___ Office of Contract Compliance Period One Ashburton Place, 16th FL Contract Date:

Boston MA 02108

ATTN:_________________

Compliance Officer Construction Contract

RE: MA State Project:

The undersigned hereby certifies under the pains and penalties of perjury that the Contractor/Designer named below has made the following payment to the named Minority/Women Business Enterprises for work performed on the above named Project:

MBE/WBE Firm Name Work Performed Subcontract Payments Cumulative Amount This QTR Payments

□MBE

□WBE__________________________________________$__________________$_______________$_______________

□MBE

□WBE__________________________________________$__________________$_______________$_______________

□MBE

□WBE__________________________________________$__________________$_____________ $__ ____________

□MBE

□WBE__________________________________________$__________________$______________ $_______________

□MBE

□WBE__________________________________________$__________________$______________ $_______________

MBE /WBE payment reports are required for each quarter of the Commonwealths fiscal year for each of your DCAMM projects. Reports are to cover the following three month periods: 1st quarter, July 1st – September 30th; 2nd quarter, October 1st – December 31st; 3rd quarter, January 1st – March 31st; 4th quarter, April 1st – June 30th.

Date Submitted:______________________________ __________________________________________ General Contractor

Telephone NO.:______________________________ __________________________________________ Authorized Signature

Fax No/Email:________________________________ __________________________________________ Print Name & Title

Blank COP Construction