Enclosure F - Exhibit G-4 Supplier Utilization Plan.pdf

OFFICE OF CONTRACTOR AND SUPPLIER DIVERSITY

Exhibit G-4 MWBE AND SDVOB UTILIZATION PLAN

INSTRUCTIONS: This form must be submitted with any bid, proposal, or proposed negotiated contract or within a reasonable time thereafter, but prior to contract award. This MWBE and SDVOB Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (M/WBE) and/or Service Disabled Veteran Owned Business (SDVOB) under the contract. Attach additional sheets if necessary.

* indicates mandatory fields

*Contractor Name: Address:

*Representative Name: Town, State & Zip:

*Phone: *ESD Contract/Project Number:

*Fax: RFP/RFQ/Solicitation Number:

*Email: *MWBE Goal: MBE % + WBE % = MWBE GOAL %

*Total Dollar Value of Contract/Grant: $ *SDVOB Goal: %

1.

* Certified MWBE or SDVOB Firm Name, Contact Person’s Name, Address, Phone and Email.

2.

* Check All That Apply

3.

* Federal ID

No.

4.

*Detailed Description of

Work (Attach additional sheets, if necessary, Attach Contract if available)

5.

*Check Firm Type That

Applies for Work Completed on this

Project

6.

*Dollar Value of Contract

(if unavailable or yet undetermined, indicate

$1)

A.

NYS CERTIFIED

MBE

WBE

SDVOB

Subcontractor

Subconsultant

Materials Supplier

Trade Agents/Brokers

B. NYS CERTIFIED

MBE

WBE

SDVOB

Subcontractor

Subconsultant

Materials Supplier

Trade Agents/Brokers

OFFICE OF CONTRACTOR AND SUPPLIER DIVERSITY

Exhibit G-4 MWBE AND SDVOB UTILIZATION PLAN

7. If unable to fully meet the MWBE and/or SDVOB goals set forth in the contract, the Contractor must submit a Waiver Request form, which may be obtained from the Office of Contractor and Supplier Diversity, at OCSD@ESD.NY.GOV.

PREPARED BY (Signature): ______________________________ DATE: __________

Preparer’s Name (Print or Type): __________________________________________

Preparer’s Title: ___________________________________________

Date: ________________

SUBMISSION OF THIS FORM CONSTITUTES THE CONTRACTOR’S ACKNOWLEDGEMENT

AND AGREEMENT TO COMPLY WITH THE MWBE AND SDVOB REQUIREMENTS SET

FORTH UNDER NYS EXECUTIVE LAW ARTICLES 15-A AND 17-B, 5 NYCRR PART 143, 9

NYCRR PART 252, AND THE ABOVE-REFERENCED SOLICITATION. FAILURE TO SUBMIT

COMPLETE AND ACCURATE INFORMATION MAY RESULT IN A FINDING OF

NONCOMPLIANCE AND POSSIBLE TERMINATION OF YOUR CONTRACT.

The MWBE Certification status of the firms listed on this form MUST be verified using the New York State Contract System’s Directory of Certified Minority and Women-owned Business Enterprises.

This directory is available at https://ny.newnycontracts.com.

The SDVOB Certification status of the firms listed on this form MUST be verified using the Directory of New York State Certified Service-Disabled Veteran-Owned Businesses.

This directory is available at https://online.ogs.ny.gov/SDVOB/search.

TELEPHONE NO.:

EMAIL ADDRESS:

Policy Regarding Use of MWBE Suppliers and Brokers Only sums paid to MWBEs for the performance of a commercially useful function, as that term is defined in 5 NYCRR § 140.1, may be applied towards the achievement of the applicable MWBE participation goal.

FOR CONSTRUCTION/CAPITAL PROJECTS – The portion of a contract with an MWBE serving as a supplier that shall be deemed to represent the commercially useful function performed by the MWBE shall be 60% of the total value of the contract. The portion of a contract with an MWBE serving as a broker that shall be deemed to represent the commercially useful function performed by the MWBE shall be the monetary value for fees, or the markup percentage, charged by the

MWBE.

FOR ALL OTHER PROJECTS - The portion of a contract with an MWBE serving as a broker that shall be deemed to represent the commercially useful function performed by the MWBE shall be 25% of the total value of the contract.

** FOR OCSD USE ONLY **

REVIEWED BY: DATE:

UTILIZATION PLAN APPROVED?

YES PARTIAL NO Date:

mailto:OCSD@ESD.NY.GOV https://ny.newnycontracts.com/ https://online.ogs.ny.gov/SDVOB/search