Enclosure G - Exhibit G-6 Supplier Compliance and Payment Report.pdf

OFFICE OF CONTRACTOR AND SUPPLIER DIVERSITY

Exhibit G-6 MWBE AND SDVOB COMPLIANCE AND PAYMENT REPORT

CONTRACTOR/GRANTEE:

ADDRESS:

TOWN/COUNTY/ZIP:

CONTACT PERSON:

TELEPHONE:

EMAIL:

ESD OCSD REPRESENTATIVE:

CONTRACT/PROJECT NAME:

CONTRACT/PROJECT #:

PROJECT START DATE:

PERCENT COMPLETE:

ACTUAL COMPLETION DATE:

REPORTING PERIOD: Monthly for the Month of: (Month) (Year) Quarterly (Check Applicable): Quarter 1 (4/1-6/30) | Quarter 2 (7/1-9/30) | Quarter 3 (10/1-12/31) | Quarter 4 (1/1-3/31)

Attach MWBE and SDVOB executed contracts, wire transfer confirmations and cancelled checks as proof of payment to the identified MWBEs and SDVOBs. This report should be completed and signed by an officer of the Reporting Company. Attach additional sheets if necessary.

PRIME CONTRACTOR, if different from above

(Name, Address, Contact Person, Title and Phone # with area code)

PRIME

CONTRACT

AMOUNT

MWBE or SDVOB

SUBCONTRACTOR

(Name, Address, Contact Person, Title and Phone

# with area code)

NYS

CERTIFICATION

(Check One)

DESCRIPTION OF

SERVICES

CONTRACT

AMOUNT

PAYMENTS

PREVIOUSLY

REPORTED

PAYMENTS

ON

CURRENT

REPORT

TOTAL

PAYMENTS

TO DATE

MBE WBE

SDVOB

CERTIFICATION: I, (Print Name), the (Title) of the Reporting Company above, do certify that (i) I have read this Compliance Report and (ii) to the best of my knowledge, information and belief, the information contained herein is complete and accurate.

SIGNATURE: DATE:

Submission of this form constitutes the Contractor’s acknowledgement as to the accuracy of the information contained herein. Failure to submit complete and accurate information may result in a finding of noncompliance, non-responsibility, suspension and/or termination of the Contract.

OFFICE OF CONTRACTOR AND SUPPLIER DIVERSITY

Exhibit G-6 MWBE AND SDVOB COMPLIANCE AND PAYMENT REPORT

SUBMIT REPORT TO: Office of Contractor and Supplier Diversity Empire State Development 633 Third Avenue, 35th Floor New York, NY 10017

Completed forms may be emailed directly to OCSD at ocsd@esd.ny.gov. All email submissions must include ESD’s project/contract number(s), and the name and contact information of the individual or firm submitting the information.

QUESTIONS? Please contact the OCSD’s Compliance Managers or email the office at ocsd@esd.ny.gov.

Danielle Adams Danah Alexander Geraldine Ford Denise Ross Jordan Lopez Jazmin Thomas

(518) 292-5187 (212) 803-3244 (716) 846-8205 (212) 803-3226 (212) 803-3109 (212) 803-3571 Danielle.Adams@esd.ny.gov Danah.Alexander@esd.ny.gov Geraldine.Ford@esd.ny.gov Denise.Ross@esd.ny.gov Jordan.Lopez@esd.ny.gov Jazmin.Thomas@esd.ny.gov

R E G I O N S :

Capital District North Country Finger Lakes Mid-Hudson Central NY ESD Procurement Mohawk Valley NYC- Brooklyn, Bronx, Western New York NYC- Manhattan, Southern Tier Contracts SUNY Poly Portfolio Queens ESD Subsidiaries – Staten Island ESD Subsidiary – ESD Subsidiaries – CCDC, Department of Economic Development

Long Island ESD Subsidiaries – HCDC, MSDC

ECHDC, USA Niagara AYCDC QWDC, LMDC, ESNMC mailto:ocsd@esd.ny.gov mailto:ocsd@esd.ny.gov mailto:Danielle.Adams@esd.ny.gov mailto:Danah.Alexander@esd.ny.gov mailto:Geraldine.Ford@esd.ny.gov mailto:Denise.Ross@esd.ny.gov mailto:Jordan.Lopez@esd.ny.gov mailto:Jazmin.Thomas@esd.ny.gov