Attachment D – MBE Forms Page D-1 effective date: February 5, 2021

Attachment D. Minority Business Enterprise (MBE) Forms

D-1A

MBE UTILIZATION AND FAIR SOLICITATION AFFIDAVIT

& MBE PARTICIPATION SCHEDULE

PART 1 - INSTRUCTIONS

PLEASE READ BEFORE COMPLETING THIS DOCUMENT

This form includes Instructions and the MBE Utilization and Fair Solicitation Affidavit & MBE Participation Schedule which must be submitted with the bid/proposal. If the bidder/offeror fails to accurately complete and submit this Affidavit and Schedule with the bid or proposal, the Procurement Officer shall deem the bid non-responsive or shall determine that the proposal is not reasonably susceptible of being selected for award unless the inaccuracy is determined to be the result of a minor irregularity that is waived or cured in accordance with COMAR 21.06.02.04.

1. Contractor shall structure its procedures for the performance of the work required in this Contract to attempt to achieve the minority business enterprise (MBE) subcontractor participation goal stated in the Invitation for Bids or Request for Proposals. Contractor agrees to exercise good faith efforts to carry out the requirements set forth in these Instructions, as authorized by the Code of Maryland Regulations (COMAR) 21.11.03.

2. MBE Goals and Subgoals: Please review the solicitation for information regarding the Contract’s MBE overall participation goals and subgoals. After satisfying the requirements for any established subgoals, the Contractor is encouraged to use a diverse group of subcontractors and suppliers from the various MBE classifications to meet the remainder of the overall MBE participation goal.

3. MBE means a minority business enterprise that is certified by the Maryland Department of Transportation (“MDOT”). Only MBEs certified by MDOT may be counted for purposes of achieving the MBE participation goals. In order to be counted for purposes of achieving the MBE participation goals, the MBE firm, including a MBE prime, must be MDOT-certified for the services, materials or supplies that it is committed to perform on the MBE Participation Schedule.

A firm whose MBE certification application is pending may not be counted.

4. Please refer to the MDOT MBE Directory at https://mbe.mdot.maryland.gov/directory/ to determine if a firm is certified with the appropriate North American Industry Classification System (“NAICS”) Code and the product/services description (specific product that a firm is certified to provide or specific areas of work that a firm is certified to perform). For more general information about NAICS codes, please visit https://www.census.gov/eos/www/naics/. Only those specific products and/or services for which a firm is certified in the MDOT Directory can be used for purposes of achieving the MBE participation goals. CAUTION: If the firm’s NAICS Code is in graduated status, such services/products may not be counted for purposes of achieving the MBE participation goals. A NAICS Code is in the graduated status if the term “Graduated” follows the Code in the MDOT MBE Directory.

5. Guidelines Regarding MBE Prime Self-Performance. Please note that when a certified MBE firm participates as a prime contractor on a Contract, a procurement agency may count the distinct, clearly defined portion of the work of the Contract that the certified MBE firm performs with its own workforce toward fulfilling up to, but no more than, fifty-percent (50%) of the overall

Attachment D – MBE Forms Page D-2 effective date: February 5, 2021

MBE participation goal, including up to one hundred percent (100%) of not more than one of the MBE participation subgoals, if any, established for the Contract.

✓ In order to receive credit for self-performance, an MBE prime must be certified in the appropriate NAICS code to do the work and must list its firm in the MBE Participation Schedule, including the certification category under which the MBE prime is self-performing and include information regarding the work it will self-perform.

✓ For the remaining portion of the overall goal and the remaining subgoals, the MBE prime must also identify on the MBE Participation Schedule the other certified MBE subcontractors used to meet those goals or request a waiver.

✓ These guidelines apply to the work performed by the MBE Prime that can be counted for purposes of meeting the MBE participation goals. These requirements do not affect the MBE Prime’s ability to self-perform a greater portion of the work in excess of what is counted for purposes of meeting the MBE participation goals.

✓ Please note that the requirements to meet the MBE participation overall goal and subgoals are distinct and separate. If the contract has subgoals, regardless of MBE Prime’s ability to self-perform up to 50% of the overall goal (including up to 100% of any subgoal), the MBE Prime must either commit to use other MBEs for each of any remaining subgoals or request a waiver. As set forth in Attachment 1-B Waiver Guidance, the MBE Prime’s ability to self-perform certain portions of the work of the Contract will not be deemed a substitute for the good faith efforts to meet any remaining subgoal or the balance of the overall goal.

✓ In certain instances where the percentages allocated to MBE participation subgoals add up to more than 50% of the overall goal, the portion of self-performed work that an MBE Prime may count toward the overall goal may be limited to less than 50%. Please refer to the Governor‘s Office of Small Minority & Women Business Affairs’ website for the MBE Prime Regulations Q&A for illustrative examples.

http://www.goMDsmallbiz.maryland.gov/Documents/MBE_Toolkit/MBEPrimeRegulatio n_QA.pdf

6. Subject to items 1 through 5 above, when a certified MBE performs as a participant in a joint venture, a procurement agency may count a portion of the total dollar value of the Contract equal to the distinct, clearly-defined portion of the work of the Contract that the certified MBE performs with its own forces toward fulfilling the Contract goal, and not more than one of the Contract subgoals, if any.

7. The work performed by a certified MBE firm, including an MBE prime, can only be counted towards the MBE participation goal(s) if the MBE firm is performing a commercially useful function on the Contract. Please refer to COMAR 21.11.03.12-1 for more information regarding these requirements.

8. Materials and Supplies: New Guidelines Regarding MBE Participation.

Regular Dealer (generally identified as a wholesaler or supplier in the MDOT Directory):

Up to 60% of the costs of materials and supplies provided by a certified MBE may be counted towards the MBE participation goal(s) if such MBE is a Regular Dealer of such materials and supplies. Regular Dealer is defined as a firm that owns, operates, or maintains a store, a warehouse, or any other establishment in which the materials, supplies, articles, or equipment are of the general character described by the specifications required under the contract and are bought, kept in stock, or regularly sold or leased to the http://www.gomdsmallbiz.maryland.gov/Documents/MBE_Toolkit/MBEPrimeRegulation_QA.pdf http://www.gomdsmallbiz.maryland.gov/Documents/MBE_Toolkit/MBEPrimeRegulation_QA.pdf

Attachment D – MBE Forms Page D-3 effective date: February 5, 2021 public in the usual course of business; and does not include a packager, a broker, a manufacturer’s representative, or any other person that arranges or expedites transactions.

Example for illustrative purposes of applying the 60% rule:

Overall contract value: $2,000,000 Total value of supplies: $100,000

Calculate Percentage of Supplies to overall contract value: $100,000 divided by $2,000,000 = 5%

Apply 60% Rule - Total percentage of Supplies/Products 5% x 60% = 3%

3% would be counted towards achieving the MBE Participation Goal and Subgoal, if any, for the MBE supplier in this example.

Manufacturer: A certified MBE firm’s participation may be counted in full if the MBE is certified in the appropriate NAICS code(s) to provide products and services as a manufacturer.

Broker: With respect to materials or supplies purchased from a certified MBE that is neither a manufacturer nor a regular dealer, a unit may apply the entire amount of fees or commissions charged for assistance in the procurement of the materials and supplies, fees, or transportation charges for the delivery of materials and supplies required on a procurement toward the MBE contract goals, provided a unit determines the fees to be reasonable and not excessive as compared with fees customarily allowed for similar services. A unit may not apply any portion of the costs of the materials and supplies toward MBE goals.

Furnish and Install and other Services: The participation of a certified MBE supplier, wholesaler, and/or regular dealer certified in the proper NAICS code(s) to furnish and install materials necessary for successful contract completion may be counted in full.

Includes the participation of other MBE service providers in the proper NAICS code(s) may be counted in full.

9. Dually certified firms. An MBE that is certified in more than one subgroup category may only be counted toward goal fulfillment of ONE of those categories with regard to a particular contract.

Example: A woman-owned Hispanic American (dually certified) firm may be used to fulfill the women-owned OR Hispanic American subgoal, but not both on the same contract.

10. CAUTION: The percentage of MBE participation, computed using the percentage amounts determined for all of the MBE firms listed in PART 3, MUST meet or exceed the MBE participation goal and subgoals (if applicable) as set forth in PART 2- for this solicitation. If a bidder/offeror is unable to meet the MBE participation goal or any subgoals (if applicable), then the bidder/offeror must request a waiver in PART 2 or the bid will be deemed not responsive, or the proposal not reasonably susceptible of being selected for award. You may wish to use the attached Goal/Subgoal Worksheet to assist in calculating the percentages and confirming that your commitment meets or exceeds the applicable MBE participation goal and subgoals (if any).

11. If you have any questions as to whether a firm is certified to perform the specific services or provide specific products, please contact MDOT’s Office of Minority Business Enterprise at 1-

Attachment D – MBE Forms Page D-4 effective date: February 5, 2021

800-544-6056 or via email to mbe@mdot.state.md.us sufficiently prior to the submission due date.

Subgoals (if applicable)

Total African American MBE Participation: _____________% Total Asian American MBE Participation: _____________% Total Hispanic American MBE Participation: _____________% Total Women-Owned MBE Participation: _____________%

Overall Goal

Total MBE Participation (include all categories): _____________% mailto:mbe@mdot.state.md.us

Attachment D – MBE Forms Page D-5 effective date: February 5, 2021

PART 2 - MBE UTILIZATION AND FAIR SOLICITATION AFFIDAVIT &

MBE PARTICIPATION SCHEDULE

This MBE Utilization and Fair Solicitation Affidavit and MBE Participation Schedule must be completed in its entirety and included with the bid/proposal. If the bidder/offeror fails to accurately complete and submit this Affidavit and Schedule with the bid or proposal as required, the Procurement Officer shall deem the bid non-responsive or shall determine that the proposal is not reasonably susceptible of being selected for award.

In connection with the bid/proposal submitted in response to Solicitation No. _______________, I affirm the following:

1. MBE Participation (PLEASE CHECK ONLY ONE)

☐ I acknowledge and intend to meet IN FULL both the overall certified Minority Business

Enterprise (MBE) participation goal of percent and all of the following subgoals:

percent for African American-owned MBE firms percent for Hispanic American-owned MBE firms percent for Asian American-owned MBE firms percent for Women-owned MBE firms

Therefore, I am not seeking a waiver pursuant to COMAR 21.11.03.11. I acknowledge that by checking the above box and agreeing to meet the stated goal and subgoal(s), if any, I must complete PART 3 - MBE Participation Schedule and Part 4 Signature Page in order to be considered for award.

OR

☐ After making good faith outreach efforts prior to making this submission, 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 I acknowledge that by checking this box and requesting a partial waiver of the stated goal and/or one or more of the stated subgoal(s) if any, I must complete Part 3, the MBE Participation Schedule and Part 4 Signature Page for the portion of the goal and/or subgoal(s) if any, for which I am not seeking a waiver, in order to be considered for award. I acknowledge that by checking this box and requesting a full waiver of the stated goal and the stated subgoal(s) if any, I must complete Part 4 Signature Page in order to be considered for award.

[AGENCY SHOULD INSERT THE MBE GOAL & ANY PERTINENT SUBGOAL AMOUNTS FROM THE PRG & SUBGOAL

WORKSHEET IN THE BLANKS BELOW & ENTER "N/A" FOR ANY SUBGOALS THAT DO NOT APPLY]

[FIRMS MUST COMPLETE THE SECTION ABOVE IF MEETING FULL GOAL/SUBGOALS

OR FILL IN THE CHECK BOX HERE IF THEY WILL NOT MEET THE FULL GOALS ABOVE AND FILL OUT PART 3 & PART 4 FOR THE PORTION OF THE GOAL(S) THEY WILL MEET OR FILL IN THE CHECKBOX

HERE AND COMPLETE PART 4 IF REQUESTING A FULL WAIVER.

Nichelle Highlight

Attachment D – MBE Forms Page D-6 effective date: February 5, 2021

Additional MBE Documentation

I understand that if I am notified that I am the apparent awardee or as requested by the Procurement Officer, I must submit the following documentation within 10 working days of receiving notice of the potential award or from the date of conditional award (per COMAR 21.11.03.10), whichever is earlier:

(a) Good Faith Efforts Documentation to Support Waiver Request (Attachment D-1C)

(b) Outreach Efforts Compliance Statement (Attachment D-2);

(c) MBE Subcontractor/MBE Prime Project Participation Statement (Attachments D-3A and

3B);

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

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.

Information Provided to MBE firms

In the solicitation of subcontract quotations or offers, MBE firms were provided not less than the same information and amount of time to respond as were non-MBE firms.

Governor’s Office of Small, Minority & MBE Form Examples 9/15/2021 Women Business Affairs

Example 1: IT Services Contract Example

Established Goals from the PRG, listed in the solicitation:

Overall MBE Participation Goal: 18%

Subgoals: None

(Contract under $200,000)

Prime:

Certified MBE Firm

Hispanic American

Conditions:

Self-performing: 9%

All minority classifications: 9%

Total Commitment: 18%

Attachment D – MBE Forms Page D-7 effective date: February 5, 2021

PART 3 - MBE PARTICIPATION SCHEDULE

SET FORTH BELOW ARE THE (I) CERTIFIED MBES I INTEND TO USE, (II) THE PERCENTAGE OF THE TOTAL CONTRACT VALUE ALLOCATED TO EACH MBE FOR THIS PROJECT AND, (III) THE ITEMS OF WORK EACH MBE WILL PROVIDE UNDER THE CONTRACT. I HAVE CONFIRMED WITH THE MDOT DATABASE THAT THE MBE FIRMS IDENTIFIED BELOW (INCLUDING ANY SELF-PERFORMING MBE PRIME FIRMS) ARE PERFORMING WORK ACTIVITIES FOR WHICH

THEY ARE MDOT-CERTIFIED.

Prime Contractor Project Description Project/Contract Number

LIST INFORMATION FOR EACH CERTIFIED MBE FIRM YOU AGREE TO USE TO ACHIEVE THE MBE PARTICIPATION GOAL AND

SUBGOALS, IF ANY. MBE PRIMES: PLEASE COMPLETE BOTH SECTIONS A AND B BELOW.

SECTION A: For MBE Prime Contractors ONLY (including MBE Primes in a Joint Venture)

MBE Prime Firm Name:________________________________

MBE Certification Number: ___________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Percentage of total Contract Value to be performed with own forces and counted towards the MBE overall participation goal (up to 50% of the overall goal): _______% Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Percentage of total Contract Value to be performed with own forces and counted towards the subgoal, if any, for my MBE classification (up to 100% of not more than one subgoal): _______%

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work your firm is self-performing to calculate amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage amount of subcontract where the MBE Prime firm is being used for manufacturer, furnish and install, and/or services (excluding products / services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage amount for items of work where the MBE Prime firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule).

Total percentage of Supplies/Products ___% x 60% = ___%

C. Percentage amount of fee where the MBE Prime firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed with MBE prime’s own forces:

[FOR SELF-PERFORMING PRIMES ONLY]

EXAMPLE #1 PAGE 1

IT CONSULTANT MBE IT GENERAL CONSULTING 2021-001-01

IT CONSULTANT MBE

XX-XXX

X

N/A

X

PLEASE NOTE: 9% IS 50% OF THE 18% GOAL.

THIS LINE SHOULD NOT CONTAIN FIGURES

SUCH AS 50% OR 100%.

GENERAL IT CONSULTING

541690

Nichelle Highlight

Attachment D – MBE Forms Page D-8 effective date: February 5, 2021

SECTION B: For all Contractors (including MBE Primes and MBE Primes in a Joint Venture)

MBE Firm Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

MBE Firm Name:______________________________________

MBE Certification Number: _____________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE Firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

[FOR ALL OTHER SUBCONTRACTORS]

EXAMPLE #1 PAGE 2

ABC WEB DESIGN, INC.

XX-XXX

x

541511

X

WEB DESIGN SERVICES

[NAICS CODE MUST BE A CODE THAT ALIGNS

WITH THE SCOPE OF WORK FOR THIS

CONTRACT AND THE SUBCONTRACTOR(S)

MUST BE SERVING A COMMERCIALLY

USEFUL FUNCTION]

MBE Form Examples 9/15/2021

Example 2: Construction Contract Example

Established Goals from the PRG, listed in the solicitation:

34%

8% African American subgoal

11% Women subgoal

17.0% (which includes the 8% African American Subgoal)

11% (At least 11% or prime must request a waiver)

6%

Overall MBE Participation Goal:

Subgoals:

Prime:

Certified MBE Firm

African American

Conditions:

Self-performing:

Woman certified Firm

All minority classifications:

Total Commitment:

Governor’s Office of Small, Minority &

34%

SET FORTH BELOW ARE THE (I) CERTIFIED MBES I INTEND TO USE, (II) THE PERCENTAGE OF THE TOTAL CONTRACT VALUE ALLOCATED TO EACH MBE FOR THIS PROJECT AND, (III) THE ITEMS OF WORK EACH MBE WILL PROVIDE UNDER THE CONTRACT. I HAVE CONFIRMED WITH THE MDOT DATABASE THAT THE MBE FIRMS IDENTIFIED BELOW (INCLUDING ANY SELF-PERFORMING MBE PRIME FIRMS) ARE PERFORMING WORK ACTIVITIES FOR WHICH

THEY ARE MDOT-CERTIFIED.

Prime Contractor Project Description Project/Contract Number

LIST INFORMATION FOR EACH CERTIFIED MBE FIRM YOU AGREE TO USE TO ACHIEVE THE MBE PARTICIPATION GOAL AND

SUBGOALS, IF ANY. MBE PRIMES: PLEASE COMPLETE BOTH SECTIONS A AND B BELOW.

SECTION A: For MBE Prime Contractors ONLY (including MBE Primes in a Joint Venture)

MBE Prime Firm Name:________________________________

MBE Certification Number: ___________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Percentage of total Contract Value to be performed with own forces and counted towards the MBE overall participation goal (up to 50% of the overall goal): _______% Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Percentage of total Contract Value to be performed with own forces and counted towards the subgoal, if any, for my MBE classification (up to 100% of not more than one subgoal): _______%

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work your firm is self-performing to calculate amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage amount of subcontract where the MBE Prime firm is being used for manufacturer, furnish and install, and/or services (excluding products / services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage amount for items of work where the MBE Prime firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule).

Total percentage of Supplies/Products ___% x 60% = ___%

C. Percentage amount of fee where the MBE Prime firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed with MBE prime’s own forces:

[FOR SELF-PERFORMING PRIMES ONLY]

EXAMPLE #2, PAGE 1

GENERAL CONTRACTOR MBE NEW OFFICE BUILDING

CONSTRUCTION 2021-002-001

GENERAL CONTRACTOR MBE

XX-XXX

X

X

GENERAL CONTRACTOR

236220

PLEASE NOTE, THE MBE PRIME IS SELF

PERFORMING 50% OF THE OVERALL

GOAL OR 17% AND THIS INCLUDES

PERFORMING 100% OF ONE

SUBGOAL, THE AFRICAN AMERICAN

SUBGOAL OF 8%.

MBE Firm Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

MBE Firm Name:______________________________________

MBE Certification Number: _____________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE Firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

[FOR ALL OTHER SUBCONTRACTORS]

PAINTING FIRM, LLC

XX-XXX

X

X

SUPPLY AND INSTALL PAINT

EXAMPLE #2, PAGE 2

238320

WATT ELECTRICAL SUPPLY, INC

XX-XXX

X

X

5 3

423610

PROVIDE ELECTRICAL SUPPLIES

Attachment D – MBE Forms Page D-9 effective date: February 5, 2021

MBE Firm Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that for the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of the total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

MBE Firm Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker___ %

Description of the work to be performed:

CONTINUE ON SEPARATE PAGE IF NEEDED

EXAMPLE 2, PAGE 3

CARPET & TILE WORKS, INC.

XX-XXX

X

X

SUPPLY AND INSTALLATION OF CARPET AND TILE

238330

Example #3: Services Contract

Established Goals from the PRG, listed in the solicitation:

Overall MBE Participation Goal: 30%

Subgoals: 10% Women subgoal

3% Asian American subgoal

2% Hispanic American subgoal

Prime:

Certified MBE Firm

Asian American Woman Firm

Considerations:

As a dually certified firm, there are several ways this prime contractor could choose to fulfill the MBE goal requirements. The prime can fulfill up to 50% of the overall goal, or 15%, which could include 100% of ONE subgoal; either the Asian American subgoal of 4% or the Women subgoal of 10% but not both, only ONE. If the firm wants to maximize the use of its workforce, it will choose to fulfill the Women subgoal.

OR

If the Prime does not want to perform a subgoal, they can choose to perform 50% of the overall goal

(15%) and choose other firms to fulfill all of the MBE subgoals.

Conditions:

OPTION 1

Self-performing: 15% (which includes the 10% Women Subgoal)

Asian American certified MBE 3% (At least 3% or prime must request a waiver)

Hispanic American certified MBE 2% (At least 2% or prime must request a waiver)

All minority classifications: 10%

Total Commitment: 30%

15% (which includes the 3% Asian American subgoal)

10% (At least 10% or prime must request a waiver)

2% (At least 2% or prime must request a waiver)

3%

30%

15%

10% (At least 10% or prime must request a waiver)

3% (At least 3% or the prime must request a waiver)

2% (At least 2% or prime must request a waiver)

OPTION 2

Self-performing:

Women certified MBE

Hispanic American certified MBE

All minority classifications:

Total Commitment:

OPTION 3

Self-performing:

Woman certified MBE

Asian American certified MBE

Hispanic American certified MBE

Total Commitment: 30%

SET FORTH BELOW ARE THE (I) CERTIFIED MBES I INTEND TO USE, (II) THE PERCENTAGE OF THE TOTAL CONTRACT VALUE ALLOCATED TO EACH MBE FOR THIS PROJECT AND, (III) THE ITEMS OF WORK EACH MBE WILL PROVIDE UNDER THE CONTRACT. I HAVE CONFIRMED WITH THE MDOT DATABASE THAT THE MBE FIRMS IDENTIFIED BELOW (INCLUDING ANY SELF-PERFORMING MBE PRIME FIRMS) ARE PERFORMING WORK ACTIVITIES FOR WHICH

THEY ARE MDOT-CERTIFIED.

Prime Contractor Project Description Project/Contract Number

LIST INFORMATION FOR EACH CERTIFIED MBE FIRM YOU AGREE TO USE TO ACHIEVE THE MBE PARTICIPATION GOAL AND

SUBGOALS, IF ANY. MBE PRIMES: PLEASE COMPLETE BOTH SECTIONS A AND B BELOW.

SECTION A: For MBE Prime Contractors ONLY (including MBE Primes in a Joint Venture)

MBE Prime Firm Name:________________________________

MBE Certification Number: ___________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Percentage of total Contract Value to be performed with own forces and counted towards the MBE overall participation goal (up to 50% of the overall goal): _______% Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Percentage of total Contract Value to be performed with own forces and counted towards the subgoal, if any, for my MBE classification (up to 100% of not more than one subgoal): _______%

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work your firm is self-performing to calculate amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage amount of subcontract where the MBE Prime firm is being used for manufacturer, furnish and install, and/or services (excluding products / services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage amount for items of work where the MBE Prime firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule).

Total percentage of Supplies/Products ___% x 60% = ___%

C. Percentage amount of fee where the MBE Prime firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed with MBE prime’s own forces:

[FOR SELF-PERFORMING PRIMES ONLY]

EXAMPLE #3, OPTION 1, PAGE 1

SERVICES MBE, LLC MARKETING 2001-003-001

SERVICES MBE, LLC

XX-XXX

X

541613 X

MARKETING SERVICES

MBE Firm Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

MBE Firm Name:______________________________________

MBE Certification Number: _____________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE Firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

[FOR ALL OTHER SUBCONTRACTORS]

OUTREACH FIRM MBE

XX-XXX

X

541820

PUBLIC OUTREACH

MEETINGS

X

EXAMPLE #3, OPTION 1, PAGE 2

ABC MARKETING

XX-XXX

X

541910

POLLING AND RESEARCH SERVICES

X

Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that for the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of the total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

MBE Firm Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker___ %

Description of the work to be performed:

CONTINUE ON SEPARATE PAGE IF NEEDED

PRINTER SERVICES LLC

XX-XXX

X

X

PRINTING OF MARKETING MATERIALS

EXAMPLE #3, OPTION 1, PAGE 3

323111

SET FORTH BELOW ARE THE (I) CERTIFIED MBES I INTEND TO USE, (II) THE PERCENTAGE OF THE TOTAL CONTRACT VALUE ALLOCATED TO EACH MBE FOR THIS PROJECT AND, (III) THE ITEMS OF WORK EACH MBE WILL PROVIDE UNDER THE CONTRACT. I HAVE CONFIRMED WITH THE MDOT DATABASE THAT THE MBE FIRMS IDENTIFIED BELOW (INCLUDING ANY SELF-PERFORMING MBE PRIME FIRMS) ARE PERFORMING WORK ACTIVITIES FOR WHICH

THEY ARE MDOT-CERTIFIED.

Prime Contractor Project Description Project/Contract Number

LIST INFORMATION FOR EACH CERTIFIED MBE FIRM YOU AGREE TO USE TO ACHIEVE THE MBE PARTICIPATION GOAL AND

SUBGOALS, IF ANY. MBE PRIMES: PLEASE COMPLETE BOTH SECTIONS A AND B BELOW.

SECTION A: For MBE Prime Contractors ONLY (including MBE Primes in a Joint Venture)

MBE Prime Firm Name:________________________________

MBE Certification Number: ___________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Percentage of total Contract Value to be performed with own forces and counted towards the MBE overall participation goal (up to 50% of the overall goal): _______% Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Percentage of total Contract Value to be performed with own forces and counted towards the subgoal, if any, for my MBE classification (up to 100% of not more than one subgoal): _______%

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work your firm is self-performing to calculate amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage amount of subcontract where the MBE Prime firm is being used for manufacturer, furnish and install, and/or services (excluding products / services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage amount for items of work where the MBE Prime firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule).

Total percentage of Supplies/Products ___% x 60% = ___%

C. Percentage amount of fee where the MBE Prime firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed with MBE prime’s own forces:

[FOR SELF-PERFORMING PRIMES ONLY]

EXAMPLE #3, OPTION 2, PAGE 1

SERVICES MBE, LLC MARKETING SERVICES 2021-003-002

SERVICES MBE, LLC

XX-XXX

X

X

541613

MARKETING SERVICES

MBE Firm Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

MBE Firm Name:______________________________________

MBE Certification Number: _____________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE Firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

[FOR ALL OTHER SUBCONTRACTORS]

EXAMPLE #3, OPTION 2, PAGE 2

OUTREACH MBE, INC.

XX-XXX

X

X

541820

PUBLIC OUTREACH MEETINGS

WEB DESIGN, LLC

XX-XXX

X

541511

X

WEBSITE PLATFORM DESIGN

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that for the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of the total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker (count reasonable fee/commission only) ___ %

Description of the work to be performed:

MBE Firm Name:______________________________________

MBE Certification Number: ______________________

(If dually certified, check only one box.)

African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification

NAICS code: _______________________________

Please refer to Item #8 in Part 1- Instructions of this document for new MBE participation guidelines regarding materials and supplies.

Supplier, wholesaler and/or regular dealer (count 60%) Manufacturer (count 100%) Broker (count reasonable fee/commission only) Furnish and Install and other Services (count 100%)

Complete the applicable prompt (select only one) from prompts A-C below that applies to the type of work that the MBE firm named to the left will be performing to calculate the amount to be counted towards achieving the MBE Participation Goal and Subgoal, if any.

A. Percentage of total contract amount where the MBE firm is being used for manufacturer, furnish and install, and/or services (excluding products/services from suppliers, wholesalers, regular dealers and brokers) ___%

B. Percentage of total contract amount for items of work where the MBE firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).

Total percentage of Supplies/Products ___% X 60% = ___%

C. Percentage amount of fee where the MBE firm is being used as broker___ %

Description of the work to be performed:

CONTINUE ON SEPARATE PAGE IF NEEDED

EXAMPLE #3, OPTION 2, PAGE 3

Name:______________________________________

XX-XXX

X X

PRINTING OF MARKETING MATERIALS

323111

PRINTER INC.

SET FORTH BELOW ARE THE (I) CERTIFIED MBES I INTEND TO USE, (II) THE PERCENTAGE OF THE TOTAL CONTRACT VALUE ALLOCATED TO EACH MBE FOR…