Exhibit B _ Certificate of Minority Form.docx

This is a Certificate of Insurance and Minority Status form for Exhibit B associated with project J-463, the TLC Lecture Hall Renovation and Systems Renewal at the University of West Georgia in Carrollton, Georgia. The form serves as a documentation requirement for applying firms to provide proof of professional liability insurance coverage and to declare their minority business enterprise (MBE) or women business enterprise (WBE) status. Firms must identify the name and address of their professional liability insurance carrier, specify the amount of coverage and deductible per claim, and indicate whether they qualify as an MBE, WBE, or other minority status category. If applicable, firms must also declare the minority status of any associated firms involved in the project.

The form requires notarization by a public notary, with the notary providing their signature, seal, and commission expiration date. This documentation appears to be part of a larger procurement package that also references Gordon State College project PPV-89-1201 for a Student Activity and Recreation Center. The form establishes baseline insurance and diversity requirements for contractors bidding on these state and local construction projects.