First Tier Subcontractor_designation_form-final 8-2023 (3).pdf

WAYNE COUNTY HUMAN RELATIONS/BUSINESS INCLUSION DIVISION

FIRST TIER SUBCONTRACTOR DESIGNATION FORM

*To be completed by Prime Contractors for “First Tier” Subcontractors Only*

This form MUST be completed by all prime contractors receiving a contract, of more than $50,000 (supplies/services) or more than $100,000 (construction), from Wayne County regardless of the dollar amount at which the subcontractor participates.

**THIS FORM MUST BE COMPLETED EVEN IF NO SUBCONTRACTORS WILL BE USED**

1. CONTRACT NUMBER: 37 - 25 - 041 (Number on Bid Announcement)

TCM NUMBER: _______-_______-_________ (Internal use only)

2. CURRENT AND/OR CUMULATIVE CONTRACT (Check one):

SUPPLIES/SERVICES contract (over $50,000? YES NO)

OR

CONSTRUCTION contract (over $100,000? YES NO)

3. WILL SUBCONTRACTORS BE USED FOR THIS CONTRACT? (Check one)

YES* NO

*If you answered “YES”, you must complete the next page.

4. Are there any related parties between the subcontractor(s) and any contract managers for this proposed contract? (Check one) YES* NO

*If you answered “YES”, you must complete the next page.

Prime Company Name: Fed Tax ID:

Address:

City: County: State: Zip:

Phone: ( )

Fax: ( )

Authorized Contact Person: Email:

I declare that all of the information contained in this form is complete and accurate to the best of my knowledge and, as signatory, am authorized to bind the contractor.

Print Name: _Title:

Signature: Date:

Human Relations/Business Inclusion Division 500 Griswold , Detroit, MI 48226 313 224-5021 rev 8/23

SUBCONTRACTOR LIST

(MAKE ADDITIONAL COPIES OF THIS PAGE TO LIST ADDITIONAL SUBCONTRACTORS)

Prime Contractor Name Contract #___37___-__25____-___041___ Subcontractor # TCM#_____-_____-_____ (Internal use only)

Company Name: Fed Tax ID:

City: County: State: Zip:

Authorized contact: Phone:

Fax:

Subcontract Amount: $ % of Contract:

Work to be performed:

Are there any related parties between the subcontractor(s) and any contract managers for this proposed contract? (Check one) YES* NO

*If there are any related parties, please provide the name(s) and relevant relationship here:

(Attach additional pages as needed)

Name: ____________________________________ Relationship: __________________________________

Department: _______________________________ Title: ________________________________________

Subcontractor #

Company Name: Fed Tax ID:

City: County: State: Zip:

Authorized contact: Phone:

Fax:

Subcontract Amount: $ % of Contract:

Work to be performed:

Are there any related parties between the subcontractor(s) and any contract managers for this proposed contract? (Check one) YES* NO

*If there are any related parties, please provide the name(s) and relevant relationship here:

(Attach additional pages as needed)

Name: ____________________________________ Relationship: __________________________________

Department: _______________________________ Title: _________ _______________________________

Human Relations/Business Inclusion Division 500 Griswold, Detroit, MI 48226 313 224-5021 rev 8/23