First Tier Subcontractor_designation_form-final 8-2023.pdf

PDF 84 KB Posted

Attached to
Traffic Signal Modernization - Engineering Services State and local contract opportunity
Solicitation number
37-25-037
Issued by
Wayne County, Michigan

About this file

Written by GovTribe AI ·

The document is a Wayne County Human Relations/Business Inclusion Division First Tier Subcontractor Designation Form, which is required for prime contractors receiving contracts over $50,000 for supplies/services or over $100,000 for construction from Wayne County. This form is specifically associated with a Traffic Signal Modernization project involving Professional Engineering Services for preparing construction bid documents for three traffic signal projects funded through the FY 2026 Highway Safety Improvement plan.

The form mandates that prime contractors complete this document even if no subcontractors will be used, and requires detailed disclosure of any first-tier subcontractors, including their company information, contract percentage, specific work to be performed, and potential related party relationships with contract managers. The form includes sections for documenting the prime contractor's details, subcontractor information such as federal tax ID, address, contact information, subcontract amount, and a declaration of any potential conflicts of interest. This documentation supports Wayne County's business inclusion and transparency requirements for municipal contracts.

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Appendix D - Debarment Form.pdf PDF
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attachment-download.doc DOC document
Appendix A - Price Sheet.xlsx XLSX spreadsheet
RFP 37-25-037 - Traffic Signal Design.docx DOCX document
Appendix C - DBE Form - 37-25-037.pdf PDF

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

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: - - (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:

WAYNE COUNTY HUMAN RELATIONS/BUSINESS INCLUSION DIVISION

FIRST TIER SUBCONTRACTOR DESIGNATION FORM

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

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

Subcontractor #

Contract #______-______-______

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: _________ _______________________________

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