FORM_-_3_Personal-Professional_Contract_-_Monthly_Sub-consultant_Payment_and_Utilization_Report_.pdf

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Attached to
Private Utility Locating Services
Solicitation number
24-050
Issued by
Washington County, Barlow City, Oregon

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The document is a Professional Service - Monthly Subcontractor Payment and Utilization Report (Program: Form 3), designed for tracking subcontractor details in state and local government contracts. The form is structured to capture comprehensive information about subcontractors, including their business certifications such as Emerging Small Business (ESB), Minority-owned Business (MBE), Women-Owned Business (WBE), Service-Disabled Veteran-Owned (SDV), and Disadvantaged Business Enterprise (DBE & ACDBE).

The form requires the prime consultant to document each subcontractor's original and amended award amounts, total payments for the specific pay period, and their certification status. The contractor must obtain written authorization from the Purchasing Agent before replacing, substituting, or adding subcontractors. The form includes a certification statement where the authorized contractor representative attests to the accuracy and completeness of the information provided, and must sign and date the document to validate the reported subcontractor utilization and payment details.

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PROGRAM: FORM 3

PROFESSIONAL SERVICE - MONTHLY SUBCONTRACTOR PAYMENT AND UTILIZATION REPORT

Date Submitted: ______________________________________ Report for FY: __________________ Month: ____________

Project Name: ________________________________________________________________________ Contract Number: _________________________

Prime Consultant: _____________________________________________________________________ Total Contract Amt.: ______________________

Progress Report No.: __________________________________________________________________ Final Progress Report? ☐ Yes ☐ No

* Before replacing, substituting, or adding any subcontractor, Contractor must receive written authorization from the Purchasing Agent.

** ESB: Emerging Small Business; MBE: Minority-owned Business; WBE: Women-Owned Business; SDV: Service-Disabled Veteran-Owned; DBE & ACDBE: Disadvantaged Business Enterprise

BY SIGNING BELOW, I HEREBY CERTIFY THAT THE BUSINESS HAS UTILIZED THE ABOVE LISTED FIRMS IN THE AMOUNTS REPRESENTED ABOVE AND THAT

THE INFORMATION CONTAINED HEREIN IS COMPLETE AND ACCURATE.

Authorized Signature of Contractor: __________________________________________________________ Date: __________________

Printed Name of Signatory: _________________________________________________________________

NAME OF SUBCONTRACTOR*

(INCLUDE ALL LISTED ON BID PLAN)

COBID

Certified

TYPE OF CERTIFICATION**

(Check all that apply) ORIGINAL AWARD

AMOUNT

AMENDED AWARD

AMOUNT

(IF APPLICABLE)

TOTAL AMOUNT

PAID

THIS PAY PERIOD ONLY

MBE WBE SDV ESB

DBE &

ACDBE

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

Date Submitted:
Report for FY:
Month:
Project Name:
Contract Number:
Prime Consultant:
Total Contract Amt:
Progress Report No:
Final Progress Report: Off
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow1:
undefined: Off
MBEYes No:
WBEYes No:
SDVYes No:
ESBYes No:
DBE ACDBEYes No:
ORIGINAL AWARD AMOUNTYes No:
AMENDED AWARD AMOUNT IF APPLICABLEYes No:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow2:
undefined_2: Off
MBEYes No_2:
WBEYes No_2:
SDVYes No_2:
ESBYes No_2:
DBE ACDBEYes No_2:
ORIGINAL AWARD AMOUNTYes No_2:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_2:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_2:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow3:
undefined_3: Off
MBEYes No_3:
WBEYes No_3:
SDVYes No_3:
ESBYes No_3:
DBE ACDBEYes No_3:
ORIGINAL AWARD AMOUNTYes No_3:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_3:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_3:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow4:
undefined_4: Off
MBEYes No_4:
WBEYes No_4:
SDVYes No_4:
ESBYes No_4:
DBE ACDBEYes No_4:
ORIGINAL AWARD AMOUNTYes No_4:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_4:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_4:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow5:
undefined_5: Off
MBEYes No_5:
WBEYes No_5:
SDVYes No_5:
ESBYes No_5:
DBE ACDBEYes No_5:
ORIGINAL AWARD AMOUNTYes No_5:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_5:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_5:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow6:
undefined_6: Off
MBEYes No_6:
WBEYes No_6:
SDVYes No_6:
ESBYes No_6:
DBE ACDBEYes No_6:
ORIGINAL AWARD AMOUNTYes No_6:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_6:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_6:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow7:
undefined_7: Off
MBEYes No_7:
WBEYes No_7:
SDVYes No_7:
ESBYes No_7:
DBE ACDBEYes No_7:
ORIGINAL AWARD AMOUNTYes No_7:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_7:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_7:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow8:
undefined_8: Off
MBEYes No_8:
WBEYes No_8:
SDVYes No_8:
ESBYes No_8:
DBE ACDBEYes No_8:
ORIGINAL AWARD AMOUNTYes No_8:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_8:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_8:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow9:
undefined_9: Off
MBEYes No_9:
WBEYes No_9:
SDVYes No_9:
ESBYes No_9:
DBE ACDBEYes No_9:
ORIGINAL AWARD AMOUNTYes No_9:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_9:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_9:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow10:
undefined_10: Off
MBEYes No_10:
WBEYes No_10:
SDVYes No_10:
ESBYes No_10:
DBE ACDBEYes No_10:
ORIGINAL AWARD AMOUNTYes No_10:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_10:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_10:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow11:
undefined_11: Off
MBEYes No_11:
WBEYes No_11:
SDVYes No_11:
ESBYes No_11:
DBE ACDBEYes No_11:
ORIGINAL AWARD AMOUNTYes No_11:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_11:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_11:
Date:
Printed Name of Signatory:

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