FORM 4 - SBE AFFIRMATION.pdf

FORM 4 – SBE AFFIRMATION

TO BE COMPLETED BY PRIME AND ALL SUBCONTRACTORS (SBE AND NON-SBE) THAT WILL

SUBCONTRACT TO A SBE BUSINESS.

INSTRUCTIONS: Complete and sign this SBE Affirmation on your behalf to affirm that you will utilize the SBE businesses listed on Form 1 and its Attachments. This form must be signed by the SBE business acknowledging that it has submitted a written quote to you and has been listed to perform work on this Contract.

ADDITIONAL INSTRUCTIONS TO PRIME (OFFEROR) ONLY:

1. In addition to completing and signing this SBE Affirmation on your behalf, obtain all completed and signed SBE Affirmations from all Subcontractors

(SBE and Non-SBE) of any tier that will subcontract to a SBE business and verify that the information provided in the SBE Affirmations are consistent with Form 1 and its Attachments.

2. Attach your SBE Affirmation and all SBE Affirmations received from Subcontractors (SBE and Non-SBE) of any tier that will subcontract to a SBE business. For a bid to be responsive, you must submit with your bid a completed and signed SBE Affirmation for your firm as the prime and for each Subcontractor (SBE and Non-SBE) of any tier that will subcontract to a SBE business.

3. If there is any discrepancy or conflict between the information listed on the submitted SBE Affirmations and any of the Forms 1 to 3, LACMTA may issue requests for clarification seeking information or clarification from the Prime (Offeror) and/or Subcontractor in accordance with this solicitation.

In all events, Prime shall be required to meet the SBE commitment listed in the SBE Affidavit, which will be enforced by LACMTA under the Contract.

1. Solicitation Number: _____________________________________________________________________________

2. Project Name: _____________________________________________________________________________

3. Prime/Subcontractor Name: _________________________ ___________________________________________________

4. Prime/Subcontractor Business Address:____________________________________________________________________ (Street) (City) (State) (Zip)

5. Name of Proposed SBE Business: _____________________________________________________________________

6. SBE Business Address: _____________________________________________________________________ (Street) (City) (State) (Zip)

7. Financial Description: Total $ Amount listed for this SBE business is: $ ________________________________________

8. Technical Description: Identify the scope of work and corresponding North American Industry Classification System (NAICS) Code(s) that will be performed by this SBE business. To receive credit, SBE firms must be certified in applicable NAICS Codes for listed scope of work.

DESCRIPTION OF WORK OR SERVICE TO BE

PERFORMED, OR MATERIALS TO BE SUPPLIED ON

THIS CONTRACT

ONLY LIST APPLICABLE NAICS CODE(S)

(6 DIGITS) FOR WORK TO BE PERFORMED

Affirmation: Signatures of the authorized representatives of the Prime/Subcontractor and of the SBE business below represent the commitment by both parties to enter into a formal subcontract agreement.

(Prime/Subcontractor Name) (SBE Business Name)

(Authorized Signature of Business)1 (Date) (Authorized Signature of Business) (Date)

(Typed or Printed Name of Signee) (Typed or Printed Name of Signee)

(Title of Signee) (Title of Signee)

(Email) (Email)

(Telephone) (Telephone)

1 Signature of the Prime/Subcontractor to which the SBE business will report to directly.