FORM 4 - SBE AFFIRMATION.pdf
PDF 103 KB Posted
- Attached to
- 115-lb Head-Hardened Rail 80-ft Sections
- Solicitation number
- DR143862
- Issued by
- California
About this file
This is a Small Business Enterprise (SBE) Affirmation form used by the Los Angeles County Metropolitan Transportation Authority (LACMTA) for state and local contract opportunities. The form must be completed and signed by the prime contractor and all subcontractors (both SBE and non-SBE entities) that will subcontract to an SBE business. The form serves as a binding commitment between the prime/subcontractor and the SBE business to enter into a formal subcontract agreement. Key information required on the form includes the solicitation number, project name, prime and subcontractor business details, the proposed SBE business name and address, the total dollar amount allocated to the SBE business, and a detailed description of the scope of work with corresponding six-digit North American Industry Classification System (NAICS) codes that the SBE will perform. For a bid to be deemed responsive, the prime contractor must submit completed and signed SBE Affirmations for itself and for each subcontractor of any tier that will engage an SBE business.
The prime contractor bears responsibility for obtaining all completed SBE Affirmations from subcontractors, verifying consistency between submitted affirmations and Forms 1 through 3, and ensuring that the SBE commitment listed in the SBE Affidavit is met and enforced by LACMTA under the contract. Any discrepancies or conflicts between the SBE Affirmations and other required forms may result in LACMTA issuing clarification requests to the prime contractor and/or subcontractors. SBE firms must be certified in the applicable NAICS codes for the listed scope of work to receive credit toward the SBE commitment.
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Text version
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.
| TABLE 1 - SBE COMMITMENT FORMS |
| SUBCONTRACTOR LISTING FORM FOR IFB ONLY |
| FORM 1 - SBE SUBCONTRACTORS & SUPPLIERS |
| ATTACHMENT A TO FORM 1: SUPPORTING INFORMATION FROM SBE SUBCONTRACTOR |
| ATTACHMENT A TO FORM 1: SUPPORTING INFORMATION FROM SBE SUBCONTRACTOR |
| FORM 2 - COMMERCIALLY USEFUL FUNCTION AFFIDAVIT |
| FORM 3 - BUSINESS DATA SHEET Page 1 of 2 |
| FORM 4 – SBE AFFIRMATION |
| 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: |
| undefined: |
| PrimeSubcontractor Name: |
| undefined_2: |
| Street: |
| State: |
| Zip: |
| City: |
| Street_2: |
| State_2: |
| Zip_2: |
| undefined_3: |
| DESCRIPTION OF WORK OR SERVICE TO BE PERFORMED OR MATERIALS TO BE SUPPLIED ON THIS CONTRACTRow1: |
| ONLY LIST APPLICABLE NAICS CODES 6 DIGITS FOR WORK TO BE PERFORMEDRow1: |
| DESCRIPTION OF WORK OR SERVICE TO BE PERFORMED OR MATERIALS TO BE SUPPLIED ON THIS CONTRACTRow2: |
| ONLY LIST APPLICABLE NAICS CODES 6 DIGITS FOR WORK TO BE PERFORMEDRow2: |
| DESCRIPTION OF WORK OR SERVICE TO BE PERFORMED OR MATERIALS TO BE SUPPLIED ON THIS CONTRACTRow3: |
| ONLY LIST APPLICABLE NAICS CODES 6 DIGITS FOR WORK TO BE PERFORMEDRow3: |
| PrimeSubcontractor Name_2: |
| SBE Business Name: |
| Date: |
| Date_2: |
| Typed or Printed Name of Signee: |
| Typed or Printed Name of Signee_2: |
| Title of Signee: |
| Title of Signee_2: |
| Email: |
| Email_2: |
| Telephone: |
| Telephone_2: |
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