FORM 5 - SBE AFFIRMATION.pdf

LACMTA

SBE INSTR TO BIDDERS/PROPOSER SET-ASIDE (NON-FED)

PRO FORM 069C

REVISION DATE: 02.06.19:

FORM 5 – SBE AFFIRMATION

TO BE COMPLETED BY PRIME AND ALL SUBCONTRACTORS THAT WILL SUBCONTRACT TO AN

SBE BUSINESS.

Prime and subcontractor(s) at any tier level that will subcontract work to an SBE business are required to complete this form to affirm that it will utilize the SBE businesses listed on Form 1 or Form 4. This form must be signed by the SBE business acknowledging that it has submitted a written quote to the respective Prime or Subcontractor and has been listed to perform work on this contract.

1. IFB/RFP/RFIQ Number: _____________________________________________________________________________

2. Project Name: _____________________________________________________________________________

3. Name of the Prime: _____________________________________________________________________________

4. Prime 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: $ ________________________________________ (amount should match $ Amount listed for this business on Form 1 and Form 4)

8. Technical Description Identify the scope of work and corresponding North American Industry Classification System (NAICS) Code(s) that will be performed by this business. If business is an SBE, list only the NAICS Code(s), in which the firm is certified to perform work on this contract ONLY.1

DESCRIPTION OF WORK, SERVICE, OR MATERIALS

SUPPLIED TO BE PERFORMED ON THIS CONTRACT

CORRESPONDING NAICS CODE(S) (6 DIGITS)

Affirmation:

Signatures of the authorized representatives of this Contractor and of the SBE business below represent the commitment by both parties to enter into a formal subcontract agreement.

(Prime 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 Contractor to which the SBE business will report to directly.