FORM 5A SBE AFFIRMATION.pdf
PDF 50 KB Posted
- Solicitation number
- AE141998
- Issued by
- California
About this file
This is a Small Business Enterprise (SBE) Affirmation Form required to be completed by prime contractors and subcontractors at any tier level that will subcontract work to SBE businesses on state and local contracts. The form documents the commitment between a prime or subcontractor and an SBE business to enter into a formal subcontract agreement, conditioned upon the proposer being awarded the contract. The form requires completion of basic information including the IFB/RFP/RFIQ number, project name, prime contractor details, and the proposed SBE business information with complete business addresses. Bidders must identify the specific scope of work to be performed by the SBE business and provide the corresponding six-digit North American Industry Classification System (NAICS) codes for each work category.
The financial section requires the total dollar amount allocated to the SBE business, which must match the amounts listed on Form 1 and Form 4. The technical description section allows for documentation of up to seven different work, service, or materials categories with their corresponding NAICS codes. The form must be signed by authorized representatives of both the prime contractor (or direct subcontractor) and the SBE business, with signatures affirming the mutual commitment to the subcontract terms and conditions. Required signatory information includes typed or printed names, titles, email addresses, and telephone numbers for both parties.
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Text version
FORM 5A - 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 that will be performed by this SBE business. For SBE Firms, provide applicable Northern America Industry Classification System (NAICS) code(s).
Description of Work, Service, or Materials Supplied (To be performed on this contact) 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 for the work and any terms or conditions described above and in the accompanying attachments, conditioned on the Proposer/Proposer being awarded this Contract.
(Name of Prime) (Name of SBE Business)
(Authorized Signature of Prime)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.
| respective Prime or Subcontractor and has been listed to perform work on this contract: |
| undefined: |
| undefined_2: |
| Street: |
| State: |
| Zip: |
| City: |
| Street_2: |
| City_2: |
| State_2: |
| Zip_2: |
| amount should match Amount listed for this business on Form 1 and Form 4: |
| Description of Work Service or Materials Supplied To be performed on this contactRow1: |
| Corresponding NAICS Codes 6 digitsRow1: |
| Description of Work Service or Materials Supplied To be performed on this contactRow2: |
| Corresponding NAICS Codes 6 digitsRow2: |
| Description of Work Service or Materials Supplied To be performed on this contactRow3: |
| Corresponding NAICS Codes 6 digitsRow3: |
| Description of Work Service or Materials Supplied To be performed on this contactRow4: |
| Corresponding NAICS Codes 6 digitsRow4: |
| Description of Work Service or Materials Supplied To be performed on this contactRow5: |
| Corresponding NAICS Codes 6 digitsRow5: |
| Description of Work Service or Materials Supplied To be performed on this contactRow6: |
| Corresponding NAICS Codes 6 digitsRow6: |
| Description of Work Service or Materials Supplied To be performed on this contactRow7: |
| Corresponding NAICS Codes 6 digitsRow7: |
| Name of Prime: |
| Name of SBE Business: |
| 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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