FORM 5B DVBE AFFIRMATION.pdf

FORM 5B - DVBE AFFIRMATION

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

DVBE BUSINESS.

Prime and subcontractor(s) at any tier level that will subcontract work to a DVBE business are required to complete this form to affirm that it will utilize the DVBE businesses listed on Form 1 or Form 4. This form must be signed by the DVBE 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 DVBE Business: _____________________________________________________________________

6. DVBE Business Address: _________________________________________________________________________ (Street) (City) (State) (Zip)

7. Financial Description Total $ Amount listed for this DVBE 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 DVBE business. For DVBE Firms, provide applicable United Nations Standard Products and Services (UNSPSC) code(s).

Description of Work, Service, or Materials Supplied (To be performed on this contract) Corresponding UNSPSC Code(s) (8 digits)

Affirmation:

Signatures of the authorized representatives of this Contractor and of the DVBE 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 DVBE Business)

(Authorized Signature of Prime)2 (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)

2 Signature of the Contractor to which the SBE business will report to directly.