Form_MBD-30_Payments.pdf

Page 1 of 2 –DMI Payment

City of Tampa – DMI Sub-(Contractors/Consultants/Suppliers) Payments

(FORM MBD-30)

[ ] Partial [ ] Final Contract No.: WO#,(if any): Contract Name:

Contractor Name: Address:

Federal ID: Phone: Fax: Email:

GC Pay Period: Payment Request/Invoice Number: City Department:

Total Amount Requested for pay period: $ Total Contract Amount (including change orders):$ -Type of Ownership - (F=Female M=Male), BF BM = African Am., HF HM = Hispanic Am., AF AM = Asian Am., NF NM = Native Am., CF CM = Caucasian S = SLBE

Type

Company Name Address

Phone & Fax

Total Sub Contract

Or PO Amount

Amount Paid To Date

Amount To Be Paid

For This Period Trade/Work

Activity []Sub

[]Supplier Amount Pending

Previously Reported

Sub Pay Period Ending Date Federal ID

(Modifying This Form or Failure to Complete and Sign May Result in Non-Compliance) Certification: I hereby certify that the above information is a true and accurate account of payments to sub – contractors/consultants on this contract.

Signed: Name/Title: Date:

DMI form 30 (rev. 01/15/2020) Note: Detailed Instructions for completing this form are on the next page

Page 2 of 2 – DMI Payment

Instructions for completing The DMI Sub-(Contractors/Consultants/ Suppliers) Payment Form (Form MBD-30)

This form must be submitted with all invoicing or payment requests where there has been subcontracting rendered for the pay period.

If applicable, after payment has been made to the subcontractor, “Waiver and Release of Lien upon Progress Payment”, “Affidavit of Contractor in Connection with Final Payment”, or an affidavit of payment must be submitted with the amount paid for the pay period.

The following will detail what data is required for this form. The instructions that follow correspond to the headings on the form required to be completed. (Modifying or omitted information from this form my result in non-compliance).

• Contract No. This is the number assigned by the City of Tampa for the bid or proposal.

• W.O.# If the report covers a work order number (W.O.#) for the contract, please indicate it in that space.

• Contract Name. This is the name of the contract assigned by the City of Tampa for the bid or proposal.

• Contractor Name. The name of your business.

• Address. The physical address of your business.

• Federal ID. A number assigned to a business for tax reporting purposes.

• Phone. Telephone number to contact business.

• Fax. Fax number for business.

• Email. Provide email address for electronic correspondence.

• Pay Period. Provide start and finish dates for pay period. (e.g. 05/01/13 – 05/31/13)

• Payment Request/Invoice Number. Provide sequence number for payment requests. (ex. Payment one, write 1 in space, payment three, write 3 in space provided.)

• City Department. The City of Tampa department to which the contract pertains.

• Total Amount Requested for pay period. Provide all dollars you are expecting to receive for the pay period.

• Total Contract Amount (including change orders). Provide expected total contract amount. This includes any change orders that may increase or decrease the original contract amount.

• Signed/Name/Title/Date. This is your certification that the information provided on the form is accurate.

• See attached documents. Check if you have provided any additional documentation relating to the payment data. Located at the bottom middle of the form.

• Partial Payment. Check if the payment period is a partial payment, not a final payment. Located at the top right of the form.

• Final Payment. Check of this period is the final payment period. Located at the top right of the form.

The following instructions are for information of any and all subcontractors used for the pay period.

• (Type) of Ownership. Indicate the Ethnicity and Gender of the owner of the subcontracting business or SLBE.

• Trade/Work Activity. Indicate the trade, service, or material provided by the subcontractor.

• SubContractor/SubConsultant/Supplier. Please indicate status of firm on this contract.

• Federal ID. A number assigned to a business for tax reporting purposes. This information is critical in proper identification of the subcontractor.

• Company Name, Address, Phone & Fax. Provide company information for verification of payments.

• Total Subcontract Amount. Provide total amount of subcontract for subcontractor including change orders.

• Amount Paid To Date. Indicate all dollars paid to date for the subcontractor.

• Amount Pending, Previously Reported. Indicate any amount previously reported that payments are pending.

• Amount To Be Paid for this Period. Provide dollar amount of dollars requested for the pay period.

• Sub Pay Period Ending Date. Provide date for which subcontractor invoiced performed work.

Forms must be signed and dated or will be considered incomplete. The company authorized representative must sign and certify the information is true and accurate. Failure to sign this document or return the document unsigned can be cause for determining a company is in non-compliance of Ordinance 2008-89.

If any additional information is required or you have any questions, you may call the Office of Equal Business Opportunity at (813) 274-5522.