Form_MBD-30_Payments.pdf
PDF 271 KB Posted
- Attached to
- Bunker Gear Services State and local contract opportunity
- Solicitation number
- 25-P-00167
- Issued by
- Hillsborough County, Florida
About this file
This is a Diversity Management Initiative (DMI) payment reporting form (Form MBD-30) for the City of Tampa, designed to track payments to subcontractors, consultants, and suppliers on city contracts. The form serves as a mandatory submission requirement whenever subcontracting work is rendered during a pay period and requires detailed documentation of all subcontractor payments, ownership demographics, trade activities, and federal identification information. The form must be completed and signed by an authorized company representative for each payment period and submitted alongside invoicing requests. Failure to complete the form accurately or to submit required supporting documentation—such as waiver and release of lien forms or affidavits of payment—may result in determination of non-compliance with City of Tampa Ordinance 2008-89. The City of Tampa's Office of Equal Business Opportunity administers the form and can be contacted at (813) 274-5522 for clarification or questions.
The form requires comprehensive tracking of subcontractor information including company name, address, phone, fax, federal identification number, total subcontract amounts, amounts paid to date, amounts pending from previous periods, and amounts to be paid in the current period. Contractors must identify the ownership demographics of subcontracting businesses by ethnicity and gender (Female/Male, African American, Hispanic American, Asian American, Native American, or Caucasian) and designate whether firms qualify as Small Local Business Enterprises (SLBE). The form is part of the City of Tampa's Equal Business Opportunity Program, which emphasizes participation of underutilized Women and Minority Business Enterprises (U-WMBE) and SLBE firms on city contracts. All data entries must be accurate and complete, with the company's authorized representative providing certification through signature and date that the payment information submitted is true and accurate.
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Text version
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.
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