MBE_D-3A.pdf

MBE Attachment D-3A

MBE SUBCONTRACTOR PROJECT PARTICIPATION CERTIFICATION

Please complete and submit one form for each certified MBE firm listed on the MBE Participation Schedule (Attachment D-1A) within 10 Working Days of notification of apparent award. If the Bidder/Offeror fails to return this Affidavit within the required time, the Procurement Officer may determine that the Bidder/Offeror is not responsible and therefore not eligible for Contract award.

Provided that _________________________________________________ (Prime Contractor’s Name) is awarded the State contract in conjunction with Solicitation No.

_______________________, such Prime Contractor intends to enter into a subcontract with ____________________(Subcontractor’s Name) committing to participation by the MBE firm ___________________ (MBE Name) with MDOT Certification Number _______________ which will receive at least $___________ which equals to___% of the Total Contract Amount for performing the following products/services for the Contract:

NAICS CODE WORK ITEM, SPECIFICATION NUMBER, LINE

ITEMS OR WORK CATEGORIES (IF

APPLICABLE)

DESCRIPTION OF SPECIFIC PRODUCTS

AND/OR SERVICES

Each of the Contractor and Subcontractor acknowledges that, for purposes of determining the accuracy of the information provided herein, the Procurement Officer may request additional information, including, without limitation, copies of the subcontract agreements and quotes.

Each of the Contractor and Subcontractor solemnly affirms under the penalties of perjury that: (i) the information provided in this MBE Subcontractor Project Participation Affidavit is true to the best of its knowledge, information and belief, and (ii) has fully complied with the State Minority Business Enterprise law, State Finance and Procurement Article §14-308(a)(2), Annotated Code of Maryland which provides that, except as otherwise provided by law, a contractor may not identify a certified minority business enterprise in a Bid/Proposal and:

(1) fail to request, receive, or otherwise obtain authorization from the certified minority business enterprise to identify the certified Minority Business Enterprise in its Bid/Proposal;

(2) fail to notify the certified Minority Business Enterprise before execution of the Contract of its inclusion of the Bid/Proposal;

(3) fail to use the certified Minority Business Enterprise in the performance of the Contract;

or

(4) pay the certified Minority Business Enterprise solely for the use of its name in the Bid/Proposal.

PRIME CONTRACTOR

Signature of Representative:

Printed Name and Title:

Firm’s Name:

Federal Identification Number:

Address:

Telephone:

Date:

SUBCONTRACTOR

Signature of Representative:

Printed Name and Title:

Firm’s Name:

Federal Identification Number:

Address:

Telephone:

Date:

MBE Attachment D-3A