MBE_Form_D.pdf
PDF 90 KB Posted
- Solicitation number
- BPM051187
- Issued by
- Anne Arundel County, Maryland
About this file
The document is an MDOT Minority Business Enterprise (MBE) Form D for State-Funded Contracts, specifically a Subcontractor Project Participation Affidavit issued by the Maryland Department of Transportation (MDOT). This form is designed to document and affirm the participation of Minority Business Enterprise (MBE) subcontractors in a state contract, with critical implications for contract award eligibility. The form requires detailed information about prime contractors, subcontractors, contract solicitation numbers, certification details, subcontract amounts, and specific work categories or services to be performed.
The form emphasizes the importance of MBE participation, with a warning that failure to return the affidavit within the required timeframe may result in the procurement officer determining the bidder/offeror as non-responsible and ineligible for contract award. The document provides spaces for multiple tiers of subcontractors (prime, second-tier, and third-tier) to document their involvement, NAICS codes, work items, and specific product or service descriptions. Signatories must affirm under penalty of perjury that the information provided is true, with the understanding that the procurement officer may request additional documentation such as subcontract agreements and quotes to verify the accuracy of the submitted information.
View the file
Other files
Show all 46
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
MDOT-OP 015-2 (10/08/2020)
MDOT MBE FORM D
STATE-FUNDED CONTRACTS
MBE SUBCONTRACTOR PROJECT PARTICIPATION AFFIDAVIT
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 OR THAT THE PROPOSAL IS NOT SUSCEPTIBLE OF BEING SELECTED FOR AWARD. SUBMIT ONE FORM FOR EACH CERTIFIED MBE FIRM LISTED IN THE MBE PARTICIPATION SCHEDULE. BIDDERS/OFFERORS
ARE HIGHLY ENCOURAGED TO SUBMIT FORM D PRIOR TO THE TEN (10) DAY DEADLINE.
Provided that _________________________________________________ (Prime Contractor’s Name) is awarded the Contract in conjunction with Solicitation No. _______________________, such Prime Contractor will enter into a subcontract with ____________________(Subcontractor’s Name) committing to participation by the MBE firm ___________________ (MBE Name) with MDOT Certification Number _______________ (if subcontractor previously listed is also the MBE firm, please restate name and provide MBE Certification Number) which will receive at least $___________ (Total Subcontract Amount) which is ___% (Percent) of the Total Contract Value, 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
I solemnly affirm under the penalties of perjury that the information provided in this MBE Subcontractor Project Participation Affidavit is true to the best of my knowledge, information, and belief. I acknowledge 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.
PRIME CONTRACTOR
Signature of Representative:
Printed Name and Title: _______________
Firm’s Name: _______________________
Federal Identification Number: __________
Address: ___________________________
Telephone: _________________________
Date: _____________________________
SUBCONTRACTOR (SECOND-TIER)
Signature of Representative:
Printed Name and Title: _______________
Firm’s Name: ________________________
Federal Identification Number: __________
Address: ___________________________
Telephone: _________________________
Date: ______________________________
SUBCONTRACTOR (THIRD-TIER)
Signature of Representative:
Printed Name and Title: _______________
Firm’s Name: ________________________
Federal Identification Number: __________
Address: ___________________________
Telephone: _________________________
Date: ______________________________
IF MBE FIRM IS A THIRD-TIER SUBCONTRACTOR, THIS FORM MUST ALSO BE EXECUTED BY THE SECOND-TIER
SUBCONTRACTOR THAT HAS THE SUBCONTRACT AGREEMENT WITH THE MBE FIRM.
File details come from the government source that posted it. Updated .