MBE_Form_D.pdf
PDF 90 KB Posted
- Solicitation number
- BPM051187
- Issued by
- Anne Arundel County, Maryland
About this file
The document is a Maryland Department of Transportation (MDOT) Minority Business Enterprise (MBE) Form D for State-Funded Contracts, specifically the Subcontractor Project Participation Affidavit. This form is part of the V-MUL26004C solicitation for the Maryland Motor Vehicle Administration's (MVA) On-Call Facility Repair and Renovation contract. The form is designed to document and affirm the participation of Minority Business Enterprise (MBE) subcontractors in the proposed contract, with strict requirements for submission within ten days of the bid deadline.
The form requires detailed information about the prime contractor, subcontractors (including second-tier and third-tier), and the specific MBE firm's planned participation. It mandates disclosure of the MBE firm's MDOT Certification Number, total subcontract amount, percentage of total contract value, and specific work items or services to be performed. Failure to return this affidavit within the required timeframe may result in the procurement officer determining the bidder/offeror as non-responsible and ineligible for contract award. The form includes provisions for the prime contractor and subcontractors to solemnly affirm the accuracy of the information under penalty of perjury, with the understanding that additional documentation may be requested to verify the details provided.
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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.
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