Attachment_4.A_-_Small_Business_Subcontracting_Record.pdf

ATTACHMENT 4.A

SMALL BUSINESS SUBCONTRACTING RECORD

COMPANY NAME: _______________________________________

SUBCONTRACTING ACHIEVEMENTS – Include actual dollar values subcontracted for each of the categories listed. Include the percentage goal only if a goal was established. Note: Form may be expanded.

(1) Contract Number/Title:

Check One: ____ Prime Contract ____ Subcontract

Subcontracting Plan Required ____ Yes ____ No

ACTUAL

SUBCONTRACTED

SUBCONTRACT

GOAL

(if applicable) Completion Date: Total Contract Value: $ Total Subcontracted Value: $ Whole Dollars Percent Percent

(a) Small Business Concerns (Including SDB, WOSB, HUBZone, VOSB, SDVOSB and AbilityOne entities) (Dollar amount and percent of line c.)

Small Business Concerns (Non-Federal Certifications Examples:

MBE (Minority Business Enterprise), DBE (Disadvantaged Business Enterprise), DVBE (Disabled Veteran Business Enterprise), SB (Small Business), WBE (Women’s Business Enterprise).

(b) Other Than Small (OTS) Business Concerns (Dollar amount and percent of line c.)

(c) Total (sum of lines a & b above)

(d) Small Disadvantaged Business Concerns (Dollar amount and percent of line c.) Including MBE & DBE

(e) Women-Owned Small Business Concerns (Dollar amount and percent of line c.) Including WBE

(f) HUBZone Small Business Concerns (Dollar amount and percent of line c.)

(g) Veteran-Owned Small Business Concerns (Dollar amount and

(h) Service Disabled Veteran-Owned Small Business Concerns (Dollar amount and percent of line c.) Including DVBE

Name of customer reference for this project: ___________________________________________ Phone Number: _______________________ FAX Number: _______________________ Email address: ________________________________________

(2) Contract Number/Title:

SUBCONTRACT

GOAL

(if applicable) Completion Date: Contract Dollar Value: $ Total Subcontracted Value: $ Whole Dollars Percent Percent

(b) Small Business Concerns (Including SDB, WOSB, HUBZone, VOSB, SDVOSB and AbilityOne entities) (Dollar amount and percent of line c.)

Small Business Concerns (Non-Federal Certifications Examples:

MBE (Minority Business Enterprise), DBE (Disadvantaged Business Enterprise), DVBE (Disabled Veteran Business Enterprise), SB (Small

(b) OTS Business Concerns (Dollar amount and percent of line c.)

Email address: ________________________________________

(3) Contract Number/Title:

SUBCONTRACT

GOAL

(if applicable) Completion Date: Contract Dollar Value: $ Total Subcontracted Value: $ Whole Dollars Percent Percent

(c) Small Business Concerns (Including SDB, WOSB, HUBZone, VOSB, SDVOSB and AbilityOne entities) (Dollar amount and percent of line c.)

Small Business Concerns (Non-Federal Certifications Examples:

MBE (Minority Business Enterprise), DBE (Disadvantaged Business Enterprise), DVBE (Disabled Veteran Business Enterprise), SB (Small

(b) OTS Business Concerns (Dollar amount and percent of line c.)

Email address: ________________________________________