OCSD-4-Utilization-Plan.pdf

OFFICE OF CONTRACTOR AND SUPPLIER DIVERSITY

OCSD-4 MWBE AND SDVOB UTILIZATION PLAN

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INSTRUCTIONS: This form must be submitted with any bid, proposal, or proposed negotiated contract or within a reasonable time thereafter, but prior to contract award. This MWBE and SDVOB Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (M/WBE) and/or Service Disabled Veteran Owned Business (SDVOB) under the contract. Attach additional sheets if necessary.

* indicates mandatory fields

*Contractor Name: __________________________________________________ Address: ______________________________________________

*Representative Name: ______________________________________________ Town, State & Zip: _____________________________________

*Phone: ________________________________ *ESD Contract/Project Number: ____________________________

*Fax: __________________________________ RFP/RFQ/Solicitation Number: ____________________________

*Email: ______________________________________________________________ *MWBE Goal: MBE % + WBE % = MWBE GOAL %

*Total Dollar Value of Contract/Grant: $ *SDVOB Goal: %

1.

* Certified MWBE or SDVOB Firm Name, Contact Person’s Name, Address, Phone and Email.

2.

* Check All That

Apply

3.

* Federal ID No.

4.

Detailed Description of Work (Attach additional sheets, if necessary, Attach Contract if available)

5.

Dollar Value of Contract (if unavailable or yet undetermined, indicate $1)

A.

NYS CERTIFIED

MBE

WBE

SDVOB

B. NYS CERTIFIED

MBE

WBE

SDVOB

OFFICE OF CONTRACTOR AND SUPPLIER DIVERSITY

OCSD-4 MWBE AND SDVOB UTILIZATION PLAN

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6. If unable to fully meet the MWBE and/or SDVOB goals set forth in the contract, the Contractor must submit a Waiver Request form, which may be obtained from the Office of Contractor and Supplier Diversity, at OCSD@ESD.NY.GOV.

PREPARED BY (Signature): ______________________________ DATE: __________

Preparer’s Name (Print or Type): __________________________________________

Preparer’s Title: ___________________________________________

Date: ________________

SUBMISSION OF THIS FORM CONSTITUTES THE CONTRACTOR’S

ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH THE MWBE AND

SDVOB REQUIREMENTS SET FORTH UNDER NYS EXECUTIVE LAW ARTICLES 15-A

AND 17-B, 5 NYCRR PART 143, 9 NYCRR PART 252, AND THE ABOVE-

REFERENCED SOLICITATION. FAILURE TO SUBMIT COMPLETE AND ACCURATE

INFORMATION MAY RESULT IN A FINDING OF NONCOMPLIANCE AND POSSIBLE

TERMINATION OF YOUR CONTRACT.

TELEPHONE NO.:

EMAIL ADDRESS:

** FOR OCSD USE ONLY **

REVIEWED BY: DATE:

UTILIZATION PLAN APPROVED?

YES NO Date:

Contract No.:

Project No. (if applicable):

Contract Award Date:

Estimated Date of Completion:

Amount Obligated Under the Contract:

Description of Work:

NOTICE OF DEFICIENCY ISSUED?

YES NO Date of Issue:

NOTICE OF ACCEPTANCE ISSUED?

YES NO Date of Issue:

The MWBE Certification status of the firms listed on this form MUST be verified using the New York State Contract System’s Directory of Certified Minority and Women-owned Business Enterprises.

This directory is available at https://ny.newnycontracts.com.

The SDVOB Certification status of the firms listed on this form MUST be verified using the Directory of New York State Certified Service-Disabled Veteran-Owned Businesses.

This directory is available at https://online.ogs.ny.gov/SDVOB/search.

mailto:OCSD@ESD.NY.GOV https://ny.newnycontracts.com/ https://online.ogs.ny.gov/SDVOB/search