SB FORM 2028-A fillable~4.pdf

PDF 144 KB Posted

Attached to
RR-24-4977 Jane Addams Memorial Tollway (I-90) Bridge Repairs Rockton Rd to Rote Rd MP 2. 6 to 14. 5
Solicitation number
25-557THA-ENGCO-B-45901
Issued by
Rock Island County, Illinois

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This is Illinois State Toll Highway Authority's Small Business Form 2028-A, which serves as a Small Business Subcontractor Plan form for prime contractors to document their small business participation commitments. The form must be submitted at the time of bid and requires prime contractors to provide detailed information about their small business subcontractors, including firm names, scope of work descriptions, and subcontract amounts in both dollars and percentages.

The form requires that all listed companies must be registered in the Tollway SBI directory or be in the application process as specified in the Special Provision. Changes affecting DBE/VOSB participation require prior written consent from ISTHA and must follow DBE and VOSB Special Provisions. The form includes fields for SBSP registration status and verification of whether firms are included in the DBE/VET Plan. The document concludes with spaces for authorized signature, contact information, and date of submission.

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ILLINOIS STATE TOLL HIGHWAY

AUTHORITY

Small Business Form 2028-A Small Business Subcontractor Plan

PRIME CONTRACTOR: ________________________________

CONTRACT NUMBER: __________________________ CONTACT NAME: ____________________________________

CONTACT PHONE: ___________________________________

CONTACT EMAIL: ____________________________________

Instructions to vendors:

1. Contractors are required to comply with the Special Provision.

2. This SBE Form 2028-A must:

• be submitted at the time of bid

• be an accurate representation of work and pricing agreed upon between the prime and the subcontractor

3. Each company listed on the Small Business Plan must be listed in the Tollway SBI directory or be in the process of application as stipulated in the Special Provision.

4. In no case should a Contractor remove, replace or reduce the commitment to a firm listed in the initial Small Business Small Business Plan without prior written consent of ISTHA. Any changes that may affect the DBE/VOSB participation shall be requested in accordance with the DBE and VOSB Special Provisions.

Small Business subcontractor plan

Firm Name

Scope of Work Brief description of overall work to be performed

(or indicate if supplier only)

Subcont ract

Amount

Subcont ract

Amount

SBSP

registrati on (Yes/No)

SBI

Regist ration

Is this firm included in the

DBE/VET

Plan (Yes/No)

TOTAL

Print Name: _________________________ Phone contact: __________________________

Position: ___________________________ E-mail address: _________________________

Signature: ____________________________ Date: __________________________________

CONTRACT NUMBER:
PRIME CONTRACTOR:
CONTACT NAME:
CONTACT PHONE:
CONTACT EMAIL:
F rm NameRow1:
Scope of Work Br ef descr pt on of overal work to be performed or ndicate if suppl er onlyRow1:
Subcont ract Amount Row1:
Subcont ract Amount Row1_2:
SBSP registrat on YesNoRow1:
SBI Regist rat onRow1:
Is th s firm included in the DBEVET P an YesNoRow1:
F rm NameRow2:
Scope of Work Br ef descr pt on of overal work to be performed or ndicate if suppl er onlyRow2:
Subcont ract Amount Row2:
Subcont ract Amount Row2_2:
SBSP registrat on YesNoRow2:
SBI Regist rat onRow2:
Is th s firm included in the DBEVET P an YesNoRow2:
F rm NameRow3:
Scope of Work Br ef descr pt on of overal work to be performed or ndicate if suppl er onlyRow3:
Subcont ract Amount Row3:
Subcont ract Amount Row3_2:
SBSP registrat on YesNoRow3:
SBI Regist rat onRow3:
Is th s firm included in the DBEVET P an YesNoRow3:
F rm NameRow4:
Scope of Work Br ef descr pt on of overal work to be performed or ndicate if suppl er onlyRow4:
Subcont ract Amount Row4:
Subcont ract Amount Row4_2:
SBSP registrat on YesNoRow4:
SBI Regist rat onRow4:
Is th s firm included in the DBEVET P an YesNoRow4:
F rm NameRow5:
Scope of Work Br ef descr pt on of overal work to be performed or ndicate if suppl er onlyRow5:
Subcont ract Amount Row5:
Subcont ract Amount Row5_2:
SBSP registrat on YesNoRow5:
SBI Regist rat onRow5:
Is th s firm included in the DBEVET P an YesNoRow5:
F rm NameRow6:
Scope of Work Br ef descr pt on of overal work to be performed or ndicate if suppl er onlyRow6:
Subcont ract Amount Row6:
Subcont ract Amount Row6_2:
SBSP registrat on YesNoRow6:
SBI Regist rat onRow6:
Is th s firm included in the DBEVET P an YesNoRow6:
F rm NameRow7:
Scope of Work Br ef descr pt on of overal work to be performed or ndicate if suppl er onlyRow7:
Subcont ract Amount Row7:
Subcont ract Amount Row7_2:
SBSP registrat on YesNoRow7:
SBI Regist rat onRow7:
Is th s firm included in the DBEVET P an YesNoRow7:
F rm NameRow8:
Scope of Work Br ef descr pt on of overal work to be performed or ndicate if suppl er onlyRow8:
Subcont ract Amount Row8:
Subcont ract Amount Row8_2:
SBSP registrat on YesNoRow8:
SBI Regist rat onRow8:
Is th s firm included in the DBEVET P an YesNoRow8:
Subcont ract Amount TOTAL:
Subcont ract Amount TOTAL_2:
Print Name:
Phone contact:
Position:
Email address:
Date:

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