WIFA_DSB_Outreach_Forms_1-2-3.pdf

FORM EO1 - WIFA

Disadvantaged Small Business (DSB) Program - WIFA

FORM EO1 - WIFA - STATEMENT OF OUTREACH COMMITMENT

(Due with initial submittal)

Project Number: Project Title:

On behalf of the Submitter, I certify under penalty of perjury that the following information is true and correct.

If selected as the Successful Submitter, the Successful Submitter will:

1) Fulfill all required small business outreach requirements and shall submit all required outreach efforts documentation for contracting opportunities within 5 business days.

2) Conduct all required small business outreach and will submit all supporting documentation; and

3) Comply with the Race - and Sex -Neutral post-award requirements stated in the DSB WIFA Contract Clause.

Company Name:_______________________________

Company Mailing Address: ____________________________________________________

Representative Name: ________________________________________________________

Title: ______________________________________________________________________

Email Address: ______________________________________________________________

Phone Number: _____________________________________________________________

Signature: __________________________________ Date: _____________________

ROC#: ____________________

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FORM EO2 - WIFA

Form EO2 - WIFA - SMALL BUSINESS OUTREACH EFFORTS AND BIDDERS LIST

(Due within 5 business days after award of JOA) Name of Company (Submitter)/ ROC#: Contract # / Project #: Contract Name:

Contact Person: Phone #: Email:

Submitter must conduct outreach efforts and submit supporting documentation of those efforts, as described in the 2 CFR Part 200, in accordance with the detailed instructions in the Contract Clauses. Successful submitter should make copies of this form as needed.

Section A, B and C must be completed for all businesses which includes ALL BIDDERS.

Sections D, E, and F are required to be competed for all DBE, SBC, SBE and other Small Business firms. Supporting documentation is required for columns D and F.

(A) Small Business Name and Contact Information

(B) Business

Status

(C) Scope(s) of Work

Solicited

(D) Solicitation

Method

(E) Selection Decision

(F) Communication Final

Selection Outcome

Name:

DBE

SBC - Small

Business Concern

NAICS Codes and Scope(s) of Work:

E-mail Blast

Phone Call

In-Person

Newspaper

Website

Trade Listing

Outreach Event

Other

Firm was selected

Firm was not selected

Provide explanation of why firm NOT selected

Date Firm was Notified:

Method used to

Communicate Selection:

Email

Phone

Fax

Letter

In person

Address:

City, State, Zip: Number of Employees:

Phone Number: Email or Fax:

Number of Years in Business:

Range of Annual Gross Receipts:

Sex of Majority Owner:

Race of Majority Owner:

Name:

DBE

SBC - Small

Business Concern

SBE - City of

Phoenix Certified

NAICS Codes and Scope(s) of Work:

E-mail Blast

Phone Call

In-Person

Newspaper

Website

Trade Listing

Outreach Event

Other

Firm was selected

Firm was not selected

Provide explanation of why firm NOT selected

Date Firm was Notified:

Method used to

Communicate Selection:

Email

Phone

Fax

Letter

In person

Address:

City, State, Zip: Number of Employees:

Phone Number: Email or Fax:

Number of Years in Business:

Range of Annual Gross Receipts:

Sex of Majority Owner:

Race of Majority Owner:

*Firms must be notified of final selection outcome prior to submittal of columns E & F of this form.

SBE - City of

Phoenix Certified

Other Small Business

Other Small Business

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FORM EO3 - WIFA

FORM EO3 - WIFA - SMALL BUSINESS UTILIZATION COMMITMENT

(Due within 5 business days after award of JOA) Project Number: Project Title:

On behalf of the Successful Submitter, I certify under the penalty of perjury that the information submitted herein is true and correct:

1. The firms indicated as “Selected” in Form EO2 - WIFA - Small Business Outreach Efforts, will participate in this contract;

2. The Submitter will comply with the Race- and Sex-Neutral post-award compliance requirements as stated in the DSB contract clause;

3. Successful Submitter understands and agrees that any and all changes or substitutions to subcontracts with DBE’s and Small Businesses must be authorized by the Phoenix EO Compliance Specialist prior to implementation; and

4. The following statement is true and correct:

The proposed total participation of firms on this contract will be:

DBE: %

% SBE:

Company Name: ______________________________

Company Mailing Address: _________________________________________________________

Representative Name: _____________________________________________________________

Title: ___________________________________________________________________________

Email Address: ___________________________________________________________________

Phone Number: __________________________________________________________________

Signature: _______________________________________ Date: _______________________

DBE: SBC:

Other Small:

ROC#:________________________