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, , <br /> Section El1: SeEected MBE Subcontractors <br /> Es#.°lo of Tota1 Actual°!o of <br /> Subconfrac#ar Name Estimated Amount Contract Ac#uaE Amount Tatat Con#ract <br /> MBE Subco�tractor Totats <br /> If more subcontractors are utilized,please capy this form and attach fhe additionai information. <br /> CHECK ALL THAT APPLY. SPECtFIC SUPPORTtNG DOGUMENTATIQN MUST BE SUBMITTED AS INDiCATED. <br /> ❑ MBE Gaal#or subcontracfor utilization of 10°lo has{�een reached <br /> � MBE Gaal for subcontractor utilization af 10%has nat been reached but Contrac#or has met the goat es#imated on <br /> the Subcan#ractor Uti[ization Stafement submitted at Bid <br /> � MBE Goal for subcontractor utilization a#'tQ°lo has not been reached and Confractor has nat met the gaal <br /> estima#ed on the Subcontractor Utitization Statement submitted at Bid (attach explanation) <br /> � 4ther—{State season and attach ex�a[anafiot�} <br /> The undersigned certifies that the information included herein is true and carrect,failure to submit this form may result in <br /> detay o#the�nal payment. <br /> Signature of Prime Con#sac#ar E}ate <br /> -25- <br />