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�,,, . City ofi Decatur, Iliinois RETURN WITH BID FOR EACH <br /> � #1 Gary K. Anderson Plaza <br /> Decatur, IL 62523-1196 MBE SUBCONTRACTOR <br /> MBE Subcontractor information Form <br /> Date: 2 Z� (C� Project Title: ��1�� �,����� �.��,� M�i� Q�;gIA�.C.tYlc�7 j" �aSE�.t <br /> Total Contract Value: `�z�(,,Zt� ?rj�, (�(� Project Number: �(�(�� .t(� <br /> Section I: MBE Subcontractor Information <br /> Subcontractor: �(��.Eti«� �,.i-�C2�2.tSti:S �,.`..G <br /> 3y�(a L�:���a�.�� �o , <br /> Address: , <br /> �.-.0�'l(l_iJ . ��L- �1 1 C. 1 <br /> Phone: Z�1 - C,,��j - 2'��L� <br /> Contact Person: ���(Lti� t�;L�.ui;(=,�1't3a <br /> Email: 1'Y�i�t�A , tY1�2�c�t� �E�.i-'C' c�� V��(atL :CAt^!l <br /> Section 11: Estimated Work <br /> Description of Scope of Work Agreed Upon Estimated Amount Estimated %of <br /> Total Contract <br /> �c�t� f T�uc,k��c.� - SPat�S (��ucX���, �3�(j,b�1,�U i�`�a <br /> This form must be completed and submitted with the bid proposal for each MBE Subcontractor All Subcontractors <br /> intended for use on this project shall have an MBE Subcontractor Information Form signed by the prime contractor and <br /> subcontractor. If for whatever reason the Prime Contractor changes or adds a Subcontractor, a Notification of Change in <br /> Participation Form and MBE Subcontractor Information Form with the necessary support documentation must be submitted <br /> and approved. <br /> The undersigned certifies that the information included herein is true and correct and the subcontractor has agreed to perform <br /> the scope of worlc described. The undersigned further certifies that this form is not a Contract between the City, Prime <br /> Contractor or Subcontractor. <br /> Prime C Print <br /> • 'J�.FF ��^��c.�. <br /> Title Date � � <br /> 1 C.� 42ES�� ;t.:N"C ��ZC) I i`� _ <br /> Subcontractor Signature Print <br /> ��2t�J`� i�i�t.-c...,i;�t 1� , <br /> Title Date <br /> ����co;��-c z I2�t `� <br /> 24 <br />