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Section III: Selected MBE Subcontractors <br /> Est. %of Total Actual % of <br /> Subcontractor Name Estimated Amount Contract Actual Amount Total Contract <br /> MBE Subcontractor Totals <br /> If more subcontractors are utilized, please copy this form and attach the additional information. <br /> CHECK ALL THAT APPLY. SPECIFIC SUPPORTING DOCUMENTATION MUST BE SUBMITTED AS INDICATED. <br /> ❑ MBE Goal for subcontractor utilization of 10% has been reached <br /> � MBE Goal for subcontractor utilization of 10% has not been reached but Contractor has met the goal estimated on <br /> the Subcontractor Utilization Statement submitted at Bid <br /> � MBE Goal for subcontractor utilization of 10% has not been reached and Contractor has not met the goal <br /> estimated on the Subcontractor Utilization Statement submitted at Bid (attach explanation) <br /> � Other—(State reason and attach explanation) <br /> The undersigned certifies that the information included herein is true and correct, failure to submit this form may result in <br /> delay of the final payment. <br /> Signature of Prime Contractor Date <br /> 26 <br />