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� �� City of Decatur, Iliinois <br /> � #1 Gary K. Anderson Piaza RETURN WITH BID FOR EACH <br /> � Decatur, IL 62523-1196 MBE SUBCONTRACTOR <br /> MBE Subcontractor Information Form <br /> Date: Project Titte: <br /> Total Contract Value: Project Number: <br /> Section I: MBE Subcontractor Information <br /> Subcontractor: <br /> Address: <br /> Phone: <br /> Contact Person: <br /> Email: <br /> Section II: Estimated Work <br /> Description of Scope of Work Agreed Upon Estimated Amount Estimated %of <br /> Total Contract <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 unde�signed certifies that the information included herein is true and correct and the subcontractor has agreed to perform <br /> the scope of work described. The undersigned further certifies that this form is not a Contract between the City, Prime <br /> Contractor or Subcontractor. <br /> Prime Contractor Si nature Print <br /> Title Date <br /> Subcontractor Signature Print <br /> Title Date <br /> 22 <br />