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� <br /> , City of Decatur, ![linas <br /> � #1 Gary K. Andersan Piaza RETURN WITH BID FOR EACH <br /> ' Decatur, IL 62523-1196 MBE SUBC0�ITRACTOR <br /> MBE Subcantractor Infarmation �orm <br /> ' p,�t�;_.^� �June 5, 2019 Project Title: 2Q19 Trenchlr�ss Long Lining Repairs T <br /> Total Contract Value: �J `��d(�7? Project Number: � 2019-28 �g� <br /> t , y � <br /> Section t. MBE Subcontractor information - � <br /> :�� <br /> �:. . .. ., <br /> �.,._..:,...�,. :-:,::. . <br /> � � t _ _... _�.�.____�... _ <br /> Subcontractor: �,���`����� � <br /> Address; --� <br /> � __ � ���s �� � �'� <br /> Phane: � <br /> , Cantact Person: /,�,�"_,l�p!'y�-j,v��+,+"` _ ,_,_�.. <br /> EtTtail: ' r� 'G.�t� <br /> , Section 11: Estimated Work <br /> Description of Scape of Work Agreed Upon Estinnated Amount ����mated°l�of <br /> � py� Mw,y� Total Contract <br /> , �.C"..�T'V 'T�,s'�ec�'on � �,/e�n�n Set.�.�r' G.:h tS ,� �(a,3t� � <br /> � <br /> ' <br /> ' �_. <br /> Th�s form must be comz�leted and submikted with the bid orat�osal�or e�ch MBE Subcontractor. AIt Subcontrac#ors <br /> intended for usa an this projact shalt have an MBE Sabcorytractar Infarmakiat�Forrn signed by the prime contrac#or and <br /> � subcontractor. Ef for whatever reasan the Prime Contraator changes or adds a Subcontrac#or, a Notificatian of Change in <br /> Pa�#�cipation Forrri and iVlBE Subcantractur lnformation Form wi#h the necessary support c3ocumentation must be submitt�c! <br /> and approved. <br /> , The undersigned cectifes thaf the infcsrmatioh inciuded herein is true and correct and the subcontractor has agreed to perform <br /> the scope of work described. The undersigned furkher certifies that this form is not a Contract between the City, Prime <br /> Cont�actar or Subcontractor. �rv_W <br /> Prim Contractor Si nature Print . .__. __. .._��_,.....�__.._ <br /> ' �.. Janet Hass <br /> i Titte 9� Date � <br /> ' ����ntracting & Attesting t3fficer June 5, 2019 <br /> � Subcontracto Signatu� �� Pr�nt <br /> ,�,� �"°"� - =�, �-�.�,..� <br /> � Tftle Date <br /> ' ___�___���__._�...���3 L t�4.t... .�...a� �.�, 3 / <br /> � <br /> � <br />