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1 City of Decatur, Illinois RETURN W[TH BID FOR EACH <br /> #1 Gary K. Anderson Plaza MBE SUBCONTRACTOR <br /> ' Decatur, IL 0^2523-1196 . MBE Subcontractor Information Form <br /> jDate: 7,27-1 -Project Title: <br /> Total Contract Value: r�� 5't L.'I Project Number- <br /> ,r <br /> Section I: MSE Subcontractor Information 2w -T j 4�4'S( <br /> Subcontractor: 7o <br /> 1 Address: �' � <br /> 1 Phone: 2M f4ak- <br /> t � <br /> Contact Person: &4 <br /> iEmail: j''Y ( , <br /> Section p: Estimated Work <br /> 1 Description of Scope of Work Agreed Upon Estimated Amount Estimated%of <br /> Total Contract <br /> U1S 2 2 , <br /> z � �oo. <br /> 1 This form trust 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 /> 1 Participation Form and MBE Subcontractor Information Form Wth 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 work described. The undersigned further certifies that this form is not a Contract between the City,Prime <br /> Contractor or Subcontractor. <br /> Prime Contractor Signature Print <br /> QA,7_-& - <br /> Title Date <br /> Subconfractor Signature Print <br /> s °� 1� �f\�- l�' � �yL ��at�✓� l� � � 'i� <br /> j <br /> Title Date <br /> i <br /> 23 <br />