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City of Decatur, Illinois RETURN WITH BID FOR EACH <br /> ! <br /> #1 Gary K.Anderson Plaza MBE SUBCONTRACTOR <br /> Decatur, IL 62523-1196 MBE Subcontractor Information Form <br /> Date: (a v C.3 I Project Title: acv ' ire l.re--v Lim C l e( S <br /> r ' <br /> Total Contract Value: Project Number: <br /> Section I: MBE Subcontractor Information <br /> Subcontractor: 4A CL(-,e i i-11 t, C- fc'.e r4 L C <br /> i <br /> Address: 161x.J. iT f� l ' <br /> 01 i it t , n =I 1-7:4--7 <br /> Phone: <br /> Contact Person: <br /> J <br /> Email: li'l i 1'11c P(AUC(II-ilf, i-11-P-/, :(' <br /> Section 11: Estimated Work <br /> Description of Scope of Work Agreed Upon Estimated Amount Estimated%of <br /> Total Contract <br /> 20 it) <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 work described. The undersigned further certifies that this form is not a Contract between the City,Prime <br /> Contractor or Subcontractor. <br /> rime Contractor signature Print <br /> Title Date <br /> J ` <br /> Subcontractor Signature Print <br /> ( <br /> N 1t( <br /> Title Date <br /> AMI.— 7 <br /> 26 <br />