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,wi► City of Decatur, Illinois RETURN WITH BID FOR EACH MBE <br /> #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIER <br /> Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> Date: �- ( Q—2 Project Title: 202-1 C DJ36 Sd ew , r1 fave VIQ�I <br /> Total Contract Value: 0 /I `i U Project Number: 12-02-1 -2-1 <br /> Section I: Minority Business Enterprise L (MBE)Inform LLC�i <br /> Name: Loact 1 C SP,ry ick L.-L C <br /> Address: 3-12-1 —ru I CLot <br /> 1yQ- .�� TL-L- to 22S Z'- <br /> Phone: Z I - S -2,2-014c <br /> Contact Person: TT <br /> Email: <br /> Section II: Description of Services or Materials to be Provided <br /> Description of Scope of Services Agreed Upon Estimated Amount Estimated %of <br /> Total Contract <br /> . a r� <br /> 35, 0 0 `7.0 J /A <br /> This form must be completed and submitted with the bid proposal for each MBE. All MBEs intended for use on this <br /> project shall have an MBE Information Form signed by the prime contractor and MSE. If for whatever reason the Prime <br /> Contractor changes or adds an MBE, a Notification of Change in Participation Form and MBE Information Form with the <br /> necessary support documentation must be submitted and approved. <br /> The undersigned certifies that the information included herein is true and correct and the MBE subcontractor or material supplier <br /> has agreed to the scope of services described. The undersigned further certifies that this form is not a Contract between the <br /> City, Prime Contractor or Subcontractor/Material Supplier. <br /> Prime Contractor Signature Print <br /> art E ni I-cc <br /> Title Date <br /> re <br /> Mi 'ty Business Enterprise Signature Print <br /> le Date <br />