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' Section III: Selected MBE Subcontractors <br /> Est. %of Total Actual %of <br /> Subcontractor Name Estimated Amount Contract Actual Amount Total Contract <br /> MBE Subcontractor Totals <br /> ' If more subcontractors are utilized, please copy this form and attach the additional information. <br /> Section III: Selected MBE purchase of Goods, Materials,and Equipment <br /> r Est. % of Total Actual%of <br /> Name Estimated Amount Contract Actual Amount Total Contract <br /> MBE Totals <br /> If more MBE's are utilized, please copy this form and attach the additional information. <br /> CHECK ALL THAT APPLY. SPECIFIC SUPPORTING DOCUMENTATION MUST BE SUBMITTED AS INDICATED. <br /> ❑ MBE Goal of 10% has been reached <br /> ❑ MBE Goal of 10% has not been reached but Contractor has met the goal estimated on the MBE Utilization <br /> Statement submitted at Bid <br /> ❑ MBE Goal of 10% has not been reached and Contractor has not met the goal estimated on the MBE Utilization <br /> Statement submitted at Bid (attach explanation) <br /> ❑ MBE Goal of 20% has been reached and qualifies for a 2% Bonus of the final Contract Value up to a maximum of <br /> $50,000 <br /> Jul Other—(State reason and attach explanation) <br /> The undersigned certifies that the information included herein is true and correct, failure to submit this form may result in <br /> delay o al paymen <br /> ' Pt� September 22, 2021 <br /> Sionature of Pri ontractor Date <br /> 24 <br />