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City of Decatur, Illinois <br /> Kt <br /> 1 UKN WI I H ts1U tUK LAI.H Mist <br /> Q" ) #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIERLIER ' <br /> Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> Date: February 16, 2022 Project Title: 2022 Trenchless Long Lining Repairs <br /> Total Contract Value: Project Number: 2022-28 <br /> Section I: Minority Business Enterprise (MBE)Information <br /> Name: <br /> Address: -- -- <br /> Phone: <br /> Contact Person: <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 /> 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 MBE. 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 /> - Janet Hass <br /> Title Date <br /> ., Contracting &Attesting Officer February 16, 2022 <br /> Minority Business Enterprise Signature Print <br /> Title Date <br /> February 16, 2022 <br /> 25 <br />