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Section 111: Selected MBE Subcontractors <br /> Est. %of Total Actual % of <br /> Subcontractor Name Estimated Amount Contract Actual Amount Total Contract <br /> i <br /> 1 <br /> I <br /> l <br /> i <br /> i <br /> s <br /> i <br /> 4 <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 /> � Actual %of <br /> Contract Name Estimated Amount Est. % tr act Total Actual Amount Total Contract <br /> i <br /> i <br /> i <br /> i <br /> , <br /> , <br /> i <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 /> ❑ 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 of the final payment. <br /> " �► -�,- February 16, 2022 <br /> Sionatuof Prime Contractor Date <br /> re <br /> Janet Hass, Contracting & Attesting Officer <br /> 27 <br />