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City of Decatur, Illinois <br /> #1 Gary K. Anderson Plaza Notification ®f Change in Participation <br /> -, Decatur, IL 62523-1196 <br /> Date: Project Title: <br /> Project Number: <br /> Prime Contractor: <br /> Address: <br /> Phone: <br /> Contact Person: <br /> Email: <br /> If changing from a previously identified subcontractor/material supplier to another or to change from self-performing tc <br /> a subcontractor, complete the following: <br /> From Name: To Name: <br /> Address: Address: <br />' Phone: Phone: <br /> Status: ❑ MBE ❑ Non-MBE Status: ❑ MBE ❑ Non-MBE <br /> Contract <br /> Amount: <br /> Will the scope of work change? ❑ Yes ❑ No <br /> Describe the scope of work change: <br /> PReasonubcontractor change: <br /> Describe good faith efforts to utilize an MBE: <br /> 1 Signature of Prime Contractor Date <br /> Signature of Prime Contractor Date <br /> 23 <br />