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RETURN VV1TH BID FOR EACH MBE 1 <br /> „\ City of Decatur, Illinois <br /> (c'� #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIER <br /> ✓V• Decatur, 1!_ 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> Date: -- Project � -— - <br /> (3 • �lP Title: De.(.-ri CA 1 u pqiuctp Ino Orcoom St. <br /> Total Contract Value: I07 Project Number: t-pu 2 2025_ I <br /> Section I: Minority Business Enterprise(MBE)Infonnation <br /> Name: D u n k.er F�2G-f f A L 5o pp , \4\',C) (ID C/) <br /> Address: 1 TO N 22nd 5f <br /> De±t hlr�Z�l tQ252 --Phone: 211-42 ir- ;LKr3 <br /> Contact Person: LU r t \4(Jotd,( S t'o n <br /> Emai!: Wri @ &Von Ykrelec c, corn <br /> ecc.on ezc; -len of Services or Materials to be Provided <br /> Description of Scope of Services Agreed Upon I Estimated Amount Estimated%of <br /> _ _ __ -__--- Tota!Contract <br /> Jvc ptm (tndwI-{-I Cu Cti Ctnick groufidin 3 e Dro °c r\. 4 `1 i <br /> 11twAJ')ra(S- <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 chances or adds an MBE,n Notification of Change in Pxrticipz tion Form end 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 <br /> supplier has agreed to the scope of services described. The undersigned further certifies that this form is not a Contract <br /> between the City.Prime Contractor or Subcontractor!Material Supplier. <br /> Prime Contractor Signature Print <br /> )1 G 1 -Q u A,-1-2 <br /> `itle j Date <br /> ( (0I 50 (WV 1 OJ(knGi 13tr' 2-0'1 lc <br /> Minority Business Enterprise Signature Print <br /> j0 : /%c-ii& <br /> Title D.E. <br /> P.yv_si �tcrr_<c. ;1,. Jiff-i..c.nrj 13 <br /> �.s <br /> IL:v 08/2020 <br />