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Ea <br /> ?c----c1)-rc'l\A. City of Decatur, Illinois + RETURN WITH BED FOR EACH MBEc'..._\ --->-: - #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIER <br /> ' o`'` Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> information Form <br /> j , <br /> Date: ( f t I� , �-(to I Project Title: DeL.--i GCI �l po ra uy O II 70 Orci J(1d 8±. <br /> Total Contract Value: .i /i-/ -,507 .°t) Project Number () 2 2025_I l <br /> Section 1: Minority Business Enterprise(MBE)Information <br /> Name: K1UYQ.Y C, l �t �Sfl stri At �JU pc)tit) <br /> Address: 31)3 u Ij/,�T-J2r+n/ �G,,,,t-6 2c. ,.,_ --5S <br /> QQC i — (12221 - <br /> Phone: 2n,- 142ct-w55-‘61 <br /> Contact Person: Oi/v(,u1 CIA '5�0(/0 a / <br /> I CD <br /> TY) <br /> ' tycia�-Q- F-�tt�N1tsaIe'hi , W71n <br /> Section 11: Description of Services or Materials to be Provided <br /> Description of Scope of Services Agreed Upon { Estimated Amount Estimated%of <br /> I Total Contract <br /> 5tippU p.P, e and tai suvnabus_ 10, 000-0° H =' T <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 <br /> supplier has agreed to the scope of services described. The undersigned further certifies that this form is not a Contract <br /> between the Cite,Prime Contractor or SubcontractorlMate ial Supplier. <br /> Prime Contractor Signature Print <br /> /71 -271 Sra a -Pauti-u <br /> Title , Date <br /> 110( ccisc,rrimi IvhrxtS, G ituyudiorprfioDur V u/1W n LI i i 2020 <br /> Minority Business Enterprise Signature Print _ <br /> n <br /> >It i'' i Z. i 1 7Z—(2 //e/1.42A-/ 4. ,,,4,__ <br /> Nile 47;2�S‘O6-ice" Date <br /> lI37zv7-4- <br /> Rev 08/2020 <br />