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Section III: Selected MBE Subcontractors <br /> Est.%of Total Actual%of <br /> Subcontractor Name Estimated Amount Contract Actual Amount Total Contract <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 /> Est.%of Total Actual%of <br /> Name Estimated Amount Contract Actual Amount Total Contract <br /> MBE Totals <br /> If more MBEs 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 qualities for a 2% Bonus of the final Contract Value up to a maximum of <br /> $50,000 <br /> Q 5ti014i'leeue0 <br /> Other—(State reason and attach explanation) ., } _. t <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 /> Signature bf Prime Contractor I I Date <br /> Rev 08/2020 <br />