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0,.�‘ "1(f._ of Decatur, Illinois <br /> RETURN WITH BID FOR EACH MBE <br /> A #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIER <br /> Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> Date: Project Title: 2026 MISCELLANEOUS SANITARY& STORM SEWER <br /> 1 � IMPROVEMENT PRO ECT <br /> Total Contract Value: i Project Number: 2026-09 <br /> Section I: Minority Business Enterprise(MBE)Information <br /> Name: \ -\(1(X0 1\\E .J <br /> Address: <br /> 3(- C) Le 1 r✓1 \c� <br /> G(; �..--"-C) .N L (en 2 —1 <br /> Phone: <br /> Contact Person: P/Vir'(\0.-- ‘ < rIk..) <br /> Email: � 1CV\.. _ A 1P C �0C ,n VV\ <br /> Section II: Description of Services or Materials to be Provided <br /> Description of Scope of Services Agreed Upon Estimated Amount Estimated % of <br /> Total Contract <br /> fvt t.)\ Clit ,v-x- <br /> �. <br /> Ir <br /> ) _�G . i ?� <br /> ta <br /> 1 <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 supplier <br /> has agreed to the scope of services described. The undersigned further certifies that this form is not a Contract between the <br /> City, Prime Contractor or Subcontractor/Material Supplier. <br /> Prime o•ntractor Signatu e i Print <br /> T le Date <br /> 'e.S;c\ecC 5\‘3 (( _ <br /> Minority Business Enterprise Signature Print _ <br /> XfribLiteV (,c1)c-I- )�-c.� i t� rv' &. L-5 40t_).6 LO <br /> Title Date <br /> le <br /> C L.,_Wk - (3- 2(00 <br /> 28 <br />