Affirmative Action Plan Format Page 40
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43QUARTERLY SMALL CONTRACTOR AND
MINORITY BUSINESS ENTERPRISE
PAYMENT STATUS REPORT
Quarter Ending _____
1)
General Contractor Name
2)
State Contract Number
3)
State Contract Award Agency
4)
Project Name
5)
Estimated Completion Date ____
6)
Project Value
7)
Percent Completed to Date ____
(Include all change orders)
8)
Listing of all small contractors and minority business enterprise contractors on the project
to comply with contractual small business set aside provisions:
Company Name
Total Contract Amount
Total Payment
Total Payment
(Indicate & Include all
this Quarter
to Date
change orders)
___________________
___________________
____________
____________
___________________
___________________
____________
____________
___________________
___________________
____________
____________
___________________
___________________
____________
____________
___________________
___________________
____________
____________
___________________
___________________
____________
____________
___________________
___________________
____________
____________
______________________________________
_______________
Signature of Company Official
Date of Report
_________________________________________
Printed Name and Printed Title of Person Signing
Copy:
1) Contract Awarding Agency
2) Commission on Human Rights & Opportunities:
21 Grand Street, Hartford, CT 06106
Form CHRO 258
Page 40 of 43
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