Fillable Subcontractor Verification Form printable pdf download

Subcontractor Verification Form

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Disadvantage Business Enterprise (DBE)

Subcontractor Verification Form

Prime Contractor Company Name: ________________________________________________________

Contract Name/Number: ________________________________________________________________

Contract Award Amount: $______________________

Note to prime contractor: You are required to complete this form listing each DBE (MBE or WBE)

subcontractor to be employed in work eligible for the Drinking Water State Revolving Fund within the table

below. Please submit an original of this completed form, along with each subcontractor's current, valid

DBE certificate, to the municipality within 14 days of bid opening. In the event that this form is not

submitted with the bid application, the bid could be rendered nonresponsive and rejected.

Subcontractor

Address/Phone/E-mail

Name of Contact

Dollar

MBE %

WBE %

Name

Amount*

(25% for

Contract

Suppliers)

0.00%

Totals:

0.00

0.00%

Page 1 of 2

8/25/2014

Subcontractor Verification Form

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