Cbi Form 6: Payment Affidavit Form - Subcontractor / Supplier Utilization (Sbe/mbe)

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CBI FORM 6: Payment Affidavit - Subcontractor / Supplier Utilization
To be submitted with each request for payment from the City of Charlotte showing work that has been paid for all
subcontractors, suppliers, manufacturers, brokers, and / or members of a joint venture in connection with the contract. Copy
this form as needed. The Prime is responsible for collecting and submitting CBI Form 6 from all subsequent lower tiers.
Project Name:
Contractor Name:
Payment / Invoice #
Contract Number:
Invoice Amount:
$
Payment Period:
From
To
City Department:
FINAL PAYMENT
Check this box only when submitting Final Pay request.
Section 1: Payments to SUBCONTRACTORS (MSBEs and Non-MSBEs)
Complete the chart below for all subcontractors used on the Project/Contract regardless of dollar amount. All subcontractors must be
registered in the City’s Vendor Management System.
Mark X for
each
Subcontractor’s
Description of Work
Payments
Cumulative
Certification
NIGP Code
Vendor #
Name
Performed
this Period
Payments
SBE
MBE
Section 2: Payments to SUPPLIERS
All suppliers providing goods under City contracts must be listed on the Sales Tax Statement submitted with each pay request. The City may
request on a case-by-case basis that the Contractor require certain suppliers to be registered in the City’s Vendor System and may withhold
payment of any amounts due the Contractor in the event the Contractor fails to comply with such request.
The undersigned Company certifies the preceding chart is a true and accurate statement of all payments that have been made to
subcontractors on this Project/Contract, and that all Suppliers providing goods under this contract have been listed in the Sales Tax
Statements submitted to the City in connection with this Payment Affidavit. If no subcontractors or suppliers are listed on the preceding chart
or Sales Tax Statements, the Company certifies that no subcontractors or suppliers were used in performing the Project/Contract for the
payment period indicated. Failure to provide accurate and truthful information is a violation of the Charlotte Business INClusion Policy and
may result in the sanctions prescribed therein.
This
day of
20
Signature
Print Name and Title
To be completed by City for FINAL PAYMENT
SBE Goal:
%
MBE Goal:
%
Total Paid to Contractor:
$
SBE Goal Commitment:
%
MBE Goal Commitment:
%
Total Paid to SBEs:
$
SBE Goal Attainment:
%
MBE Goal Attainment:
%
Total Paid to MBEs:
$

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