Fillable Ocfs-4631 - Local Assistance Mwbe Waiver Request Form printable pdf download

Ocfs-4631 - Local Assistance Mwbe Waiver Request Form

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New York State Division of Homeland Security and Emergency Services

LOCAL ASSISTANCE MWBE WAIVER REQUEST FORM

IMPORTANT: Separate attachments must be included with this form, detailing the basis for a partial or total waiver request. By submitting this document, the grantee

(contractor) certifies that the grantee has made a good faith effort to promote MWBE participation pursuant to the MWBE requirements set forth in the grant contract.

2. NYS SFS Number :

1. Grantee (Contractor) Name:

3. Federal Identification Number:

1a. Preparer Name/Title:

4. Contract Number:

5. Contract Amount:

1b. Street Address:

6. Approved MWBE Goals:

1c. City, State, Zip Code:

MBE

Amount $

WBE

Amount $

Type of MWBE Waiver Requested:

Full

Partial

MBE Waiver

If partial waiver, please enter the requested revised MBE percentage and amount

% / $

WBE Waiver

If partial waiver, please enter the requested revised WBE percentage and amount

% / $

8. Signature:

Date:

Email Address:

Telephone Number:

By signing and submitting this form, the grantee (contractor) certifies that a good faith effort has been made to promote MWBE participation pursuant to the MWBE

requirements set forth under the contract. Failure to submit complete and accurate information may result in a finding of noncompliance, non-responsibility, and a

suspension or termination of the contract.

FOR DHSES USE ONLY

Submit to:

New York State Division of Homeland Security and /Emergency Services

REVIEWED BY:

Grant Program Administration (GPA)

DATE:

1220 Washington Avenue

Waiver Granted: YES:__ MBE:__ WBE:__

Building 7A,6

Floor

Waiver Denied:__