Form Pb040 - Minority Participation Affidavit

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MINORITY PARTICIPATION AFFIDAVIT
A.
AUTHORIZED REPRESENTATIVE
I HEREBY AFFIRM THAT:
I am the [title]________________________________________ and the duly authorized representative of [business]
_______________________________________ (the “Business”) and that I possess the legal authority to make this Affidavit
on behalf of myself and the Business for which I am acting.
B.
AFFIRMATION REGARDING MINORITY PARTICIPATION
I FURTHER AFFIRM THAT:
I am aware that, pursuant to the June 4, 2009 Executive Order of Baltimore County, Maryland, the following words have
the meanings indicated.
(A) “Minority Business Enterprise” or “MBE” means a business enterprise that is owned, operated and controlled by one
or more minority group members (African American, Hispanic American, Asian American, or Native American) who have at
least 51% ownership and in which the minority group members have operational and managerial control, interest in capital and
earnings commensurate with their percentage of ownership.
(B) “Women’s Business Enterprise” or “WBE” means a business enterprise that is owned, operated and controlled by one
or more women who have at least 51% ownership and in which the women have operational and managerial control, interest in
capital and earnings commensurate with their percentage of ownership.
____
The Business is a certified MBE with
[____] Maryland State Department of Transportation (MDOT) #_____________________
[____] City of Baltimore #_____________________
[____] Name Other Jurisdiction: __________________________________ #_____________________
____ The Business is a certified WBE with
[____] Maryland State Department of Transportation (MDOT) #_____________________
[____] City of Baltimore #_____________________
[____] Name Other Jurisdiction: __________________________________ #_____________________
_____ The Business is not a certified MBE or WBE, however:
[____] The ownership of the Business consists of ___% minorities and ___% women (for a total of ___%), each of which
has operational and managerial control, interest in capital and earnings commensurate with their percentage of
ownership.
[____] The Business anticipates utilizing MBE or WBE subcontractors for ___% of the work on the contract.
[____] The Business is not a certified MBE or WBE nor is it 51% owned, operated and controlled by one or more minority
group members or a woman.
[____] Due to the specific nature of work, this contract does not lend itself to subcontracting opportunities. Therefore,
_________________________________________________ is requesting a full waiver of the MBE/WBE
requirement.
I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE CONTENTS OF THIS
AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF.
Date: ________________________
By:___________________________________________
Name:
Title:
(Authorized Representative and Affiant)
PB040
Revised 06/29/2009

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