Miami Dade County Schedule Of Intent Affidavit

THIS FORM MUST BE COMPLETED

SCHEDULE OF INTENT AFFIDAVIT

COMMUNITY SMALL BUSINESS ENTEPRISE PROGRAM

Name of Prime Contractor Firm ______________________________________________________________________ Contact Person ______________________________________

Address ___________________________________________________________________________________________ Phone ______________________ Fax ____________________

Project Name ______________________________________________________________________________________ Project Number ______________________________________

CSBE Contract Measure _______________________________________

This form must be completed by the Prime Contractor and the CSBE Subcontractor that will be utilized for scopes of work on the project. Bidders must include this form in a separate envelope

at the time of bid submission. This form must also include the percentage for CSBE make-up, if applicable.

Certification

Prime

Certification No.

Expiration Date

Contractor

Name of Prime Contractor

(if applicable)

(if applicable)

Type of CSBE work to be performed by Prime Contractor

% of Bid

Prime Contractor Total Percentage:

The undersigned intends to perform the following work in connection with the above contract:

CSBE

Make-Up %

Make-Up

Subcontractor %

Certification

of Bid CSBE

of Bid

Yes

No

Name of Subcontractor

Certification No.

Expiration Date

Type of CSBE work to be performed by Subcontractor

Subcontractor Total Percentage:

I certify that the representations contained in this form are to the best of my knowledge true and accurate.

______________________________

______________________________

______________________________

______________________

Prime Signature

Prime Print Name

Prime Print Title

Date

The undersigned has reasonably uncommitted capacity sufficient to provide the required goods or services, all licenses and permits necessary to provide such goods or services, ability to obtain

bonding that is reasonably required to provide such goods or services consistent with normal industry practice, and the ability to otherwise meet the bid specifications.

______________________________

______________________________

______________________________

______________________

Subcontractor Signature

Subcontractor Print Name

Subcontractor Print Title

Date

Check this box if this project is a set-aside and you are performing 100% of the work with your own work forces.

Check this box if Form DBD 305A and Form DBD 305B have been submitted in your pricing envelope.

DBD 400 (Revised 06/10)