MWBE UTILIZATION PLAN Contract No. - New York
NYS Department of Labor Division of Equal Opportunity Development W. Averell Harriman State Office Building Campus ? Room 540
Albany, NY 12240 (518) 457-1984 (phone) (518) 485-2575 (fax)
MWBE UTILIZATION PLAN
Contract No.:
INSTRUCTIONS: This form must be submitted with any bid or proposal if required. Otherwise, form must be submitted at the time of execution of the contract. This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (MWBE) under the contract. Attach additional sheets if necessary.
Contractor's Name, Address and Telephone No.
Contract Description Location (Region)
MWBE Goals In Contract
MBE
%
WBE
%
Federal Identification No. Certified M/WBE Subcontractors/Suppliers
Name, Address, Telephone No, E-mail Address
Federal ID. No.
NYS ESD CERTIFIED
MBE
WBE
Detailed description of Work (Attach additional sheets if necessary)
Dollar Value of Subcontracts/ supplies/ services and intended performance dates of
each component of the contract
$
Phone: ( ) -
E-mail:
$
Phone: ( ) -
E-mail:
$
Phone: ( ) -
E-mail:
IF UNABLE TO FULLY MEET THE MBE AND WBE GOALS SET FORTH IN THE CONTRACT, CONTRACTOR MUST SUBMIT A REQUEST FOR WAIVER (Form MWBE 101/BDC 333)
Submission of this form constitutes the contractor's acknowledgement and agreement to comply with the M/WBE requirements set forth under NYS Executive Law, Article 15-A and 5 NYCRR Part 142. Failure to submit complete and accurate information may result in a finding of noncompliance or rejection of the bid/proposal and/or suspension or termination of the contract.
Prepared By (Signature)
Email Address
Name and Title of Preparer (Print or Type) Reviewed By
Telephone No.: ( ) -
Date
FOR M/WBE USE ONLY Date
Utilization Plan Approved
Yes
No
Date
Contract No.
Project No. (If applicable)
Contract Award Date
Estimated Completion Date
Contract Amount Obligated
Notice of Deficiency Issued Notice of Acceptance Issued
Date Yes No
Date Yes No
Description of Work
MWBE 100/BDC 334 (12/11)
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