QUARTERLY M/WBE COMPLIANCE REPORT

tract. QUARTERLY M/WBE COMPLIANCE REPORT

M/WBE 102 (v.2015.12.09es)

a con As evidence of the progress made toward achievement of the minority and women owned business enterprise (MWBE) Goal(s),

REPORTING PERIOD

of contractor is required to complete and submit the following for each NYS-certified MWBE (please use additional sheets if

April 1 ? June 30 Oct. 1 ? Dec. 31

rm necessary). Beginning THIRTY (30) days after a contract is awarded Quarterly MWBE Contractor Compliance Reports are due on

July 1 ? Sept. 30 Jan. 1 ? Mar. 31

te Jan.15, April 15th, July 15th, and October 15th to report MWBE utilization for the preceding quarter.

g the Contract Overview

durin . Offeror/Contractor Name:

Telephone:

M/WBE NYS Certified Firm?

ported ystem Address ill be re tract S City, State, Zip:

Federal ID No: Solicitation No:

SFS Vendor ID:

t w Con Please place the name of your company in Box A only if you are a NYS-Certified M/WBE and include quarterly contract payments received.

Y If Yes, proceed to box A N If No, proceed to box B

tion tha rk State A Name: rma Yo FEIN:

SFS Vendor ID:

Actual CIO/OFT Contract payment(s) received by the NYS-Certified M/WBE $ Contractor during the reporting period:

info New MBE

DUAL

Actual total of payments made over the life of this contract:

$

end the WBE E sp ugh om In boxes B thru E, please include quarterly expenditures your company made to NYS-certified M/WBE companies only. Check the DIRECT box for expenditures required to meet WB thro ts.c CIO/OFT Contract obligations, and INDIRECT box for expenditures not specific to contract obligations.

the M line trac B Name: of on ycon FEIN:

SFS Vendor ID:

Actual payment(s) made to the NYS-Certified M/WBE Contractor during

the reporting period:

$

ample quired .newn MBE n ex is re ://ny WBE only a ation : https C Name: rm is inform go to FEIN:

DUAL

DIRECT INDIRECT

SFS Vendor ID:

Actual total of payments made over the life of this contract:

$

Description of Work:

Dates of Services:

Actual payment(s) made to the NYS-Certified M/WBE Contractor during

the reporting period:

$

is fo end ation MBE

DUAL

DIRECT

Actual total of payments made over the life of this contract:

$

Th E sp form WBE

INDIRECT

Description of Work:

. MWFBor more in Dates of Services:

Page - 1 - of 2

In

boxes

B

thru

E,

please

include

quarterly

expenditures

QUARTERLY M/WBE COMPLIANCE REPORT

your company made to NYS-certified M/WBE companies only. Check

the

DIRECT

box

for

expeonfdMiat/uWrceBsEor1ne0q2tur(ivar.e2cd0t1t.5o.1m2.e0e9tes)

rm CIO/OFT Contract obligations, and INDIRECT box for expenditures not specific to contract obligations.

te D Name: g the FEIN:

SFS Vendor ID:

Actual payment(s) made to the NYS-Certified M/WBE Contractor during

the reporting period:

$

durin . MBE

DUAL

DIRECT

Actual total of payments made over the life of this contract:

$

rted tem WBE

INDIRECT

Description of Work:

repo Sys Dates if Services:

ill be tract E Name: that w te Con FEIN:

SFS Vendor ID:

Actual payment(s) made to the NYS-Certified M/WBE Contractor during

the reporting period:

$

tion Sta MBE

DUAL

DIRECT

Actual total of payments made over the life of this contract:

$

a ork WBE

INDIRECT

Description of Work:

inform ew Y Dates of Services:

end the N I hereby affirm that the information supplied in this quarterly compliance report is true and correct to the best of my knowledge. E sp ugh om I hereby affirm that the information supplied in the previous quarterly report is true and correct. If not, attached is a revised compliance report for the previous quarter. WB thro cts.c _SUBMISSION OF THIS FORM CONSTITUTES THE OFFEROR/CONTRACTOR'S ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH THE M/WBE REQUIREMENTS SET FORTH UNDER NYS the M line tra EXECUTIVE LAW, ARTICLE 15-A, 5 NYCRR PART 142, AND THE ABOVE REFERENCED SOLICITATION. FAILURE TO SUBMIT COMPLETE AND ACCURATE INFORMATION MAY RESULT IN A FINDING OF n on NONCOMPLIANCE AND/OR TERMINATION OF THE CONTRACT.

xample of required o y.newnyc ______________________________________

n e is ://n Signature

Date

ly a tion ttps _______________________________________ is on rma to: h Print Name

rm info go _______________________________________ is fo end tion Title

Th E sp forma _______________________________________

. MWB re in Email

Telephone

Sworn to before me this _____ day of ____________ 20____

_________________________________________________ Notary Public

Seal:

FOR AUTHORIZED USE ONLY Reviewed by: Date Received:

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