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Subcontractor Verification Form This is to certify that I, has been contacted by (Subcontractor) (General Contractor) to provide the following services for Bid No. for (Name of Project) Utilization Category Bid Item No.1 Scope of Work to be Performed1 MBE Amount WBE Amount Advance Payment Amount2 Balance to be Paid as Work Progresses Materials/Supplies including Labor or Installation Service Provider/Installer Hauling Services Supplier/Distributor Broker/Dealer Other (Specify) 1Indicate the Bid Item under which the MBE scope of work will be performed and provide a description of this work and the associated cost amount. If the scope of work encompasses multiple pay items, please indicate all items and amounts. If necessary a second sheet may be attached to provide this information. 2Shall not exceed 5% of the stated utilization amount and will be subject to the withholding of retainage. If the Advanced Payment Amount is “blank” or zero, Subcontractor must confirm by checking the box below that the Prime Contractor did offer to make an advance payment in accordance with the Contract Documents and that Subcontractor declined this offer. Offer of Advance Payment was Declined Signature Date Type or Print Name Email MBE/WBE SUBCONTRACTOR/VENDOR VERIFICATION FORM