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CITY OF SOUTH BEND ,<`°""6% <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY a <br />DEVELOPMENT PROGRAM <br />FORM MWBE-1.0 ',. r10 <br />PROOF OF MBE/WBE PARTICIPATION GOAL <br />his completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects requiring proof of MBEIMBE <br />iarticipation goal. It is the bidder's sole responsibility to verify whether any listed minority or woman business meets the qualifications of a <br />linority or Women's owned business. <br />Project Number: 116.083F Project Name: Chippewa Avenue Emergency Repairs <br />Bidder: 1.6%rti: 5 hS�Vtlr1-trja G. J. u Total Bid Amount 95 9 -. 0 G� MBENJBE Goal: <br />Page of <br />Name & Address of MBEIMBE <br />Primary Contact <br />Person <br />(Name/Telephone <br />Scope of Work to be Performed <br />(Attach scope/schedule if you need additional <br />space) <br />Dollar Amount of <br />MBENVBE <br />Component <br />Percentage <br />of Total <br />Bid/Proposal <br />s�.1a Ba�r�adi� <br />29903 vs 70 y 4 <br />Mary <br />2 12� <br />a 90/1 <br />Gy\Si'I,Av) <br />La <br />c. GotiGheycr,y(Par 1tar-^S <br />17'45i <br />71'/0 <br />Submitted by: U'(? c,6,.W ZWL-1 0 <br />Print Name Slgrt7 Date <br />Version 7/28/16 Page - 23 Public Works Quote <br />