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CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM M WBE-1.0 <br />PROOF OF MBEIWBE PARTICIPATION GOAL <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects <br />requiring proof of MBE/MBE participation goal. It is the bidder's sole responsibility to verify whether any listed <br />minority or woman business meets the qualifications of a Minority or Women's owned business. <br />Project <br />Project Number: 116-083G Name: Ireland Road Storm Repairs <br />Total Bid MBE/WBE <br />Bidder: LaVortt,- Ui,5frj&oy) Go. Amount: 10 , 31�.G 6 Goal: <br />Page Of <br />Name&Address of MBENJBE <br />Primary Contact Person <br />Namerrehone <br />( le p)I <br />Scope of Work to be Performed <br />(Attach scope/schedule reed <br />Dollar Amount of <br />MBEANBE Component <br />Percentage <br />of Total <br />gitllPro osal <br />Lv7oV�r WNIS�fiIVrlOh <br />l -1(I W�fLJ <br />l—U <br />cu�fy�'hINCJ '%LC�J I"J'�J7Y4�IL <br />-M oa 0 <br />7210 <br />Submitted � C� / r <br />by: WY't `���� 4 IU 2a h <br />Print Name Sligna6ture Date <br />Version 7/28/16 Page 19 Public Works Quote <br />