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CITY OF SOUTH SEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-11.0 <br />MBE[WBE PARTICIPATION <br />gas <br />This completed form should be supplied with Bids that pertain to City of South Bond Public Works Projects involving MBE/MBE <br />participation. It is the bidder's sole responsibility to verify whether any listed minority or woman business meets the qualifications of a <br />Minority or Women's owned business. <br />Project Number: <br />Bidder: <br />117-127 — Project Name: South Bend Fire Department Training Center Classroom Bulldli!lq _ <br />Gibson -Lewis, LLC .. ... .. ................. .. .. Total Bid Amount: <br />MBENVBE Goal: <br />Pageof <br />Narne & Address of MBENVBE <br />Primary Contact Person <br />(Namerrelophone) <br />Scope of Work to be Performed <br />(Attach scope/schedule if you need additional space) <br />Dollar Amount of <br />MBENVBE Component <br />Percentage, <br />131 YFOf Total I <br />Jxc's <br />0 <br />Submitted by: Hobert A. Lingenfelter, President — 3/27/18 <br />Print Name SigmaDate <br />Version 10/17/2017 Contractors Bid for Public Works - 8 <br />