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-,,A K <br />CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-1,0 <br />MWBE PARTICIPATION <br />This completed form should be supplied with Bids that pertain to City of South Bend 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 <br />qualifications of a Minority or Women's owned business. <br />Project Number: 120-019 — Project Name: 1201 Western Ave. Sidewalk Vault Repair <br />Bidder: John Boettcher Sewer & Excavating COM61191(gid Amount: 91,594.04 MWBE Goal: 0% <br />Page 1 of 1 <br />Name & Address of MWBE <br />Primary Contact Person <br />(Nance/Telephone) <br />.... .. . . .. <br />Scope of Work to be Performed <br />(Attach scope/schedulo, if you need additional space) <br />Dollar Amount of MWBE <br />Co trip o r e n I <br />ge <br />of ToPercentatal <br />- — — — <br />----------------- <br />Submitted by: John W. Boettcher <br />Print Name <br />September 8, 2020 <br />bate <br />Version 2/1412020 Page - 12 Public Works Quote <br />