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CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-1.0� R <br />MBE/WBE PARTICIPATION <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE/MBE participation. <br />It is the bidder's sole responsibility to verify whether any listed minority or woman business meets the qualifications of a Minority or Women's <br />owned business. <br />Project Number: 120-036 Project Name: WWTP Masonry Improvements Gallery Buildings 1-4 <br />arson Daniel -Ron <br />Bidder: r Inc Total Bid Amount: MBE/WBE Goal: 7 0/5 0 <br />Page 1 of 1 <br />Name & Address of MBE/WBE <br />Primary ContactPerson ` <br />(Name/Telephone) <br />Scope of Work to be Performed <br />(Attach scope/schedule if you need additional space) <br />Dollar Amount of <br />MBE/WBE Component <br />Percentage <br />of Total <br />Bid/Proposal <br />Indiana Monument and Cut Stone <br />161 Guthrie Drive <br />Bedford, IN 47421 <br />Kathy -Baker Heckard <br />Limestone Supply <br />$3,000 <br />Timothy F. Larson, President X 10/13/20 <br />Submitted by: Y (�` e��'►�+--- <br />Print Name Signature ' Date <br />y�aTE. L.ARSON DANIELSON <br />Version 4/2/2019 ` Contractor's Bid for Public Works - 9 SEAL r CONSTRUCTION CO:, INC, <br />�,AiP <br />