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This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MWBE participation. It <br />is the bidder's sole responsibility to verify whether any listed minority or woman business meets the MWBE qualifications. <br />Project Number: 122-011 Project Name: 2022 Microsurfacing <br />Bidder: Sm t I Bid Amourrt:4 16W)A. 5Q MWBE Goal: NIA <br />L %X Page of <br />Name S Address of tinWBE <br />Primary Contact Person <br />(NamelTeiephone) <br />CITY OF SOUTH BEND <br />\, <br />MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN <br />FORM MWBE-1.0--f'+ <br />MWBE UTILIZATION PLAN <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MWBE participation. It <br />is the bidder's sole responsibility to verify whether any listed minority or woman business meets the MWBE qualifications. <br />Project Number: 122-011 Project Name: 2022 Microsurfacing <br />Bidder: Sm t I Bid Amourrt:4 16W)A. 5Q MWBE Goal: NIA <br />L %X Page of <br />Name S Address of tinWBE <br />Primary Contact Person <br />(NamelTeiephone) <br />Scope of Work to he Performed <br />(Attach soopelschedule if you need additional space) <br />Dollar Amount of MWBE <br />Component <br />Percentage <br />of Tota{ <br />BWPro osal <br />/ <br />V <br />Submitted by: <br />Print Name Signature Date <br />Version 2114/2022 Page - 16 Public Works Quote <br />