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CITY OF SOUTH BEND C <br />MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN <br />FORM MBE-1.0 �d <br />MBE UTILIZATION PLAN <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE participation. It is <br />the bidder's sole responsibility to verify whether any listed minority or woman business meets the MBE qualifications. <br />Project Number: <br />Bidder: <br />122-060B Project Name: Century Center Parking Lot Seal and Stripe <br />V/y%fz Ukfru( JV4(N�-A -Total Bid Amount: <br />-LE <br />MBE Goal: 4.3% <br />Page % of <br />Name 8 Address of MBE <br />Primary Contact Person <br />(Name/Telephone) <br />Scope of Work to be Performed <br />(Attach scope/schedule if you need additional space) <br />Dollar Amount of MBE <br />Component <br />Percentage <br />of Total <br />Bid/Proposal <br />AJ <br />�fv <br />Submitted by: 64,a, a �� I.tr wttA0 1 <br />Print Name Signature <br />c / -Z3 <br />Date <br />Version 06/01/2022 Page - 22 Public Works Quote <br />