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:,Oi <br />CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION P <br />FORM MBE-1.0 <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 -owned business meets the MBE qualifications. <br />***Goals should be calculated based on the Base Bid only.*** <br />Project Number: 123-014R Project Name: Demolition of 1000 West Sample Street <br />Bidder: X=nd ghpt �Ih�. /V� Base Bid Amount: Z2.1/ Zc» MBE Goal: 1.39% <br />Page_-L--of--)- <br />Name & Address of MBE <br />Primary Contact Person <br />(Nam <br />( p hone) <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 />Submitted by: GVM1^ IAK b5!„A <br />Print Name Signature <br />***Goals should be calculated based on the Base Bid only.*** <br />Version 07/19/2023 Contractor's Bid for Public Works - 8 <br />alp 'XU <br />Date <br />