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CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM' <br />FORM MWBE-1.0' <br />MBEIWBE 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 verity whether any listed minority or woman business meets the qualifications of a Minority or Women's <br />owned business. <br />Project Number: 119-064 Project Name: 315 & 319 W. Jefferson Exterior Renovations <br />Bidder: Walsh & Kelly, Inc. Total Bid Amount: $41,219.00 MBE/WBE Goal: 2.40% <br />Page 1 of 1 <br />Name &Address of MBEMIBE <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 <br />MBE/WBE Component <br />Percentage <br />of Total <br />Bid/Proposal <br />C. Lee Construction Services, Inc. <br />Chip Lee <br />Hauling <br />$990.00 <br />2.40% <br />1011 S. Lake Street <br />219-922-7733 <br />Gary, IN 46403 <br />Submitted by: Walsh & Kelly, Inc. <br />Print Name <br />Version 4/2/2019 Contractor's Bid for <br />8/13/19 <br />Date <br />