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CITY OF SOUTH BEND, INDIANA <br />CONTRACTOR'S BID FOR PUBLIC WORK <br />M/WBE CHECKLIST <br />Project Name River Glen Office Building Demolition <br />Project No. 126-030 <br />For Bids Due Tuesday, April 28, 2026, by 9:00 A.M. Local Time <br />Contractor Name: Green Demolition Contractors, Inc. <br />The City seeks to promote equal opportunity for minority and women -owned businesses, including small <br />local businesses, and to encourage utilization of such businesses in City contracting and procurement. <br />THIS FORM MUST BE SUBMITTED WITH YOUR BID IF THE BID IS AT OR ABOVE $150,000. <br />"THIS FORM ONLY APPLIES TO BIDS GREATER THAN $150,000. ** <br />It is the sole responsibility of the potential bidder to comply with all submission requirements applicable to <br />the bidder in Section 14.5 of the City of South Bend, Indiana Code of Ordinances and the Minority and <br />Women Business Program Plan. <br />INSTRUCTIONS: <br />If you intend to comply with the stipulated MBE and WBE participation goals, complete Section I <br />only. <br />If you are unwilling to affirm in writing your intent to comply with the stipulated MBE and WBE <br />participation goals and wish to propose adjusted goals, complete Section II and complete forms <br />MBE-2.0, WBE-2.0, MBE-2.1, and WBE-2.1. <br />I. M/WBE CHECKLIST FOR INTENT TO MEET STIPULATED MBE AND WBE PARTICIPATION <br />a) X <br />By checking this box, I hereby acknowledge that the City reserves the right to <br />request supplemental information, additional verification of any information <br />provided by me. <br />b) X <br />By checking this box, I hereby acknowledge that I will meet or exceed the stipulated <br />MBE and WBE participation goals of this contract. <br />c) X <br />By checking this box, I agree to comply with all tracking and reporting, including <br />online tracking software for M/WBE participation. <br />d) X <br />By checking this box, I understand that a failure to meet the contractual obligations <br />for M/WBE participation shall be a breach of contract. I understand that the City <br />shall impose a penalty against the Contractor in the amount of the difference <br />between the stipulated MBE and WBE goals and the actual amount paid to MBE <br />and WBE subcontractors. <br />Version 2/18/2026 General Conditions -11 <br />