OTHER CATEGORIES. DISABLED INDIVIDUAL • VIETNAM ERA VETERAN • GENDER any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. a veteran who served at any time between and including January 1, 1963 and May 7, 1975. Male or Female Failure to submit this form will result in non-compliance Is this a final report? Check one. Yes No M/WBE Quarterly Report of NYS AGENCY/AGENCIES Contract No. Project No. The following information indicates the payment amounts made by the grantee/contractor to the NYS Certified M/WBE subcontractor on this project. The payments as shown are in compliance with contract documents for the above reference project. Contractor’s Name and Address Federal ID# Goals/Dollar Amount MBE % = $ WBE % = $ Contract Type: Paid to Contractor this Quarter: Total Paid to Contractor to Date: Project Completion Date Work Location Reporting Period: 1st Quarter (4/1-6/30) 3rd Quarter (10/1-12/31) 2nd Quarter (7/1-9/30) 4th Quarter (1/1-3/31) M/WBE Subcontractor/Vendor Product Code* Work Status this Report Total Subcontractor Contract Amount Payments this Quarter Previous Payments Total Payments Made to Date MBE WBE MBE WBE MBE WBE MBE WBE Name: Fed ID#: Active Inactive Complete Name: Fed ID#: Active Inactive Complete Name: Fed ID#: Active Inactive Complete Name: Fed ID#: Active Inactive Complete Total: *See Next Page for Product Codes Date: Name: Title: Signature: HOUSING TRUST FUND CORPORATION 00-00 XXXXX XXXXXX, XXXXXX, XXX XXXX 00000 APPENDIX IV CONSTRUCTION REQUIREMENTS AND PROCEDURES FOR CONTRACTS WITH HOUSING TRUST FUND CORPORATION New York State CUMULATIVE PAYMENT STATEMENT (Instructions on Reverse Side) Homes & Community Renewal Office of Fair Housing and Equal Opportunity Web Site: xxx.xxxxxx.xxx Contractors Name and Address: Federal ID # Goals Reporting Period MBE % WBE % Quarter Year SHARS/Project # Work Location Name of Firm and Address (List All Firms) Type of Service Provided (Select only one) NYS Certified MBE WBE Payment This period Contract Amount Federal ID# • Construction • Supplier • Consultant Service • Service/Commodity • Section 3 No Payment Federal ID# • Construction • Supplier • Consultant Service • Service/Commodity • Section 3 No Payment Federal ID# • Construction • Supplier • Consultant Service • Service/Commodity • Section 3 No Payment Federal ID# • Construction • Supplier • Consultant Service • Service...
OTHER CATEGORIES. DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. • VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975. • GENDER Male (M) or Female (F) PROC-1 (revised 2/2012) REQUEST FOR WAIVER FORM INSTRUCTIONS: SEE PAGE 2 OF THIS ATTACHMENT FOR REQUIREMENTS AND DOCUMENT SUBMISSION INSTRUCTIONS. Offeror/Contractor Name: Federal Identification No.: Address: Solicitation/Contract No.: City, State, Zip Code: M/WBE Goals: MBE % WBE % By submitting this form and the required information, the offeror/contractor certifies that every Good Faith Effort has been taken to promote M/WBE participation pursuant to the M/WBE requirements set forth under the contract.
OTHER CATEGORIES. DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. • VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975. • GENDER Male (M) or Female (F) PROC-1 (revised 2/2012) M/WBE UTILIZATION PLAN INSTRUCTIONS: This form must be submitted with any bid, proposal, or proposed negotiated contract or within a reasonable time thereafter, but prior to contract award. This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (M/WBE) under the contract. Attach additional sheets if necessary. Offeror’s Name: Federal Identification Number: Address: Solicitation Number: City, State, Zip Code: Telephone Number: Region/Location of Work: M/WBE Goals in the Contract: MBE % WBE %
OTHER CATEGORIES. DISABLEDINDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975. GENDER Male (M) or Female (F) PROC-1 (revised 2/2012) M/WBE UTILIZATION PLAN INSTRUCTIONS: This form must be submitted with any bid, proposal, or proposed negotiated contract or within a reasonable time thereafter, but prior to contract award. This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (M/WBE) under the contract. Attach additional sheets if necessary. Offeror’s Name: Federal Identification Number: Address: Solicitation Number: City, State, Zip Code: Telephone Number: Region/Location of Work: M/WBE Goals in the Contract: MBE % WBE %
OTHER CATEGORIES. DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. • VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975. • GENDER Male (M) or Female (F) PROC-1 (revised 2/2012) Xxxxxx Associates, P.C. 0000 Xxxxxxxx Xxx, Xxxxxxxxx, XX 00000 New York Metropolitan Area 201709_062 Bay Environmental Consulting LLC 000 Xxx Xxx, Xxxxxxx, XX 00000 x Xxxxxx Engineering (MBE) x 00 Xxxxxxx Xxxxxxxxx Xxxxx, Xxxxx 000X Permitting and Environmental/ Ecological Services Engineering Services XXX XXX 11/10/2017 Xxxxxx Associates, P.C. 0000 Xxxxxxxx Xxx, Xxxxxxxxx, XX 00000 Xxx Xxxx Xxxxxxxxxxxx Xxxx 000000_000 Xxxxxx Engineering 0000 Xxxxx 000, X. 000, Xx Xxxx. Station, NY SDVOB Civil Engineering / Building Assessments TBD SACKS (WBE) 00 Xxxxxxxx, Xxxxx 0000, XX, XX 00000 x Community Outreach / Public Participation TBD 11/10/2017 Page3 of 3 Xxxxxx Associates, P.C. 0000 Xxxxxxxx Xxx, Xxxxxxxxx, XX 00000 New York Metropolitan Area 201709_062 Rising Tide Waterfront Solution 000 Xxxxxxx Xxxxxxx, Xxxxx 000 11/10/2017 Section 3 Coastal Engineering, Underwater Inspection TBD REQUEST FOR WAIVER FORM INSTRUCTIONS: SEE PAGE 2 OF THIS ATTACHMENT FOR REQUIREMENTS AND DOCUMENT SUBMISSION INSTRUCTIONS. Offeror/Contractor Name: Federal Identification No.: Address: Solicitation/Contract No.: City, State, Zip Code: M/WBE Goals: MBE % WBE % By submitting this form and the required information, the offeror/contractor certifies that every Good Faith Effort has been taken to promote M/WBE participation pursuant to the M/WBE requirements set forth under the contract.
OTHER CATEGORIES. DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. • VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975. • GENDER Male (M) or Female (F) PROC-1 (revised 2/2012) M/WBE UTILIZATION PLAN INSTRUCTIONS: This form must be submitted with any bid, proposal, or proposed negotiated contract or within a reasonable time thereafter, but prior to contract award. This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (M/WBE) under the contract. Attach additional sheets if necessary. Offeror’s Name: Xxxxx Xxxxx US, Inc Federal Identification Number: Address: 412 Mt. Xxxxxx Avenue PO Box 1946 Solicitation Number: City, State, Zip Code: Morristown, NJ 00000-0000 Telephone Number: Region/Location of Work: Queens, New York M/WBE Goals in the Contract: MBE 15 % WBE %
OTHER CATEGORIES o DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. o VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975.
OTHER CATEGORIES. DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. • VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975. • GENDER Male or Female AC 3292-S (Rev. 9/13) NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT CONSTRUCTION (CCA-2) You have selected the For-Profit Construction questionnaire, commonly known as the “CCA-2,” which may be printed and completed in this format or, for your convenience, may be completed online using the New York State VendRep System. The person(s) completing the questionnaire must be knowledgeable about the vendor’s business and operations. An owner or official must certify the questionnaire and the signature must be notarized. COMPLETION & CERTIFICATION The Vendor ID is a ten-digit identifier issued by New York State when the vendor is registered on the Statewide Vendor File. This number must now be included on the questionnaire. If the business entity has not obtained a Vendor ID, contact the IT Service Desk at XXXxxxxxxXxxx@xxx.xxxxx.xx.xx or call 000-000-0000. NEW YORK STATE VENDOR IDENTIFICATION NUMBER (VENDOR ID) All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” found at xxxx://xxx.xxx.xxxxx.xx.xx/vendrep/documents/questionnaire/definitions.pdf. These terms may not have their ordinary, common or traditional meanings. Each vendor is strongly encouraged to read the respective definitions for any and all underlined terms. By submitting this questionnaire, the vendor agrees to be bound by the terms as defined in the "New York State Vendor Responsibility Definitions List" existing at the time of certification.
OTHER CATEGORIES. DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. • VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975. • GENDER Male or Female PROSPECTIVE BIDDERS NOTICE SERVICE DISABLED VETERAN-OWNED BUSINESS ENTERPRISE REQUIREMENTS: CONSTRUCTION-RELATED CONSULTANT SERVICES CONTRACTS To Prospective Bidders: Consistent with the State University of New York (SUNY) ’s commitment and in accordance with Article 17-B of the New York State Executive Law and its implementing regulations, state agencies and Consultants are required to ensure that good faith efforts are made to include meaningful participation by Service Disabled Veteran-Owned Business (SDVOB). The requirements apply to all SUNY construction- related consultant services contracts in excess of $25,000. Receipt of SDVOB documentation is required with submittal of qualifications for construction related consultants service contracts. Such documentation shall be submitted on the forms listed below in sub-parts (a) and (b). The MWBE Program Coordinator is given the statement of qualifications and short list of qualified consultants developed by the evaluation/selection committee for review and approval.
OTHER CATEGORIES. DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment. VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975. GENDER Male (M) or Female (F) The Community Preservation Corporation Page 18 Program Adminstrator Contract EXHIBIT E (Exhibit to follow this page) F:\Legal8-Contract\Contracts - Procurement\C\Contract\Program Administrator Agreement Response to CPC 150626 b clean_FINAL docx WORKFORCE EMPLOYMENT UTILIZATION
