TA-W10 UTILIZATION PLAN Page 1 of 4 (CONSULTANT) · TA-W1060 (07/2019) UTILIZATION PLAN...

E. AgreementAmount

D. Items of Work, Servicesor Supplies to be Provided

C. EstimatedStart/End Date

B. Certification/Designations

F. 60% Supplier orBroker Credit

Agreement Amount

A. List all DBE/MWBE/SDVOB SUBCONSULTANTSName, address, phone number and email address for each

subconsultant. (Check appropriate box if Firm is a certified DBE/MWBE/SDVOB.)

TA-W1060 (07/2019) UTILIZATION PLAN (CONSULTANT)

Email completed form to the Office of Compliance at Compliance@thruway.ny.gov or mail to P.O. Box 189, Albany, NY 12201-0189

Consultant Name and Address

Preparer's Name (Print)

Date Submitted

INSTRUCTIONS: This form must be submitted by the consultant to identify all certified DBEs/MWBEs/SDVOBs and all other Non-certified subconsultant's. Complete and accurate forms must be submitted within 10 days following execution of the agreement to Compliance@thruway.ny.gov.

Prepared by:

Supplier @ 60%

OFFICE OF COMPLIANCE USE ONLY:

Modified Plan(Check if modified)

Approved

Modification ApprovedConditionally Approved

SDVOBDBE

MBE Supplier @ 60%

SDVOBDBE

MBE Supplier @ 60%

SDVOBDBE

MBE Supplier @ 60%

Phone No.-)(

Chief Compliance Officer Signature Date

Broker (Fee Only)

Preparer's Signature

Email Address

Contract Goals

MBE % - $ % - $

WBE % - $ DBE % - $

MBE Sub Total $

WBE Sub Total $

DBE Sub Total $

SDVOB Sub Total $

Grand Total $

Submission:

Subconsultant/Supplier To:

Start Date

End Date

Start Date

End Date

Start Date

End Date

Start Date

End Date

Contract Value

Contract Number

D. No.

E. AgreementAmount

B. Certification/ Designations

Agreement Amount

Approved

Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date

Supplier @ 60%

SDVOBDBE

$Broker (Fee Only)

Submission:Subconsultant/Supplier To:

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

D. No.

E. AgreementAmount

Agreement Amount

Approved

Supplier @ 60%

SDVOBDBE

$Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

D. No.

TA-W1060 (07/2019) Page 4 of 4

E. AgreementAmount

Agreement Amount

Approved

Supplier @ 60%

SDVOBDBE

$Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

$Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

$Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

Supplier @ 60%

Broker (Fee Only)

Start Date

End Date

UTILIZATION PLAN (CONSULTANT)

D. No.

TA-W10 UTILIZATION PLAN Page 1 of 4 (CONSULTANT) · TA-W1060 (07/2019) UTILIZATION PLAN...

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