TA-W10 UTILIZATION PLAN Page 1 of 4 (CONSULTANT) · TA-W1060 (07/2019) UTILIZATION PLAN...
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E. Agreement Amount D. Items of Work, Services or Supplies to be Provided C. Estimated Start/End Date B. Certification/ Designations F. 60% Supplier or Broker Credit Agreement Amount A. List all DBE/MWBE/SDVOB SUBCONSULTANTS Name, 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 [email protected]. Prepared by: Page 1 of 4 Supplier @ 60% $ OFFICE OF COMPLIANCE USE ONLY: Modified Plan (Check if modified) Approved Modification Approved Conditionally Approved SDVOB DBE WBE MBE $ $ SDVOB DBE WBE MBE Supplier @ 60% $ $ $ SDVOB DBE WBE MBE Supplier @ 60% $ $ $ SDVOB DBE WBE MBE Supplier @ 60% $ $ Phone No. - ) ( Chief Compliance Officer Signature Date Broker (Fee Only) Broker (Fee Only) Broker (Fee Only) 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: Submission: Submission: Submission: Subconsultant/Supplier To: Subconsultant/Supplier To: Subconsultant/Supplier To: Subconsultant/Supplier To: % % % % Start Date End Date Start Date End Date Start Date End Date Start Date End Date Contract Value SDVOB Contract Number D. No. $
Transcript of 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 [email protected] 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 [email protected].
Prepared by:
Page 1 of 4
Supplier @ 60%
$
OFFICE OF COMPLIANCE USE ONLY:
Modified Plan(Check if modified)
Approved
Modification ApprovedConditionally Approved
SDVOBDBE
WBE
MBE
$
$
SDVOBDBE
WBE
MBE Supplier @ 60%
$$
$
SDVOBDBE
WBE
MBE Supplier @ 60%
$$
$
SDVOBDBE
WBE
MBE Supplier @ 60%
$$
Phone No.-)(
Chief Compliance Officer Signature Date
Broker (Fee Only)
Broker (Fee Only)
Broker (Fee Only)
Broker (Fee Only)
Preparer's Signature
Email Address
Contract Goals
MBE % - $ % - $
WBE % - $ DBE % - $
MBE Sub Total $
WBE Sub Total $
DBE Sub Total $
SDVOB Sub Total $
Grand Total $
Submission:
Submission:
Submission:
Submission:
Subconsultant/Supplier To:
Subconsultant/Supplier To:
Subconsultant/Supplier To:
Subconsultant/Supplier To:
%
%
%
%
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Contract Value
SDVOB
Contract Number
D. No.
$
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certification/ Designations
F. 60% Supplier orBroker Credit
Agreement Amount
TA-W1060 (07/2019) UTILIZATION PLAN (CONSULTANT)
Approved
Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date
Page 2 of 4
$
Supplier @ 60%
$
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
$Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
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.)
OFFICE OF COMPLIANCE USE ONLY:
D. No.
TA-W1060 (07/2019) UTILIZATION PLAN (CONSULTANT)
Page 3 of 4
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certification/ Designations
F. 60% Supplier orBroker Credit
Agreement Amount
Approved
Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date
$
Supplier @ 60%
$
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
$Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
A. List all DBE/MWBE/SDVOB SUBCONSULTANTSName, address, phone number and email address for each
subconsultant. (Check appropriate box if Firm is a certified DBE/MWBE/SDVOB.)
OFFICE OF COMPLIANCE USE ONLY:
D. No.
TA-W1060 (07/2019) Page 4 of 4
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certification/ Designations
F. 60% Supplier orBroker Credit
Agreement Amount
Approved
Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date
$
Supplier @ 60%
$
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
$Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subconsultant/Supplier To:
Start Date
End Date
UTILIZATION PLAN (CONSULTANT)
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.)
OFFICE OF COMPLIANCE USE ONLY:
D. No.
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