TA-W1022 ( UTILIZATION PLAN Page 1 of 4 (CONTRACTOR) · TA-W1022 (07/2019) Page 4 of 4 TA No. D....
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E. Agreement Amount D. Items of Work, Services or Supplies to be Provided C. Estimated Start/End Date B. Certifications/ Designations F. 60% Supplier or Broker Credit Agreement Amount A. List all Firms (Subcontractors, Suppliers and Trucking) Name, address, phone number and email address for each Firm. (Check appropriate box if Firm is a certified DBE/MWBE/SDVOB.) TA-W1022 (07/2019) Email completed form to the Office of Compliance at [email protected] or mail to P.O. Box 189, Albany, NY 12201-0189 UTILIZATION PLAN (CONTRACTOR) Contractor Name and Address $ Preparer's Name (Print) Date Submitted INSTRUCTIONS: This form must be submitted by the contractor to identify all certified DBEs/MWBEs/SDVOBs and all other Non-certified Firms. Complete and accurate forms must be submitted along with corresponding AAPHC-89 (TA-W1037) within 10 days following the bid opening 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 Contract Numbers MBE % - $ SDVOB % - $ WBE % - $ DBE % - $ MBE Sub Total $ WBE Sub Total $ DBE Sub Total $ SDVOB Sub Total $ Grand Total $ Submission: Submission: Submission: Submission: Subcontractor/Supplier To: Subcontractor/Supplier To: Subcontractor/Supplier To: Subcontractor/Supplier To: % % % % Start Date End Date Start Date End Date Start Date End Date Start Date End Date Contract Value $ TA No. D No.
Transcript of TA-W1022 ( UTILIZATION PLAN Page 1 of 4 (CONTRACTOR) · TA-W1022 (07/2019) Page 4 of 4 TA No. D....
E. AgreementAmount
D. Items of Work, Servicesor Supplies to be Provided
C. EstimatedStart/End Date
B. Certifications/Designations
F. 60% Supplier orBroker Credit
Agreement Amount
A. List all Firms (Subcontractors, Suppliers and Trucking)Name, address, phone number and email address for each Firm.(Check appropriate box if Firm is a certified DBE/MWBE/SDVOB.)
TA-W1022 (07/2019)
Email completed form to the Office of Compliance at [email protected] or mail to P.O. Box 189, Albany, NY 12201-0189
UTILIZATION PLAN (CONTRACTOR)
Contractor Name and Address
$
Preparer's Name (Print)
Date Submitted
INSTRUCTIONS: This form must be submitted by the contractor to identify all certified DBEs/MWBEs/SDVOBs and all other Non-certified Firms. Complete and accurate forms must be submitted along with corresponding AAPHC-89 (TA-W1037) within 10 days following the bid opening 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%
$$
Phone No.-)(
Chief Compliance Officer Signature Date
Broker (Fee Only)
Broker (Fee Only)
Broker (Fee Only)
Broker (Fee Only)
Preparer's Signature
Email Address
Contract GoalsContract Numbers
MBE % - $ SDVOB % - $
WBE % - $ DBE % - $
MBE Sub Total $
WBE Sub Total $
DBE Sub Total $
SDVOB Sub Total $
Grand Total $
Submission:
Submission:
Submission:
Submission:
Subcontractor/Supplier To:
Subcontractor/Supplier To:
Subcontractor/Supplier To:
Subcontractor/Supplier To:
%
%
%
%
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Contract Value $
TA No.
D No.
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certifications/Designations
F. 60% Supplier orBroker Credit
Agreement Amount
TA-W1022 (07/2019) UTILIZATION PLAN (CONTRACTOR)
Approved
Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date
Page 2 of 4
TA No.
$
Supplier @ 60%
$
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
$Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
A. List all Firms (Subcontractors, Suppliers and Trucking)Name, address, phone number and email address for each Firm.(Check appropriate box if Firm is a certified DBE/MWBE/SDVOB.)
OFFICE OF COMPLIANCE USE ONLY:
TA-W1022 (07/2019) UTILIZATION PLAN (CONTRACTOR)
Page 3 of 4
TA No.
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certifications/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:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
A. List all Firms (Subcontractors, Suppliers and Trucking)Name, address, phone number and email address for each Firm.(Check appropriate box if Firm is a certified DBE/MWBE/SDVOB.)
OFFICE OF COMPLIANCE USE ONLY:
TA-W1022 (07/2019) Page 4 of 4
TA No.
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certifications/Designations
F. 60% Supplier orBroker Credit
Agreement Amount
Approved
Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date
$
Supplier @ 60%
$
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
SDVOBDBE
WBE
MBE
$Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
UTILIZATION PLAN (CONTRACTOR)
A. List all Firms (Subcontractors, Suppliers and Trucking)Name, address, phone number and email address for each Firm.(Check appropriate box if Firm is a certified DBE/MWBE/SDVOB.)
OFFICE OF COMPLIANCE USE ONLY:
