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Okaloosa County BOCC — April 5, 2016 — Palm Beach Bid 15-063-LC — reading text
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Palm Beach Bid 15-063-LC — extracted reading text
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M/WBE M/WBE Change SBE- for SBE-M/WBE drawn for Date for SBE- Starting Business Business Specify)
Subcontractor Total Orders M/WBE Sub This Period SBE-M/WBE M/WBE Date (√) (√) Black Hispanic Women Caucasian
Contract Contract Sub to Date Subcontractor
Amount Amount
I hereby certify that the above information is true to the best of my knowledge____________________________________________________________________________________
(Signature and Title)
Return to: Palm Beach County
Additional Sheets May Be Used As Necessary
NOTE: Firms may be certified as an SBE and/or an M/WBE. If firms are certified as both an SBE and M/WBE, the dollar amount will not be
counted twice.
Revised 9/7/2011
Page 19
OSBA SCHEDULE 4 - SBE-M/WBE PAYMENT CERTIFICATION
The Prime Contractor is to submit Schedule 4 with its Monthly Payment Request to Palm Beach County to
reflect actual payments made to the SBE-M/WBE Subcontractor. The Prime Contractor is not to request
signature from an SBE-M/WBE Subcontractor unless it has made a payment to the SBE-M/WBE Subcontractor.
The SBE-M/WBE Subcontractor is not to complete and sign this form unless it has received a payment
from the Prime Contractor for services actually performed by the SBE-M/WBE Subcontractor. A separate
Schedule 4 is required for each SBE-M/WBE Subcontractor payment.
This is to certify that ___________________________________________________________ received
(SBE or M/WBE Subcontractor Name)
(Monthly) or (Final) payment of $ .
- -
On from ____________________________________________________
MM DD YYYY (Prime Contractor Name)
For labor and/or materials used on ______________________________________ / _______________
(Project Name) (Work Order)
DEPT.: PROJECT NO.:
PRIME CONTRACTOR VENDOR CODE:
SBE OR M/WBE SUBCONTRACTOR VENDOR CODE:
============================================================================================
If the SBE Subcontractor intends to disburse any funds associated with this payment to any
Subcontractor for labor and/or material provided on this project, please provide the following
information:
*Subcontractor Name: __________________________________ Amount to be paid: _________
*Note: If the subcontractor listed in this section is an SBE or M/WBE a separate schedule 4 is required
to verify payment.
============================================================================================
By: __________________________________________ _____________________________________________
(Signature of Subcontractor) (Print Name & Title of Person executing on
behalf of Subcontractor)
STATE OF FLORIDA
COUNTY OF ____________________________________
Sworn to and subscribed before me this ____________ day of __________________, 20__________
By: __________________________________________
__________________________________________________
Notary Public, State of Florida
__________________________________________________
Print, Type or Stamp Commissioned Name of Notary
Personally Known ____ OR Produced Identification ____ Type of Identification ______________
Rev. 5 Last updated: 11/18/11