HomeMy WebLinkAboutexhibit1EATTACHMENT E
ATTACHMENT E
�'II-DADE DEPARTMENT OF HUMAN SERVICES
MIA
BYRNE GRANT ADMINISTRATION
PROVIDER'S DISCLOSURE OF SUBCONTRACTORS AND SUPPLIERS
PROVID (Ordinance 97-104)
Address:
Name of Organization:
REQUIRED LISTING OF SUBCONTRACTORS ON COUNTY CONTRACT first ti
Orinance
-104,
subcontractors or sub-consultan
the Provider must submit the list o
In compliance with Miami-Dadef ts whoy ill 7
perform any part of the Sco a of Services Work, if th
Contract is for $100,000 or more.
The Provider must comp
lete lete this information. If the Provider will not utilize subcontractors, then t
Provider must state "No subcontractors will be used"; do not state CITY AND STATE
NAME OF SUBCONTRACTOR OR SUS -CONSULTANT
ADDRESS
No subcontractors will be used.
REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT su l
it a
w compliance wi
th Miami -Dade County Ordinance 97-104, t ePrProv def must
submContract is list of sup0l
Who will supply materials for the Scope of Services tot e
more. pliers, the Provider i
Th
e Provider must fill out this informationIN he Provider will not use su p
state "No suppliers will be used" , do not state"N/A".
ADDRESS
NAME OF SUPPLIER
No suppliers will be used.
oregoing information is true, correct and complete:
1 hereby certify that the f
Signature of Authorized Representative:
Date:
Title: Fed. ID No.
Firm Name.
City/ State/Zip:
Address: E-mail:
Fax:
Telephone:
CITY AND STATE