HomeMy WebLinkAboutExhibit 10ATTACHMENT E
ATTACHMENT E
MIAMI-DADE DEPARTMENT OF HUMAN SERVICES
BYRNE GRANT ADMINISTRATION
PROVIDER'S DISCLOSURE OF SUBCONTRACTORS AND SUPPLIERS
(Ordinance 97-104)
Name of Organization: Address:
REQUIRED LISTING OF SUBCONTRACTORS ON COUNTY CONTRACT
In compliance with Miami -Dade County Ordinance 97-104, the Provider must submit the list of first tier
subcontractors or sub -consultants who will perform any part of the Scope of Services Work, if this
Contract is for $100,000 or more.
The Provider must complete this information. If the Provider will not utilize subcontractors, then the
Provider must state "No subcontractors will be used"; do not state "N/A".
NAME OF SUBCONTRACTOR OR SUB -CONSULTANT
ADDRESS CITY AND STATE
No subcontractors will be used.
REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT
In compliance with Miami -Dade County Ordinance 97-104, the Provider must submit a list of suppliers
who will supply materials for the Scope of Services to the Provider, if this Contract is $100,000 or
more.
The Provider must fill out this information. If the Provider will not use suppliers, the Provider must
state "No suppliers will be used", do not state "N/A".
NAME OF SUPPLIER
ADDRESS CITY AND STATE
No suppliers will be used.
I hereby certify that the foregoing information is true, correct and complete:
Signature of Authorized Representative:
Title: Date:
Firm Name: Fed. ID No.
Address: City/ State/Zip:
Telephone: ( )
Fax: ( ) E-mail: