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DocuSign Envelope ID:A9CF8A9E-4CDB-4BB9-A678-D4AD80CD1393 <br /> Do not submit with bid Do not submit with bid Do not submit with bid Do not submit with bid <br /> State of North Carolina - AFFIDAVIT ® Portion of the Work to be <br /> Performed by HUB Certified/Minority Businesses <br /> County of <br /> (Note this form is to be submitted only by the apparent lowest responsible, responsive bidder.) <br /> If the portion of the work to be executed by HUB certified/minority businesses as defined in GS143- <br /> 128.2(g) and 128.4(a),(b),(e) is equal to or greater than 10% of the bidders total contract price, then the <br /> bidder must complete this affidavit. <br /> This affidavit shall be provided by the apparent lowest responsible, responsive bidder within 72 hours <br /> after notification of being low bidder. <br /> Affidavit of I do hereby certify that on the <br /> (Name of Bidder) <br /> (Project Name) <br /> Project ID# Amount of Bid $ <br /> I will expend a minimum of % of the total dollar amount of the contract with minority business <br /> enterprises. Minority businesses will be employed as construction subcontractors, vendors, suppliers <br /> or providers of professional services. Such work will be subcontracted to the following firms listed <br /> below. Attach additional sheets if required <br /> Name and Phone Number *Minority **HUB Work Dollar Value <br /> Category Certified Description <br /> Y/N <br /> *Minority categories: Black,African American (B), Hispanic (H),Asian American (A)American Indian (I), <br /> Female (F) Socially and Economically Disadvantaged (D) <br /> ** HUB Certification with the state HUB Office required to be counted toward state participation goals. <br /> Pursuant to GS143-128.2(d), the undersigned will enter into a formal agreement with Minority Firms for <br /> work listed in this schedule conditional upon execution of a contract with the Owner. Failure to fulfill <br /> this commitment may constitute a breach of the contract. <br /> The undersigned hereby certifies that he or she has read the terms of this commitment and is <br /> authorized to bind the bidder to the commitment herein set forth. <br /> Date: Name of Authorized Officer: <br /> Signature: <br /> SEAL Title: <br /> State of , County of <br /> Subscribed and sworn to before me this day of 20 <br /> Notary Public <br /> My commission expires <br /> MBForms 2002-Revised July 2010 <br />