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DocuSign Envelope ID: B49FB256 -4ADF- 4759- AF63- 134AD44FC239 <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 C - 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 <br />(Name of Bidder) <br />(Project Name) <br />Project ID# <br />Amount of Bid $ <br />I do hereby certify that on the <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 <br />*Minority <br />Category <br />* *HUB <br />Certified <br />Y/N <br />Work <br />Description <br />Dollar Value <br />*Minority categories: Black, African American (B), Hispanic (H), Asian American (A) American Indian (1), <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 />S <br />Signature: <br />Title: <br />State of , County of <br />Subscribed and sworn to before me this <br />Notary Public <br />My commission expires <br />MBForms 2002 - Revised July 2010 <br />day of 20 <br />