Fill and Sign the Nbe Thesis Submission Form

DBE Payment Compliance Company Name (Prime Contractor): Total amount of Contract: $ Purchase Order: # Date of Contract Award: Contract Term (Dates): Reporting Quarter: Today’s Date: Amount paid to vendor for reporting quarter: $______________ Subcontractor Name (Company) Total amount paid to awarded vendor from start of contract: $________________ Committed Percentage $ $ $ $ $ $ $ $ $ (YTD) YTD paid to Sub $ (for this reporting quarter) Committed Percentage Total paid to Sub $ Total $ Description of services/work/product performed $ (Current quarter) (From date of contract) $ *Please include proof of payments made which may include but are not limited to copies of cancelled checks or wire transfers. I, ___________________________________hereby swear that I am duly authorized to represent _________________________________ which has (Authorized Representative of Prime Company) (Prime Company) contracted with the Disadvantaged Business Enterprise (DBE) sub-contractor(s) listed above on the above referenced contract. The following is a true and complete statement of contract dollars expended with the designated DBE under each sub-contract to this contract. This Compliance form verifies the work completed and the amount paid to the DBE Subcontractor on the above captioned contract. Under penalty of law for perjury or falsification, the undersigned certifies that the work reported herein was executed by the DBE, that the DBE actually performed, managed and supervised the work and that the work reported herein conforms to the work reported in the approved Schedule A together with any amendments approved by Pace. Furthermore, the undersigned certifies that the amount indicated above has been paid to the DBE contractor. SUBSCRIBED AND SWORN to me before this _______________________________________ (Signature of Authorized Representative) ______________ Day of _________________, 2013 ___________________________________________ Notary Public Seal of (binding) Notary Stamp Return signed and notarized monitoring report to the DBE Liaison Officer: Attention: Christina A. Perez DBE Liaison Officer Pace Bus 550 W. Algonquin Road Arlington Heights, IL 60005