Common use of Please check one Clause in Contracts

Please check one. By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Subscribed and sworn to before me Print Name: Print Title: this day of Notary Public , 20 Tax ID #: 000027 APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Please check one. By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Subscribed and sworn to before me Print Name: Print Title: this day of Notary Public , 20 Tax ID #: 000027 APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Please check one. By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Subscribed and sworn to before me Print Name: Print Title: this day of Notary Public , 20 Tax ID #: 000027 APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency 000060 APT E-PIN #: See Footer Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Please check one. By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Subscribed and sworn to before me Print Name: Print Title: this day of Notary Public , 20 Tax ID #: 000027 APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Xxxxxxx Xxx Xxxx Xxxx Xxx Xxxx Xxxxx XX Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Please check one. By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Subscribed and sworn to before me Print Name: Print Title: this day of Notary Public , 20 Tax ID #: 000027 000051 APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4