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Attachment D. Minority Business Enterprise (MBE) Forms
D-1A
MBE UTILIZATION AND FAIR SOLICITATION AFFIDAVIT
& MBE PARTICIPATION SCHEDULE
PART 1 - INSTRUCTIONS
PLEASE READ BEFORE COMPLETING THIS DOCUMENT
This form includes Instructions and the MBE Utilization and Fair Solicitation Affidavit &
MBE Participation Schedule which must be submitted with the bid/proposal. If the
bidder/offeror fails to accurately complete and submit this Affidavit and Schedule with the
bid or proposal, the Procurement Officer shall deem the bid non-responsive or shall
determine that the proposal is not reasonably susceptible of being selected for award unless
the inaccuracy is determined to be the result of a minor irregularity that is waived or cured
in accordance with COMAR 21.06.02.04.
1. Contractor shall structure its procedures for the performance of the work required in this Contract to
attempt to achieve the minority business enterprise (MBE) subcontractor participation goal stated in
the Invitation for Bids or Request for Proposals. Contractor agrees to exercise good faith efforts to
carry out the requirements set forth in these Instructions, as authorized by the Code of Maryland
Regulations (COMAR) 21.11.03.
2. MBE Goals and Subgoals: Please review the solicitation for information regarding the Contract's
MBE overall participation goals and subgoals. After satisfying the requirements for any established
subgoals, the Contractor is encouraged to use a diverse group of subcontractors and suppliers from
the various MBE classifications to meet the remainder of the overall MBE participation goal.
3. MBE means a minority business enterprise that is certified by the Maryland Department of
Transportation ("MDOT"). Only MBEs certified by MDOT may be counted for purposes of
achieving the MBE participation goals. In order to be counted for purposes of achieving the MBE
participation goals, the MBE firm, including a MBE prime, must be MDOT-certified for the
services, materials or supplies that it is committed to perform on the MBE Participation Schedule.
A firm whose MBE certification application is pending may not be counted.
4. Please refer to the MDOT MBE Directory at https://mbe.mdot.maryland.gov/directory/ to
determine if a firm is certified with the appropriate North American Industry Classification System
("NAICS") Code and the product/services description (specific product that a firm is certified to
provide or specific areas of work that a firm is certified to perform). For more general information
about NAICS codes, please visit https://www.census.gov/eos/www/naics/. Only those specific
products and/or services for which a firm is certified in the MDOT Directory can be used for
purposes of achieving the MBE participation goals. CAUTION: If the firm's NAICS Code is in
graduated status, such services/products may not be counted for purposes of achieving the MBE
participation goals. A NAICS Code is in the graduated status if the term "Graduated" follows the
Code in the MDOT MBE Directory.
5. Guidelines Regarding MBE Prime Self-Performance. Please note that when a certified MBE
firm participates as a prime contractor on a Contract, a procurement agency may count the
distinct, clearly defined portion of the work of the Contract that the certified MBE firm performs
with its own workforce toward fulfilling up to, but no more than, fifty-percent (50%) of the overall
Attachment D - MBE Forms Page D-1 effective date: February 5, 2021

MBE participation goal, including up to one hundred percent (100%) of not more than one of the
MBE participation subgoals, if any, established for the Contract.
In order to receive credit for self-performance, an MBE prime must be certified in the
appropriate NAICS code to do the work and must list its firm in the MBE Participation
Schedule, including the certification category under which the MBE prime is self-
performing and include information regarding the work it will self-perform.
For the remaining portion of the overall goal and the remaining subgoals, the MBE prime
must also identify on the MBE Participation Schedule the other certified MBE
subcontractors used to meet those goals or request a waiver.
These guidelines apply to the work performed by the MBE Prime that can be counted for
purposes of meeting the MBE participation goals. These requirements do not affect the
MBE Prime's ability to self-perform a greater portion of the work in excess of what is
counted for purposes of meeting the MBE participation goals.
Please note that the requirements to meet the MBE participation overall goal and
subgoals are distinct and separate. If the contract has subgoals, regardless of MBE
Prime's ability to self-perform up to 50% of the overall goal (including up to 100% of
any subgoal), the MBE Prime must either commit to use other MBEs for each of any
remaining subgoals or request a waiver. As set forth in Attachment 1-B Waiver
Guidance, the MBE Prime's ability to self-perform certain portions of the work of the
Contract will not be deemed a substitute for the good faith efforts to meet any remaining
subgoal or the balance of the overall goal.
In certain instances where the percentages allocated to MBE participation subgoals add
up to more than 50% of the overall goal, the portion of self-performed work that an MBE
Prime may count toward the overall goal may be limited to less than 50%. Please refer to
the Governor's Office of Small Minority & Women Business Affairs' website for the
MBE Prime Regulations Q&A for illustrative examples.
http://www.goMDsmallbiz.maryland.gov/Documents/MBE_Toolkit/MBEPrimeRegulatio
n_QA.pdf
6. Subject to items 1 through 5 above, when a certified MBE performs as a participant in a joint
venture, a procurement agency may count a portion of the total dollar value of the Contract equal to
the distinct, clearly-defined portion of the work of the Contract that the certified MBE performs
with its own forces toward fulfilling the Contract goal, and not more than one of the Contract
subgoals, if any.
7. The work performed by a certified MBE firm, including an MBE prime, can only be counted
towards the MBE participation goal(s) if the MBE firm is performing a commercially useful
function on the Contract. Please refer to COMAR 21.11.03.12-1 for more information regarding
these requirements.
8. Materials and Supplies: New Guidelines Regarding MBE Participation.
Regular Dealer (generally identified as a wholesaler or supplier in the MDOT Directory):
Up to 60% of the costs of materials and supplies provided by a certified MBE may be
counted towards the MBE participation goal(s) if such MBE is a Regular Dealer of such
materials and supplies. Regular Dealer is defined as a firm that owns, operates, or
maintains a store, a warehouse, or any other establishment in which the materials,
supplies, articles, or equipment are of the general character described by the specifications
required under the contract and are bought, kept in stock, or regularly sold or leased to the
Attachment D - MBE Forms Page D-2 effective date: February 5, 2021

public in the usual course of business; and does not include a packager, a broker, a
manufacturer's representative, or any other person that arranges or expedites transactions.
Example for illustrative purposes of applying the 60% rule:
Overall contract value: $2,000,000
Total value of supplies: $100,000
Calculate Percentage of Supplies to overall contract value: $100,000 divided by
$2,000,000 = 5%
Apply 60% Rule - Total percentage of Supplies/Products 5% x 60% = 3%
3% would be counted towards achieving the MBE Participation Goal and Subgoal, if any,
for the MBE supplier in this example.
Manufacturer: A certified MBE firm's participation may be counted in full if the MBE is
certified in the appropriate NAICS code(s) to provide products and services as a
manufacturer.
Broker: With respect to materials or supplies purchased from a certified MBE that is
neither a manufacturer nor a regular dealer, a unit may apply the entire amount of fees or
commissions charged for assistance in the procurement of the materials and supplies, fees,
or transportation charges for the delivery of materials and supplies required on a
procurement toward the MBE contract goals, provided a unit determines the fees to be
reasonable and not excessive as compared with fees customarily allowed for similar
services. A unit may not apply any portion of the costs of the materials and supplies
toward MBE goals.
Furnish and Install and other Services: The participation of a certified MBE supplier,
wholesaler, and/or regular dealer certified in the proper NAICS code(s) to furnish and
install materials necessary for successful contract completion may be counted in full.
Includes the participation of other MBE service providers in the proper NAICS code(s)
may be counted in full.
9. Dually certified firms. An MBE that is certified in more than one subgroup category may only
be counted toward goal fulfillment of ONE of those categories with regard to a particular
contract.
Example: A woman-owned Hispanic American (dually certified) firm may be used to fulfill the
women-owned OR Hispanic American subgoal, but not both on the same contract.
10. CAUTION: The percentage of MBE participation, computed using the percentage amounts
determined for all of the MBE firms listed in PART 3, MUST meet or exceed the MBE
participation goal and subgoals (if applicable) as set forth in PART 2- for this solicitation. If a
bidder/offeror is unable to meet the MBE participation goal or any subgoals (if applicable), then
the bidder/offeror must request a waiver in PART 2 or the bid will be deemed not responsive, or
the proposal not reasonably susceptible of being selected for award. You may wish to use the
attached Goal/Subgoal Worksheet to assist in calculating the percentages and confirming that
your commitment meets or exceeds the applicable MBE participation goal and subgoals (if any).
11. If you have any questions as to whether a firm is certified to perform the specific services or
provide specific products, please contact MDOT's Office of Minority Business Enterprise at 1-
Attachment D - MBE Forms Page D-3 effective date: February 5, 2021

800-544-6056 or via email to mbe@mdot.state.md.us sufficiently prior to the submission due
date.
Subgoals (if applicable)
Total African American MBE Participation: _____________%
Total Asian American MBE Participation: _____________%
Total Hispanic American MBE Participation: _____________%
Total Women-Owned MBE Participation: _____________%
Overall Goal
Total MBE Participation (include all categories): _____________%
Attachment D - MBE Forms Page D-4 effective date: February 5, 2021

PART 2 - MBE UTILIZATION AND FAIR SOLICITATION AFFIDAVIT &
MBE PARTICIPATION SCHEDULE
This MBE Utilization and Fair Solicitation Affidavit and MBE Participation Schedule must
be completed in its entirety and included with the bid/proposal. If the bidder/offeror fails
to accurately complete and submit this Affidavit and Schedule with the bid or proposal as
required, the Procurement Officer shall deem the bid non-responsive or shall determine
that the proposal is not reasonably susceptible of being selected for award.
In connection with the bid/proposal submitted in response to Solicitation No. _______________,
I affirm the following:
1. MBE Participation (PLEASE CHECK ONLY ONE)

I acknowledge and intend to meet IN FULL both the overall certified Minority Business
Enterprise (MBE) participation goal of percent and all of the following subgoals:
percent for African American-owned MBE firms
percent for Hispanic American-owned MBE firms
percent for Asian American-owned MBE firms
percent for Women-owned MBE firms
Therefore, I am not seeking a waiver pursuant to COMAR 21.11.03.11. I acknowledge that by
checking the above box and agreeing to meet the stated goal and subgoal(s), if any, I must
complete PART 3 - MBE Participation Schedule and Part 4 Signature Page in order to be
considered for award.
OR

After making good faith outreach efforts prior to making this submission, I conclude that I
am unable to achieve the MBE participation goal and/or subgoals. I hereby request a waiver, in
whole or in part, of the overall goal and/or subgoals I acknowledge that by checking this box and
requesting a partial waiver of the stated goal and/or one or more of the stated subgoal(s) if any, I
must complete Part 3, the MBE Participation Schedule and Part 4 Signature Page for the portion
of the goal and/or subgoal(s) if any, for which I am not seeking a waiver, in order to be
considered for award. I acknowledge that by checking this box and requesting a full waiver of
the stated goal and the stated subgoal(s) if any, I must complete Part 4 Signature Page in order to
be considered for award.
Attachment D - MBE Forms Page D-5 effective date: February 5, 2021

Additional MBE Documentation
I understand that if I am notified that I am the apparent awardee or as requested by the
Procurement Officer, I must submit the following documentation within 10 working days of
receiving notice of the potential award or from the date of conditional award (per COMAR
21.11.03.10), whichever is earlier:
(a) Good Faith Efforts Documentation to Support Waiver Request (Attachment D-1C)
(b) Outreach Efforts Compliance Statement (Attachment D-2);
(c) MBE Subcontractor/MBE Prime Project Participation Statement (Attachments D-3A and
3B);
(d) Any other documentation, including additional waiver documentation if applicable,
required by the Procurement Officer to ascertain bidder or offeror responsibility in
connection with the certified MBE participation goal and subgoals, if any.
I understand that if I fail to return each completed document within the required time, the
Procurement Officer may determine that I am not responsible and therefore not eligible for
contract award. If the contract has already been awarded, the award is voidable.
Information Provided to MBE firms
In the solicitation of subcontract quotations or offers, MBE firms were provided not less than the
same information and amount of time to respond as were non-MBE firms.
Attachment D - MBE Forms Page D-6 effective date: February 5, 2021

PART 3 - MBE PARTICIPATION SCHEDULE
SET FORTH BELOW ARE THE (I) CERTIFIED MBES I INTEND TO USE, (II) THE PERCENTAGE OF THE TOTAL CONTRACT
VALUE ALLOCATED TO EACH MBE FOR THIS PROJECT AND, (III) THE ITEMS OF WORK EACH MBE WILL PROVIDE
UNDER THE CONTRACT. I HAVE CONFIRMED WITH THE MDOT DATABASE THAT THE MBE FIRMS IDENTIFIED
BELOW (INCLUDING ANY SELF-PERFORMING MBE PRIME FIRMS) ARE PERFORMING WORK ACTIVITIES FOR WHICH
THEY ARE MDOT-CERTIFIED.
Prime Contractor Project Description Project/Contract Number
LIST INFORMATION FOR EACH CERTIFIED MBE FIRM YOU AGREE TO USE TO ACHIEVE THE MBE PARTICIPATION GOAL AND
SUBGOALS, IF ANY. MBE PRIMES: PLEASE COMPLETE BOTH SECTIONS A AND B BELOW.
SECTION A: For MBE Prime Contractors ONLY (including MBE Primes in a Joint Venture)
MBE Prime Firm Percentage of total Contract Value to be performed with own forces and
Name:________________________________ counted towards the MBE overall participation goal (up to 50% of the
overall goal): _______% Please refer to Item #8 in Part 1- Instructions
MBE Certification Number: ___________ of this document for new MBE participation guidelines regarding
materials and supplies.
(If dually certified, check only one box.)
Percentage of total Contract Value to be performed with own forces and
African American-Owned counted towards the subgoal, if any, for my MBE classification (up to
Hispanic American- Owned 100% of not more than one subgoal): _______%
Asian American-Owned
Women-Owned Supplier, wholesaler and/or regular dealer (count 60%)
Other MBE Classification Manufacturer (count 100%)
Broker (count reasonable fee/commission only)
NAICS code: _______________________________ Furnish and Install and other Services (count 100%)
Complete the applicable prompt (select only one) from prompts A-C
below that applies to the type of work your firm is self-performing to
calculate amount to be counted towards achieving the MBE
Participation Goal and Subgoal, if any.
A. Percentage amount of subcontract where the MBE Prime firm is being
used for manufacturer, furnish and install, and/or services (excluding products
/ services from suppliers, wholesalers, regular dealers and brokers) ___%
B. Percentage amount for items of work where the MBE Prime firm is being
used as supplier, wholesaler, and/or regular dealer (60% Rule).
Total percentage of Supplies/Products ___% x 60% = ___%
C. Percentage amount of fee where the MBE Prime firm is being used as
broker (count reasonable fee/commission only) ___ %
Description of the work to be performed with MBE prime's own forces:
___________________________________________________
____________________________________________________
Attachment D - MBE Forms Page D-7 effective date: February 5, 2021

SECTION B: For all Contractors (including MBE Primes and MBE Primes in a Joint Venture)
MBE Firm Please refer to Item #8 in Part 1- Instructions of this document for new
Name:______________________________________ MBE participation guidelines regarding materials and supplies.
MBE Certification Number: ______________________ Supplier, wholesaler and/or regular dealer (count 60%)
Manufacturer (count 100%)
(If dually certified, check only one box.) Broker (count reasonable fee/commission only)
African American-Owned Furnish and Install and other Services (count 100%)
Hispanic American- Owned
Asian American-Owned Complete the applicable prompt (select only one) from prompts A-C
Women-Owned below that applies to the type of work that the MBE firm named to the
Other MBE Classification left will be performing to calculate the amount to be counted towards
achieving the MBE Participation Goal and Subgoal, if any.
NAICS code: _______________________________
A. Percentage of total contract amount where the MBE firm is being used for
manufacturer, furnish and install, and/or services (excluding products/services
from suppliers, wholesalers, regular dealers
and brokers) ___%
B. Percentage of total contract amount for items of work where the MBE firm
is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).
Total percentage of Supplies/Products ___% X 60% = ___%
C. Percentage amount of fee where the MBE firm is being used as
broker (count reasonable fee/commission only) ___ %
Description of the work to be performed:
_________________________________________________________
_________________________________________________________
MBE Firm Please refer to Item #8 in Part 1- Instructions of this document for new
Name:______________________________________ MBE participation guidelines regarding materials and supplies.
MBE Certification Number: _____________________ Supplier, wholesaler and/or regular dealer (count 60%)
Manufacturer (count 100%)
(If dually certified, check only one box.) Broker (count reasonable fee/commission only)
African American-Owned Furnish and Install and other Services (count 100%)
Hispanic American- Owned
Asian American-Owned Complete the applicable prompt (select only one) from prompts A-C
Women-Owned below that applies to the type of work that the MBE Firm named to the
Other MBE Classification left will be performing to calculate the amount to be counted towards
achieving the MBE Participation Goal and Subgoal, if any.
NAICS code: _______________________________
A. Percentage of total contract amount where the MBE firm is being used for
manufacturer, furnish and install, and/or services (excluding products/services
from suppliers, wholesalers, regular dealers
and brokers) ___%
B. Percentage of total contract amount for items of work where the MBE firm
is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).
Total percentage of Supplies/Products ___% X 60% = ___%
C. Percentage amount of fee where the MBE firm is being used as
broker (count reasonable fee/commission only) ___ %
Description of the work to be performed:
_________________________________________________________
_________________________________________________________
Attachment D - MBE Forms Page D-8 effective date: February 5, 2021

MBE Firm Please refer to Item #8 in Part 1- Instructions of this document for new
Name:______________________________________ MBE participation guidelines regarding materials and supplies.
MBE Certification Number: ______________________ Supplier, wholesaler and/or regular dealer (count 60%)
Manufacturer (count 100%)
(If dually certified, check only one box.) Broker (count reasonable fee/commission only)
African American-Owned Furnish and Install and other Services (count 100%)
Hispanic American- Owned
Asian American-Owned Complete the applicable prompt (select only one) from prompts A-C
Women-Owned below that applies to the type of work that for the MBE firm named to
Other MBE Classification the left will be performing to calculate the amount to be counted
towards achieving the MBE Participation Goal and Subgoal, if any.
NAICS code: _______________________________ A. Percentage of total contract amount where the MBE firm is being used for
manufacturer, furnish and install, and/or services (excluding products/services
from suppliers, wholesalers, regular dealers
and brokers) ___%
B. Percentage of the total contract amount for items of work where the MBE
firm is being used as supplier, wholesaler, and/or regular dealer (60% Rule).
Total percentage of Supplies/Products ___% X 60% = ___%
C. Percentage amount of fee where the MBE firm is being used as
broker (count reasonable fee/commission only) ___ %
Description of the work to be performed:
_________________________________________________________
_________________________________________________________
MBE Firm Please refer to Item #8 in Part 1- Instructions of this document for new
Name:______________________________________ MBE participation guidelines regarding materials and supplies.
MBE Certification Number: ______________________ Supplier, wholesaler and/or regular dealer (count 60%)
Manufacturer (count 100%)
(If dually certified, check only one box.) Broker (count reasonable fee/commission only)
African American-Owned Furnish and Install and other Services (count 100%)
Hispanic American- Owned
Asian American-Owned Complete the applicable prompt (select only one) from prompts A-C
Women-Owned below that applies to the type of work that the MBE firm named to the
Other MBE Classification left will be performing to calculate the amount to be counted towards
achieving the MBE Participation Goal and Subgoal, if any.
NAICS code: _______________________________ A. Percentage of total contract amount where the MBE firm is being used for
manufacturer, furnish and install, and/or services (excluding products/services
from suppliers, wholesalers, regular dealers
and brokers) ___%
B. Percentage of total contract amount for items of work where the MBE firm
is being used as supplier, wholesaler, and/or regular dealer (60% Rule)).
Total percentage of Supplies/Products ___% X 60% = ___%
C. Percentage amount of fee where the MBE firm is being used as
broker___ %
Description of the work to be performed:
_________________________________________________________
_________________________________________________________
CONTINUE ON SEPARATE PAGE IF NEEDED
Attachment D - MBE Forms Page D-9 effective date: February 5, 2021

PART 4 - SIGNATURE PAGE
To complete Affidavit committing to MBE(s) or requesting waiver,
Bidder/Offeror must sign below:
I solemnly affirm under the penalties of perjury that: (i) I have reviewed the instructions for the MBE
Utilization & Fair Solicitation Affidavit and MBE Schedule, and (ii) the information contained in the
MBE Utilization & Fair Solicitation Affidavit and MBE Schedule is true to the best of my knowledge,
information and belief.
_______________________________ __________________________________
Bidder/Offeror Name Signature of Authorized Representative
(PLEASE PRINT OR TYPE)
_______________________________ __________________________________
Address Printed Name and Title
_______________________________ __________________________________
City, State and Zip Code Date
SUBMIT THIS AFFIDAVIT WITH BID/PROPOSAL
Attachment D - MBE Forms Page D-10 effective date: February 5, 2021