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TCCD REQUEST FOR APPROVAL OF CHANGE TO ORIGINAL

SCHEDULE OF SUBCONTRACTORS FORM

(Small M/WBE Modification or Substitution)

Contractor/Company, _____________________________________________________________________, project ________________________________________________________________, requests approval of the following addition(s) and/or deletion(s) on the SCHEDULE OF SUBCONTRACTORS as originally submitted as part of the bid on the above-named project.

CHECK (X) BLOCK FOR EACH TRANSACTION

CHANGE

ADD

DELETE

COMPANY NAME

TRADE

SMALL M/WBE

STATUS

DOLLAR AMOUNT

INTENT TO PERFORM

JUSTIFICATION

CERTIFICATION OF AFFIDAVIT

The above information is true and complete to the best of my knowledge and belief.  I further understand and agree that this certification will become a part of my contract with the TCCD.

(Please Print or Type)

Name and Title of Signer: ________________________________/________________________

         Printed NameTitle

Signature: ___________________________________________Date: _____________________

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