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__________

__________

__________

__________

Third (Mar., Apr., May)

Fourth

(Jun., Jul., Aug.)

____________

APPENDIX THREE

Attachment I

Non-Subcontractors Affidavit (NON-SUB-AFF)

Document completed as a provision of the contract after the Contract has been awarded to be compliant with the HUB Subcontracting Plan.

In accordance with the HUB Subcontracting Plan, I ___________________, an authorized representative of _________________ company certify that during this reporting period, NO subcontractors have been used on this contract.

_________________________________ Printed Name of Contractor/Vendor

________________________________ Signature of Contractor/Vendor

Subscribed and sworn before me, the undersigned notary public, on this ______ (year)

____

day of

____ (month)

(Notary Public Seal)

Notary Public:

_____________________________________

My commission expires:

_____________________________

Form to be completed and submitted to the Contracting Agency, Procurement Team on a monthly or quarterly basis according to the dates below. Please identify the month or quarter being reported:

__________

__________

__________

__________

__________

__________

__________

__________

Signature:

Date: __________________________ Month or Quarter Included Deadline Identify Month/Quarter

_________________________

First

(Sep., Oct., Nov.)

Second (Dec., Jan., Feb.)

Third (Mar., Apr., May)

Fourth

(Jun.

,

Jul.

,

Aug.)

Title:

______________________________

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