IMPORTANT: A LOCAL ASSISTANCE MWBE SUBCONTRACTOR/SUPPLIER UTILIZATION PROPOSAL FORM MUST BE SUBMITTED WITH BID OR PROPOSAL. IN ADDITION TO THE INITIAL SUBMITTAL OF THIS FORM, A DCJS-3301 MUST BE SUBMITTED FOR EACH SUBSEQUENT CONTRACT/RENEWAL PERIOD AND WITH ALL APPLICABLE BUDGET MODIFICATION REQUESTS, PROVIDING DETAIL OF NEW OR REASSESSED GOALS.
Grantee (Contractor) Information:
1. Name:	Address:
Contact Person/Title:	Telephone Number:
2. Contract Number:	Project Number:	3. DUNS Number:
4. Project/RFP Title:	5. Project Location (Municipality/County/Region):
6. Contract Amount:	7.Grantee Discretionary NPS Amount:	8. Contract Award Period:
9. Description of Goods/Services/Supplies Provided:

19. MWBE Status and Certification	VERIFIED BY DCJS
NOTE: If NYS MWBE Certification is pending, a copy of the notice of application receipt issued by the NYS Empire State Development Corporation must accompany this form.

I attest that to the best of my knowledge, the information provided herein is complete and accurate. In addition, I understand that the utilization of certified minority and women owned business enterprises for non-commercially useful functions may not be counted towards utilization of certified minority and women owned business enterprises as identified in this utilization plan. 20. Contractor Certification :
21.	Date:
FOR DCJS USE ONLY
OPDF Program Representative:	MWBE Entities:	Date:
Reviewer Comments:

DCJS-3301 (Revision 7/2014)	Page 2 of 2

DCJS 3301 – LOCAL ASSISTANCE MWBE SUBCONTRACTOR/SUPPLIER UTILIZATION PROPOSAL FORM

Instructions for Completion

IMPORTANT: A LOCAL ASSISTANCE MWBE SUBCONTRACTOR/SUPPLIER UTILIZATION PROPOSAL FORM MUST BE SUBMITTED WITH BID OR PROPOSAL. IN ADDITION TO THE INITIAL SUBMITTAL OF THIS FORM, IT MUST BE SUBMITTED FOR EACH SUBSEQUENT CONTRACT/RENEWAL PERIOD AND WITH ANY REQUESTS FOR BUDGET MODIFICATION, PROVIDING DETAILS OF NEW OR REASSESSED GOALS.
1. Name and Address	Provide the grantee (contractor) name and address, and include the name, title and telephone number of the contact person responsible for answering questions related to the MWBE information submitted on this form.
2. Contract and Project Number	Input the DCJS contract and project numbers of the award being supported by this RFP or funding appropriation.
3. DUNS Number	Provide the grantee DUNS Number (a nine digit number assigned via Dun and Bradstreet’s Data Universal Numbering System).
4. Project/RFP Title	Provide the name of the project being supported by this RFP or contracted funding appropriation.
5. Project Location	Enter the name of the municipality, county, and/or region in which the majority of contractual activity will occur.
6. Contract Amount	Supply the total dollar amount awarded during the current contract period.
7. Grantee Discretionary NPS Amount	This is defined as the Non-Personal Service line in the contract budget, minus any item for which there is no opportunity to procure services/supplies with a NYS Certified MWBE (this may be due to a contractor’s lack of discretion in the choice of supplier/vendor, or due to the lack of availability of NYS Certified MWBE’s to provide the requisite services/supplies). If there are no identifiable NPS discretionary funds, this amount may be listed as $0; however, the contractor must submit a Local Assistance MWBE Discretionary Budget Determination Worksheet delineating their expenditures. Upon request, a separate more detailed written justification may also be required. Note: Appropriate MWBE suppliers/contractors may be identified by searching the MWBE directory located at: https://ny.newnycontracts.com.
8. Contract Award Period	Enter the current contract time period of the funded award.
9. Description of Discretionary NPS Goods, Services, and/or Supplies to be Provided/ Purchased	Provide a brief description of the product type(s) or services, which are to be purchased using NPS discretionary funds; for example computer/office equipment, supplies, trainers, printing services, IT consulting services, vehicle maintenance, etc.
10. List of MWBE Subcontractors/Suppliers	List the firm name and address of the NYS Certified MWBE subcontractor/supplier funded from NPS discretionary funds to provide the contracted requisite services and/or commodities. Note: Certified MWBE suppliers and contractors may be located by searching the MWBE directory at: https://ny.newnycontracts.com.
11. NYS ESD Vendor ID Number	Provide the eight digit NYS ESD Vendor ID Number. Subcontractors/suppliers can access this information via their NYS ESD MWBE account at: https://ny.newnycontracts.com.
12. Description of Services/Supplies	Provide a brief description of the product type(s) or services, per subcontractor, which are to be purchased using NPS discretionary funds; for example computer/office equipment, supplies, trainers, printing services, IT consulting services, vehicle maintenance, etc.
13. MBE Goal Amount	Indicate the funding amount allocated for the MBE goal associated with this subcontractor.
14. WBE Goal Amount	Indicate the funding amount allocated for the WBE goal associated with this subcontractor.
15. MWBE Goal Amount	May be utilized when identifying subcontractors/suppliers as To Be Determined (TBD). This amount indicates a combined MBE and WBE goal amount.
16. Discretionary NPS Amount	This is the portion of the Grantee Discretionary NPS Amount (provided in item number 7) dedicated per subcontractor to meet MWBE goals.
17. Total MWBE Goals	Calculate the total MWBE goal amounts for columns 13 and 14. Note: The MWBE Subcontractor/Supplier Table is an embedded fillable Excel worksheet. Totals will calculate automatically utilizing this feature.
18. Total MWBE Percentages	Calculate the total MBE and WBE goal amount percentages. This is calculated by dividing the discretionary NPS amount, field 16, by the total MWBE goal amounts, field 17. Note: The MWBE Subcontractor/Supplier Table is an embedded fillable Excel worksheet. Percentages will calculate automatically utilizing this feature.
19. MWBE Status and Certification	Check the appropriate boxes. If a vendor is both Minority and Women owned, both MBE and WBE boxes should be checked. Check NYS Certified only if the vendor is certified by the NYS Empire State Development Corporation. Check Certification Pending if NYS certification is pending action by the NYS Empire State Development Corporation. NOTE: If NYS MWBE Certification is pending, a copy of the notice of application receipt issued by the NYS Empire State Development Corporation must accompany this form.
20. Contractor Certification	The grantee (contractor) must certify their intent to utilize the MWBE subcontractors specified. Certify and date this form in the designated fields. Note: This form will not be accepted without a stated goal, certification or date.
21. Contractor Attestation	The grantee (contractor) must attest that the information provided is complete, accurate, and that certified minority and women owned businesses identified on this utilization form will be utilized for commercially useful functions, in correlation to the program objectives, and in adherence to all rules and regulations governing this funding award.