Prime Contractor Paid/unpaid Mbe Invoice Report Template
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3MBE Attachment D-4A
Department of Juvenile Services
Minority Business Enterprise Participation
Prime Contractor Paid/Unpaid MBE Invoice Report
Report #: ________
Contract #: __________________________________
Contracting Unit: ______________________________
Contract Amount: ______________________________
Reporting Period (Month/Year): _____________
MBE Subcontract Amt: __________________________
Project Begin Date: _____________________________
Prime Contractor: Report is due to the MBE Liaison by the
th
Project End Date: _______________________________
10
of the month following the month the services were
Services Provided: ______________________________
provided.
Note: Please number reports in sequence
Prime Contractor:
Contact Person:
Address:
City:
State:
ZIP:
Phone:
Fax:
E-mail:
MBE Subcontractor Name:
Contact Person:
Phone:
Fax:
Subcontractor Services Provided:
List all payments made to MBE subcontractor named above
List dates and amounts of any outstanding invoices:
during this reporting period:
Invoice#
Amount
Invoice #
Amount
1.
1.
2.
2.
3.
3.
4.
4.
Total Dollars Paid: $____________________________
Total Dollars Unpaid: $__________________________
If more than one MBE subcontractor is used for this contract, you must use separate __-4A forms for
each subcontractor.
Information regarding payments that the MBE prime will use for purposes of meeting the MBE
participation goals must be reported separately in Attachment __-4B
Return one copy (hard or electronic) of this form to the following addresses (electronic copy with
signature and date is preferred):
Signature:________________________________________________ Date:_____________________
(Required)
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