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i m <br /> j HEHNEPtN GOUNTY SMALL BUSINESS ENTERPRISE PROGRAM - = <br /> � <br /> � PROGRESS PAYMENT REPORT N <br /> � m <br /> � OMOI�THLY ❑QUARTERLY N <br /> i (Check One) � �,, <br /> I �� W <br /> (1) PROJECT�10. i (2)GONTRACT t�lO. p <br /> �3) COMPANY NAh9E � (4)TELEPHOtJE N0.�___.__} <br /> (5) A��t�ss � FEvc No.(_) � <br /> � <br /> STATE I ZIP CODE � <br /> (6� COPfTRACT AMOtI[dT $ (7)PAYMENTS RECENED TO DATE $ � <br /> (8)Fli�€AL REPORT? �(YES) ❑ (id0) W <br /> This fnr�r m�st be used by fhe Prime Cortb�actor to corrfirm the payments ot fhe Certifred Small Busiaess Enterprise{S8E)Contracfors/Suppliers <br /> who wrl/be"used�o�eet the S8E uEi/izafforr goal. <br /> Note: S8E Su�bcantractors/Suppliers who are approved by fhe County's SBE Program car►be appBed toward the SBF utilizat7on goaL <br /> I <br /> (9) REPORT P! RIOD (11) (12) (13) ('l4) i (15) <br /> FROM: _ SMALL , � TOTAL � <br /> BUSINESS : AMOUNT PAID AMOUNT� <br /> TO: CONTRACT WORKISERVICE PERFORMED TO SBE PAI� I BAI.ANCE <br /> � � AMOUNT � TFitS PERIOD TO DATE� DUE �- <br /> (1 O) I�AME UF S ALL B�SJNESS[SBE� � i N <br /> r <br /> a <br /> � <br /> c <br /> r <br /> 0 <br /> -D <br /> I <br /> � ' . <br /> ; <br /> I <br /> 4 <br /> j <br /> I ' <br /> * I <br /> If you have more SBEs to report than can fit in tt�e space provided, please copy,complete,and attach:additional pages of this form. <br /> 7he infarmatian on this form is true and acc�rate to the best of my knowledge. � n <br /> � <br /> � m <br /> ��6� i ' <br /> Print or Type Name of Company's Authorized RepresentaEive Signature o# Company's Authori�ed Representative Date � <br /> � <br /> � <br /> FORIN SBEB � 3/4/02 <br /> � 7 n/? <br />