Form A-4 "Subcontractor Payment Report - Minority Business Enterprise Participation" - Maryland

What Is Form A-4?

This is a legal form that was released by the Maryland Department of Health - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Maryland Department of Health;
  • Easy to use and ready to print;
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  • Fill out the form in our online filing application.

Download a printable version of Form A-4 by clicking the link below or browse more documents and templates provided by the Maryland Department of Health.

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Download Form A-4 "Subcontractor Payment Report - Minority Business Enterprise Participation" - Maryland

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A-4
Maryland Department of Health and Mental Hygiene
Minority Business Enterprise Participation
Subcontractor Payment Report
To Be Completed Monthly by MBE Subcontractor
Contract #__________________________________
Report Month/Yr_______________
Contracting Unit_____________________________
Report Due by 15th of following
Contract Amount_____________________________
month.
MBE Subcontract Amount______________________
Contract Begin Date___________End Date_________
Services Provided____________________________
MBE Subcontractor Name_________________________________________________MDOT Certification #_____________
Contact Person__________________________________________________________________________________________
Address_______________________________________________________________________________________________
City _____________________________________________________State________________Zip______________________
Phone ___________________________________________________Fax__________________________________________
Subcontractor Services Provided____________________________________________________________________________
Total payments received from Prime
List outstanding invoices over 30 days old. Attach additional pages if necessary.
Contractor during above reporting period.
1.
$
2.
3.
Total Dollars Unpaid $________________________
Prime Contractor Name_____________________________________Contact Person________________________
Address_______________________________________________________________________________________
City___________________________________________________State___________Zip_____________________
_____________________________________
Phone __________________________________________Fax___
Return one copy of this form to each of the following addresses:
__________________________________________, (Contracting Unit)
Ms. Beverly Spence
__________________________________________, Contract Monitor
Maryland DHMH
Office of Community Relations
Maryland Department of Health and Mental Hygiene
201 West Preston St. 5th floor
___________________________________________________
Baltimore, MD 21201
___________________________________________________
Subcontractor Signature__________________________________________________ Date________________________
A-4
Maryland Department of Health and Mental Hygiene
Minority Business Enterprise Participation
Subcontractor Payment Report
To Be Completed Monthly by MBE Subcontractor
Contract #__________________________________
Report Month/Yr_______________
Contracting Unit_____________________________
Report Due by 15th of following
Contract Amount_____________________________
month.
MBE Subcontract Amount______________________
Contract Begin Date___________End Date_________
Services Provided____________________________
MBE Subcontractor Name_________________________________________________MDOT Certification #_____________
Contact Person__________________________________________________________________________________________
Address_______________________________________________________________________________________________
City _____________________________________________________State________________Zip______________________
Phone ___________________________________________________Fax__________________________________________
Subcontractor Services Provided____________________________________________________________________________
Total payments received from Prime
List outstanding invoices over 30 days old. Attach additional pages if necessary.
Contractor during above reporting period.
1.
$
2.
3.
Total Dollars Unpaid $________________________
Prime Contractor Name_____________________________________Contact Person________________________
Address_______________________________________________________________________________________
City___________________________________________________State___________Zip_____________________
_____________________________________
Phone __________________________________________Fax___
Return one copy of this form to each of the following addresses:
__________________________________________, (Contracting Unit)
Ms. Beverly Spence
__________________________________________, Contract Monitor
Maryland DHMH
Office of Community Relations
Maryland Department of Health and Mental Hygiene
201 West Preston St. 5th floor
___________________________________________________
Baltimore, MD 21201
___________________________________________________
Subcontractor Signature__________________________________________________ Date________________________