MassDOT Form AD4MW Page 1 of 1 Last Modified: March 23, 2018 (A)
Project Expenditure Report
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Minority/Women Business Enterprise (M/WBE)
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Participation
(For State-sponsored Projects)
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PROJECT __________________________________________________________________________________________________
M/WBE CONTRACTOR_______________________________________________________________________________________
MASSDOT PAYMENT VOUCHER (PV) NO. ______________ TOTAL M/WBE CONTRACTOR PARTICIPATION $_____________
PERCENTAGE OF CONTRACT __________________________
Contract
Item No.
Description of Work to be Performed by M/WBE Contractor
Estimated
Quantity
Unit Price
Item
Amount
Total amount requested by M/WBE contractor this invoice (add item amounts): TOTAL $
Total amount previously requested by M/WBE contractor: $
Total amount requested by M/WBE contractor to date: $
The undersigned certifies that the M/WBE Contractor has successfully completed the above referenced work associated with
this project and further assures that said M/WBE Contractor will be paid in full for the amount indicated above for said
services.
Prime Contractor
Authorized Signature
Date
M/WBE Contractor
Authorized Signature
Date
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Form must be submitted with each PV. Separate forms for each M/WBE contractor.
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Must be register with the MA Supplier Diversity Office (SDO) and must be listed as a MBE or WBE with a valid certification
when work is completed. PBE contractors cannot be counted as M/WBE contractors.
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For projects with no federal participation.
