NJSDA Form 803B/804B
NJSDA Form 803B/804B
Revised 12/14/09
Contractor/Consultant Name:
Contract Number:
Requisition Number:
Period Covered:
District Name:
To be provided with each payment request for both Contractors and Professional Services
Firm Name included
with Bid
% Award
Proposed
For
(SBE/MBE/WBE)
Firm Type
(SBE/MBE/WBE)
Trade
Classification
Current Firm
under Contract
%
Awarded
Reason for substitution of
subcontractor/subconsultant
Please attach additional documentation, if necessary
I certify that the foregoing statements made by me are true. I am aware that if any statement made herein is willfully false
or fraudulent, I am subject to penalties provided by law.
Signed By: Contractor/Consultant Name:
Contractor/Consultant Email:
Contractor/Consultant Phone Number:
Name (Sign):
(Print):
Date:
I certify that this information is accurate and complete and that required certified payroll information for construction
contracts is on file for the contractor and subcontractor(s) that performed work during the period covered as indicated
above. I also certify that any substitution of a subcontractor for a construction contract conforms with the provisions of
article 6 of the general conditions of that contract. As for Consultant contracts, I certify that any substitution of a
subconsultant adheres to the provisions of article 2.1.9 of the general conditions.
Acknowledged By:
NJSDA:
Name
(Sign):
(Print):
Date:
PMF/CM:
PMF/CM Phone:
Name (Sign): (Print):
Date:
PMF/CM Email:
Verification Form
SUBCONTRACTOR/SUBCONSULTANT
Print Form
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