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<br />A TT ACHME~T E <br /> <br />MIAMI-DADE DEPARTMENT OF HUMAN SERVICES <br />BYRNE GRANT ADMINISTRATION <br /> <br />PROVIDER'S DISCLOSURE OF SUBCONTRACTORS AND SUPPLIERS <br />(Ordinance 97-104) <br /> <br />Name of Organization: tl:; tJf ~LlIJI1:1.J::b ~cA. Address: /flJ7'tJ t'J;/!J/u I!vel1LJt:?- <br />..bUI11'1j1 ..1J./e.t I&ea~ /'L...s3/~v <br /> <br />REQUIRED LISTING OF SUBCONTRACTORS ON COUNTY CONTRACT <br /> <br />In compliance with Miami-Dade County Ordinance 97-104, the Provider must submit the list of first tier <br />subcontractors or sub-consultants who will perform any part of the Scope of Services Work, if this <br />Contract is for $100,000 or more. <br /> <br />The Provider must complete this information. If the Provider will not utilize subcontractors, then the <br />Provider must state "No subcontractors will be used"; do not state "N/ A". <br /> <br />NAME OF SUBCONTRACTOR OR SUB-CONSULTANT <br /> <br />ADDRESS <br /> <br />CITY AND STATE <br /> <br />No subcontractors will be used. <br /> <br />REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT <br /> <br />In compliance with Miami-Dade County Ordinance 97-104, the Provider must submit a list of suppliers <br />who will supply materials for the Scope of Services to the Provider, if this Contract is $100,000 or <br />more. <br /> <br />The Provider must fill out this information. If the Provider will not use suppliers, the Provider must <br />state "No suppliers will be used", do not state "N/ A". <br /> <br />NAME OF SUPPLIER <br /> <br />ADDRESS <br /> <br />CITY AND STATE <br /> <br />No suppliers will be used. <br /> <br />I hereby certify that the foregoing inf~tion is true, c1rr"J! ~~Plete: / <br />Signature of Authorized Representative: , ,,"- dB-- ??E-?~t" <br />Title: UL) 01 Date:--.NovetY\ her I'I,d-Oos- <br />Firm Name: tly fJ/ ~L/t1Y .itb I (jju,cJJ Fed. ID No. 105.. o1g-Jj'!LJJ/ 7 <br />Address: /f'tJ"f/J LJJ)/;/U. I1U~/lll~ City/ State/Zip: .~,//ll'l.J J::k.-.< .$each ~L. 3.3//,0 <br />) <br />Telephone: <.:&;.5) 9J/1- /JI.,Of, Fax: (3t7~ Cf~C}-3 110 E-mail: AJ..&:k/c.ULJ rfi) ~:.a//. t1e./ <br />I <br /> <br /> <br />