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<br />ATTACHMENT 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 />,1. ' /- ~ /. ) ' , , //' <br />NameofOrganization:L'/fli t:/!.,.'lf,/"l/! L-kj .r!.ih'lii: Address: jff}J2) L~7/;//d )j~'I"II'l/C <br /> <br /> <br /> <br />REQUlRE~ISTING O;/SUBCONTRACTORS ON ~~~;&y {:TI:f~'~fj;;1c~ <br /> <br />In compliance with Miami-Dade County Ordinance 97- I 04, 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- I 04, 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 "NI 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 infor <br />y <br />Signature of Authorized Representative: <br /> <br />Title: I ;;j!/L'i'~ <br />./ /J, /'/1 __/ .; <br />Firm Name: {. /It/ l'l A'//Jlili /rk< /;~d/Ir. <br />/ / . <br />Address: /{j.:~ L;:,Ii;j I/~;'I/I//' i!/J/~t-/City/ State/Zip: :Jhi/J /LI.hi!; ,!'ffL/I/~ ..// 1"3J/liti <br />/ ./ , / / <br />Telephone: (_.:5~b) 9~1- !Iif/;. Fax: {j'l~:)17t /5//1' E-mail: A.!,tVL' Lil/r' 1C)3r/_~/l- . I/c., <br /> <br /> <br />, <br /> <br />Date: i' ~ . ~ <br />Fed.JDNo. t.~5'" 07&-4c,47 <br />