Free 45129.FH11 - Indiana

QUARTERLY REPORT OF CONTRACTING WITH MINORITY AND WOMENS BUSINESS ENTERPRISES
State Form 45129 (R / 8-04) INSTRUCTIONS: This form must be typed or word-processed and... Name of reporting agency 1. Each agency must report all expenditures and disbursements originating in the 2. Any agency with separate facilities may submit an individual report for each facility. 3. Each agency must report expenditures and disbursements by minor object code
and category. Purchase orders should be reported when a P.O. number has been issued by the parent organization. 4. Completed reports are to be submitted no later than 45 days following the end of the quarter. agency.

Submit to: DEPARTMENT OF ADMINISTRATION Minority and Womens Business Enterprises 402 W. Washington St., Room W469 Indianapolis, IN 46204

Name of contact person Quarter Fiscal year Date submitted

1st (July-Sept) 2nd (Oct.-Dec.)

3rd (Jan.-Mar.) 4th (Apr.-June)

SUMMARY OF MINORITY BUSINESS ENTERPRISE (MBE) CONTRACTING
SPECIAL DISBURSING OFFICER (SDO) (All disbursements made during report period) CLAIM VOUCHERS (Vouchers transmitted to IDOA/Auditor during period) PURCHASE ORDERS RELEASED (All P.O.s issued during period)

Total of all SDOs for period: Total MBE SDOs for period: Percentage with WBE firms: Percentage with MBE firms:
DETAILS
MIN. OBJ. ALL

$ $ $ % %

Total of all SDOs for period: Total MBE SDOs for period: Percentage with WBE firms: Percentage with MBE firms:
DETAILS
MBE WBE MIN. OBJ. ALL

$ $ $ % %

Total of all SDOs for period: $ Total MBE SDOs for period: $ Percentage with WBE firms: $ Percentage with MBE firms:
DETAILS
MBE WBE MIN. OBJ. ALL MBE WBE

% %

.1 .2 .3 .4 $ $ $ $ $ $ $ $ $ .2 .3 .4 .5 Other Totals $ $ $ $ $ $ Other Totals

$ $ $ $ $ $ $

$ $ $ $ $ $ $

$ $ $ $ $ $ $

.1 .2 .3 .4 .5 Other Totals

$ $ $ $ $ $ $

$ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $

GRAND TOTAL MINORITY BUSINESS SUBCONTRACTING ACTIVITY (MBE subcontracts on non-MBE prime contracts reported above) Purchase Order Number Prime Contractor $ $ $ $ $ $ $ $ Minority Subcontractor Totals Value of Contract Minority Business Enterprise firm

Subcontractor Amount $ $ $ $ $ $ $ $ $

DETAIL OF AGENCY'S MINORITY BUSINESS ENTERPRISE (MBE) PRIME CONTRACTING ACTIVITY ACCOUNTING TYPE DESCRIPTION NAME AND FULL ADDRESS MINOR OBJECT OF ACTIVITY OF PURCHASE OF COMPANY CODE 1. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O. S.D.O. Voucher P.O.

VALUE OF PURCHASE

$

2.

$

3.

$

4.

$

5.

$

6.

$

7.

$

8

$

9.

$

10.

$

11.

$

12.

$

13.

$

14.

$

15.

$

16.

$

17.

$

18.

$

CERTIFICATION This will certify that, to the best of my knowledge, the information Signature of agency head contained herein is an accurate report of this agency's contracting activity, with Minority and Womens Business Enterprises, during the reporting period.

Date signed