Client Transaction Verification Form

Minority Business Development Agency

Client Transaction Verification Form

Pursuant to the mutually agreed upon terms of the Minority Business Development Agency (MBDA) Internal/External Client Engagement Form, your firm contracted with MBDA to provide one or more of the following services:

__Contract Assistance __Financing Assistance __Business Consulting __ Other

For transactions in which the services provided by MBDA, either directly or indirectly, by providing business consulting, referrals or other services, resulted in either a contract or capital award, please answer the following questions:

Contract Award

Did you receive a contract award? Yes___ No___

What type of contract? ___ Standard ___ Multiple/Multi-Year ___ IDIQ

If yes, what was/were the Dollar Amount(s) of the award(s)?

Date: __________ $___________ From Whom: _______________________________________________

Date: __________ $ ___________ From Whom: _______________________________________________

Date: __________ $ ___________ From Whom: _______________________________________________

Capital Award (loan, bonding, equity, or other)

Did you receive a capital award? Yes___ No___

If yes, what was/were the Dollar Amount(s) of the capital obtained?

Date: _________ $__________ From Whom: _________________________________________________

Date: _________ $ _________ From Whom: _________________________________________________

Date: _________ $ _________ From Whom: _________________________________________________

Job Opportunities Created

New Jobs Created: _______ b. Jobs Retained: _______

Pursuant to the client responsibilities outlined in Section (d) of the MBDA Internal/External Client Engagement Form, please provide any and all documentary evidence (contract award documents, agreements, etc.) to your servicing MBDA Business Center Program or MBDA Business Development Specialist as evidence of the above transaction(s). All documentation will be kept on file and confidential within the MBDA Business Center. MBDA and MBDA Business Center Programs will take reasonable action to restrict access to such information by non-governmental entities. All information will remain confidential to the fullest extent of the law.

Please provide a brief narrative description of the MBDA services provided to your firm:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

I hereby certify that the information and statements provided in this document are truthful and accurate representations of the transaction(s) that occurred as a result of MBDA’s services. I also certify that all verifying documents are authentic and accurately represent the transaction(s) referenced above.

Client Firm Name:_______________________________________________________________

Print Name: _______________________________________________

Authorized Client Representative_________________ Title________________

Signature: ________________________________________________

Date: ______________