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EXHIBIT 12 (cont.) <br /> 4. Efforts made to assist WIMBE in obtaining bonding, lines of credit or insurance, and any technical assistance <br /> related to the plans,specifications and requirements for the work which was provided to W/MBE: <br /> 5. Any additional data to support a demonstration of good faith effort, such as contracts with W/MBE assistance <br /> agencies: <br /> I declare tender penalty ol'pe�jtvy that the foregoing information is trite and correct to the best of my Itnowledge. I <br /> understand that the City of Scats Ana and/or the U.S. Department of Housing and Urban Development may verify <br /> the information provided herein in connection with W/MBE coniplitxnce evttlasratian/[�itclit �acdivides and tlzcrt fcrilure <br /> to fully and truthfully complete this form may result in economic or other sanctions. <br /> Signature: <br /> Nalne: <br /> Title: <br /> Date: <br /> Name of Contractor/Subcontractor: <br /> Contractor/Subcontractor Identification <br /> Number: <br /> Address(Street,City,State,Zip): <br /> Business Racial/EtlauielGender Code: <br /> Circle the numertic code which indicates the racial/ethnic/gender character of the owner(s) and controller(s) of 51% <br /> of the business. When 51% or more is not owned and controlled by any single racial/ethnicity/gender category, <br /> circle the code which seems most appropriate. <br /> t =White Americans 4-Hispanic Americans <br /> 2=Black Americans 5=Asian/Pacific Americans <br /> 3=Native Americans 6=Hasidic Jews <br /> Woraaan Owned Business: <br /> Circle One: <br /> Yes I or No <br /> F-kDOCSIPRC)P5VC5ti14UUFORM;X UU5804AMB-SeCUDn3Sp.ws.D0C <br />