00015267_RFP_Attachment E_Responsibility Inquiry.docx

RFP/Bid Solicitation #S-73000-00015267 – Variance Permit Issuing Agent Attachment E

ATTACHMENT E

RESPONSIBILITY INQUIRY FORM

Agency will determine responsibility of a firm prior to award and execution of a contract. In addition to this form, Agency may obtain any information Agency deems necessary to make the determination. Agency will notify the firm of any other documentation required, which may include, but is not limited to, Oregon Department of Revenue Letter of Debt Compliance, recent profit-and-loss history; current balance statements and cash flow information; assets-to-liabilities ratio, including number and amount of secured versus unsecured creditor claims; availability of short and long-term financing; bonding capacity; insurability, credit information; material; equipment; facility and personnel information; record of performance under previous contracts; etc. Agency may postpone the award of the Contract in order to complete its investigation and evaluation. Failure to promptly provide requested information and clearly demonstrate Responsibility may result in offer rejection and ineligibility of contract award.

YES |_| / NO |_|. b) Does your firm have sufficient cash flow to fund day-to-day operations throughout the proposed contract period? YES |_| / NO |_| If "YES” on question 3.a or “NO” on question 3.b, please provide additional details.

Response:

4. Within the last 3-year period, has your firm had one or more contracts terminated for contractor default by any federal, state or local government agency, or any lawsuits filed against it by creditors or involving contract disputes? YES |_| / NO |_|. If "YES," please explain. (With regard to judgments, include jurisdiction and date of final judgment or dismissal.)

Response:

5. Is your firm, a major partner or major shareholder (defined as a partner or shareholder owning 10% or more of your firm), a major subcontractor (defined as receiving 10% or more of the total Contract amount), or any principal officer of your firm, major partner, major shareholder, or major subcontractor presently, or within the last 3 years has been convicted of, indicted for, or otherwise criminally or civilly charged by a governmental entity with the commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract; violation of federal or state antitrust statutes relating to the submission of bids or Proposals; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property?

YES |_| / NO |_|. If "YES," indicate the jurisdiction, date of indictment, charge or judgment and names and summary of charges.

Response:

6. Within the last 3-year period, has your firm filed a bankruptcy action, filed for reorganization, made a general assignment of assets for the benefit of creditors, or had an action for insolvency instituted against it? YES |_| / NO |_|. If "YES," indicate the filing dates, jurisdictions, type of action, ultimate resolution, and dates of judgment or dismissal, if applicable.

Response:

7. a) Within the last 3-year period, has your firm been notified of any delinquent Federal or State taxes in an amount that exceeds $3,000 for which the liability remains unsatisfied. YES |_| /NO |_|.

b) Does your firm have any liquidated and delinquent debt owed to the State or any department or agency of the State? If "YES" on 7.a or 7.b or both, please explain. YES |_| /NO |_|

Response:

8. Does your firm have all required licenses, insurance and/or registrations, if any, and is the firm legally authorized to do business in the State of Oregon. YES |_| /NO |_|. If "NO," please explain.

Response:

9. Within the last 3-year period, has your firm completed previous contracts of a similar nature with a satisfactory record of performance? [For purposes of this question, a satisfactory record of performance means that to the extent that the costs associated with and time available to perform a previous contract remained within your firm′s control, your firm stayed within the time and budget allotted for the procurement and otherwise performed the contract in a satisfactory manner.] YES |_| /NO |_|. If "NO," please explain.

Response:

10. Pay Equity Certificate. This certificate is required if your firm employs 50 or more full-time workers and the prospective contract or price agreement is estimated to exceed $500,000. This requirement does not apply to architectural, engineering, photogrammetric mapping, transportation planning or land surveying and related services contracts. If applicable, does a current authorized representative of your firm possess an unexpired Pay Equity Certificate? YES |_| / NO |_| / N/A |_|. (If the certificate was provided with the Bid or Proposal submitted for a solicitation related to the prospective contract, then it is not necessary to resubmit it. Just indicate “see Bid” or “see Proposal” in the response field. Otherwise, if applicable, submit a copy of the certificate with this form. For more information regarding the Pay Equity Certificate, please visit https://www.oregon.gov/das/procurement/pages/payequity.aspx.)

Response:

RESPOND TO ITEMS 11 & 12 IF THE PROSPECTIVE CONTRACT INCLUDES SALE OF EQUIPMENT TO Agency. (If this information was provided in the Bid or Proposal submitted for this solicitation, then it is not necessary to repeat it here. Just indicate “see Bid” or “see Proposal” in the response fields.)

(Create additional rows or use additional sheets if necessary)

AUTHORIZED SIGNATURE

By signature below, the undersigned Authorized Representative on behalf of Bidder/Proposer certifies that the responses provided on this form are complete, accurate, and not misleading.

Project Name:

Authorized Signature Date

Print Name Title Responsibility Inquiry; 4/9/24