1-Attachment A-Public Entity Crimes.pdf

SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES

THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC

OR OTHER OFFICIAL AUTHORIZED TO AND MINISTER OATHS.

1. This sworn statement is submitted to_________________________________________________________ [print name of the public entity] by____________________________________________________________________________________ [print individual’s name and title] for____________________________________________________________________________________ [print name of entity submitting sworn statement] whose business address is and (if applicable) its Federal Employer Identification Number (FEIN) is ___________________________

(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement:_____________________________________________________________________________.)

2. I understand that a “public entity crime” as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or of the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

3. I understand that “convicted” or “conviction” as defined in Paragraph 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.

4. I understand that an “affiliate” as defined in Paragraph 287.133(1)(a), Florida Statutes, means:

1. A predecessor or successor of a person convicted of a public entity crime; or

2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term “affiliate” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm’s length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.

5. I understand that a “person” as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term “person” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.

ATTACHMENT A

6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. [Indicate which statement applies]

_____ Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.

_____ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.

_____ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (attach a copy of the final order)

I UNDERSTAND THAT THE SUBMISSION OF THE FORM TO THE CONTRACTING OFFICER FOR THE

PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO

ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION

287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION

CONTAINED IN THIS FORM.

[signature]

Sworn to and subscribed before me this _________day of ________________________________, 20_________.

Personally known________________________________ ___________________________________________

Or Produced identification__________________________ Notary Public – State of _______________________

______________________________________________ My commission expires_______________________ (Type of Identification)

(Printed, typed or stamped commission name of notary public)

Form PUR 7068 (Rev 6/11/92)

Human Trafficking Attestation

Pursuant to Florida Statutes Section 787.06(13), this attestation must be completed by an officer or representative of any nongovernmental entity that is executing, renewing, or extending a contract with Halifax Health.

The undersigned, as an authorized representative or officer of, and on behalf of, the “Nongovernmental Entity,” by executing below, attests, under penalty of perjury, to the following:

The Nongovernmental Entity does not use coercion for labor or services as such italicized terms are defined in Florida Statutes Section 787.06, as the same may be amended from time to time.

The undersigned understands that the statements made herein are made for the benefit of Halifax Health, and its compliance with Florida Statutes Section 787.06, and if at any time the attestation made herein is untrue, the Nongovernmental Entity will immediately notify Halifax Health of same and will not, thereafter, enter into any future contracts with Halifax Health, and will not renew or extend any existing contracts.

Nongovernmental Entity:________ ____________________________

/s/ ________________________________________________________

By: ________________________________________________________

Title: ________________________________________________________

ATTACHMENT B

Construction Management Qualifications Supplement

PROJECT NUMBER: PROJ-24-084

PROJECT NAME: CONSTRUCTION MANAGEMENT SERVICES

APPLICANT NAME: ______________________________________________________________________

ADDRESS OF PROPOSED OFFICE IN CHARGE: _____________________________________________

Telephone & Fax Numbers: ________________________________________________________________

E-Mail Address & Website Address: _________________________________________________________

Florida Corporate Charter Number(s): ________________________________________________________

Is the Applicant a Joint-Venture? □ YES □ NO

For how many years has the applicant been providing general contracting or construction management services? ____________________________________________________

Architectural and/or engineering design services? Design- build services?____________________________

Total billings in 2021, 2022, and 2023 (builder entity)?____________________________________________

Total billings in 2021, 2022, and 2023 (arch. design entity)?_______________________________________

Notarized signature below certifies the following:

I. Regarding information furnished by the applicant herewith, and as may be provided subsequently (including information presented at interview, if a finalist):

a) AU information of a factual nature is certified to be true and accurate (subject to perjury laws, Chapter 837, Florida Statutes).

b) All statements of intent or proposed future action (including the assignment of personnel and the provision of services) are commitments that will be honored by the applicant if awarded the contract.

c) The provision of false information could be cause for my firm's disqualification from applying for other Halifax Health work for a period of up to three years.

II. Applicant acknowledges that:

a) If any information provided by the applicant is found to be, in the opinion of the Selection

Committee or Halifax Health, substantially unreliable, this application may be rejected.

b) The Selection Committee may reject all applicants and may stop the selection process at any time.

c) The selection of finalists for the interview will be made on the basis of the information provided herein. Finalists will be ranked based on additional criteria, the interview, and the results of reference checks.

Construction Management Qualifications Supplement

d) It is understood that four (4) hard copies of the proposal must be received at Halifax Health Medical Center, 303 N. Clyde Morris Blvd., Daytona Beach, FL 32114, Attn:

Christina Crowe, VP of Supply Chain Services. One (1) proposal must be submitted online via the Halifax Health Procurement Portal Bonfire. All proposals, hard copy or digital, must be received by 1:00 p.m. local time October 3, 2024.

e) Failure to file a protest within the time prescribed in s. 120.57(3), Florida Statutes, shall constitute a waiver of proceedings under chapter 120, Florida Statutes.

f) Failure to sign this form will result in a loss of 5 points.

Ill. The undersigned certifies that he/she is a principal or officer of the firm applying for consideration and is authorized to make the above acknowledgments and certifications for and on behalf of the applicant.

IV. The undersigned certifies that the Firm has not been convicted of a public entity crime within the past 36 months, as set forth in Section 287.133(3)(a), Florida Statutes.

AUTHORIZED REPRESENATIVE’S SIGNATURE

TYPED NAME AND TITLE

DATED: ____________________________________________________

STATE OF _________________________

COUNTY OF ________________________

SUBSCRIBED and SWORN to before me, a Notary Public, this ________________ day of

____________________, 2024.

Notary Public

(Seal)

Exhibit A

Bonfire Frequently Asked Questions

How do I create a Vendor Profile on Bonfire?

You can click on the “Log In/Register” icon in the upper right corner of the Bonfire screen https://halifaxhealth.bonfirehub.com/portal/?tab=openOpportunities and follow the prompts. You may also watch this quick video on creating an account https://vendorsupport.gobonfire.com/hc/en-us/articles/7322917689367-Creating-a-Bonfire- Account-VIDEO.

If a firm has multiple people in the firm registered in Bonfire, can they all work on the same submittal?

Multiple accounts cannot work on the same vendor submission at the same time. For example: If John at firm A starts the submission, John will need to be the one who finalizes/submits the submission. A Best Practice is to have the team work on the submittal documents outside of Bonfire and select one person to go into Bonfire, submit the Intent to Bid, and proceed with uploading documents and completing the submittal.

Will individual registrations from the same firm be linked to that firm? Will all submittals by the firm be seen in all of the individuals' accounts?

No. Bonfire treats each individual account as an individual and does not link them. A best practice will be to determine internally which individual is responsible for each solicitation to prevent the duplication of submittals.

I am having difficulty registering as a vendor on Bonfire or have not received an email account confirmation from Bonfire. Who do I contact?

First, look through your trash, junk, etc. email accounts (sometimes a vendor's network will treat outside emails as junk). Second, reach out for assistance from Bonfire Support by clicking on the “Log In/Register” icon in the upper right corner of the Bonfire screen https://halifaxhealth.bonfirehub.com/portal/?tab=openOpportunities. You may also submit a question to Bonfire by clicking on the "Help" button at the lower left corner of the screen.

Miscellaneous Information:

If you have been notified of a bid release, and do not wish to bid, there is nothing further you need to do. If the Bid Due Date/Time has passed and no bid submittal is received this would be deemed a 'no bid'.

Instructions for adding additional new lines are in the instructions paragraph at the top of the sheet.

If I have other questions, who can I email?

You can email questions to support@gobonfire.com more clarity. Or please visit Bonfire’s Vendor Help Desk at https://vendorsupport.gobonfire.com/hc/en-us for additional information.