1-CD 50-3.10.8 REQ DOCS statements affidavits compliance.pdf

Contractor Affidavit of Eligibility

, being first duly sworn, deposes and says that he is

Of (sole owner, partner, president, secretary, etc) (Name of Firm) and that he is authorized to make this affidavit on behalf of the firm, and its owners, directors, and officers. He is the person responsible in my firm for accurate submission of this bid.

1. , its affiliates subsidiaries, officers, directors, (Name of Firm) and employees are not currently under investigation by any governmental agency and have not in the last four years been convicted or found liable for any act prohibited by State or Federal law in any jurisdiction with respect to bidding on any public contract, except as follows:

2. , its affiliates subsidiaries, officers, directors, and employees are not debarred, suspended, proposed for debarment, excluded or disqualified under the nonprocurement common rule, or otherwise declared ineligible from receiving Federal contracts, certain subcontracts, and certain Federal assistance and benefits.

3. I state that , understand and acknowledges that the above representations are material and important, and will be relied on by Steel Rivers

Council of Governments in awarding the contract(s) for which this bid is submitted. I understand and my firm understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from Steel Rivers Council of Governments of the true facts relating to the submission of bids for this contract.

Signed:

By:

Title:

Sworn to and subscribed before me this Day of

20 .

Notary Public

Date My Commission Expires

Non Collusion Affidavit To Be Executed by Each Bidder

State of: Municipality:

County of: Contract Name:

, being first duly sworn, deposes and says that he is

Of (sole owner, partner, president, secretary, etc) and that he is authorized to make this affidavit on behalf of the firm, and its owners, directors, and officers. He is the person responsible in my firm for the price (s) and the amount of this bid.

To state that:

1. The price(s) and amount of this bid have been arrived at independently and without consultation, communication or agreement with any other contractor, bidder or potential bidder.

2. That such bid is not made in the interest of or on behalf of any undisclosed person, partnership, company association, organization, or corporation; that such bid is genuine and not collusive or sham;

3. The bid of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit an complementary or other noncompetitive bid.

4. That said bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of said bidder or of any other bidder, nor to fix any overhead, profit, or cost element of such bid price nor of that of any other bidder, nor to secure any advantage against the public body awarding the contract to anyone interested in the proposed contract;

5. No attempt has been made or will be made to induce any firm or person to refrain from bidding on this contract, or to submit a bid higher than this bid, or to submit any intentionally high or noncompetitive bid or other form of complementary bid.

6. That said bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and has not directly or indirectly induced or solicited any other bidder connived, or agreed with any bidder or anyone else to put in a sham bid.

7. Neither the price(s) nor the amount of this bid, and neither the approximate price(s) nor approximately amount of this bid, have been disclosed to any other firm or person who is a bidder or potential bidder, and they will not be disclosed before bid opening.

8. That all statements contained in such bid are true; and, further, that said bidder has not directly or indirectly, submitted his bid price or any breakdown thereof, nor the contents there of, nor divulged information or data relative thereto, nor paid and will not pay fee in connection therewith to any corporation, partnership, company, association, organization, bid depository, nor to any member or agent thereof, nor to any other individual except to such person or persons as have a partnership or other financial interest with said bidder in his general business.

9. , its affiliates subsidiaries, officers, directors, and employees are not currently under investigation by any governmental agency and have not in the last four years been convicted or found liable for any act prohibited by

State or Federal law in any jurisdiction involving conspiracy or collusion with respect to bidding on any public contract, except as follows:

10. I state that , understand and acknowledges that the above representations are material and important, and will be relied on by Steel

Rivers Council of Governments in awarding the contract(s) for which this bid is submitted. I understand and my firm understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from Steel Valley Council of

Governments of the true facts relating to the submission of bids for this contract.

Signed:

By:

Sworn to and subscribed before me this Day of

20 .

Notary Public

Date My Commission Expires

Qualification Statement (Type or Print Legibly)

1. Name of Bidder: Federal ID#

2. Address of Bidder:

Business Telephone Number: Cell Number: Fax Number:

Email address:

3. Date When Organized:

4. Type of Organization

(Individual) (Partnership) (Corporation)

5. Years Engaged in Contracting Business

6. Experience Record: Name, address, phone number and contact person of four (4) organizations you have performed similar work.

1)

2)

3)

4)

7. Contracts on Hand: Anticipated

Project Gross Amount Completion Date

8. Ever fail to complete any work awarded to you?

9. If so, where and why?

10. Most Important Contracts recently Completed by You:

Project Gross Amount Completion Date

11. Background and Experience of Principal Members of your Company:

12. Major Equipment Available for this Contract:

13. Do you agree to submit a detailed financial statement if requested?

Contractor Name:

Signed By:

Date:

Project Name:

C :

Agency Signature

Print Name

Date:Signature:

Title:

THIS P IS TO BE BY OPERATING AGENCY ONLY:

Contract Award Amount $

Project Location:

Date

Title

RS ID

Contractor CDBG Contract Amount $___________________

Contractor HOME Contract Amount $___________________

Contractor Contract Amount $_________________

THIS FORM MUST BE COMPLETED, SIGNED, AND SUBMITTED FOR ALL CONTRACTORS USED ON THE JOB.

ALL INFORMATION MUST BE FILLED IN COMPLETELY OR FORM MUST BE RESUBMITTED.

(Check One)

PL3- Award Notice for Prime Contractor PL4- Award Notice for Subcontractor

To be filled out by Prime/ Subcontractor: