PART I

(To be completed for all bids. Please type or print)

Date (month, day, year):__________________________

1. Governmental Unit (Owner):___________________________________________________________

2. County :___________________________________________________________________________

3. Bidder (Firm):_______________________________________________________________________

Address:___________________________________________________________________________

City/State/ZIPcode:__________________________________________________________________

4. Telephone Number:__________________________________________________________________

5. Agent of Bidder (if applicable):__________________________________________________________

Pursuant to notices given, the undersigned offers to furnish labor and/or material necessary to complete the public works project of _____________________________________________________________________

(Governmental Unit) in accordance with plans and specifications prepared by _____________________________

_________________________________________________ and dated _____________________ for the sum of

The undersigned further agrees to furnish a bond or certified check with this bid for an amount specified in the notice of the letting. If alternative bids apply, the undersigned submits a proposal for each in accordance with the notice. Any addendums attached will be specifically referenced at the applicable page.

If additional units of material included in the contract are needed, the cost of units must be the same as that shown in the original contract if accepted by the governmental unit. If the bid is to be awarded on a unit basis, the itemization of the units shall be shown on a separate attachment.

The contractor and his subcontractors, if any, shall not discriminate against or intimidate any employee, or applicant for employment, to be employed in the performance of this contract, with respect to any matter directly or indirectly related to employment because of race, religion, color, sex, national origin or ancestry.

Breach of this covenant may be regarded as a material breach of the contract.

CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS

(If applicable)

I, the undersigned bidder or agent as a contractor on a public works project, understand my statutory obligation to use steel products made in the United States (I.C. 5-16-8-2). I hereby certify that I and all subcontractors employed by me for this project will use U.S. steel products on this project if awarded. I understand that violations hereunder may result in forfeiture of contractual payments.

CONTRACTOR'S BID FOR PUBLIC WORK - FORM 96

State Form 52414 (R2 / 2-13) / Form 96 (Revised 2013) Prescribed by State Board of Accounts

ACCEPTANCE

The above bid is accepted this _____________ day of _________________, ________, subject to the following conditions: _______________________________________________________________________

Contracting Authority Members:

PART II

(For projects of $150,000 or more – IC 36-1-12-4)

Governmental Unit: ___________________________________________________________

Bidder (Firm) ___________________________________________________________

Date (month, day, year): _______________________________________________________

These statements to be submitted under oath by each bidder with and as a part of his bid.

Attach additional pages for each section as needed.

SECTION I EXPERIENCE QUESTIONNAIRE

1. What public works projects has your organization completed for the period of one (1) year prior to the date of the current bid?

Contract Amount

Class of Work

Completion Date

Name and Address of Owner

2. What public works projects are now in process of construction by your organization?

Contract Amount

Class of Work

Expected Completion

Date

Name and Address of Owner

3. Have you ever failed to complete any work awarded to you? _______________ If so, where and why?

4. List references from private firms for which you have performed work.

SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE

1. Explain your plan or layout for performing proposed work. (Examples could include a narrative of when you could begin work, complete the project, number of workers, etc. and any other information which you believe would enable the governmental unit to consider your bid.)

2. Please list the names and addresses of all subcontractors (i.e. persons or firms outside your own firm who have performed part of the work) that you have used on public works projects during the past five (5) years along with a brief description of the work done by each subcontractor.

3. If you intend to sublet any portion of the work, state the name and address of each subcontractor, equipment to be used by the subcontractor, and whether you will require a bond. However, if you are unable to currently provide a listing, please understand a listing must be provided prior to contract approval. Until the completion of the proposed project, you are under a continuing obligation to immediately notify the governmental unit in the event that you subsequently determine that you will use a subcontractor on the proposed project.

4. What equipment do you have available to use for the proposed project? Any equipment to be used by subcontractors may also be required to be listed by the governmental unit.

5. Have you entered into contracts or received offers for all materials which substantiate the prices used in preparing your proposal? If not, please explain the rationale used which would corroborate the prices listed.

SECTION III CONTRACTOR’S FINANCIAL STATEMENT

Attachment of bidder’s financial statement is mandatory. Any bid submitted without said financial statement as required by statute shall thereby be rendered invalid. The financial statement provided hereunder to the governing body awarding the contract must be specific enough in detail so that said governing body can make a proper determination of the bidder’s capability for completing the project if awarded.

SECTION IV CONTRACTOR'S NON – COLLUSION AFFIDAVIT

The undersigned bidder or agent, being duly sworn on oath, says that he has not, nor has any other member, representative, or agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to include anyone to refrain from bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or combination with any other person in reference to such bidding.

He further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account of such sale.

SECTION V OATH AND AFFIRMATION

I HEREBY AFFIRM UNDER THE PENALTIES FOR PERJURY THAT THE FACTS AND INFORMATION

CONTAINED IN THE FOREGOING BID FOR PUBLIC WORKS ARE TRUE AND CORRECT.

Dated at ____________________ this ______________ day of __________________, _______

(Name of Organization)

By________________________________________________________

(Title of Person Signing)

ACKNOWLEDGEMENT

STATE OF ______________________)

) ss

COUNTY OF_____________________)

Before me, a Notary Public, personally appeared the above-named _________________________________ and swore that the statements contained in the foregoing document are true and correct.

Subscribed and sworn to before me this ____________ day of ___________________, ________.

Notary Public

My Commission Expires:_____________________

County of Residence:________________________

Part of State Form 52414 (R2 / 2-13) / Form 96 (Revised 2013)

BID OF

(Contractor)

(Address)

FOR

PUBLIC WORKS PROJECTS

OF

Filed ________________________________, _______

Action taken __________________________________