1-Documents Required with Bid.pdf

NON-COLLUSION AFFIDAVIT OF PRIME BIDDER

State of ________________________________________)

County of _______________________________________)

______________________________________, being first duly sworn, deposes and says that:

1) He/She is (Owner, Partner, Officer, Representative or Agent) of __________________, the bidder that has submitted the attached Bid;

2) He/She is fully informed respecting the preparation and contents of the attached Bid and of all pertinent circumstances respecting such Bid;

3) Such Bid is genuine and is not a collusive or sham Bid;

4) Neither the said bidder nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, has in any way colluded, conspired, connived, or agreed, directly or indirectly, with any other bidder firm or person to submit a collusive or sham Bid in connection with the Contract for which the attached Bid has been submitted, or to refrain from bidding in connection with such Contract, or has in any manner, directly or indirectly, sought by agreement or collusion or communication or conference with any other bidder, firm or person to fix the price or prices in the attached Bid or of any other bidder, or to fix any overhead, profit, or cost element for the Bid prices or the Bid price of any other bidder, or to secure through any collusion, conspiracy, connivance or unlawful agreement any advantage against the ___________________________________ or any person interested in the proposed Contract;

and

5) The price or prices quoted in the attached Bid are fair and proper and are not tainted by any collusion, conspiracy, connivance or unlawful agreement on the part of the bidder or any of its officers, partners, agents, representatives, owners, employees, or parties in interest, including this affiant.

Signed

Title

Subscribed and sworn to before me this _________ day of __________________, 20__

Title __________________________________

My commission expires _______________________________

CERTIFICATION OF NON-SEGREGATED FACILITIES

AND NON-EMPLOYMENT OF ILLEGAL ALIEN LABOR

The Bidder certifies that he/she does not maintain or provide for his/her employees any segregated facilities at any of his/her establishments, and that he/she does not permit his/her employees to perform their services at any location, under his/her control, where segregated facilities are maintained. The Bidder agrees that a breach of this certification will be a violation of the Equal Employment Opportunity Clause in any contract resulting from acceptance of this Bid. As used in this certification, the term “segregated facilities" means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin, because of habit, local custom, or otherwise. The Bidder agrees that (except where he/she has obtained identical certifications from proposed subcontractors) prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Employment Opportunity Clause, that he/she will retain such certifications in his/her files.

The Bidder further certifies in accordance with Act 43 (PL May 11, 2006) that he/she shall not knowingly employ, or knowingly permit any of its subcontractors to knowingly employ, the labor services of an illegal alien.

In the event that the Bidder

(a) knowingly employs or knowingly permits any of its subcontractors to knowingly employ, the labor services of an illegal alien; and

(b) the Bidder or any of its subcontractors are sentenced under Federal law for an offense involving knowing use of labor by an illegal alien, The Bidder shall be subject to penalty as prescribed in Pennsylvania Act 43 (PL May 11, 2006).

NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. § 1001.

Date: __________________, 20___ _________________________________ (Name of Bidder)

Official Address By: _____________________________ (including ZIP CODE):

(Title)

Employer Identification Number ______________________________________

CERTIFICATION OF BIDDER REGARDING EQUAL EMPLOYMENT OPPORTUNITY

INSTRUCTIONS

This certification is required pursuant to Executive Order 11246 (30 F.R. 12319-25). The implementing rules and regulations provide that any bidder or prospective contractor, or any of their proposed subcontractors, shall state as an initial part of the bid or negotiations of the contract whether it has participated in any previous contract or subcontract subject to the Equal Employment Opportunity Clause; and, if so, whether it has filed all compliance reports due under applicable instructions.

Where the certification indicates that the Bidder has not filed a compliance report due under applicable instructions, such Bidder shall be required to submit a compliance report within seven (7) calendar days after bid opening. No contract shall be awarded unless such report is submitted.

CERTIFICATION BY BIDDER

NAME AND ADDRESS OF BIDDER (Include ZIP code)

1. Bidder has participated in a previous contract or subcontract subject to the Equal Employment Opportunity

Clause.

_____ Yes _____ No

2. Compliance reports were required to be filed in connection with such contract or subcontract.

3. Bidder has filed all compliance reports due under applicable instructions, including SF-100.

_____ Yes _____ No _____ None required

4. Have you ever been or are you being considered for sanction due to violation of Executive Order 11246, as amended?

Name and Title of Signer (Please Type)

Signature Date

MINORITY AND WOMEN’S BUSINESS ENTERPRISE

BIDDER INSTRUCTIONS

This Project is funded in part with Community Development Block Grant (CDBG) funds. In accordance with CDBG rules and regulations, municipalities must uphold the conditions of the Minority/Women’s Business Enterprise (MBE/WBE) Action Plan. The objective of the plan is to facilitate the strengthening and expansion of MBE/WBE business concerns. Complete copies are available by contacting the Adams County Office of Planning & Development, 670 Old Harrisburg Road, Suite 100, Gettysburg, PA 17325, or by calling (717) 337-9824.

The County has established minimum participation levels of five percent (5%) for Minority Business Enterprises and three percent (3%) for Women Business Enterprises of the dollar amount of the bid for contracts of $25,000 or more.

The successful bidder will be required to submit evidence that these goals have been met either through his/her own employment practices or through the use of MBE/WBE subcontractors and vendors. Failure to comply may result in the bidder being determined not responsible.

Contractor is utilizing federal funds for this project and hereby agrees to comply with the following when applicable:

The requirements of Executive Orders 11625 and 12432 (concerning Minority Business Enterprise), and 12138 (concerning Women’s Business Enterprise). Accordingly, the Contractor hereby agrees to take affirmative steps to assure that women and minority businesses are utilized when possible as sources of supplies, equipment, construction, and services.

In preparation of your bid, you shall contact MBE/WBE firms listed in these bid documents in order to solicit subcontractor and supplier proposals. You may also contact other MBE/WBE firms of which you are aware.

As part of your bid, you are expected to complete and submit the MBE/WBE Contract Solicitation and Commitment Statement form. This form will be used during bid review to ascertain your level of MBE/WBE utilization. Your efforts and success in utilizing these firms will be one of the tests of bidder responsibility. Failure to meet this Project’s MBE/WBE goal does not automatically disqualify your bid; however, the MBE/WBE Bidder Certification must be submitted with the bid. At the municipality’s discretion, elements of the MBE/WBE may be waived, provided the bidder can submit adequate evidence of an effort to enlist MBE/WBE subcontractors and suppliers for the Project.

If you are the successful bidder you will be expected to document, at the pre-construction conference, your efforts to solicit MBE/WBE business enterprises, and to confirm the percentage of participation you will achieve.

Finally, at the completion of the Project and before final payment, you will be required to furnish a completed Minority/Women Business Enterprise Utilization Report for yourself and your subcontractors along with a Minority/Women Business Certification form, if applicable.

MBE/WBE CONTRACT SOLICITATION AND COMMITMENT STATEMENT

TO BE SUBMITTED WITH THE BID

Goals of 5% for minority business enterprise and 3% for women business enterprise participation have been established.

Name of Bidder:

Project Name:

Address:

Email Address:

Bid Opening Date:

Telephone Number:

Contact Person:

List those minority/women owned businesses from which you solicited quotes and/or received quotes in regard to this invitation for bid. Bidder’s contract with Subcontractors and suppliers should be at least five days prior to the bid opening date.

* Ethnic Code: A- Asian-Pacific Americans; B-African Americans; H-Hispanic Americans; N- Native Americans

Company Name &

Telephone Number

EIN/SSN

MBE*

(enter code from below)

WBE

(X)

Type of

Construction, Equipment, Services, and/or

Supplies to be provided to the

Project

Total Dollar Amount of Quote Received

(Please mark NR If no response was received)

Awarded

(If not awarded indicate reason)

Prepared By: Title:

MINORITY AND WOMEN BUSINESS ENTERPRISE BIDDER CERTIFICATION

The submittals of each bidder are subject to review to determine whether the bidder has discriminated in the selection of manufacturers, subcontractors and suppliers. If a bidder has met the goals for MBE/WBE participation, the bidder will be presumed not to have discriminated in their selections.

Where the goals are not met, the below statements, if accurate, shall be certified by the bidder:

1. The limited number or no commitment to MBEs/WBEs was not motivated by consideration of race or gender.

2. MBEs/WBEs were not treated less favorably than other businesses in the contract solicitation and commitment process.

3. Solicitation and commitment decisions were not based upon policies which disparately affect

MBEs/WBEs.

By signing below, I certify that the above statements are true and accurate.

Company Name

SECTION 3 BUSINESS CONCERNS

BIDDER INSTRUCTIONS

This Project is funded in part with Community Development Block Grant (CDBG) funds. In accordance with CDBG rules and regulations, municipalities must uphold the conditions of the Section 3 Action Plan. The objective of the plan is to promote local economic development, neighborhood economic improvement, and individual self-sufficiency for low- and very low-income individuals and business concerns as summarized in the “Section 3 Clause” included herein. Complete copies are available by contacting the Adams County Office of Planning & Development, 670 Old Harrisburg Road, Suite 100, Gettysburg, PA 17325, or by calling (717) 337-9824.

Section 3 minimum numerical goals apply to any contractor who provides labor when a contract is greater than $100,000. The bidder must attempt to meet the minimum numerical goals of contracting of at least ten percent (10%) of the total project construction cost to Section 3 business concerns. Additionally, the bidder must attempt to employ Section 3 residents resulting in at least thirty percent (30%) of the aggregate number of new hires. Failure to comply may result in the bidder being determined not responsible.

As part of your bid, you are expected to complete and submit the Section 3 Workforce Needs Table, the Contractor’s and Subcontractor’s Section 3 Certifications of Compliance and the Section 3 Contract Solicitation and Commitment Statement form. These forms will be used during bid review to ascertain your level of Section 3 utilization. Your efforts and success in utilizing these firms will be one of the tests of bidder responsibility. Failure to meet this Project’s Section 3 goal does not automatically disqualify your bid. However, contractors and subcontractors failing to meet the goals must document actions taken to comply with the Section 3 requirements. At the municipality’s discretion, elements of the Section 3 requirements may be waived, provided the bidder can submit adequate evidence of an effort to enlist Section 3 residents and business concerns for the Project.

If you are the successful bidder you will be expected to document, at the pre-construction conference, your efforts to solicit Section 3 residents and business concerns, and to confirm the percentage of participation you will achieve.

This will be documented in the Section 3 Implementation Action Plan, which is to be submitted by the successful bidder after the award but prior to start of construction.

Finally, at the completion of the Project and before final payment, you will be required to furnish a completed Section 3 Business Enterprise Utilization Report for yourself and your subcontractors along with a Section 3 Business Certification Form, if applicable.

SECTION 3 CLAUSE

A. The work to be performed under this contract is subject to the requirements of Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u (Section 3). The purpose of Section 3 is to ensure that employment and other economic opportunities generated by HUD assistance or HUD-assisted projects covered by Section 3, shall, to the greatest extent feasible, be directed to low- and very low-income persons, particularly persons who are recipients of HUD assistance for housing.

B. The parties to this contract agree to comply with HUD’s regulations in 24 CFR part 135, which implement Section

3. As evidenced by their execution of this contract, the parties to this contract certify that they are under no contractual or other impediment that would prevent them from complying with the part 135 regulations.

C. The contractor agrees to send to each labor organization or representative or workers with which the contractor has a collective bargaining agreement or other understanding, if any, a notice advising the labor organization or workers’ representative of the contractor’s commitments under this Section 3 clause, and will post copies of the notice in conspicuous places at the work site where both employees and applicants for training and employment positions can see the notice. The notice shall describe the Section 3 preference, shall set forth minimum number and job titles subject to hire, availability of apprenticeship and training positions, the qualifications for each; and the name and location of the person(s) taking applications for each of the positions; and the anticipated date the work shall begin.

D. The contractor agrees to include this Section 3 clause in every subcontract subject to compliance with regulations in 24 CFR part 135, and agrees to take appropriate action, as provided in an applicable provision of the subcontract or in this Section 3 clause, upon a finding that the subcontractor is in violation of the regulations in 24 CFR part

135. The contractor will not subcontract with any subcontractor where the contractor has notice or knowledge that the subcontractor has been found in violation of the regulations in 24 CFR part 135.

E. The contractor will certify that any vacant employment positions, including training positions, that are filled (1) after the contractor is selected but before the contract is executed, and (2) with persons other than those to whom the regulations of 24 CFR part 135 require employment opportunities to be directed, were not filled to circumvent the contractor’s obligations under 24 CFR part 135.

F. Noncompliance with HUD’s regulations in 24 CFR part 135 may result in sanctions, termination of this contract for default, and debarment or suspension from future HUD assisted contracts.

G. The contractor agrees that in order for a Section 3 resident to be counted as a new hire, the resident must work a minimum of 50 percent of the average staff hours worked for the category of work for which they were hired throughout the duration of time that the category of work is performed on the covered project.

H. The contractor agrees to award, to the greatest extent feasible, 10 percent of the total dollar amount of subsequent subcontracts awarded in connection with the Section 3 covered project or activity to Section 3 businesses, or provide written justification that is consistent with 24 CFR Part 75 describing why it was unable to meet that goal, despite their efforts to comply with the provisions of this clause.

I. The contractor agrees to notify Section 3 residents and businesses about the availability of new employment, training, or contracting opportunities created as a result of the receipt of Section 3 covered financial assistance, as stipulated by the awarding agency.

J. The contractor agrees to verify the eligibility of prospective Section 3 residents and businesses for employment, training, or subcontracting opportunities, in accordance with the recipient’s policies and procedures.

K. The contractor agrees to provide priority consideration to eligible residents and businesses in accordance with 24 CFR Part 75, as applicable.

L. The contractor agrees to notify potential bidders on subcontracts that are associated with Section 3 covered projects and activities about the requirements of Section 3 and include this Section 3 clause in its entirety into every subcontract awarded.

M. The contractor agrees to impose sanctions upon any subcontractor that has violated the requirements of this clause in accordance with the awarding agency’s Section 3 policies and procedures.

N. The contractor agrees to comply with all monitoring, reporting, recordkeeping, and other procedures specified by the awarding agency.

O. If applicable, the contractor agrees to notify each labor organization or representative of workers with which the recipient, sub-recipient, or contractor has a collective bargaining or similar labor agreement or other understanding, if any, about its obligation to comply with the requirements of Section 3 and ensure that new collective bargaining or similar labor agreements provide employment, registered apprenticeship, training, subcontracting, or other economic opportunities to Section 3 residents and businesses, and to post notices in conspicuous places at the work site advising the labor union, organization, or workers’ representative of the contractor’s commitments under this part.

P. Failure to comply with this clause shall result in the imposition of sanctions. Appropriate sanctions for noncompliance may include: Requiring additional certifications or assurances of compliance; termination or cancelation of the contract, subcontract, memorandum of understanding, cooperative agreement, or similar legally binding arrangement for default; refraining from entering into subsequent contracts, subcontracts, memoranda of understanding, cooperative agreements, or similar legally binding arrangement; repayment of funds, and withholding a portion of contract awards, subcontracts, memoranda of understanding, cooperative agreements, or similar legally binding arrangements

WORK FORCE NEEDS TABLE

EMPLOYEES

EMPLOYMENT CERTIFICATION

The CONTRACTOR hereby certifies that the above table represents the approximate number of employee positions that are needed and are not presently filled by regular and permanent employees, for which new employees will be required in the execution of the

___________________________________ contract, and also represents the number of lower income Project area residents that the

CONTRACTOR proposes to make a good faith effort to employ.

The CONTRACTOR certifies that he/she will make a good faith effort to employ the number of lower income employees by following the OWNER’S Section 3 Action Plan.

The CONTRACTOR, prior to subcontracting any portion of the Work covered by this contract, will require this Work Force Needs

Table and certification to be executed.

The CONTRACTOR certifies that any vacant employment positions, including training positions that are filled (1) after the

CONTRACTOR is selected but before the contract is executed, and (2) with persons other than those, to whom the regulations of

Section 3 require employment opportunities to be directed, were not filled to circumvent the contractor’s obligation under Section 3.

1 The following are the occupational category classifications that should be inserted in the Table:

1. Asbestos Workers 7. Glaziers 13. Plasterers

2. Brick Layers 8. Iron Workers 14. Plumbers

3. Carpenters 9. Lathers 15. Roofers

4. Cement Masons 10. Machinists 16. Sheet Metal

5. Electricians 11. Operating Engineers 17. Tile Setters

6. Elevator Constructors 12. Painters 18. Other (Specify)

Occupation

Category1

Approximate Number of Skilled Employees

Required

Total Number of

Skilled Employees

Presently on Payroll

Total Number of

Skilled Employees to be

Hired

Total Number of Lower

Income Residents to Be

Hired

SECTION 3 CONTRACT SOLICITATION AND COMMITMENT STATEMENT

Minimum Participation Levels (MPL): Section 3- 10% construction & 3% non-construction

Section 3- 30% aggregate new hires

Name of Bidder:

E-Mail:

Address:

Bid Opening Date:

Telephone Number:

Contact Person:

List those Section 3 business concerns from which you solicited quotes or which contacted you and gave you quotes in regard to this invitation for bid. Bidder’s contract with Subcontractors and suppliers should be at least five days prior to the bid opening date.

(1) Indicate whether Section 3 Business Concerns were solicited for each type of work the bidder expects to subcontract for and for all materials which the bidder expects to procure and, if not, the reason(s) why no such solicitation was made;

(2) Indicate the reason why a Section 3 Business Concern has not been committed to for a type of subcontract work or materials in any area where a quote was received from a Section 3 Business Concern, and;

(3) In any case where no quotations are received or commitments made to a Section 3 Business Concern, indicate that no quotes were received, and if there is another reason for no commitments being made, the reason for the lack of commitments.

Company Name &

Telephone Number

EIN/SSN

Type of Construction, Equipment, Services, and/or Supplies to be provided to the Project

Total Dollar Amount of

Quote Received

(Please mark NR if no response was received)

Awarded

(If not awarded indicate the reason)

IF NO COMMITMENT WAS

MADE TO A SECTION 3

BUSINESS- EXPLAIN

Preparers Signature: Title

CONTRACTOR’S

CERTIFICATION OF COMPLIANCE

SECTION 3

CERTIFICATION OF COMPLIANCE WITH REGULATIONS FOR SECTION 3 OF THE HOUSING AND URBAN

DEVELOPMENT ACT OF 1968 AS REQUIRED FOR PARTICIPATION IN THE SMALL COMMUNITIES

PROGRAM, PURSUANT TO THE HOUSING AND COMMUNITY DEVELOPMENT ACT OF 1974, P.L. 93-383, AS AMENDED.

PURPOSE, AUTHORITY AND RESPONSIBILITY

Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u

(hereinafter Section 3) requires that to the greatest extent feasible, opportunities for training and employment in a Section 3 covered Project be given to lower income residents of the Project area, and that contracts for Work in connection with the Project be awarded to business concerns which are located in or owned in substantial part by persons residing in the area of the Project.

(hereinafter called the CONTRACTOR ) upon being awarded a contract for _______________________________________________________ in _______________________________________ project area, the CONTRACTOR, to the extent

(MUNICIPALITY)

feasible, will make a good faith effort to utilize the services of businesses located in or substantially owned by persons who live within the Project boundaries.

The CONTRACTOR has been informed by the OWNER, that the Project area boundaries for the

Small Communities Program are the municipal limits.

To complete the Project, it is also estimated that the CONTRACTOR may be subcontracting for supplies and services for which certain business concerns eligible under Section 3 could provide. In order to comply with the regulations for utilization of businesses under Section 3, the

CONTRACTOR shall comply with the OWNER’S Section 3 Action Plan.

Signature/CONTRACTOR

SUBCONTRACTOR’S

CERTIFICATION OF COMPLIANCE

SECTION 3

CERTIFICATION OF COMPLIANCE WITH REGULATIONS FOR SECTION 3 OF THE HOUSING AND URBAN

DEVELOPMENT ACT OF 1968 AS REQUIRED FOR PARTICIPATION IN THE SMALL COMMUNITIES

PROGRAM, PURSUANT TO THE HOUSING AND COMMUNITY DEVELOPMENT ACT OF 1974, P.L. 93-383, AS AMENDED.

PURPOSE, AUTHORITY AND RESPONSIBILITY

Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u

(hereinafter Section 3) requires that to the greatest extent feasible, opportunities for training and employment in a Section 3 covered Project be given to lower income residents of the Project area, and that contracts for Work in connection with the Project be awarded to business concerns which are located in or owned in substantial part by persons residing in the area of the Project.

(hereinafter called the SUBCONTRACTOR ) upon being awarded a subcontract for_____________________________________________________ in _______________________________________ project area, the CONTRACTOR, to the extent

(MUNICIPALITY)

feasible, will make a good faith effort to utilize the services of businesses located in or substantially owned by persons who live within the Project boundaries.

The SUBCONTRACTOR has been informed by the OWNER, that the Project area boundaries for the Small Communities Program are the municipal limits.

To complete the Project, it is also estimated that the SUBCONTRACTOR may use lower tier subcontracts for supplies and services for which certain business concerns eligible under Section 3 could provide. In order to comply with the regulations for utilizat ion of businesses under Section

3, the SUBCONTRACTOR shall comply with the OWNER’S Section 3 Action Plan.

Signature/SUBCONTRACTOR

STATEMENT OF BIDDER'S QUALIFICATIONS

All questions must be answered, and the date given must be clear and comprehensive. This statement must be notarized. If necessary, questions may be answered on separate, attached sheets. The bidder may submit any additional information he/she desires.

1. Name of bidder.

2. Permanent main office address.

3. When organized.

4. If a corporation, where incorporated.

5. How many years have you been engaged in the contracting business under your present firm or trade name?

6. Contracts on hand: (Schedule these, showing amount of each contract and the appropriate anticipated dates of completion.)

7. General character of work performed by your company.

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

9. Have you ever defaulted on a contract? If so, where and why?

10. List the more important projects recently completed by your company, stating the approximate cost for each, and the month and year completed.

11. List your major equipment available for this contract.

12. Experience in work similar to this Project.

13. Background and experience of the principal members of your organization, including the officers.

14. Credit Available: $____________________

15. Give bank reference: ____________________________________

16. Will you, upon request, fill out a detailed financial statement and furnish any other information that may be required by the Owner?

17. The undersigned hereby authorizes and requests any person, firm, or corporation to furnish any information requested by the Owner in verification of the recitals comprising this Statement of Bidder's Qualifications.

Dated at __________ this ___________ day of __________________, 20__.

(Name of Bidder)

By: _______________________________

Title: ______________________________

State of _____________________)

County of ____________________)

______________________________________________, being a duly sworn representative of (Name of Bidder)

, deposes and says that all statements herein contained are true and correct.

Subscribed and sworn to before me this ______ day of __________, 20___.

Notary Public

My commission expires __________________, 20___.

STATEMENT OF BIDDER'S QUALIFICATIONS (continued)

Certifications:

I, ____________________________________________________________, certify that I am the

_______________________________________of the Corporation named as CONTRACTOR herein; that

____________________________________________ who signed this Agreement on behalf of the

CONTRACTOR, was the ______________________________________________________ of said

Corporation; that said Agreement was duly signed for and in behalf of said Corporation by authority of its governing body, and is within the scope of its corporate powers.

Title: ________________________________

(Corporate Seal)

Street Address 2

City State Zip Code

Doing Business As:

(if different from Legal Name)

Commonwealth of Pennsylvania Public Works Employment Verification Form

Complete and return the form to the contracting Public Body prior to the award of the contract.

Company Legal Name: ___________________________________________________________

Mailing Address: ______________________________________________________

Check one: Contractor Subcontractor

Contracting Public Body: _________________________________________________________

Contract/Project Number: ________________________________________________________

Project Description: _____________________________________________________________

Project Location: _______________________________________________________________

Date Enrolled in E-Verify (MM/DD/YYYY): ___________________________________________ As a contractor/subcontractor for the above referenced public works contract, I hereby affirm that as of today’s date, __________________________, our company is in compliance with the Public Works Employment Verification Act (‘the Act’) through utilization of the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. To the best of my/our knowledge, all employees hired are authorized to work in the United States.

It is also agreed to that all public works contractors/subcontractors will utilize the federal EVP to verify the employment eligibility of each new hire within five (5) business days of the employee start date throughout the duration of the public works contract. Documentation confirming the use of the federal EVP upon each new hire shall be maintained in the event of an investigation or audit.

I,____________________________________________, authorized representative of the company above, attest that the information contained in this verification form is true and correct and understand that the submission of false or misleading information in connection with the above verification shall be subject to sanctions provided by law.

Authorized Representative Signature Date of Signature

Printed Name: _________________________________________________________________

Phone Number: ______________________ Email: ____________________________________

Street Address 1