1. Appendix C- Mandatory CC Form.docx
DOCX document 110 KB Posted
- Attached to
- CID Firearms and Accessories
- Solicitation number
- ITB-15084
- Issued by
- Leon County, Florida
About this file
This is a Mandatory Criteria Certification Form issued by the State of Florida Department of Financial Services for an Invitation to Bid solicitation from the Division of Criminal Investigations for Firearms and Accessories. Respondents must complete and submit the certification form along with the PUR 7801 Vendor Certification Form to be considered eligible for award. The form requires respondents to certify compliance with five mandatory criteria: authorization of the submitting person, disclosure of conflicts of interest, compliance with respondent representations and authorizations, registration status with the Florida Department of State, and confirmation of no contract termination under Section 448.095(2)(c), F.S. within the prior year. Failure to provide complete certifications for all questions will result in the respondent being deemed non-responsive and ineligible for consideration. Annual resubmissions of attestation forms do not require written contract amendments.
The certification process requires vendors to attest to compliance with multiple Florida statutory requirements, including non-participation in boycotts of Israel, absence from various scrutinized vendor lists, status on suspension and convicted vendor lists, E-Verify registration and compliance, disclosure requirements under Section 286.101, F.S., and prohibition from using coercion for labor. Vendors must also certify that any commodities provided have not been produced by forced labor. The Department reserves the right to deem a respondent non-responsive and cease consideration if any information is found to be false prior to award, or to terminate the contract and hold the vendor liable for re-procurement costs if false information is discovered after award.
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Other files
| File | Type | Posted |
|---|---|---|
| 0. ITB Document Final Packet.pdf | ||
| 0. ITB Document Final Packet.pdf | ||
| 2. Appendix B- Questions Template (1).xlsx | XLSX spreadsheet | |
| 2. Appendix B- Questions Template (1).xlsx | XLSX spreadsheet | |
| 1. Appendix C- Mandatory CC Form.docx | DOCX document | |
| Addendum_1.pdf |
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Text version
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
APPENDIX C
Mandatory Criteria Certification Form
By submitting this form, and the PUR 7801 which appears on the next pages, the Respondent acknowledges that the Department will rely on the representations made on this form and the PUR 7801 in making its decision of award. If the Department discovers that any of the information on this form is false prior to the award of the Contract, the Department reserves the right to deem the Respondent non-responsive and cease any consideration of its Response. If the Department discovers that any information on this form is false after the award to the Respondent is made, the Department reserves the right to terminate the Contract and hold the Respondent liable for costs associated with re-procurement.
A Respondent’s failure to provide the below certification for each Certification Question and/or the PUR 7801 below will result in the Respondent being deemed non-responsive. Annual resubmissions of the following attestation forms will not require a written amendment to the Contract.
As the person authorized to sign this form, I certify that the Certification Answers provided below are accurate as to the Respondent.
Respondent Name: _____________________________________________________________________
Authorized Representative: __________________________ __________________________ ______ Printed Name Signature Date
| # |
| Certification Question |
| Certification Answer |
| 1. |
| Does the Respondent certify that the person submitting the Response is authorized to respond to this solicitation on the Respondent’s behalf? |
| __ Yes |
| __ No |
| 2. |
| Does the Respondent certify that it has met the disclosure requirements for Conflicts of Interest as outlined in Section 6 of the PUR 1001? |
| __ Yes |
| __ No |
| 3. |
| Does the Respondent certify compliance with Section 9, Respondent’s Representation and Authorization, of the PUR 1001, as modified by section 3.1, Instructions to Respondents, of the Invitation to Bid document? |
| __ Yes |
| __ No |
| 4. |
| Does the Respondent certify that: (a) it is registered with the Florida Department of State, (b) if awarded a contract under this solicitation, it will register with the Florida Department of State prior to contract execution, or (c) it is not required to register with the Florida Department of State (see applicable sections of Title XXXVI, Business Organizations, chapters 605-623, F.S.)? |
| __ Yes |
| __ No |
| 5. |
| Does the Respondent certify that it has not had a contract terminated pursuant to section 448.095(2)(c), F.S., by a public employer as defined in section 448.095(1)(i), F.S., within the last 1 year? |
| __ Yes |
| __ No |
Attachment 7, Mandatory Criteria Certification Form v2024.11.13 Page 1 of 10 Form PUR 7801 (07/2024) Rule 60A-1.002, F.A.C.
Vendor Certification Form
I hereby certify the following on behalf of the vendor identified below:
| Customer Indicator (Required, N/A, Determined by Vendor) |
| Vendor Indicator (Certified, N/A) |
| Certification |
| Required | |
| Choose an item. | Regardless of the dollar value of the goods or services provided, in accordance with the requirements of section 287.135(5), F.S., the vendor is not participating in a boycott of Israel and is not on the State Board of Administration’s “Quarterly List of Scrutinized Companies that Boycott Israel,” available at https://www.sbafla.com/fsb/FundsWeManage/FRSPensionPlan/GlobalGovernanceMandates.aspx. |
| N/A | |
| Choose an item. | If the goods or services to be provided are $1 million or more, in accordance with the requirements of section 287.135, F.S., the vendor is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Terrorism Sectors List (collectively, “Scrutinized List of Prohibited Companies”); does not have business operations in Cuba or Syria; and is not on the State Board of Administration’s “Scrutinized List of Prohibited Companies” available under the quarterly reports section at https://www.sbafla.com/fsb/PerformanceReports.aspx. |
| Required | |
| Choose an item. | The vendor is not on the Suspended Vendor List; it and its suppliers, subcontractors, or consultants to be utilized under the contract are not on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists; and there is no pending or threatened action, proceeding, or investigation, or any other legal or financial condition, that would in any way prohibit, restrain, or diminish the vendor’s ability to satisfy the contract obligations. |
The vendor is hereby informed of the provisions of sections 287.133(2)(a), 287.134(2)(a), and 287.137(2)(a), F.S., that identify the impacts to the vendor's ability or its affiliates’ ability to respond to the competitive solicitations of a public entity; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a public entity; or to transact business with a public entity if it, or its affiliates, are placed on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists of the Department of Management Services. The vendor is hereby further informed of the provisions of section 287.1351, F.S., that identify the impacts to the vendor’s ability to enter into or renew a contract with an agency, as defined in section 287.012, F.S., if it is placed on the Suspended Vendor List of the Department of Management Services.
| N/A | |
| Choose an item. | If the contract grants the vendor access to an individual’s personal identifying information, the vendor is not prohibited from entering into the contract pursuant to section 287.138, F.S., and has completed the Form PUR 1355, “Foreign Country of Concern Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15843, and attached it hereto. |
| N/A | |
| Choose an item. | If the vendor is a common carrier, as defined in section 908.111, F.S., or a contracted carrier, it is not prohibited from entering into the contract pursuant to section 908.111, F.S., and has completed the Form PUR 1808, “Common Carrier or Contracted Carrier Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14614, and attached it hereto. |
| Required | |
| Choose an item. | The vendor is registered with, and uses, the E-Verify system for all newly hired employees in accordance with section 448.095, F.S.; and has not, within the last year, had a contract terminated under section 448.095(5)(c), F.S., by a public employer, contractor, or subcontractor, as defined by section 448.095(1), F.S. |
| Required | |
| Choose an item. | The vendor is in compliance with all applicable disclosure requirements set forth in section 286.101, F.S., and has not been deemed ineligible for a grant or contract funded by a state agency pursuant to section 286.101(7), F.S. |
| Required | |
| Choose an item. | If the contract is between a nongovernmental entity and a governmental entity, in accordance with section 787.06, F.S., the vendor has completed an affidavit signed by an officer or a representative of the vendor under penalty of perjury attesting that the vendor does not use coercion for labor or services as defined in section 787.06, F.S. |
By signing below, I certify that I am authorized to complete and submit this Vendor Certification Form on behalf of the vendor.
Vendor Information Signatory
Name Signature Date
FEIN Typed or Printed Name
Title
Form PUR 7801 (07/2024) Rule 60A-1.002, F.A.C.
PUR 2024
Part B: Provision of Commodities Produced by Forced Labor
Pursuant to section 287.1346(4)(b), Florida Statutes, this portion of the form must be completed by a member of the company’s senior management, as defined in section 287.1346, F.S., when the company submits a response to a solicitation for the provision of commodities and before the company enters into or renews a contract for the provision of commodities.
I certify that to the best of my knowledge, the commodities Name of entity is offering to the Department have not been produced, in whole or in part, by forced labor.
Entity Name:
Senior Management’s Printed Name:
Senior Management member’s Title:
Signature: Date:
787.06(13) F.S.
Form PUR 2024 (07/2024) image1.png
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