1._Bidder_Declaration_GSPD-05-105_v2009.pdf

State of California—Department of General Services, Procurement Division

GSPD–05–105 (REV 08/09)

BIDDER DECLARATION

Solicitation Number

1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form):

a. Identify current California certification(s) (MB, SB, NVSA, DVBE):

b. Will subcontractors be used for this contract? Yes No or None (If “None”, go to Item #2)

(If yes, indicate the distinct element of work your firm will perform in this contract e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary.

c. If you are a California certified DVBE: (1) Are you a broker or agent? Yes No

(2) If the contract includes equipment rental, does your company own at least 51% of the equipment provided in this contract (quantity and value)? Yes No N/A

2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary):

Subcontractor Name, Contact Person, Phone Number & Fax Number

Subcontractor Address & Email Address

CA Certification (MB,SB, NVSA, DVBE or None)

Work performed or goods provided for this contract

Corresponding % of bid price

Good Standing?

51% Rental?

CERTIfICATION: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct.

Signature Date Page of

Vendor Name

State of California—Department of General Services, Procurement Division

GSPD–05–105 (REV 08/09) Instructions

BIDDER DECLARATION Instructions

All prime bidders (the firm submitting the bid) must complete the Bidder Declaration.

1.a. Identify all current certifications issued by the State of California. If the prime bidder has no California certification(s), check the line labeled “None”and proceed to Item #2. If the prime bidder possesses one or more of the following certifications, enter the applicable certification(s) on the line:

• Microbusiness (MB)

• Small Business (SB)

• Nonprofit Veteran Service Agency (NVSA)

• Disabled Veteran Business Enterprise (DVBE)

1.b. Mark either “Yes”or “No” to identify whether subcontractors will be used for the contract. If the response is

“No”, proceed to Item #1.c. If“Yes”, enter on the line the distinct element of work contained in the contract to be performed or the goods to be provided by the prime bidder. Do not include goods or services to be provided by subcontractors.

Bidders certified as MB, SB, NVSA, and/or DVBE must provide a commercially useful function as defined in

Military and Veterans Code Section 999 for DVBEs and Government Code Section 14837(d)(4)(A) for small/ microbusinesses.

Bids must propose that certified bidders provide a commercially useful function for the resulting contract or the bid will be deemed non-responsive and rejected by the State. For questions regarding the solicitation, contact the procurement official identified in the solicitation.

Note: A subcontractor is any person, firm, corporation, or organization contracting to perform part of the prime’s contract.

1.c. This item is only to be completed by businesses certified by California as a DVBE.

(1) Declare whether the prime bidder is a broker or agent by marking either “Yes”or “No”. The Military and

Veterans Code Section 999.2 (b) defines “broker”or “agent”as a certified DVBE contractor or subcon-tractor that does not have title, possession, control, and risk of loss of materials, supplies, services, or equipment provided to an awarding department, unless one or more of the disabled veteran owners has at least 51-percent ownership of the quantity and value of the materials, supplies, services, and of each piece of equipment provided under the contract.

(2) If bidding rental equipment, mark either “Yes”or “No” to identify if the prime bidder owns at least 51% of the equipment provided (quantity and value). If not bidding rental equipment, mark “N/A”for “not applicable.”

2. If no subcontractors are proposed, do not complete the table. Read the certification at the bottom of the form and complete “Page of ”on the form.

If subcontractors will be used, complete the table listing all subcontractors. If necessary, attach additional pages and complete the “Page of ”accordingly.

2. (continued) Column Labels

Subcontractor Name, Contact Person, Phone Number & Fax Number—List each element for all subcontractors.

Subcontractor Address & Email Address—Enter the address and if available, an Email address.

CA Certification (MB, SB, NVSA, DVBE or None)—If the subcontractor possesses a current State of

California certification(s), verify on this website (www.eprocure.pd.dgs.ca.gov).

Work performed or goods provided for this contract—Identify the distinct element of work contained in the contract to be performed or the goods to be provided by each subcontractor. Certified subcontractors must provide a commercially useful function for the contract. (See paragraph 1.b above for code citations regarding the definition of commercially useful function.) If a certified subcontractor is further subcontract-ing a greater portion of the work or goods provided for the resulting contract than would be expected by normal industry practices, attach a separate sheet of paper explaining the situation.

Corresponding % of bid price—Enter the corresponding percentage of the total bid price for the goods and/or services to be provided by each subcontractor. Do not enter a dollar amount.

Good Standing?—Provide a response for each subcontractor listed. Enter either “Yes”or “No” to indicate that the prime bidder has verified that the subcontractor(s) is in good standing for all of the following:

• Possesses valid license(s) for any license(s) or permits required by the solicitation or by law

• If a corporation, the company is qualified to do business in California and designated by the State of California Secretary of State to be in good standing

• Possesses valid State of California certification(s) if claiming MB, SB, NVSA, and/or DVBE status

51% Rental?—This pertains to the applicability of rental equipment. Based on the following parameters, enter either “N/A”(not applicable),“Yes”or “No” for each subcontractor listed.

Enter “N/A” if the:

• Subcontractor is NOT a DVBE (regardless of whether or not rental equipment is provided by the subcontractor) or

• Subcontractor is NOT providing rental equipment (regardless of whether or not subcontractor is a

DVBE)

Enter “Yes” if the subcontractor is a California certified DVBE providing rental equipment and the subcontractor owns at least 51% of the rental equipment (quantity and value) it will be providing for the contract.

Enter “No” if the subcontractor is a California certified DVBE providing rental equipment but the sub-contractor does NOT own at least 51% of the rental equipment (quantity and value) it will be providing.

Read the certification at the bottom of the page and complete the “Page of ” accordingly.