14. Appendix C - Mandatory Criteria.docx

DEPARTMENT OF FINANCIAL SERVICES

Mandatory Criteria Certification Form

2425-07 RFP COS

Appendix C 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.

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

VENDOR CERTIFICATION FORM

PUR 7801

I hereby certify the following on behalf of the vendor identified below:

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.

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

Use of Coercion for Labor and Services Example Affidavit

Pursuant to section 787.06(13), Florida Statutes, this form must be completed by an officer or representative of the nongovernmental entity executing, renewing, or extending a contract with a governmental entity.

Name of entity does not use coercion for labor or services as defined in section 787.06, Florida Statutes.

Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.

Printed Name:

Title:

Signature: Date:

Appendix C – Service Region 3 Rev. 9/28/22