15BH088__Request_for_Quote.pdf

California Department of State Hospitals - Atascadero Request for Quotation of Goods

Department of State Hospitals - Atascadero

Request For Quotation Goods

QUOTE DUE DATE May 6, 2016

QUOTE DUE TIME: 11:00 A.M.

Responses must be delivered to:

Department of State Hospitals - Atascadero before 11:00 AM on the due date

Delivery Date

# Days ARO

Supplier name and address:

SOLICITATION NO. REV. # DATE

REQUISITION OR CONTROL #

15BH088 4/21/16

Contact:

Phone: Fax:

E-mail:____________________________

For further information contact:

Bea Howell

(805) 468-2020 beatrice.howell@dsh.ca.gov

Ship To:

Receiving Dock/Warehouse 10333 El Camino Real Atascadero CA 93422-5808

ARE YOU CLAIMING PREFERENCE

AS A CERTIFIED SMALL BUSINESS/MB/DVBE:

YES ________ CSB/MB/DVBE #_____________

NO ________

IF YES, MANUFACTURER?

YES ________ NO ________

ARE YOU A NON-SMALL BUSINESS CLAIMING AT

LEAST 25% SMALL BUSINESS SUBCONTRACTOR

PREFERENCE?

YES ________ NO ________

Name (Print):

Title:

Signature:

_______________________ Date:_______

Federal Employer Identification Number:

CA. Retailer’s Seller Permit NO., (as per page 2):

Return quote to:

Attn: Procurement P O Box 7002 Atascadero CA 93423-7002

Facsimile machine (fax) bids will be considered only if they are sent to the buyer at

(805) 468-3261.

SECTION 14838 ET SEQ. OF THE

CALIFORNIA GOVERNMENT CODE

REQUIRES THAT A 5% PREFERENCE BE

GIVEN TO BIDDERS WHO QUALIFY AS A

SMALL BUSINESS OR AS A NON-SMALL

BUSINESS CLAIMINIG AT LEAST 25%

CALIFORNIA CERTIFIED SMALL BUSINESS

PARTICIPATION. FOR REQUIREMENTS

SEE TITLE 2, CALIFORNIA CODE OF

REGULATIONS SECTION 1896 ET SEQ.

THE REQUIREMENTS FOR NONPROFIT

VETERAN SERVICE AGENCIES

QUALIFYING AS A SMALL BUSINESS ARE

CONTAINED IN SECTION 999.50 ET SEQ.

OF THE MILITARY AND VETERANS CODE.

Bidder offers and agrees if this response is accepted within 60 calendar days following the date the response is due to furnish all the items upon which prices are quoted, at the prices set opposite each item, delivered at the designated point(s) by the method of delivery and within the times specified and subject to General Provisions (as per page 2). DELCARATIONS UNDER PENALTY OF PERJURY; By signing above, with inclusion of the date of signature, the above signed bidder DECLARES UNDER PENALTY OF PERJURY under the laws of the State of California as follows: (1) (STATEMENT OF COMPLIANCE). The above signed as complied with the non-discrimination program requirements of Government Code 12990 and Title 2, California Administrative Code Section 8103, and such declaration is true and correct. (2) The National Labor Relations Board declaration set forth in Paragraph 43 of the General Provisions is true and correct. (3) If a claim is made for the Small Business or Disabled Veterans Business preference, the information set forth within is true and correct.

Please see page 2 for product specifications and requirements.

California Department of State Hospitals - Atascadero Request for Quotation of

REQUEST FOR QUOTATION

CONTINUATION

Supplier Name: Solicitation No.

15BH088

Rev.

ITEM

NO.

QTY UNIT

COMMODITY/

PRODUCT CODE

DESCRIPTION UNIT PRICE EXTENSION

1.

5 cases

Brand & Code # Vinyl Gloves:

NO LATEX, Powder Free, Safe for Food Service, Single Use COLOR: Translucent Size: Small Reference: Safety Zone GVP9-SM-1

Color:

100 / box 10 boxes / case

2.

50 cases

Brand & Code #

100 / box

10 boxes / case

Vinyl Gloves:

NO LATEX, Powder Free, Safe for Food Service, Single Use COLOR: Translucent Size: Medium Reference: Safety Zone GVP9-MD-1

3.

60 cases

100 / box 10 boxes / case

Vinyl Gloves:

NO LATEX, Powder Free, Safe for Food Service, Single Use COLOR: Translucent - Size: X-Large Reference: Safety Zone GVP9-XL-1

60 cases

GREEN ONLY

144 pairs / case

Dishwashing Nitrile Gloves:

NO LATEX

Flock Lined, Powder Free Embossed Grip Length: 12”-13” Thickness: 15 mil Size: X-Large

BID REQUIREMENTS:

1. Substitutions will be accepted based on comparability to proposed product.

2. Bidder MUST indicate a product brand / code and color for each line item bid.

3. Bidder MUST provide a product specification sheet for each line item if bidding other than proposed brand.

TOTAL PROPOSED PRICE: $____________________

Supplier Name: Solicitation No.

Bid Requirements

1. Delivery: Delivery shall take place during regular working hours, 7:00 a.m. to 3:00 p.m., Monday through Friday, except State observed holidays. Final delivery, inspection and acceptance shall be at the location described herein.

2. Quotation Award: Quotation Award: This solicitation shall be awarded either by line item or all or none for all line items, whichever is deemed by the State to be in its best interest. The award will be made to the lowest responsive and responsible bidder(s) meeting all administrative and technical requirements, terms, and conditions of this solicitation.

3. Cash Discounts: Cash discounts will not be considered when evaluating bid responses for award purposes. However, cash discounts may be offered and taken by departments processing invoices within the timeframe specified.

4. Shipment: For the purposes of this solicitation, only bid responses quoting F.O.B. Destination, freight paid, will be accepted.

5. Inquiries/questions: Written questions must be received by May 2, 2016.

6. Bidder’s Instructions and General Provisions: The Bidder’s Instructions are incorporated by reference to Form GSPD-451, Bidders Instructions, revised 11/9/11, and the General Provisions are incorporated by reference to Form GSPD-401 Non-IT, General Provisions revised 6/8/10 and published at website: www.pd.dgs.ca.gov/modellang/GeneralProvisions. The General Provisions have recently been updated, please read carefully.

7. Quote/Bid Submittal: Quotes submitted on the suppliers own form will be accepted, if the supplier also submits the first page of this Request for Quote with a signature and date in the appropriate box. However, if the supplier’s own form references supplier attachments, which include legal terms and conditions that conflict with the State’s General Provisions, the bid shall be considered non-responsive and such bids may be rejected.

Responsible Bidder: The California Department of State Hospitals, Atascadero State Hospital, may require bidder(s) to submit evidence of their qualifications at such times and under conditions, as it may deem necessary. The question of whether a particular bidder is a responsible bidder may involve an evaluation of the bidder’s experience, type of facility, expertise or financial resources regarding the particular items requested by the pertinent solicitation. If a bidder has been determined to be non-responsible, the bid shall be rejected.

Facsimile (FAX) Bids: Facsimile machine (fax) bids will be considered only if they are sent to (805) 468-3261. Bids sent to any other fax number will not be considered. To be considered, all pages of a faxed bid must be completely received prior to the bid due date and time specified in this solicitation. Please be advised that there is a heavy demand placed on the fax machine receiving bids, and the State assumes no responsibility if a bidder cannot transmit their bid via fax, or if the entire bid is not received prior to the bid due date and time.

Recycled Content Products: State agencies are required to report purchases in many product categories The successful bidder will be required to submit a Recycled Content Certification. Failure to complete and return the form may disqualify your bid from consideration.

Darfur Contracting Act: State agencies are required to comply with Public Contract Code (PCC) sections 10475 through 10481, which apply to any company that currently or within the previous three years has had business activities or other operations outside of the United States. For such a company to bid on or submit a proposal for a State of California contract, the company must certify, by completing the attached Darfur Contracting Act Certification form, that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit proposals. However, if your company has not, within the previous three years, had any business activities or other operations outside of the United States, you do not need to complete this form.

Payee Data Record: The successful bidder will be required to submit a Payee Data Record, STD. Form 204 listing their Taxpayer Identification Number, see attached.

Seller’s Permit: If applicable, please note that award will be conditional on providing the following document prior to award:

You must provide your company’s California retailer’s seller’s permit or certification of registration and, if applicable, the permit or certification of all participating affiliates, issued by California’s State Board of Equalization (BOE), pursuant to all requirements as set form in Sections 6487, 7101 and sections 6452.1, 6487.3, 18510 of the Revenue and Taxation Code, and Section 10295.1 of the Public Contract code. In order to expedite the process of verifying the validity of the permit, provide the BOE permit number in the space provided on page 1 (or attach a copy of the permit with your bid.)

California Disabled Veteran Business Enterprise (DVBE) Program Requirements: The State hereby waives the mandatory Disabled Veteran Business Enterprise (DVBE) participation requirement for this IFB; however, an incentive for bidders who include DVBE participation is available and encouraged. For evaluation purposes only, the State shall apply an incentive to bids that include California certified DVBE participation and confirmed by the State. To receive the incentive, bidders must complete and return the Bidder Declaration GSPD-05-105 and, if applicable, the DVBE Declaration STD 843. Failure to complete and submit all required forms with the bid response may cause the bid to be rejected. See the attached California Disabled Veteran Business Enterprise (DVBE) Bid Incentive Instructions document for more information on claiming the incentive.

Small Business Regulations: The Small Business regulations, located in the California Code of Regulations (Title 2, Division 2, Chapter 3, Subchapter 8, Section 1896 et. seq.), concerning the application and calculation of the small business preference, small business certification, responsibilities of small business, department certification, and appeals can be viewed at (www.pd.dgs.ca.gov/smbus). For those without Internet access, a copy of the regulations can be obtained by calling the Office of Small Business and DVBE Services at (916) 375-4940.

http://www.pd.dgs.ca.gov/modellang/GeneralProvisions http://www.pd.dgs.ca.gov/smbus

Supplier Name: Solicitation No.

Non-Small Business Subcontractor Preference: A 5% bid preference is now available to a non-small business claiming 25% California certified small business subcontractor participation. If applicable, claim the preference in the box on the right hand side of the first page of this solicitation and submit a completed Bidder Declaration form with your bid.

Small Business Nonprofit Veteran Service Agencies (SB/NVSA): SB/NVSA prime bidders meeting requirements specified in the Military and Veterans Code Section 999.50 et seq. and obtaining a California certification as a small business are eligible for the 5% small business preference. If applicable, claim the preference in the box on the right hand side of the first page of this solicitation and submit a completed Bidder Declaration form with your bid.

Small business nonprofit veteran service agencies (SB/NVSA) claiming the small business preference must possess certification by California prior to the day and time bids are due.

Small Business Certification: Bidders claiming the small business preference must be certified by California as a small business or must commit to subcontract at least 25% of the net bid price with one or more California certified small businesses. Completed certification applications and required support documents must be submitted to the Office of Small Business and DVBE Services (OSDS) no later than 5:00 p.m. on the bid due date, and the OSDS must be able to approve the application as submitted. Questions regarding certification should be directed to the OSDS at (916) 375-4940.

Declaration Forms:

Bidder Declaration – GSPD-05-105 All bidders must complete the Bidder Declaration (GSPD-05-105) and include it with the bid response. When completing the declaration, bidders must identify all subcontractors proposed for participation in the contract. Bidders awarded a contract are contractually obligated to use the subcontractors for the corresponding work identified unless the State agrees to a substitution and it is incorporated by amendment to the contract.

If claiming the non-small business subcontractor preference, the Bidder Declaration form must list all the California small businesses with which you commit to subcontract in an amount of at least twenty-five percent (25%) of the net bid price. All certified small businesses must perform a “commercially useful function” in the performance of the contract as defined in Government Code Section 14837(d)(4).

The Bidder Declaration Form is available as a separate attachment to this RFQ and/or on the internet at:

www.documents.dgs.ca.gov/pd/poliproc/MASTEr-BidDeclar08-09.pdf. If the form is not available in the solicitation and you do not have access to the internet, please give Kimberly Gramespacher a call at (805) 468-2020 to obtain the document.

DVBE Declaration – STD. 843 Bidders who have been certified by California as a DVBE (or who are bidding rental equipment and have obtained the participation of subcontractors certified by California as a DVBE) must also submit a completed form(s) STD. 843 (Disabled Veteran Business Enterprise Declaration). All disabled veteran owners and disabled veteran managers of the DVBE(s) must sign the form(s). Should the form not be included with the solicitation, contact the State contracting official or obtain a copy online from the Department of General Services Procurement Division, Office of Small Business and DVBE Services (OSDS) website at www.pd.dgs.ca.gov/smbus. The completed form should be included with the bid response.

Attachments: The following documents are considered part of this solicitation and those marked with an asterisk must be returned with the bid response or the bid may be considered invalid and be rejected. The low bidder may be required to furnish additional information.

1. Bid Package*

2. Darfur Contracting Act, if applicable (see page 2)*

3. Bidder Declaration form (GSPD-05-105) see above*

4. California Disabled Veteran Business Enterprise (DVBE) Bid Incentive Instructions

5. DVBE Declaration (STD 843), if applicable (see above)*

6. Payee Data Record (STD 204)

7. Bidder Instructions (Form GSPD-451), by reference and published at website: www.pd.dgs.ca.gov/modellang/ModelSolicitation

8. General Provisions (Form GSPD-401), by reference and published at website: www.pd.dgs.ca.gov/modellang/GeneralProvisions

At the State’s option prior to award, bidders may be required to submit additional written clarifying information. Failure to submit the required written information as specified may be grounds for bid rejection.

http://www.documents.dgs.ca.gov/pd/poliproc/MASTEr-BidDeclar08-09.pdf http://www.pd.dgs.ca.gov/smbus http://www.pd.dgs.ca.gov/modellang/ModelSolicitation http://www.pd.dgs.ca.gov/modellang/GeneralProvisions

DARFUR CONTRACTING ACT CERTIFICATION

Public Contract Code Sections 10475 -10481 applies to any company that currently or within the previous three years has had business activities or other operations outside of the United States. For such a company to bid on or submit a proposal for a State of California contract, the company must certify that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit a proposal.

If your company has not, within the previous three years, had any business activities or other operations outside of the United States, you do not need to complete this form.

OPTION #1 - CERTIFICATION

If your company, within the previous three years, has had business activities or other operations outside of the United States, in order to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete the certification below.

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that a) the prospective proposer/bidder named below is not a scrutinized company per Public Contract Code 10476; and b) I am duly authorized to legally bind the prospective proposer/bidder named below. This certification is made under the laws of the State of California.

Company/Vendor Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County and State of

OPTION #2 – WRITTEN PERMISSION FROM DGS

Pursuant to Public Contract Code section 10477(b), the Director of the Department of General Services may permit a scrutinized company, on a case-by-case basis, to bid on or submit a proposal for a contract with a state agency for goods or services, if it is in the best interests of the state. If you are a scrutinized company that has obtained written permission from the DGS to submit a bid or proposal, complete the information below.

We are a scrutinized company as defined in Public Contract Code section 10476, but we have received written permission from the Department of General Services to submit a bid or proposal pursuant to Public Contract Code section 10477(b). A copy of the written permission from DGS is included with our bid or proposal.

Company/Vendor Name (Printed) Federal ID Number

Initials of Submitter

Printed Name and Title of Person Initialing

Rev. 7-2010

State of California—Department of General Services, Procurement Division Solicitation Number 15BH088

GSPD–05–105 (REV 08/09)

BIDDER DECLARATION

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): ____________ or None ___ (If “None”, go to

Item #2)

b. Will subcontractors be used for this contract? Yes ___ No ___ (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

Corresponding % of bid price

Good Standing?

51% Rental?

0% ___ ___

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

Page ____of____

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), Nonprofit Veteran Service Agency (NVSA), Small Business (SB), 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 subcontractor 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.

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 subcontracting 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 subcontractor 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.

CALIFORNIA DISABLED VETERAN BUSINESS ENTERPRISE (DVBE)

BID INCENTIVE INSTRUCTIONS

The State hereby waives the mandatory Disabled Veteran Business Enterprise (DVBE) participation requirement for this IFB; however, an incentive for bidders who include DVBE participation is available and encouraged. For evaluation purposes only, the State shall apply an incentive to bids that include California certified DVBE participation and confirmed by the State. The incentive amount will vary in conjunction with the percentage of DVBE participation in accordance with the following formula:

DVBE Incentive Participation of: DVBE Incentive:

5% or Over 5%

4% to 4.99% inclusive 4%

3% to 3.99% inclusive 3%

2% to 2.99% inclusive 2%

1% to 1.99% inclusive 1%

The net bid price of responsive bids with DVBE participation will be reduced (for evaluation purposes only) by the amount of DVBE incentive as applied to the lowest responsive net bid price. If the #1 ranked, responsive, responsible bid is a California Certified Small Business, the only bidders eligible for the incentive will be other California Certified Small Businesses. The incentive adjustment for awards based on low price cannot exceed 5% or $100,000.00, whichever is less, of the #1 ranked net bid price. When used in combination with a Small Business preference adjustment, the cumulative adjustment amount cannot exceed $100,000.00. Please note that a non-small business bidder with a DVBE Incentive preference may not displace a small business bidder [CA Code of Regulations, Title 2, 1896.99.100(c)].

Information submitted by the bidder to claim the DVBE incentive will be verified by the State. Only the DVBEs who shall perform a commercially useful function relevant to the Scope of Work included in the IFB may be used to qualify the bidder for a DVBE incentive.

Bidders must document DVBE participation commitment by completing and submitting the Bidder Declaration GSPD-05-105 and the DVBE Declarations, STD 843 (5/2006), as applicable, see attached documents.

REPORTING DVBE PAYMENTS – If for this Agreement contractor made a commitment to achieve Disabled Veteran Business Enterprise (DVBE) participation, then contractor must within 60 days of receiving final payment under this Agreement certify in a report to the awarding department: (1) the total amount the prime contractor received under the contract; (2) the name and address of the DVBE(s) that participated in the performance of the contract; (3) the amount each DVBE received from the prime contractor; (4) that all payments under the contract have been made to the DVBE(s); and (5) the actual percentage of DVBE participation that was achieved. A person or entity that knowingly provides false information shall be subject to a civil penalty for each violation. (Military & Veterans Code § 999.5(d))

SUBSTITUTION OF DVBE SUBCONTRACTORS - Contractor understands and agrees that should award of this contract be based in part on their commitment to use the Disabled Veteran Business Enterprise (DVBE) subcontractor(s) identified in their bid or offer, per Military and Veterans Code 999.5(e), a DVBE subcontractor may only be replaced by another DVBE subcontractor and must be approved by the Department of General Services (DGS). Changes to the scope of work that impact the DVBE subcontractor(s) identified in the bid or offer and approved DVBE substitution will be documented by contract amendment.

Failure of Contractor to seek substitution and adhere to the DVBE participation level identified in the bid or offer may be cause for contract termination, recovery of damages under rights and remedies due to the State, and penalties as outlined in Military & Veterans Code § 999.9; Public Contract Code (PCC) § 10115.10 or PCC § 4110 (applies to public works only). Contractor must immediately notify the Department’s SB/DVBE advocate that substitution of a DVBE subcontractor is requested.

Please refer to the following website for more information regarding locating DVBE Suppliers, Resources and Information, and the definition of “commercially useful function”:

www.documents.dgs.ca.gov/pd/poliproc/MASTER-DVBEIncentivePkg.pdf.

http://www.documents.dgs.ca.gov/pd/poliproc/MASTER-DVBEIncentivePkg.pdf

STATE OF CALIFORNIA – DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

STD. 843 (Rev. 5/2006)

Instructions: The disabled veteran (DV) owner(s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment (Military and Veterans Code Section 999.2). Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty or perjury.

SECTION 1

Name of certified DVBE: _________________________________________ DVBE Ref. Number: _____________

Description (materials/supplies/services/equipment proposed): ___________________________________________

Solicitation/Contract Number: ________________________________ SCPRS Ref. Number: __________________

(FOR STATE USE ONLY)

SECTION 2

APPLIES TO ALL DVBEs. Check only one box in Section 2 and provide original signatures.

I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2(b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.

Pursuant to Military and Veterans Code Section 999.2(f), I (we) declare that the DVBE is a broker or agent for the principal(s) listed below or on an attached sheet(s). (Pursuant to Military and Veterans Code 999.2(e), State funds expended for equipment rented from equipment brokers pursuant to contracts awarded under this section shall not be credited toward the 3-percent DVBE participation goal.)

All DV owners and managers of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Owner/Manager) (Signature of DV Owner/Manager) (Date Signed)

(Printed Name of DV Owner/Manager) (Signature of DV Owner/Manager) (Date Signed)

Firm/Principal for whom the DVBE is acting as a broker or agent: ________________________________________________________

(If more than one firm, list on extra sheets.) (Print or Type Name)

Firm/Principal Phone: ____________________________ Address: _______________________________________________________

SECTION 3

APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AND DECLARE THE DVBE IS NOT A BROKER.

Pursuant to Military and Veterans Code Section 999.2 (c), (d), and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.

The undersigned owner(s) own(s) at least 51% of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsection (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax return(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections (c) and (g), will result in the DVBE being deemed an equipment broker.

Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):

(Printed Name) (Signature) (Date Signed)

(Address of Owner) (Telephone) (Tax Identification Number of Owner)

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Manager) (Signature of DV Manager) (Date Signed)