16-Attachment D Forms Affidavits and Documentation (2.8.22) (1).pdf

FORMS, AFFIDAVITS AND DOCUMENTATION CHECKLIST

Any contract/purchase order resulting from this solicitation shall include the forms indicated below.

Contractor shall complete the required forms and return them, along with the required documentation and the checklist, with the signed bid/proposal document. Failure to submit the completed forms and documentation may be a basis for rejection of your proposal.

Forms and Affidavits ☐ 1. Certificate of Authority ☐ 2. Amendment Form ☐ 3. Conflict of Interest and Disclosure Form ☐ 4. Debarment and Suspensions ☐ 5. Byrd Anti-Lobbying Amendment ☐ 6. Consolidated Affidavits

I. HIRING POLICY COMPLIANCE

II. SLAVERY ERA RECORDS AND INSURANCE, AND PRISON INDUSTRY AND

IMMIGRATION DETENTION SYSTEM RECORDS AND INTERESTS DISCLOSURE

III. COVENANT OF EQUAL OPPORTUNITY

IV. STATEMENT OF POLITICAL CONTRIBUTIONS AND EXPENDITURES

☐ 7. Non-Collusion Affidavit

☐ 8. COVID & ARPA FEDERAL REQUIREMENTS

Documentation Instructions for Completion ☐ 9. Sample Employment Application Attach a copy of a sample employment application

☐ 10. Income and Revenue Tax Clearance Approved clearances are not required to submit a response to the RFP but will be required of the successful respondent prior to City Council approval.

Submit requests for clearances electronically via a link in the bid response Requirement Section in the Supplier Portal. Attach evidence showing you have submitted or received clearances.

☐ 11. Three (3) years Financial Information Attach your organization’s financial statements (Balance Sheets, Income Statements and Statement of Cash Flows) for the previous three (3) years. Please do not submit your tax returns.

☐ 12. System of Awards Management

(SAM)

Attach a PDF screenshot to show proof of registration, or of SAM documentation. Instructions for registering are provided in this Attachment, “SAM.GOV Registration Steps”)

CERTIFICATE OF AUTHORITY

CORPORATION CERTIFICATE OF AUTHORITY

I, _________________________________________________________, Corporate Secretary of (name of corporate secretary)

_________________________________________________, a __________________________________ (complete name of corporation) (state of incorporation)

__________________________ corporation (the “Corporation”), DO HEREBY CERTIFY that the (non-profit or for profit) following is a true and correct excerpt from the minutes of the meeting of the Board of Directors duly called and held on ___________________, and that the same is now in full force and effect:

(date of meeting)

“RESOLVED, that the Chairman, the President, each Vice President, the Treasurer, and the Secretary and each of them, is authorized to execute and deliver, in the name of and on behalf of the Corporation and under its corporate seal of otherwise, any agreement or other instrument or document (‘Contract’) in connection with any matter or transaction that shall have been duly approved; and the execution and delivery of any Contract by any of the aforementioned officers shall be conclusive evidence of such approval.”

FURTHER, I CERTIFY that _________________________ is Chairman

________________________________________________________ is President, ________________________________________________________ is/are Vice President(s), ________________________________________________________ is Treasurer, ________________________________________________________ is Secretary, ________________________________________________________ is Executive Director, and ________________________________________________________ is __________________.

FURTHER, I CERTIFY that any of the aforementioned officers or employees of the Corporation are authorized to execute and commit the Corporation to the conditions, obligations, stipulations and undertakings contained in the foregoing Contract between the City and the above-referenced Corporation and that all necessary corporate approvals have been obtained in relationship thereto.

IN WITNESS THEREOF, I have set my hand this _____ day of __________, 20____.

CORPORATE SEAL

(if any)

Corporation Secretary

PLEASE NOTE THAT THE PERSON WHO SIGNS THE CONTRACT ON BEHALF OF

YOUR CORPORATION MUST BE ONE OF THE INDIVIDUALS LISTED ABOVE AS

PERSON AUTHORIZED TO EXECUTE CONTRACTS IN THE NAME OF AND ON

BEHALF OF THE CORPORATION.

LIMITED LIABILITY COMPANY

I, ______________________________________________________, a Manager or Member of (name of manager) ______________________, L.L.C, a limited liability company (the “Company”), DO HEREBY (name of company) CERTIFY that I am a Manager or Member of the Company who has the authority to act as an agent of the Company in executing this Certificate of Authority. I further certify that the following individuals are Managers or Members of the Company who have the authority to execute and commit the Company to the conditions, obligations, stipulations and undertakings contained in the foregoing Contract between the City and the Company:

FURTHER, I CERTIFY that all necessary approvals by the Managers or Members of the Company have been obtained with respect to the execution of said Contract.

IN WITNESS THEREOF, I have set my hand this _____ day of ________, 20______.

COMPANY SEAL

( if any )

Manager or Member

PLEASE NOTE THAT THE PERSON WHO SIGNS THE CONTRACT ON BEHALF OF

YOUR LIMITED LIABILITY COMPANY MUST BE ONE OF THE INDIVIDUALS

LISTED ABOVE AS A PERSON AUTHORIZED TO EXECUTE CONTRACTS IN THE

NAME OF AND ON BEHALF OF THE LIMITED LIABILITY COMPANY.

PARTNERSHIP

I, __________________________, A General Partner in _________________________, (name of general partner) a __________________________ County, _________________ Partnership (“the Partnership”) (county of registration) (state in which county lies)

DO HEREBY CERTIFY that I am a General Partner in the Partnership formulated pursuant to a Partnership Agreement dated ______________________, and that the following is a true and (date of meeting) correct excerpt from the minutes of the meeting of the General Partnership held on ___________ and that the same is now in full force and effect:

“RESOLVED, that each General Partner is authorized to execute and deliver, in the name and on behalf of the Partnership, any agreement or other instrument or document (‘Contract’) in connection with any matter or transaction that shall have been duly approved; and the execution and delivery of any Contract by a general partner shall be conclusive evidence of such approval.”

FURTHER, I CERTIFY that the following persons are General Partners:

FURTHER, I CERTIFY that any of the aforementioned General Partners of the Partnership are authorized to execute and commit the Partnership to the conditions, obligations, stipulations and undertakings contained in the foregoing Contract between the City and the above-referenced partnership that all necessary approvals have been obtained in relationship thereto.

IN WITNESS THEREOF, I have set my hand this ______ day of ________, 20_______.

CORPPORATE SEAL

General Partner

PLEASE NOTE THAT THE PERSON WHO SIGNS THE CONTRACT ON BEHALF OF

YOUR PARTNERSHIP MUST BE ONE OF THE INDIVIDUALS LISTED ABOVE AS A

PERSON AUTHORIZED TO EXECUTE CONTRACTS IN THE NAME OF AND ON

BEHALF OF THE PARTNERSHIP.

UNINCORPORATED ASSOCIATION

I, _____________________________, Secretary of ____________________________, (name of association secretary) an unincorporated association (the “Association”), DO HEREBY CERTIFY that the following is a true and correct excerpt from the minutes of the meeting of the Board of

Directors duly called and held on ______________, and that the same is now in full (date of meeting) Force and effect:

“RESOLVED, that the Chairman, the President, each Vice President, the Treasurer, and the Secretary and each of them, is authorized to execute and deliver, in the name of an on behalf of the Association and under its Association seal or otherwise, any agreement or other instrument or document (‘Contract”) in connection with any matter or transaction that shall have been duly approved; and the execution and delivery of any Contract by any of the aforementioned officers shall be conclusive evidence of such approval.”

FURTHER, I CERTIFY that _________________________ is Chairman

________________________________________________________ is President, ________________________________________________________ is/are Vice President(s), ________________________________________________________ is Treasurer, ________________________________________________________ is Secretary, ________________________________________________________ is Executive Director, and ________________________________________________________ is __________________.

FURTHER, I CERTIFY that any of the aforementioned officers of the Association are authorized to execute or guarantee and commit the Association to the conditions, obligations, stipulations, and undertakings contained in the foregoing Contract between the City and the above-referenced Association and that all necessary Association approvals have been obtained in relationship thereto.

IN WITNESS THEREOF, I have set my hand this _______ day of ________, 20_____.

CORPORATE SEAL

Association Secretary

PLEASE NOTE THAT THE PERSON WHO SIGNS THE CONTRACT ON

BEHALF OF YOUR ASSOCIATION MUST BE ONE OF THE INDIVIDUALS

LISTED ABOVE AS A PERSON AUTHORIZED TO EXECUTE CONTRACTS IN

THE NAME OF AND ON BEHALF OF THE ASSOCIATION.

AMENDMENT FORM

Project/ RFP No.:

Project Title:

The undersigned acknowledges receipt of the following amendments to the request for Proposal (RFP) document:

Amendment No. , Dated _ Company

Name:

Authorized Signature:

Name: (Print)

Title:

Date:

CONFLICT OF INTEREST AND DISCLOSURE FORM

1. Information about Bidder. Please answer questions 1A. and 1B. as it relates to yourself.

1A. Contact information:

Last Name: First Name: MI:

Title:

Company Name

Home Address:

1B. Conflicting Interests and Relationships. In accordance with the Conflict of Interest and Disclosure Policy, please list any interest or relationship that you have that presents a potential Conflict of Interest

1C. Please provide any information that would help to clarify any listed above (use additional pages if necessary).

2. Information about Employee’s Family Members. Please answer 2A and 2B as to your spouse, domestic partner, parent, child, and/or any dependents (“Family Members”).

2A. Conflicting Interests and Relationships of Family Members. In accordance with the Conflict of Interest and Disclosure Policy, please list any interest or relationship your Family Members have with any Entity that presents a potential conflict of interest for you (check for each Entity listed the type of interest or relationship that your Family Members have with the Entity).

Entity Name:

o Council Member o Employee o Consultant o Provider of Goods or services o Purchaser of Goods or services o Other Describe

2B. Please add any information that would help to clarify any of the above (use additional pages if necessary).

By signing this form you certify the information and any supplemental information herein is complete and accurate to the best of your knowledge; and acknowledge your continuing obligation to complete and submit a new form when there is any significant change in outside activities or related Financial Interests.

Signature: Date:

DEBARMENT AND SUSPENSIONS

POLICY

Debarment and Suspension (Executive Orders 12549 and 12689) - A contract award (see 2 CFR 180.220) must not be made to parties listed on the governmentwide exclusions in the System for Award Management (SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3 CFR part 1989 Comp., p. 235), “Debarment and Suspension.” SAM Exclusions contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549.

https://www.law.cornell.edu/cfr/text/2/180.220 https://www.law.cornell.edu/cfr/text/2 https://www.law.cornell.edu/cfr/text/3/part-1986 https://www.law.cornell.edu/cfr/text/3/part-1986 https://www.law.cornell.edu/cfr/text/3/part-1989 https://www.govinfo.gov/link/cpd/executiveorder/12549

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AFFIDAVIT OF DISCLOSURE OF INTERESTS

Instructions. Completing and submitting this disclosure affidavit fulfills the disclosure requirements of Section 2-

106.2 of the 2012 Detroit City Charter and Section 2-5-34 of the 2019 Detroit City Code of Ordinances, as well as Sections 200.212, .318(c) of the Uniform Guidance found at 2 C.F.R. 200 et seq. Please complete all applicable sections by typing or legibly printing. Where a section does not apply, please check the appropriate box and skip to the next section. If necessary, provide additional information on page 4 or attach additional documents to this disclosure affidavit. This disclosure affidavit must be signed, notarized, and filed with the applicable bid or response to a Notice of Funds Availability (NOFA), as well as with the City of Detroit Board of Ethics, 7737 Kercheval, Suite #213, Detroit, MI 48214 (City Code § 2-5-34(b)).

Note: An “immediate family member” of a person is that person’s spouse, domestic partner, an individual living in the person’s household, or an individual claimed as a dependent or spouse’s dependent under the Internal Revenue Code at 26 USC 1, et seq. (City Charter § 2-105.A.20; City Code § 2-5-3)

Section 1 - Identity of Disclosing Filer (Individual/Contractor/Vendor) (Charter § 2-106.2.2; Code § 2-5-34)

Provide the complete name of the filer (individual or business entity/organization seeking to do business with the City of Detroit) making this disclosure:

Name Street Address City State Zip code Telephone Fax Email

If the filer is a business entity, print the name, title, and contact information of the authorized individual making the disclosure and signing for the business entity, and include the certificate or resolution of authority authorizing the individual as an attachment to this affidavit.

Name Title

Telephone Fax Email

Section 2 - Financial Interests in Contracts or Matters Pending Before City (Charter § 2-106.2.1(a), (b); Code § 2-5- 34(a)(1), (2))

The above-named contractor or vendor; its direct and/or indirect owners, officers, directors, and managers; and/or an immediate family member of any owner, officer, director, or manager thereof has (if checked, complete rest of section below) does not have (if checked, skip to next section) a direct or indirect financial interest in the following matters that are pending before the Detroit City Council or the following office, department, or agency of the City

Matter

Interested Party (if an immediate family member, please provide an address and phone number and the nature of the relationship to the filer): Name

Street Address

City State Zip code

Telephone Relationship https://detroitmi.gov/sites/detroitmi.localhost/files/2018-05/2_29_2012_CharterDocument_2_1_WITHOUT_COMMENTARY_1.pdf https://library.municode.com/mi/detroit/codes/code_of_ordinances?nodeId=PAIVCOCH1--20_CH17FI_ARTVPUSU_DIV1GOSE_SDBPUGOSE_S17-5-17REMACO

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Nature of financial interest

Estimated value of the financial interest

Section 3 - Interests in Property Subject to Decision by City (City Charter § 2-106.2.1(c); City Code § 2-5-34(a)(3))

The above-named contractor or vendor; its direct and/or indirect owners, officers, directors, and managers; and/or an immediate family member of any owner, officer, director, or manager thereof has (if checked, complete rest of section below) does not have (if checked, skip to next section) an interest in real or personal property that is subject to a decision by the City regarding the purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement or a development agreement.

Interested Party (if an immediate family member, please provide an address and phone number and the nature of the relationship to the filer): Name

Street Address

City State Zip code

Telephone Relationship

Description of real or personal property

Nature of interest

Estimated value of the interest

Section 4 - Immediate Family Members Employed by or Seeking Employment with City (City Charter § 2- 106.2.1(e); City Code § 2-5-34(a)(5))

Please identify any immediate family member of the filer, including any immediate family members of a direct or indirect owner, officer, director, or manager thereof, who is currently employed by or applying for employment with the City of Detroit.

If none, check here and skip to next section; otherwise, complete rest of section below:

Name

Street address

City State Zip code

Phone

Nature of relationship to filer

Department/agency employed by or seeking employment with

Position held or sought

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Section 5 - Persons with Financial Interest in Contractor’s/Vendor’s Matters Pending Before City (City Charter § 2-106.2.2; City Code § 2-5-34(a)(6), (7))

Please identify all persons or entities having a direct or indirect financial interest in any matter the contractor or vendor has pending before the Detroit City Council or before any office, department, or agency of the City. Note that the term “financial interest” includes, but is not limited to receipt of a thing of value (either presently or in the future).

Complete on additional page(s), if necessary.

If none, check here and skip to next section; otherwise, complete rest of section below Name Street Address City State Zip code Contract or matter in which the person or entity named has a direct or indirect financial interest in the following matters that are pending before the Detroit City Council or the following office, department, or agency of the City:

Nature of financial interest Estimated value of the financial interest

Section 6 – Contractor/Vendor’s Role In The Solicitation Please identify whether the Contractor/Vendor contributed information, expertise or in any other way participated in the creation of the project underlying the Solicitation, including, but not limited to, participation in the creation of the scope of the project, the requirements of the project, or the budget required for the project.

Complete on additional page(s), if necessary.

If the Vendor answers this question in the negative, please check here and skip to the next section; otherwise, complete the rest of the section below. Please use extra sheets if necessary.

Describe the nature and extent of the Vendor’s contribution:

List the City employees with whom the Vendor assisted with the Solicitation:

Please list any of Vendor’s subcontractors or proposed subcontractors that contributed information, expertise or in any other way participated in the creation of the project underlying the Solicitation, including, but not limited to, participation in the creation of the scope of the project, the requirements of the project, or the budget required for the project, along with the nature and extent of the subcontractor’s contribution:

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Section 7 - Affirmation of Accuracy of Disclosure (City Charter § 2-106.2.3; City Code § 2-5-34(b))

I understand that the information provided in this disclosure will be relied upon by the City of Detroit in evaluating the proposed bid, solicitation, contract, or lease. I swear [or affirm] that the information provided is accurate. If I am signing on behalf of an entity, I swear [or affirm] that I have made a good faith and reasonable effort to verify the information provided herein, and further, that I have the authority to provide this disclosure on behalf of the entity.

Sign name:

Print name:

Sworn and subscribed to before me on , 20 by , the [name] [title] of the and am an authorized representative of that entity.

[legal entity/company]

Sign:

Print:

Notary Public, County, Michigan, Acting in County

My Commission Expires:

Notary Seal

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ADDITIONAL INFORMATION

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REFERENCES FOR DISCLOSURES BY CONTRACTORS AND VENDORS

2012 Detroit City Charter

Sec. 2-105. - Definitions and Rules of Construction.

A. As used in this Charter:

20. Immediate family member means a Public Servant’s spouse, domestic partner, individual who lives in the Public Servant’s household or an individual claimed by a Public Servant or a Public Servant’s spouse as a dependent under the United States Internal Revenue Code at 26 USC 1, et seq.

Sec. 2-106.2. - Disclosures.

1. Except as otherwise provided by applicable law, a Public Servant who exercises significant authority shall disclose:

a. Any financial interest, direct or indirect, that he or she or an immediate family member has in any contract or matter pending before City Council.

b. Any financial interest, direct or indirect, that he or she or an immediate family member has in any contract or matter pending before or within any office, department or agency of the City.

c. Any interest that he or she, or an immediate family member has in real and personal property that is subject to a decision by the City regarding purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement or a development agreement.

d. Campaign contributions and expenditures, in accordance with applicable laws.

e. The identity of any immediate family member employed by the City or who is making application to the City.

2. In addition to compliance with subsection (1) above, contractors and vendors shall disclose:

a. The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter the vendor or contractor has pending before City Council.

b. The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter the vendor or contractor has pending before or within any office, department, or agency of the City.

3. The above disclosures shall be made in writing and be made by sworn, notarized affidavit, in accordance with City ordinance and applicable laws.

https://detroitmi.gov/sites/detroitmi.localhost/files/2018-05/2_29_2012_CharterDocument_2_1_WITHOUT_COMMENTARY_1.pdf

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2019 Detroit City Code of Ordinances

Sec. 2-5-3 – Definitions.

Immediate family member means:

(1) A public servant’s spouse;

(2) A public servant’s domestic partner;

(3) An individual claimed by a public servant or a public servant’s spouse as a dependent under the United States Internal Revenue Code, being 26 USC 1 et seq.; or

(4) An individual who lives in the household of a public servant.

Sec. 2-5-34. - Disclosure of interests by contractors and vendors.

(a) Except as otherwise provided for by applicable law, all contractors and vendors doing business with the City of Detroit shall disclose the following:

(1) Any financial interest, direct or indirect, that the contractor or vendor or an immediate family member has in any contract or matter pending before City Council;

(2) Any financial interest, direct or indirect, that the contractor or vendor or an immediate family member has in any contract or matter pending before or within any office, department or agency of the City;

(3) Any interest that the contractor or vendor, or an immediate family member, has in real or personal property that is subject to a decision by the City regarding purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement, or a development agreement;

(4) Campaign contributions and expenditures in accordance with applicable law;

(5) The identity of any immediate family member employed by the City or who is making application to the City;

(6) The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter that the contractor or vendor has pending before City Council;

(7) The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter that the contractor or vendor has pending before or within any office, department, or agency of the City.

(b) All disclosures that are required under Subsection (a) of this section shall be made, in writing, on a form that is created by the Law Department and sworn to in the presence of a notary public. After completion, the form shall be filed with the Board of Ethics, which shall forward a complete copy of the form to the applicable department director or agency head.

https://library.municode.com/mi/detroit/codes/code_of_ordinances?nodeId=PAIVCOCH1--20_CH17FI_ARTVPUSU_DIV1GOSE_SDBPUGOSE_S17-5-17REMACO

Rev. 4/4/2023

NON-COLLUSION AFFIDAVIT

Negotiation No.

Negotiation Title:

State of :

County of : s.s.

I state that I am of , and that I am authorized to make this affidavit on behalf of my firm, and its owners, directors, and, officers. I am the person responsible in my firm for the price(s) and the amount of this RFP.

I state that:

The price(s) and amount of this proposal has been arrived at independently and without consultation, influence, communication or agreement with (i) any other contractor, vendor or potential vendor, or (ii) the City of Detroit, including any of its departments, boards, commissions, officers, employee, or agents.

Neither the price(s) nor the amount of this proposal, and neither the approximate price(s) nor approximate amount of this proposal, have been disclosed to any other firm or person who is a vendor or potential vendor, and they will not be disclosed before the bid opening.

No attempt has been made or will be made to induce any firm or person to refrain from responding to this contract, or to submit a proposal higher than this proposal, or to submit any intentionally high or noncompetitive proposal or other form of complementary proposal.

The proposal of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit a complementary or other noncompetitive proposal, including, but not limited to, any agreement to circumvent any regulatory or City requirements that may be applicable.

, its affiliates, subsidiaries, officers, directors, and employees are not currently under investigation by any governmental agency and have not in the last five years been convicted or found liable for any act prohibited by state or federal law in any jurisdiction, involving conspiracy or collusion with respect to submitting a proposal on any public contract, except as follows:

I state that understands and acknowledges that the above representations are material and important, and will be relied on by the City of Detroit in awarding the contract(s)/ purchase order(s) for which this proposal is submitted. I understand and my firm understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from the City of Detroit’s Office of Contracting and Procurement of the true facts relating to the submission of this RFP.

Printed Name & Title of Authorized Representative:

Signature of Authorized Representative:

Date:

**This Document MUST be Notarized**

Signature of Notary:

Printed Name of Seal of Notary:

My Commission Expires: / /

CERTIFICATION OF PRIMARY PARTICIPANT REGARDING DEBARMENT,

SUSPENSION, AND OTHER RESPONSIBILITY MATTERS

Bidders/Proposer’s Name certifies to the best of its knowledge and belief, that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible voluntarily excluded from covered transactions by any Federal Department or Agency;

2. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal or State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (2) of this certification; and

4. Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State, or local) terminated for cause or default. If you are unable to certify to any of the statements in this certification, attach an explanation to this certification.

THE BIDDER/PROPOSER , CERTIFIES

OR AFFIRMS THE TRUTHFULNESS AND ACCURACY OF THE CONTENTS OF THE

STATEMENTS SUBMITTED ON OR WITH THIS CERTIFICATION AND UNDERSTANDS

THAT THE PROVISIONS OF 31 U.S.C. SECTIONS 3801 ET SEQ. ARE APPLICABLE

THERETO.

Signature and Title of Authorized Official

The undersigned chief legal counsel for hereby certifies that the has authority under State and Local law to comply with the subject assurances and that the certification above has been legally made.

Signature of Applicant’s Attorney

CERTIFICATION OF LOWER-TIER PARTICIPANTS REGARDING

DEBARMENT, SUSPENSION, AND OTHER INELIGIBILITY AND

VOLUNTARY EXCLUSION

The Lower Tier Participant (potential subcontractor under a major third-party contract), , certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(If the Lower-Tier Participant (potential subcontractor under a major third-party contract) is unable to certify to any of the statements in this certification, such participant shall attach an explanation to this proposal).

THE LOWER-TIER PARTICIPANT (POTENTIAL SUBCONTRACTOR UNDER

A THIRD PARTY CONTRACT

, CERTIFIES OR

AFFIRMS THE TRUGHFULNESS AND ACCURACY OF THE CONTENTS OF

THE STATEMENTS SUBMITTED OR WITH THIS CERTIFICATION AND

UNDERSTANDS THAT THE PROVISIONS OF 31 U.S.C SECTION 3801 ET SEQ.

ARE APPLICABLE THERETO.

Signature and Title of Authorized Official

The undersigned chief legal counsel for the hereby certifies that the has authority under Stats and Local law to comply with the subject assurances and that the certification above has been legally made.

Signature of Applicant’s Attorney

Date

BYRD ANTI-LOBBYING AMENDMENT

Contractors who apply or bid for an award of $100,000 or more shall file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, officer or employee of Congress, or an employee of a Member of Congress in connection with obtaining any Federal contract, grant, or any other award covered by 31 U.S.C. § 1352.

Each tier shall also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the recipient who in turn will forward the certification(s) to the awarding agency.

APPENDIX A, 44 C.F.R. PART 18 – CERTIFICATION

REGARDING LOBBYING – REQUIRED FOR CONTRACTS

OVER $100,000

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

The Contractor, , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. Chap. 38, Administrative Remedies for False Claims and Statements, apply to this certification and disclosure, if any.

Signature of Contractor’s Authorized Official

Name and Title of Contractor’s Authorized Official

Date

Rev. 11/30/2022 1

CITY OF DETROIT

OFFICE OF CONTRACTING AND PROCUREMENT

CONSOLIDATED AFFIDAVITS

The following attestations must be provided to the City of Detroit as part of the contract approval process. Please fill out required information, attach required supplemental documents, and have this document notarized before uploading.

I, being a duly authorized representative of , (hereinafter “Contractor”), am authorized to enter into each of the following affidavits and disclosures on behalf of Contractor and bind Contractor to the obligations stated herein.

I. HIRING POLICY COMPLIANCE

I have reviewed the hiring policies of Contractor and I affirm that these policies are in compliance with the requirements of Chapter 17, Article V, Division 6 of the 2019 Detroit City Code, being Sections 17-5-261 through 17-5-266 thereof. I further affirm that Contractor will not inquire or consider the criminal convictions of applicants for employment needed to fulfill the terms of any City contract that may result from the competitive procedure in connection with which this affidavit is submitted, until such times as the Contractor interviews the applicant or determines that the applicant is qualified.

In support of this affidavit, I HAVE ATTACHED A COPY OF THE APPLICATION that Contractor will use to hire employees needed to fulfill the terms of any City contract that may result from the competitive procedure in connection with which this affidavit is submitted.

II. SLAVERY ERA RECORDS AND INSURANCE, AND PRISON INDUSTRY AND

IMMIGRATION DETENTION SYSTEM RECORDS AND INTERESTS DISCLOSURE

1. Name of Contractor:

2. Address of Contractor:

3. Name of Predecessor Entities (if any):

4. Prior Affidavit Submission? No Yes, on:

(Date of prior submission)

For each of questions 5, 6, and 7, please check the appropriate statement.

5. ______ Contractor was established in _ _ _ (year) and did not exist during the slavery era in the

United States, is not a successor in interest to any entity that existed during such time, and therefore has no relevant records to search, or any pertinent information to disclose.

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OR

______ Contractor has searched its records and those of any predecessor entity, and has found no record that Contractor or any predecessor(s) made any investments in, or derived profits from, the slave industry or slave holder insurance policies.

OR

Contractor has found records that Contractor or its predecessor(s) made investments in, or derived profits from, the slave industry or slave holder insurance policies. The nature of the investment, profits, or insurance policies, including the names of any slaves or slave holders, is disclosed in the attached document(s).

6. Contractor has searched its records and those of any and all predecessor entities, and has found no record that indicate Contractor or its predecessor(s) have used inmate labor, or have derived income directly from, or have had any investments in, the construction, operations, services or activities of prisons.

OR

Contractor has found records that indicate Contractor or its predecessor(s) have used inmate labor, or have derived income directly from, or have had any investments in, the construction, operations, services or activities of prisons. The nature of the use of inmate labor, profits, or investments is disclosed in the attached document(s).

7. Contractor has searched its records and those of any and all predecessor entities, and has found no record that indicates Contractor or its predecessor(s) have derived any income directly from, or have had any investments in, the construction, operations, services, or activities of facilities in the United States that are used for the detention of persons who are not citizens or nationals of the United States.

OR

Contractor has found records that indicate Contractor or its predecessor(s) have derived any income directly from, or have had any investments in, the construction, operations, services, or activities of facilities in the United States that are used for the detention of persons who are not citizens or nationals of the United States. The nature of the profits or investments is disclosed in the attached document(s).

I declare that the representations made in this Affidavit are accurate to the best of my knowledge and are based upon a diligent search of records in the Contractor’s possession or knowledge, and that all documentation attached to this Affidavit reflects full disclosure of all records that are required to be disclosed to the City of Detroit. I also acknowledge that any failure to conduct a diligent search, or to make a full and complete disclosure, shall render any contract between Contractor and City of Detroit voidable by the City of Detroit.

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III. COVENANT OF EQUAL OPPORTUNITY

Contractor and all sub-contractors will not discriminate against any employee or application for employment, training, education, or apprenticeship connected directly or indirectly with the performance of the contract, with respect to his/her hire, promotion, job, assignment, tenure, terms, conditions, or privileges of employment because of race, color, religious beliefs, public benefit status, national origin, age, marital status, disability, sex, sexual orientation, or gender identity or expression; except as otherwise exempted under Section 23-2-6 of the 2019 Detroit City Code.

Contractor will ensure that the City of Detroit Civil Rights, Inclusion and Opportunity Department shall receive notification of all potential sub-contractors and a copy of their Covenant prior to the commencement of work on any City of Detroit contract. Contractor further agrees that the City of Detroit reserves the right to require additional information prior to, during, and at any time until after this covenant is fully executed.

Contractor agrees that this covenant is valid for the life of the contract and that a breach of this covenant shall be deemed a material breach of contract and be subject to damages pursuant to Section 23- 4-11(e) of the 2019 Detroit City Code.

IV. STATEMENT OF POLITICAL CONTRIBUTIONS AND EXPENDITURES

City Charter Sec. 4-122: “For purposes of conflicts of interest, the City shall require in all of its contractual agreements, including, but not limited to, leases, service and equipment agreements and including contract renewals, that the contractor provide a statement listing all political contributions and expenditures (“Statement of Political Contributions and Expenditures”), as defined by the Michigan Campaign Finance Act, MCL 169.201, et seq., made by the contractor, its affiliates, subsidiaries, principals, officers, owners, directors, agents or assigns to elective city officials within the previous four

(4) years. Individuals shall also list any contributions or expenditures from their spouses.”

In accordance with Sec. 4-122 of the 2012 Detroit City Charter, please provide the following information. If additional space is needed, please enter “see additional sheet(s)” on the last row and attach additional sheets.

In Column A, enter the name of the person or company that made the contribution or expenditure.

If there were no political contributions or expenditures made, enter NONE or leave Column A blank. If Column A is left blank, this will be construed as an affirmative statement by Contractor that no political contributions or expenditures were made.

In Column B, enter the relationship of the donor to the Contractor. For example: Contractor, affiliate, subsidiary, principal, officer, owner, director, agent, assignee, or spouse of any of the foregoing who are individuals.

In Column C, enter the name of the recipient of the contribution or expenditure. Pursuant to Charter § 3-107, the only relevant recipients are elective city officials, which includes only the Mayor, the City

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Clerk, and members of the City Council and the Board of Police Commissioners.

In Column D, enter the amount of the contribution or expenditure, as defined in the Michigan Campaign Finance Act, 1976 PA 388, MCL 169.204 and MCL 169.206.

In Column E, enter the date of the contribution or expenditure.

A B C D E

Donor Relationship to

Contractor/Vendor Recipient

Amount of

Contribution or

Expenditure Date

I certify that except as set forth above, no contributions or expenditures were made to elective city officials of Detroit within the previous four (4) years by the Contractor, its affiliates, subsidiaries, principals, officers, owners, directors, agents, assigns, and, if any of the foregoing are individuals, their spouses.

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SIGNATURES AND ACKNOWLEDGEMENT:

I understand that the information provided in this consolidated affidavit will be relied upon by the City of

Detroit in awarding the proposed bid, solicitation, contract, or lease. I swear and affirm that I have read this document, that I have the authority to provide these disclosures and to bind the Contractor, and that the information provided herein is accurate. I have attached all required supplemental documents.

Sign name:

Print name:

Title:

Title as Listed on Certificate of Authority

STATE OF MICHIGAN)

) ss.

COUNTY OF )

Sworn and subscribed to before me on ,20 , by , Date Name of Signatory the of .

Title as Listed on Certificate of Authority

Legal Name of Contractor

Notary Public County, Michigan

My Commission Expires:

Acting in County, Michigan

COVID & ARPA FEDERAL REQUIREMENTS

The City of Detroit has sought to obtain federal funding to augment its response to the COVID- 19 pandemic. This Exhibit includes regulatory provisions and clauses as required under 2 C.F.R. 200 and other federal regulations associated with the federal funding being provided under this Contract and is attached and incorporated by reference herein to the request for proposal (RFP) (the “Contract”) with [Enter Contractor's Legal Entity Name Here] [Buyer Enter RFP #]).

I. Procurement Policy

Procurement for the City of Detroit has provided a transparent, open, and fair opportunity for all eligible Contractors to participate. This bid has been made without collusion with any other person, firm or corporation making any bid or proposal, or who otherwise makes a bid or proposal. The Contractor must have available Contract or purchase order with the required approvals to receive payment for goods or services rendered. If the Contractor performs any work without a valid Contract or purchase order, the Contractor will not be paid.

In addition to other provisions required by the Federal agency or non-Federal entity, all contracts made by the non-Federal entity under the Federal award must contain provisions covering the following, as applicable.

(A) Contracts for more than the simplified acquisition threshold, which is the inflation adjusted amount determined by the Civilian Agency Acquisition Council and the Defense Acquisition Regulations Council as authorized by 41 U.S.C. § 1908, must address administrative, contractual, or legal remedies in instances where contractors violate or breach contract terms, and provide for such sanctions and penalties as appropriate.

(B) All contracts in excess of $10,000 must address termination for cause and for convenience by the non-Federal entity including the manner by which it will be effected and the basis for settlement.

II. Bonds and Insurance Requirements

Receipt of bonds and/or insurance is part of the process of determining which Contractor may be recommended for award to the City Council. If cause is found to change the recommendation that a Contractor be awarded the contract, or if the City Council does not approve the recommendation, the City shall not be liable for any costs incurred by the Contractor in the bid process, including the cost of acquiring bonds and/or insurance. This subsection III is applicable only to Contracts pertaining to construction or facility improvement.

III. Equal Employment Opportunity

In addition to the fair employment practices agreed to by the Contractor in Article 19 of the

Contract, the Contractor hereby agrees as follows:

Except as otherwise provided under 41 C.F.R. Part 60, all contracts that meet the definition of “federally assisted construction contract” in 41 C.F.R. Part 60-1.3 must include the equal opportunity clause provided under 41 C.F.R. 60-1.4(b), in accordance with Executive Order 11246, “Equal

Employment Opportunity” (30 FR 12319, 12935, 3 C.F.R. Part, 1964-1965 Comp., p. 339), as amended by Executive Order 11375, “Amending Executive Order 11246 Relating to Equal Employment Opportunity,” and implementing regulations at 41 C.F.R. part 60, “Office of Federal Contract Compliance Programs, Equal Employment Opportunity, Department of Labor”.

(a) The Contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, or national origin. The Contractor will take affirmative action to ensure that applicants are employed, and that employees are treated during employment without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. Such action shall include, but not be limited to the following: Employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The Contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided setting forth the provisions of this nondiscrimination clause.

(b) The Contractor will, in all solicitations or advertisements for employees placed by or on behalf of the Contractor, state that all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

(c) The Contractor will not discharge or in any other manner discriminate against any employee or applicant for employment because such employee or applicant has inquired about, discussed, or disclosed the compensation of the employee or applicant or another employee or applicant. This provision shall not apply to instances in which an employee who has access to the compensation information of other employees or applicants as a part of such employee's essential job functions discloses the compensation of such other employees or applicants to individuals who do not otherwise have access to such information, unless such disclosure is in response to a formal complaint or charge, in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or is consistent with the Contractor's legal duty to furnish information.

(d) The Contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other Contract or understanding, a notice to be provided advising the said labor union or workers' representatives of the Contractor's commitments under this section and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

(e) The Contractor will comply with all provisions of Executive Order 11246 of September

24, 1965, and of the rules, regulations, and relevant orders of the Secretary of Labor.

(f) The Contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, and by rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by the administering agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations, and orders.

(g) In the event of the Contractor's noncompliance with the nondiscrimination clauses of this Contract or with any of the said rules, regulations, or orders, this Contract may be canceled, terminated, or suspended in whole or in part and the Contractor may be declared ineligible for further

Government Contracts or federally assisted construction Contracts in accordance with procedures authorized in Executive Order 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as provided in Executive Order 11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law.

The Contractor will include the portion of the sentence immediately preceding paragraph (1) and the…