1606...Phase I Template~2.doc

[Insert Company Name]

[Company name]

Response to

Massachusetts State Lottery Commission Request for Response for

Corrugated Boxes

(RFR LOT# 1606)

Submitted on [date of submittal]

Response Due Date: June 17, 2016 at 3:00 PM EST

Response Checklist

Template

Page Number

Disclosure Statement

10-12

Prompt Payment Discount Form

Certificate of Compliance Concerning Personal Data and Personal Information

General Instructions – MUST BE FOLLOWED

Instructions: The following pages are the exact form and format that all responses are to follow and use. For each form or document there is a brief “Instructions” section that precedes the form or document giving bidders as much information as possible explaining how to fill in the form. Please follow these instructions exactly.

Do not change the order of the forms or documents when providing a response. If you must separate your response into different files due to size or logistical constraints, please provide the files in a manner that retains the sequence defined herein and name the files [Bidder Name] - File x of y, where “x” is the sequence of the files and “y” is the total number of separate files.

Please make sure that all signatures on all forms are listed in the table at the top of the form called “Contractor Authorized Signatory Listing.” There should be no signature on any form that is not listed in that table. Also, please make sure you fill in all required lines, boxes, etc. on each form as the instructions dictate.

Do not put any cost related information in the main portion of the response. All cost related information, either direct, or that can be derived, must only be in the cost proposal portion of the response.

Do not delete or remove any forms. All forms are REQUIRED even if in some cases you are simply signing the form or you feel the form does not apply to your company. There is no form or submission that is considered optional. If you need to separate the forms in order to get them signed and scanned either put them in the file (PDF) in the same order or add them as a separate file as indicated above.

Cover Letter Instructions

Instructions: Fill in the cover letter as detailed below making sure that the appropriate blanks are filled in, and that the signature block is fully filled in and signed by an individual with the authority to bind the company contractually. Such person should be listed in the table on the upper half of the Contractor Authorized Signatory Listing form.

Do not list multiple names for the “Primary Point of Contact.”

Cover Letter

[Insert Company Logo if desired]

Company Name:

Company Address:

Name of Primary Contact:

Title of Primary Contact:

Address of Primary Contact:

Phone Number of Primary Contact:

Email Address of Primary Contact:

Confirmation of Key RFR Requirements

Instructions: Checking the boxes below confirms acceptance of these proposal commitments. Any unchecked items can be considered grounds for elimination from this procurement. This form must to be signed by a person who has authority to legally bind the company and is listed on the Contractor Authorized Signature Verification form.

· This proposal is a company and irrevocable offer that will be valid for 120 days from the date of submission.

· Bidder confirms that it agrees with and its proposal is in conformance with all requirements and terms in this RFR.

· Bidder confirms that the signature below binds the Company to all statements, enclosures and attachments contained within this proposal response document.

Signature:

Print Name:

Title:

Date:

Statement of Minimum Qualifications

Instructions: Check each minimum qualification that your company meets. If your company meets the qualification (by checking the box), state the basis for your company’s affirmative assertion. If your company does not meet the qualification as stated, provide information explaining why this minimum qualification does not apply to your company. It is in the PMT’s sole discretion to determine if a minimum qualification will result in disqualification.

· Bidder must have been in a business similar to that described in this Request for Response for a minimum of three (3) years and have demonstrated experience and capacity to handle the requirements herein.

[Replace this text with either your basis for your positive assertion (e.g. what is the basis for checking the box above, or the reason why this minimum qualification does not apply to your company for this procurement].

Signature:

Printed Name:

Title:

Date:

Representations and Warranties Compliance with all criteria listed below is mandatory in order for a bid to be accepted for further review. Lack of compliance may result in disqualification of the Bidder.

Note: By checking each box your company confirms that the submitted bid meets these requirements. This form should be signed by an authorized signatory of your company.

· Our company warrants that all of the information it provides in its response to the RFR is true and correct and does not omit any material facts or information that is responsive.

· Our company warrants that it carries a fidelity bond that will be applicable to respondent's actions under the Contract. (Provide a copy of a Certificate of Liability Insurance indicating that all employees who perform work under the contract are covered, unless exempt and an explanation of the exemption is attached).

· Our company warrants that it will not delegate its responsibilities assumed under the Contract without prior written approval from the MSLC.

· Our company warrants that it has not been in bankruptcy and/or receivership within the last three (3) calendar years.

· Our company warrants that it has completed, obtained and performed all registrations, filings, approvals, authorizations, consents or examinations required by a government or governmental authority for acts contemplated by the Contract.

· Our company warrants that it will adhere to the fee prices and/or discounts outlined in the Cost Proposal, any subsequently requested Best and Final Offer and any Contract.

· Our company warrants that it agrees to meet every specification, requirement or condition set forth in the RFR and any additional contract document executed by the parties.

· Our company warrants that it shall maintain workers compensation insurance, vehicle insurance if providing actual delivery, and general liability insurance.

Signature:

Print Name:

Title:

Date:

Legal and Other Requirements

Instructions: Confirm by checking each legal and other requirement. Where an item cannot be checked as 100% compliant, provide an explanation or clarification of why the item could not be checked or where there are stipulations on the verification of the requirement as stated.

· Solvency: Our company has not been in bankruptcy and/or receivership within the last three calendar years.

· Company’s State of Incorporation/Organization: [Insert state name or if not incorporated identify the company’s legal structure.]

· Corporate Good Standing: Our company is in good standing in our state of incorporation / organization and has complied with all filing requirements of the state of incorporation / organization. If the state of incorporation / organization is not Massachusetts, our company agrees to comply with all filing requirements of the Secretary of the Commonwealth within thirty days of contract award if selected.

· Licenses and Registrations: Our company meets all applicable state and federal requirements, and has all the licenses and registrations necessary to perform the contract.

· Pending Litigation (None): There are no material judgments, criminal convictions, investigations or litigations pending against our company or any of its officers, partners, or employees of which our company is aware. The Massachusetts State Lottery Commission (“MSLC”) reserves the right to reject a response based on this information. If separate responses are required for different divisions or subsidiaries of the Bidder, the Bidder must submit a separate response for each division or subsidiary.

· Pending Litigation (Yes): Our company is aware of the following material judgments, criminal convictions, investigations and/or litigations pending against our company and/or any of our officers, partners, or employees.

[List and detail any pending litigation here.]

The MSLC reserves the right to reject a response based on this information. If separate responses are required for different divisions or subsidiaries of the company, the company must submit a separate response for each division or subsidiary.

· Compliance with RFR Requirements: Our company agrees to meet every specification, requirement or condition set forth in the RFR.

· Cease and Desist: If selected for any services solicited through this RFR, the company agrees to immediately notify the MSLC of any cease and desist order issued.

· Confidentiality: Our company acknowledges that all materials and information provided to the Contractor by the MSLC or acquired by the Contractor on behalf of the MSLC shall be regarded as confidential information in accordance with federal and state law, and ethical standards. The Contractor must take all necessary steps to safeguard the confidentiality of such materials or information.

· Limitation of Liability and Indemnification: MSLC shall not be liable to our company under any theory of liability for any direct or indirect damages that may be incurred from shipping and delivery of our company’s productions. To maximum extent permitted by law, our company agrees to defend, indemnify and hold harmless the MSLC, its directors, officers and employees from and against any and all third party claims, actions, suits, or proceedings arising out of or accruing from any violation of this agreement and our product infringing upon any patent or any other intellectual property right of any person or entity which arises out of any breach of warranty or representation.

COMMONWEALTH OF MASSACHUSETTS

MASSACHUSETTS STATE LOTTERY COMMSSION

Disclosure Statement Instructions: Companies seeking to provide professional services (the “engagement”) to the Massachusetts State Lottery Commission (“MSLC”) must complete a disclosure statement providing complete and accurate responses to the questions below. Companies selected to provide such services have a continuing obligation to update responses to these questions, in writing, immediately upon any change to such responses. The questions in this Disclosure Statement should be read broadly, and any perceived ambiguity should be resolved in favor of disclosure. Any questions concerning the disclosures required should be directed to the MSLC.

Note: The total response to this disclosure should not exceed four single-sided pages.

1.

Provide a general description of your company’s organizational structure, identify any members of the management committee, officers and/or directors, and, for any affiliate entities, the managing partners, officers, and directors (all such individuals or entities hereinafter collectively referred to as the “Company”).

[Insert response here.]

2.

Identify any relationship of the company, its joint ventures, consultants, lobbyists, subcontractors or third-party contractors that relate in any way to the engagement.

[Insert response here.]

3.

Aside from the engagement, describe any services provided by the Company to the Commonwealth.

[Insert response here.]

4.

Aside from the services described in response to Question 3, above, describe any services and/or donations provided by the company to the Office of the State Treasurer and Receiver General or any trust, board, commission or authority of which the State Treasurer and Receiver General is a member or trustee by virtue of her office. (A list of such entities is attached as Appendix A to the Disclosure Statement.)

[Insert response here.]

5.

Aside from the services and/or donations described in responses to Questions 3 and 4, above, describe any services provided by the company to any of the political subdivisions of the Commonwealth.

[Insert response here.]

6.

Did or will the company provide or share, agree to provide or share, or arrange to provide or share any compensation or benefit, direct or indirect, to any individual or entity for assisting the company in:

a) Obtaining the engagement; or

b) Performing the services required by the engagement?

If the answer to Question 6 is “yes,” provide for each the individual or entity:

a) The name and address of such individual or entity;

b) A description of the assistance provided; and

c) The compensation or benefit.

[Insert response here.]

7.

Does the company have any ongoing relationship, arrangement or agreement with any individual or entity with respect to sharing compensation for services to:

a) Any trust, board, commission or authority of which the Treasurer is a member or trustee by virtue of her office; or

b) The Commonwealth of Massachusetts or its political subdivisions?

If the answer to Question 7 is “yes,” provide for each such individual or entity:

a) The name and address of such individual or entity;

b) A description of the relationship, arrangement or agreement; and

c) The compensation shared.

[Insert response here.]

Signed under the penalties of perjury this _______day of ________________, 2016.

Name:

(Print)

Signature:

Title:

Appendix A to the Disclosure Statement

TREASURER’S PRINCIPAL BOARDS, COMMISSIONS AND AUTHORITIES*

1. Advisory Board to the Comptroller – M.G.L. c. 7A, § 2

2. State Retirement Board – M.G.L. c. 10, § 18

3. State Lottery Commission – M.G.L. c. 10, § 23

4. Board of Bank Incorporation – M.G.L. c. 26, § 5

(Division of Banks and Loan Agencies)

5. Water Pollution Abatement Trust (now known as the Clean Water Trust) – M.G.L. c. 29C, § 2

6. Pension Reserves Investment Management Board – M.G.L. c. 32, § 23(2A)

7. Massachusetts Convention Center Authority – Chapter 190 of the Acts of 1982 § 31-48

8. Massachusetts School Building Authority – M.G.L. c. 70B, §§ 1A & 3A; see also M.G.L. c. 10, § 35BB

9. Teachers’ Retirement Board – M.G.L. c. 15, § 16

10. Alcoholic Beverages Control Commission – M.G.L. c. 10, § 70

11. Health Care Security Trust – M.G.L. c. 29D, § 4

12. Commissioners on Fireman’s Relief – M.G.L. c. 10, § 21

13. Economic Empowerment Trust Fund – M.G.L. c. 10, § 35QQ

* The above-listed Boards, Commissions or Authorities are any which are a Treasury Department, Division or Affiliated Entity or by statute have a position which may be held by the State Treasurer and Receiver General or her designee.

Mandatory Forms and Enclosures Note: Each and every form in this section must be filled in. Where the form provides a signature line, the form must be signed. All signatures must be legible, please also print the person’s name next to the signature. All signatories must be listed as a valid authority of the organization as indicated on the Contractor Authorized Signatory Listing contained within this section.

Commonwealth Terms and Conditions

Instructions: The Commonwealth Terms and Conditions shall be incorporated by reference into any contract for services executed pursuant to this RFR. Click on the link below to open a copy of the Commonwealth Terms and Conditions Form. Fill in 2nd page blanks. Please ensure you sign the form. This form cannot be changed or modified. This form must be signed as is.

Standard Contract Form

Instructions: This form must be executed in order to be awarded a contract. This document shall not become a final contract unless and until the MSLC accepts the Bidder's response and the Standard Contract Form is executed by an authorized signatory of the MSLC. Click on the link below to open a copy of the Standard Contract Form. Fill in boxes highlighted in yellow. Please ensure you sign the form.

Massachusetts Substitute W-9 Form Instructions: Click on the link below to open a copy of the W-9 form. Follow the instructions and paste the filled in form on this page or provide as an attachment. Filling in the form and signing is required. You do not need to provide a copy of the 2nd page instructions.

Contractor Authorized Signatory Listing Instructions: Please note this form typically accounts for 80% of the cures necessary during procurements due to bidders not following the instructions. Please read all instructions carefully at the bottom of this page is a link to the proper Contractor Authorized Signatory Form. Follow the instructions below and paste the filled in form on this page or provide as an attachment. Filling in the form and signing is required. It is essential that the person signing the cover letter and all forms is listed on this form as a signature legally authorized to bind the company. Please enter your company’s name at the top of the form where it says “Contractor Legal Name”.

Tax Compliance Certification Instructions: The Bidder must demonstrate that it is in compliance with all Federal and Commonwealth tax laws (regardless of corporate locations) including M.G.L. Chapter 62C, Section 49A. The Bidder must submit an original or photocopy of a Certificate of Tax Compliance in Good Standing, which has been issued by the Commonwealth of Massachusetts Department of Revenue (“DOR”) within the past year. This Certificate may be obtained by submitting a request to:

Taxpayer Services Division, Certificate Unit

Department of Revenue

PO Box 7066

Boston, Massachusetts 02204

(617) 887-6550

Even if the company has never had any business or tax registration in Massachusetts they still must submit to the Massachusetts DOR a request for a tax compliance certificate. If the Massachusetts DOR has no record of the bidder and is unable to provide a certificate of compliance they will provide such information to the bidder. However proof of requesting the certificate from the Massachusetts DOR is required.

The application must list the tax types for which the business is liable, including such items as meals, room occupancy, sales, use, withholding, corporate income and others as applicable. The issuance of the certificate normally takes several weeks and, as such, Bidders should indicate that their request for a certificate is sought in connection with a Commonwealth solicitation (with a deadline). If the Bidder does not submit the requested tax certificate with the proposal, the Bidder must submit documentation evidencing that the appropriate application has been filed. Evidence includes: facsimile transmittal, mailing receipt, receipt-stamped application, etc. The Certificate must be issued and provided to the Treasury prior to the final execution of the Standard Contract Form.

Simplified Instructions/Clarifications:

· A proper response to this requirement entails one of the following two submission requirements:

· If your company DOES NOT HAVE A CURRENT (within the past year) Massachusetts Compliance Certificate:

· If requested via FAX You must provide 2 things:

· A copy of the filled in request form that was sent to MA DOR. If this method is used, you simply need to print a copy of the request confirmation and insert an image or hardcopy in this response template.

· A copy of the transmission request. Make sure you retain a copy of the fax transmittal confirmation receipt and provide an image or Photocopy of the proof of transmittal along with a copy of the original form faxed.

· If you requested via the MA DOR Website at https://wfb.dor.state.ma.us/webfile/certificate/Public/Webforms/Welcome.aspx you only need to provide a screenshot or copy of the request confirmation showing the request number

· If your company DOES HAVE A CURRENT (within the past year) Massachusetts Compliance Certificate which is has a date of certificate no more than one year from your submission date of this proposal, then provide a copy of the certificate.

Do not provide a copy of the Secretary of State form from Massachusetts or your state of incorporation certifying that you are a registered corporation in your state or in Massachusetts. The form required is a Tax Compliance form that can only come from the Commonwealth of Massachusetts’ DOR. If you are not a registered tax-paying corporation in Massachusetts, the Massachusetts DOR will inform the requestor that a Certificate of Compliance cannot be provided. MA DOR not being able to provide a Certificate of Compliance to an unregistered company not doing business in Massachusetts is not grounds for disqualification.

Clicking on the link below is the PDF form to be sent to the Massachusetts DOR:

Business Reference Form Instructions: Bidders must identify three (3) customer references for which the Bidder has performed similar services to those described in this RFR or customers that can confirm the quality of the Bidder’s performance on previous contract work. Fill in the form below with the information for three (3) business references for which you have provided similar or related services as defined in this RFR:

Supplier Diversity Program Instructions: Companies are required to fill in and submit these forms even if they choose not to participate in the program. If a company does not wish to participate they should only fill in the Bidder/Contractor Information of each and sign the form. Companies are welcome to cross out the other parts of the form to make it clear that they are not participating. Companies are not obligated to participate in this program. However, 5% of the scoring points are allocated to a high quality MSLC SDP.

Massachusetts Executive Order 524 established a policy to promote the award of state contracts in a manner that develops and strengthens Minority and Women Business Enterprises (M/WBEs) that resulted in the Supplier Diversity Program in Public Contracting. M/WBEs are strongly encouraged to submit Responses to this RFR, either as prime vendors, joint venture partners or other type of business partnerships. Similarly, Executive Order 546 established the Service-Disabled Veteran-Owned Business Enterprise (SDVOBE) Program to encourage the participation of businesses owned and controlled by service-disabled veterans in all areas of state procurement and contracting, thereby including them in the SDP. All Bidders must follow the requirements set forth in the SDP section of this RFR, which will detail the specific requirements relating to the prime vendor’s inclusion of M/WBEs and/or SDVOBEs. Bidders are required to develop creative initiatives to help foster new business relationships with M/WBEs and/or SDVOBEs within the primary industries affected by this RFR. In order to satisfy the compliance of this section and encourage Bidder’s participation of SDP objectives, the Supplier Diversity Program (SDP) Plan for large procurements greater than one hundred fifty thousand dollars ($150,000.) will be evaluated at 10% or more of the total evaluation. Once an SDP commitment, expressed as a percentage of contract revenues, is approved, the agency will then monitor the contractor’s performance, and use actual expenditures with Supplier Diversity Office (SDO) certified M/WBE contractors and the Center for Veterans Enterprise certified SDVOBEs to fulfill their own SDP expenditure benchmarks. M/WBE and SDVOBE participation must be incorporated into and monitored for all types of procurements regardless of size; however, submission of an SDP Plan is mandated only for large procurements over one hundred fifty thousand dollars ($150,000).

SDP Resources

Resources available to assist prime Bidders in finding potential M/WBE partners can be found at www.mass.gov/sdp.

Resources available to assist prime Bidders in finding potential SDVOBE partners can be found on the Operational Services Division’s SDO webpage at www.mass.gov/sdo.

The Operational Services Division’s Supplier Diversity Program offers training on the SDP Plan requirements. The dates of upcoming trainings can be found at:www.mass.gov/anf/budget-taxes-and-procurement/procurement-info-and-res/osd-events-and-training/osd-training-and-outreach.html. In addition, the SDP Webinar can be located on the SDP website at www.mass.gov/SDP.

Supplier Diversity Program Subcontracting Policies In addition to the Subcontracting Policies (see Subcontracting Policies section below and see Subcontracting By Contractor, in the Commonwealth Terms and Conditions) that apply to all subcontracted services, agencies may define specific required deliverables for a contractor’s SDP Plan, including, but not limited to, documentation necessary to verify subcontractor commitments and expenditures with Minority- or Women-Owned Business Enterprises (M/WBEs) and Service-Disabled Veteran-Owned Business Enterprises (SDVOBE) for the purpose of monitoring and enforcing commitments made in a contractor’s Supplier Diversity Program (SDP) Plan.

SDP Plan Commitment.docx SDP Plan. Declaration of SDP Partners.docx SDP.Spending Report.xlsx Invest in Massachusetts Plan

Instructions: The MSLC encourages investment in our local economy and is committed to advancing the creation and preservation of jobs in the Commonwealth. Companies are required to fill in and submit this form even if they choose not to participate in the program. If a company does not wish to participate they should fill in Part I completely and in Part II check the “no” box. Companies are welcome to cross out the other parts of the form to make it clear that they are not participating. Companies are not obligated to participate in this program. However, 5% of the scoring points are allocated to a high quality Invest in Massachusetts plan.

A link for the Invest in MA response form is located below. Provide the form (not the instructions also included in a link below) along with your response in this section.

EMBED Word.Document.8 \s Certificate of Non-Collusion Instructions: Bidders are advised that they are required to certify that the bid that they are submitting has not been arrived at because of any collusive activity. A link to the Certificate of Non-Collusion response form is located below. Insert a signed version of this form here (either as a pasted image or as a hardcopy).

Insurance Policy Instructions: Bidders are required to provide a copy or proof of any fidelity bond or liability insurance policy extending to any or all employees who perform work under the contract.

EFT Form

Prompt Payment Discount Form

Certificate of Compliance Concerning

Personal Data and Personal Information

The person signing the proposal documents must be listed here.

This signature must be one of these corporate officers and Bidder must supply notarized corporate documents showing that the signatory has the right to delegate binding corporate authority.

_1514273305/certgoodstandingform.pdf

Request for a Certificate of Good Standing and/or Tax Compliance or Waiver of Corporate Tax Lien

Massachusetts

Department of

Revenue

This application may be used to request a Certificate of Good Standing/Letter of Compliance, Waiver of Corporate Tax Lien, or Certificate of Good Standing for a Non-Profit Organization.

If this matter is to be discussed with any third parties, complete the Power of Attorney section below. Mail your request as soon as possible to Massachusetts Department of Revenue, PO Box 7066, Boston, MA 02204 or fax to (617) 887-6262. For further information, call (617) 887-6550.

Name of organization Trade name or DBA Federal ID or Social Security number (required)

Street address City/Town State Zip

Contact person Daytime telephone

Street address (if different from above) City/Town State Zip

Type of Application Type of organization (check one):

Corporation Partnership Sole proprietor Individual LLP LLC Other

Purpose of application (check one):

Certificate of Good Standing/Letter of Compliance Certificate of Good Standing for a Non-Profit Organization Waiver of Corporate Tax Lien

If requesting Waiver of Corporate Tax Lien, attach price and legal description of assets to be sold and complete the following:

Name of transferee Date of transfer or sale

Affidavit (required) Under the penalties of perjury, I declare that my company is not responsible for the following taxes (check all that apply):

Withholding Sales/Use Meals Room Occupancy

Signature of taxpayer or corporate officer (required)

Power of Attorney Complete this section if you wish to authorize another individual to sign documents on your behalf. In addition, that individual (“attorney-in-fact”) must complete the Declaration of Representative section on reverse.

Name of attorney-in-fact Daytime telephone

I, , hereby authorize the above-named individual to represent me as attorney-in-fact before the Certificate Unit of the Massachusetts Department of Revenue for the following type(s) of tax, and for the period(s) of time indicated.

Type of tax Period Type of tax Period

Power of Attorney (cont’d.)

The above-named attorney-in-fact is authorized, subject to any limitations set forth below or to revocation, to receive confidential information and to perform any and all acts that can be performed by the taxpayer with respect to the above-specified tax type(s), excluding the power to receive tax refund checks. The attorney-in-fact is not authorized to:

Restriction(s)

Signature of taxpayer Date

Declaration of Representative I declare that I am not currently under suspension or disbarment from practice within the Commonwealth or in any jurisdiction, that I am aware of regulations governing the practice of attorneys, certified public accountants, public accountants, enrolled agents and others, and that I am one of the following:

1. a member in good standing of the bar of the highest court of the jurisdiction shown below;

2. duly qualified to practice as a certified public accountant or public accountant in the jurisdiction shown below;

3. enrolled as an agent under the requirements of Treasury Department Circular No. 230;

4. a bona fide officer of the taxpayer organization;

5. a full-time employee of the taxpayer;

6. a member of the taxpayer’s immediate family (spouse, parent, child, brother or sister);

7. a fiduciary for the taxpayer;

8. other (attach statement) and that I am authorized to represent the above-named taxpayer for the above-specified tax type(s).

Designation (insert appropriate Jurisdiction (state, etc.)

number from above list) or enrollment card number Signature Date

General Information If the applicant is a trust, a copy of each of the last two years of Form 3F, Income Tax Return of Corporate Trust, must be submitted.

If the applicant is a partnership, a copy of each of the last two years of Form 3, Partnership Return of Income, must be submitted.

If the applicant is a non-profit organization, a copy of your IRS letter of exemption under Section 501(c)(3) of the Internal Revenue Code must be submitted.

Note: Any correspondence or certificate will be sent to the legal address of the taxpayer recorded at the Department of Revenue. The corporate name printed on the certificate will be the same as the name recorded at the Secretary of State’s office.

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_1514273563.doc Invest in Massachusetts – Instructions

Invest in Massachusetts. The Massachusetts State Lottery Commission (“MSLC”) encourages investment in our local economy and is committed to advancing the creation and preservation of jobs in the Commonwealth. Consequently, all responsive Bidders/Proposers must submit an Invest in Massachusetts Data Form (“IMD Form”).

Submission of an IMD Form is mandatory and required in order for the Bidder/Proposer to proceed on to Phase II of the Procurement Evaluation process. Although all Bidders/Proposers are required to complete and submit the form, Bidders/Proposers are not required to complete “Part III – Certification” of the IMD Form in order to be deemed responsive and eligible for consideration in Phase II.

The IMD Form will stand for 5% of the Bidder/Proposer’s technical (Phase II) score. A Bidder/Proposer that submits an IMD Form certifying that 50% or more of the work-hours performed in connection with any contract arising out of its RFR Response will be performed in Massachusetts will be deemed “Advantageous.” A rating of “Advantageous” will earn the Bidder/Proposer 5 points on this component of the Phase II score. Any Bidder/Proposer unable to make such a certification will be deemed “Not Advantageous” and will be given 0 points on this scoring component.

Please be advised, however, that while responding to this section by submitting an IMD Form is a mandatory requirement, a Bidder/Proposer’s responses in the IMD Form, even if “Not Advantageous,” shall not prevent that Bidder/Proposer being awarded a contract if the Bidder/Proposer receives the most overall points through the entire evaluation process.

_1514273979/newmass-w9.pdf

Form W-9 (Massachusetts Substitute W-9 Form) Rev. April 2009

Request for Taxpayer Identification Number and Certification

Completed form should be given to the requesting department or the department you are currently doing business with.

Name ( List legal name, if joint names, list first & circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2)

Business name, if different from above. (See Specific Instruction on page 2)

Check the appropriate box: □ Individual/Sole proprietor □ Corporation □ Partnership □ Other ►-----------------------------------------------

Legal Address: number, street, and apt. or suite no.

Remittance Address: if different from legal address number, street, and apt. or suite no.

City, state and ZIP code

City, state and ZIP code

Phone # ( ) Fax # ( ) Email address:

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 2.

Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter.

Vendors:

Dunn and Bradstreet Universal Numbering System (DUNS))

Social security number

OR

Employer identification number

DUNS

Part II Certification

Pl ea se p rin t o r t yp e

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been…