19-0105-P-RP_Speech_Language_Therapy_Services-Attachment_Package.docx

ATTACHMENT A

REQUEST FOR PROPOSAL (RFP)

ACKNOWLEDGEMENT FORM

RFP 19-0105-P-RP – Speech Language Therapy Services

Direct all inquiries in writing to: Procurement Representative—Regina Peeples, peeplesr@lake.k12.fl.us Submittal Statements must be received by Lake County Schools, Procurement Services Department, by the due date and time as indicated above. Electronic submittals shall be accepted only through www.myvendorlink.com by the due date and time. Late submissions are not acceptable.

In addition the representative below is duly authorized to sign this submittal on behalf of Respondent, company, or corporation and fully understands that by virtue of executing and returning this Submittal Acknowledgement Form represents complete and unconditional acceptance of the requirements, terms and conditions of this RFP and all appendices and any addendums released hereto.

I hereby certify that I have read and understand the requirements of this Submittal Statement and that I, as the respondent, will comply with all requirements of this offer and any contract(s) and/or other transactions required by this award.

Mailing Address

Receipts of the following web posted Addenda are hereby acknowledged: (List all attached Addenda) Addendum No. ______ Dated ____________ Addendum No. ______ Dated ____________ Addendum No. ______ Dated ____________ Addendum No. ______ Dated ____________ Addendum No. ______ Dated ____________ Addendum No. ______ Dated ____________

Thank you for your interest in doing business with Lake County Schools.

ATTACHMENT B

REFERENCE FORM

Name of Reference: _____________ Address:

City: State: Zip:

Contact Person: Phone:

Private Sector: Yes No Public Sector: Yes No School/University: Yes No Annual Dollar Volume: $ If school/university, please identify:

Please state if services rendered by vendor were obtained by RFP, bid, contract, agreement, or other (specify):

Length of Account: Months Years

State if bid, contract, agreement has been renewed: Yes No

If bid, contract, agreement has been renewed, state length of time: Months Years

If bid, contract, agreement has not been renewed, state the reason for non-renewal:

THIS SPACE FOR LAKE COUNTY SCHOOL BOARD USE ONLY

Additional information provided by reference:

(Duplicate as needed)

ATTACHMENT C

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -- Lower Tier Covered Transactions

This certification is required by the Department of Education regulations implementing Executive Order 12549, Debarment and Suspension, 34 CFR Part 85, for all lower tier transactions meeting the threshold and tier requirements stated at Section 85.110.

Instructions for Certification

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.

2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," " person," "primary covered transaction," " principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations.

5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.

6. The prospective lower tier participant further agrees by submitti Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tier Covered Transactions, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may but is not required to, check the Nonprocurement List.

8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Certification

(1) The prospective lower tier participant 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.

(2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

NAME OF APPLICANT PR/AWARD NUMBER AND/OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE DATE

ED 80-0014, 9/90 (Replaces GCS-009 (REV.12/88), which is obsolete

ATTACHMENT D

SWORN STATEMENT UNDER SECTION 287.133(3) (a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES This form must be signed and sworn to in the presence of a notary public or other officer authorized to administer oaths.

1. This sworn statement is submitted to Insert name of public entity by Insert individual's name and title for Insert name of entity submitting sworn statement

Whose business address is:

(If applicable) its Federal Employer Identification Number (FEIN) is:

(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement on the attached sheet.) Required as per IRS Form W-9.

2. I understand that a “public entity crime” as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including but not limited to, and bid or contract for goods or services to be provided to any public entity or agency or political subdivision or any other state or of the Unites States, and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

3. I understate that “convicted” or “conviction” as defined in Paragraph 287.133(1) (b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.

4. I understand that “affiliate” as defined in Paragraph 287.133(1)(a), Florida Statutes means:

A. A predecessor or successor of a person convicted of a public entity crime or;

B. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term “affiliate” includes those offices, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of the affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not fair market value under an arm’s length agreement, shall be a facie case that one person controls another person. A person who knowingly enters into a join venture with a person who has been convicted of a public entity crime in Florida during the proceeding 36 months shall be considered an affiliate.

5. I understand that a “person” as defined in Paragraph 287.133(1) (c), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term “person” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of the entity.

6. Based on information and belief, the statement, which I have marked below, is true in relation to the entity submitting those sworn statements. (Please indicate which statement applies.)

Procurement Services 29529 CR 561 Tavares FL 32778 (352) 253-6760 Fax: (352) 253-6761 http://lake.k12.fl.us

RFP 19-0105-P-RP

Neither the entity submitted this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity nor affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989.

The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, member, or agents who are active in management of the entity, or an affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989.

The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, member, or agents who are active in management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearing and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OR ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.

(Signature)

(Date)

STATE OF

COUNTY OF

PERSONALLY APPEARED BEFORE ME, the undersigned authority, (Name of individual signing) who, after first being sworn by me, affixed his/her signature in the space provided above on this day of , 2020 .

(NOTARY PUBLIC)

My Commission Expires:

PROJECT IDENTIFICATION: Bid # Bid Name:

SOCIAL SECURITY NUMBER:

(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement on the attached sheet.) Required as per IRS Form W-9.

ATTACHMENT E

NON-COLLUSION AFFIDAVIT

State of

County of being first duly sworn, deposes and says that:

(1) He/she is the Owner, Partner, Officer, Representative, or Agent of the Proposer that has submitted the attached Proposal;

(2) He/she is fully informed respecting the preparation and contents of the attached Proposal and of all pertinent circumstances respecting such Proposal;

(3) Such Proposal is genuine and is not a collusive or sham Proposal;

(4) Neither the said Proposer nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, have in any way colluded, conspired, connived or agreed, directly or indirectly, with any other Proposer, firm, or person to submit a collusive or sham Proposal in connection with the Work for which the attached Proposal has been submitted; or to refrain from proposing in connection with such Work; or have in any manner, directly or indirectly, sought by agreement or collusion, or communication, or conference with any Proposer, firm or person to fix any overhead, profit, or cost elements of the Proposal price or the Proposal price of any other Proposer, or to secure through any collusion, conspiracy, connivance, or unlawful agreement any advantage against (Recipient), or any person interested in the proposed Work;

(5) The price or prices quoted in the attached Proposal are fair and proper and are not tainted by any collusion, conspiracy, connivance, or unlawful agreement on the part of the Proposer or any other of its agents representatives, owners, employees or parties in interest, including this affiant.

Signed, sealed, and delivered in the presence of:

Title

ATTACHMENT F

INFORMATION ONLY

(This information will not affect the contract award)

LAKE COUNTY SCHOOL BOARD

CONDITIONS FOR EMERGENCY/HURRICANE OR DISASTER

It is hereby made part of this invitation to bid that, before, during, and after a public emergency, hurricane, disaster, flood, or acts of God, that the School Board of Lake County, Florida, shall require a “first priority” basis for goods and services. It is vital and imperative that the majority of citizens are protected from any emergency situation which threatens public health and safety, as determined by the School Board of Lake County, Florida.

Vendor/Contractor agrees to rent/sell/lease all goods and services to the School Board of Lake County, Florida, as opposed to a private citizen on a first priority basis. Vendor/Contractor shall furnish a 24-hour phone number in the event of such an emergency.

Beeper or Cell Phone Number: ( ) - - Email Address:

Title Print Name Name of Company Signature I hereby understand and agree to the above statement.

Title Print Name Name of Company Signature I cannot comply with this request.

ATTACHMENT G

COST PROPOSAL

Vendor shall provide pricing for all services. The School Board of Lake County reserves the right to negotiate terms and conditions and pricing as allowed under Florida Statute.

COST PROPOSAL FORM

Bid Number: 19-0105-P-RP

Bid Name: Speech Language Therapy Services

Bid Opening: March 5, 2020

VENDOR NAME:

TOTAL COST

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