2-5. Appendix B - Required Forms.pdf

22360848.9

Appendix B.01

CERTIFICATION OF CONTRACTOR REGARDING DEBARMENT, SUSPENSION,

AND OTHER RESPONSIBILITY MATTERS

The Contractor, _________________________, 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, or voluntarily excluded from covered transactions by any Federal department or agency;

2. Have not within a three (3) 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, 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 governmental entity (Federal, State, or Local) with commission of any of the offense enumerated in paragraph (2) of this certification; and

4. Have not within a three (3) year period preceding this application/proposal had one (1) or more public transactions (Federal, State, or Local) terminated for cause or default.

If the above-named Contractor is unable to certify to any of the statements in this certification, the Contractor shall attach an explanation to this certification.

The Contractor, _________________________, certifies or affirms the truthfulness and accuracy of the contents of the statements submitted on or with this certification and understands that the provision of 31 U.S.C. Section 3801 et seq. are applicable thereto.

Signature and Title of Authorized Official

Notary Public Name (Printed)

Notary Public Signature County of Expiration Date

Appendix B.02

Federal Tax Delinquency and Conviction Certification

The Contractor must complete the following two certification statements.

The Contractor must indicate its current status as it relates to tax delinquency and felony conviction by indicating in following spaces below the applicable response. The

Contractor agrees that, if awarded a contract resulting from this solicitation, it will incorporate this provision for certification in all lower tier subcontracts.

Certifications

Delinquency: The Contractor represents that it is or is not , a corporation that has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

Conviction: The Contractor represents that it is or is not , a corporation that was convicted of a criminal violation under any Federal law within the preceding 24 months.

Note

If a Contractor responds in the affirmative to either of the above representations, the Contractor is ineligible to receive an award.

Term Definitions

Felony conviction: Felony conviction means a conviction within the preceding twenty-four

(24) months of a felony criminal violation under any Federal law and includes conviction of an offense defined in a section of the U.S. code that specifically classifies the offense as a felony and conviction of an offense that is classified as a felony under 18

U.S.C. § 3559.

Tax Delinquency: A tax delinquency is any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted, or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

Date Signature

Company Name Title

NOTE: No award can be made without this form being completed

Appendix B.03

CERTIFICATION OF RESTRICTIONS ON LOBBYING

I, __________________________ , ________________________ , hereby certify on (Name) (Title) behalf of ________________________________________ that:

(Firm)

(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 any 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.

This certification is a material representation of fact upon which reliance is 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 or not less than $10,000 and not more than $100,000 for each such failure.

Dated ____________________ ______________________________

(Name)

(Title)

(Firm)

Appendix B.04

MONTEREY-SALINAS TRANSIT BIDDER FORM

All bidders/proposers are required to provide the following information for all subcontractors (including DBE & non-DBE) firms:

MST requires all prime contractors bidding on DOT-assisted contracts to submit, at the time of bid opening, a completed copy of this form for the prime contractor and for each of the subcontractors who provided a bid in connection with this solicitation. Provide a completed form for each subcontractor regardless of whether the bid was accepted or rejected. MST will use this information to maintain and update a "Bidders List" as required by 49 CFR § 26.11.

Firm Name: Firm Owner or Primary Contact:

Phone: Fax: Email:

Firm Address: City: State: Zip:

Is the firm currently certified as a DBE* by the California Unified Certification Program?

Yes or No (Circle one) NAICS Code:

*A copy of Bidder’s DBE Certification, if applicable, must be included with this form.

List the type(s) of work/services/materials provided by the firm:

How many years has your firm been in business? ______________

Provide your firm's Gross Annual Receipts for the previous year:

Less than $1 million

Less than $5 million

Less than $10 million

Less than $15 million

More than $15 million

This form should be duplicated to report all subcontractors' (DBE and non-DBE) information.

Monterey-Salinas Transit

Attn: DBE Liaison Officer

19 Upper Ragsdale Dr., Suite 200

Monterey, CA 93940

Appendix B.05

NON-COLLUSION AFFIDAVIT

STATE OF CALIFORNIA )

COUNTY OF ________________________________)

___________________________________________, being first duly sworn, deposes and says that he or she is of (position or title)

(the Contractor) the party making the foregoing contract that the contract price is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the bid is genuine and not collusive or sham; that the Contractor, and has not directly or indirectly colluded, conspired, connived, or agreed with any Contractor or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the Contractor has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the Contractor or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other Contractor, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true; and, further, that the Contractor has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or date relative thereto, or paid, and will not pay, any free to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid.

Dated:____________________ By:_____________________

Appendix B.06

PROPOSER'S STATEMENT

REGARDING INSURANCE COVERAGE

To Be Submitted with Proposal

PROPOSER HEREBY CERTIFIES that the Proposer has reviewed and understands the insurance coverage requirements specified in the Request for Proposals (RFP) #26- 03 for Reloadable cEMV Transit Payment Cards. Should the Proposer be awarded the contract for the work, Proposer further certifies that the Proposer can meet the specified requirements for insurance, including insurance coverage of the subcontractors, and agrees to name MST as Additional Insured for the work specified.

Name of Proposer (Person, Firm, or Corporation)

Signature of Proposer's Authorized Representative

Name & Title of Authorized Representative

Date of Signing

INSURANCE REQUIREMENTS AND LIMITS

General:

CONTRACTOR, at its sole cost and expense, for the full term of this Contract (and any extensions thereof), shall obtain and maintain at minimum all of the following insurance coverage. Such insurance coverage shall allow and be endorsed primary coverage as respects MST and any insurance or self-insurance maintained by MST shall be excess of CONTRACTOR's insurance coverage and shall not contribute to it.

Types of Insurance and Minimum Limits

CONTRACTOR shall obtain and maintain during the term of this Contract:

(a) Worker's Compensation and Employer's Liability Insurance in conformance with the laws of the State of California (not required for CONTRACTOR 's or sub-

CONTRACTORs providing MST written confirmation of having no employees) with limits of not less than one million dollars ($1,000,000) each accident, $1,000,000 by disease-policy, and $1,000,000 disease-each employee.

(b) CONTRACTOR’s vehicles used in the performance of this Contract, including owned, non-owned (e.g. owned by CONTRACTOR's employees), leased or hired vehicles, shall each be covered with Commercial Automobile, Liability Insurance using Insurance Services Office (ISO) Business Automobile Coverage form CA 00

01 (or equivalent) in the minimum amount of one million dollars ($1,000,000) combined single limit per accident for bodily injury and property damage.

(c) CONTRACTOR shall obtain and maintain Commercial General Liability Insurance coverage with coverage at least as broad as Insurance Services Office (ISO) form

CG 00 01 in the minimum amount of one million dollars ($1,000,000) per occurrence, two million dollars ($2,000,000) general aggregate, and one million dollars ($1,000,000) products and completed operations aggregate. The policy shall include a per project or per location general aggregate endorsement. If a per project/location endorsement is not available, the limit for the general aggregate shall be doubled. If CONTRACTOR maintains higher limits than the specified minimum limits, MST requires and shall be entitled to coverage for the higher limits maintained by CONTRACTOR.

(d) CONTRACTOR shall obtain and maintain Professional Liability insurance that insures against professional errors and omissions that may be made in performing professional services in the minimum amount of two million dollars ($2,000,000) per claim and in the aggregate. Any policy inception date, continuity date, or retroactive date must be before the effective date of the start of work, and

CONTRACTOR agrees to maintain continuous coverage through a period no less than three (3) years after completion of the work.

(e) CONSUTANT shall provide Cyber Liability Insurance with limits not less than one million dollars ($1,000,000) per claim. Coverage shall be sufficiently broad to respond to the duties and obligations as is undertaken by CONTRACTOR in this agreement and shall include, but not be limited to, claims involving infringement of intellectual property, including but not limited to infringement of copyright, trademark, trade dress, invasion of privacy violations, information theft, damage to or destruction of electronic information, release of private information or personally identifiable information (PII), alteration of electronic information, extortion, and network security. The policy shall provide coverage for breach response costs as well as regulatory fines and penalties, and credit monitoring expenses with limits sufficient to respond to these obligations.

Other Insurance Provisions

(a) As to all insurance coverage required herein, any deductible or self-insured retention exceeding $5,000.00 shall be disclosed to and be subject to written approval by MST.

(b) Except Professional Liability, each insurance coverage required hereunder is to be provided as an “occurrence” form basis only.

(c) All required Automobile Liability Insurance and Commercial General Liability

Insurance shall contain the following endorsement as a part of each policy: “MST is hereby added as an additional insured as respects the operations of the named insured."

(d) All the insurance required herein shall include and contain the following clause: "It is agreed that this insurance shall not be canceled until thirty (30) days after MST shall have been given written notice of such cancellation or reduction." If a carrier will not provide the required notice of cancellation, the CONTRACTOR shall provide written notice to MST of a cancellation no later than five (5) business days before cancellation.

(e) All required Workers’ Compensation, Automobile Liability Insurance and

Commercial General Liability shall contain and be endorsed with a waiver of subrogation in favor of MST.

(e) CONTRACTOR shall notify MST in writing at least thirty (30) days in advance of any reduction in any insurance policy required under this Contract.

(f) CONTRACTOR agrees to provide MST at or before the effective date of this

Contract with a certificate of insurance of the coverage and amendatory endorsements required.

(g) If CONTRACTOR, for any reason, fails to maintain insurance coverage, which is required pursuant to this Contract, the same shall be deemed a material breach of contract. MST, at its sole option, may terminate this Contract and obtain damages from the CONTRACTOR resulting from said breach.

Appendix B.07

Proposer Information Sheet

A. PROPOSER QUALIFICATIONS AND REFERENCES

The Proposer is required to state what work of similar magnitude or character they have done. Give references to enable MST to judge experience, skill and business standing and provide information to assess the ability to perform the services as completely and as rapidly as is required under the terms of the contract. All questions must be answered and the data given must be clear and comprehensive. Provide the nature of the work performed, for whom, amount of contract, dates of work, and the name of a point of contact for the Transit Agency, Firm or other Public Agency. If necessary, questions may be answered on separate attached sheets.

B. GENERAL PROPOSER INFORMATION:

When organized? ___________________________________________________

If a Corporation, where incorporated? ___________________________________

How many years in business under your current firm or trade name? ___________

Has the firm ever defaulted on a contract? __________ If so, where and why?

How was it resolved? ___________________________________________________

Has there ever been a failure to complete any work? ___________ If so, where and why?

How was it resolved?

Any claims for Labor Code violations? ___________________________________

PROPOSER QUALIFICATIONS AND REFERENCES CONTINUED

A. List three (3) current projects including the contract value, scheduled completion date, and the contact person, e-mail address and telephone number.

B. List three (3) work experiences that are similar to the scope of services in this RFP. Provide contract value, date completed, and a contact name and phone number.

C. Is there currently any legal action filed or threatened against your firm? __

If yes, please list the title of the action, whether it is pending or resolved, and explain the circumstances:

D. The undersigned hereby authorizes and requests any person, firm, or corporation to furnish any credit history and financial condition or other information required by MST in verification of the information provided in this statement of PROPOSERS qualifications.

I hereby certify that the above information is true and correct to the best of my knowledge and that MST may rely on the information provided.

THIS STATEMENT MUST BE NOTARIZED.

Attach the “California All-Purpose Acknowledgement” duly notarized.

NAME OF CONTRACTOR: _______________________________________________

BY: __________________________________________________________________

Signature Title

Type/Print Name Date

Appendix B.08

COMPLIANCE OR EXCEPTIONS TO THE SAMPLE CONTRACT (APPENDIX A)

Proposer must complete and submit either A or B below (choose only one).

A. COMPLIANCE:

This is to certify that Proposer agrees and shall comply with the terms and conditions of the Sample Contract.

Firm Name: ___________________________________________________________

Proposer Signature: _____________________________________________________

Title: _________________________________________________________________

Date: _________________________________

B. EXCEPTIONS:

This is to certify that Proposer takes exception to the terms and conditions of the Sample Contract attached to this form. Proposer must identify and list the Sampel Contract Section number, Section title, and page number. For each exception, Proposer must separately identify what its exception is by including the requested change in redline format and the justification for the change.

Firm Name: ___________________________________________________________

Proposer Signature: _____________________________________________________

Title: _________________________________________________________________

Date: _________________________________

Proposer must provide the required list and explanation of exceptions attached to this form.

Appendix B.9

SUBCONTRACTOR'S STATEMENT OF ELIGIBILITY

Contractor to provide a signed Statement of Eligibility from each of its subcontractors proposed to perform work under a contract resulting from this RFP.

__________________________________________________ (Subcontractor Name) hereby certifies that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in any federal project by any federal department or agency.

Where the subcontractor is unable to certify any of the statements in this certification, such subcontractor shall attach an explanation with this form.

The subcontractor 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. Section 3801, et. seq. are applicable.

Signature of Bidder: _____________________________ Date: _________________

(SIGN HERE)

Appendix B.10

COST PROPOSAL

General Instructions

Costs listed must include all applicable fees, taxes and expenditures to perform the Scope of

Services and must be provided in a format that is clear, concise, and easy to understand.

Instructions for Tables 1 and 2

Pricing for the required elements is provided in Table 1. Table 2 lists additional costs associated with any optional features and/or services that an Agency may opt to include or exclude from the final contract.

Costs should be presented as either one-time, re-occurring or based on a per unit quantity, as noted in the "Unit" column. Please explain any pricing that is contingent on volume and detail breakpoint thresholds for discounts in the spaces provided below. Costs listed in Category 4 should include any transaction fees charged at time of fund distribution, at time of use, or at time of recovery in the event the user does not use the funds.

Outline any annual price increases, one-time start-up fees, or other costs not clearly identifiable in Tables 1 and 2, be they required or optional, in the space provided or separately in a sheet attached to the Cost Proposal and not in Tables 1 or 2. If there is no cost for an item listed in the tables below, please write "No cost" in the applicable field.

Table 1: Pricing for Required Elements

Required Element Category

Unit Comments Line Items Cost per Unit (Vendor Input)

1 Implementation Costs

One-time costs per Agency for ABT configuration and mobile wallet enablement

Detail all implementation costs and options

System setup & design

2 Card Production & Issuance

Per card costs, for the listed breakpoints

Detail all costs for issuing physical and digital cards

Physical card distribution

1-1,000 cards:

1,001-5,000:

5,001-10,000:

10,001-50,000:

50,001-100,000:

100,001-500,000:

500,000+:

Digital card issuance

1-1,000 cards:

1,001-5,000:

5,001-10,000:

10,001-50,000:

50,001-100,000:

100,001-500,000:

Required Element Category

Unit Comments Line Items Cost per Unit (Vendor Input)

500,000+:

3 Platform & Software Licensing

Cost per month Core operational software for card & account management

Platform license and operational fees

4 Transaction Processing & Settlement

Per transaction costs for the listed breakpoints of monthly revenue

Detail fees per transaction for clearing, settlement, and interchange

Percentage of monthly revenue (e.g., 1%, 1.5%, etc.)

$1-$5,000:

$5,001-$10,000:

$10,001-$15,000:

$15,001-$25,000:

$25,001-$50,000:

$50,001-$100,000:

$100,001-$500,000:

$500,001+

Retail Cash Reload Network

Implementation and Per card activation

One-time implementation fee

Retail reload setup and merchant onboarding

Per card activation

Consumer card purchase, activation, or cash reload costs

6 Customer Service Operations

Cost per month Detail scope of customer service capabilities if needed

Online helpdesk

Cardholder online account management

Agency online account

7 Fraud Prevention & Compliance

Cost per month Must comply with Exhibit C in the Sample Contract and align with California CCPA and PCI DSS requirements

Monitoring tools

Table 2: Pricing for Optional Elements

Optional Element Category Unit Comments

Line Items Cost per Unit (Vendor Input)

1 Card issuance Per card cost for mailing cards purchased online, for the listed breakpoints

See functionality 1.6 in the technical requirements

Physical card distribution via mail

1-1,000 cards:

1,001-5,000:

5,001-10,000:

10,001-50,000:

50,001-100,000:

100,001-500,000:

500,000+:

Per Top-up Machine Costs & per month maintenance costs

See functionality 1.8

Top-up machine hardware

Maintenance costs

2 Funds

One-time fee for customization of MCC/terminal restrictions

See functionality 2.2

Customization fee

3 Card loading One-time fee for enabling free and discount pass loading to cards

See functionality 3.4 and 3.5

Development

4 Customer care One-time fee for provisioning mobile wallet with real-time balance information

See functionality 4.2

One-time fee for provisioning customer service locations with account management tools

See functionality 4.3 and 4.5

Monthly cost of providing phone support in English and Spanish

See functionality 4.8

Per month cost

5 Marketing One-time fee for custom branding

See functionality 5.2

Customization

Cost of printing and distributing collateral

See functionality 5.3 and 5.4

Collateral printing and distribution

6 Reporting One-time cost for enabling API access

See functionality 6.2

Reporting API access

Please explain any pricing contingent on volume and detail breakpoint pricing and volumes thresholds for discounts below (attach a separate sheet if necessary).

Outline any annual price increases, one-time start-up fees, or other costs not clearly identifiable in the table above (attach a separate sheet if necessary).

Instructions for Table 3

Calculate total costs, as defined below, for all Required Elements for a five-year contract term for MST. Do not include costs associated with the Optional Elements.

• "Cost Per Card" means the sum of Required Element Categories 2 and 5.2.

• "Total Card Costs" means [Agency's estimated quantity of cards] x [Cost Per Card]

• "Total Monthly Service Fees" means [the sum of Required Element Categories 3, 6, and

7] x [60 months].

• "Total Implementation Costs" means Required Element Category 1 and 5.1.

• "Grand Total Cost" means the sum of Total Card Costs, Total Card Costs, and Total

Implementation Costs for each Agency. The Grand Total Cost does not include the cost for Required Category 4, Transaction Processing & Settlement because those costs will depend on amount of revenue processed.

Table 3: Per-Agency Total Costs

Agency Total Card Costs

Total Monthly Service Fees

Total Implementation Costs

Grand Total Cost

Monterey-Salinas Transit District

Proposers must provide the Per-Agency Total Costs information in Table 3 for other Participating

Agencies upon request.

Appendix B.11

TECHNICAL REQUIREMENTS FORM

Functionality Required Optional Value- Added

Included in Proposal

1 Card issuance and acceptance

1.1 Riders can purchase/obtain a card in-person at retail

locations (e.g., Pharmacy, Gas Stations, grocery stores, convenience stores) throughout each Agency's service area

X

1.2 The card can be provisioned via mobile wallet

(Apple/Google) and be selected as the rider’s “Transit Card”/”Transit Pass” sections

X

1.3 Provide a solution for agency-staffed customer service

locations to issue and load cards for riders

X

1.4 Provide a contactless EMV “tap” card (this refers to the

physical card's contactless functionality not via a digital wallet) that is accepted by a cEMV transit agency on-board payment acceptance device and/or parking payment device

X

1.5 Riders do not need to create an account or provide any

personal information to obtain or load funds onto a card

X

1.6 Riders can purchase a card online and receive via mail X

1.7 Capable of distributing cards in bulk to retail locations and the transit agency headquarters

X

1.8 Provide a top-up machine where cardholders can load

value with cash or card

X

2 Funds management

2.1 Spending is limited to transit agency on-board payment

acceptance devices and parking payment devices (Spending on non-transit/parking services and products is prohibited)

X

2.2 Spending is allowed on additional transit agencies and

parking services outside the service area of the Agency, at the direction of the Agency.

X

2.3 Fraud protection measures are in place, including

automatic fraud detection and the ability for card holders and the transit agency to block cards if fraud is detected or card is lost

X

3 Card Loading

Functionality Required Optional Value- Added

Included in Proposal

3.1 Riders can load and top-up card value with cash at retail locations (e.g., Pharmacy, Gas Stations, grocery stores, convenience stores) throughout each Agency's service area

X

3.2 Riders can load and top-up card value virtually online or via mobile wallet

X

3.3 Funds must be available within 10 minutes of loading X

3.4 Agency has the ability to assign a free fare pass product to the account

X

3.5 Agency has the ability to assign a discounted fare or pass product to the account

X

4 Customer Care

4.1 Cardholders can view balance online X

4.2 Cardholders with a digital card can view balance in mobile wallet

X

4.3 Cardholder can confirm balance at agency customer

service location or retail location

X

4.4 Cardholders can view recent transactions (payments and

top-ups) online

X

4.5 Cardholders can view recent transactions (payments and

top-ups) at agency customer service location

X

4.6 Cardholders can receive a refund of balance X

4.7 Cardholder customer support online in English and

Spanish

X

4.8 Cardholder customer support via phone in English and

Spanish

X

5 Marketing

5.1 Agency has the ability to embed a map of retail locations that sell cards and offer card loading/top-up services on the agency's website that is updated within a week of any changes

X

5.2 Agency can request custom branding on the cards X

5.3 Provide the agency with digital files and collateral to

promote card availability to customers

X

5.4 Provide retail locations with collateral to promote card

availability

X

6 Reporting

6.1 Agency can access a cloud-based portal that provides daily reporting on the number of cards issued, funds loaded, funds expended, average balance

X

6.2 Agency can access APIs that provide custom reporting X