2-Appendix 1.pdf

FORM

FL-00200

v: 12/2024

Florida Vendor Eligibility Requirements Form Page

1. E-Verification

This Contract is subject to the requirements found in Section 448.095(5), Florida Statutes. By executing this Contract, Contractor hereby certifies that it is registered with the United States Department of Homeland Security’s E-Verify system to verify the work authorization status of all new employees of Contractor and hereby acknowledges the responsibilities and obligations of both the Contractor and Toho under Section 448.095(5), Florida Statutes, which includes without limitation the right of Toho to unilaterally and immediately terminate this Contract for Contractor’s failure to comply with such provision of Florida Law and to thereafter impose upon Contractor any additional costs incurred by Toho as a result of such termination.

2. Public Entity Crimes

Contractor hereby represents, warrants, and certifies that: neither Contractor, nor one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of Contractor, nor any affiliate of the entity, has been charged with and convicted of public entity crime subsequent to July 1, 1989; Contractor has not been placed on any convicted vendor list by the State of Florida and that it will not utilize any funding provided pursuant to this Contract to subcontract with any vendor that has been placed on any such convicted vendor list; and Contractor has read and reviewed the provisions, requirements, and prohibitions of Florida’s Public Entity Crime Act, Section 287.133, Florida Statutes, and hereby affirms its compliance therewith. For the purposes of this provision, the terms “public entity crime”, “convicted”, and “affiliate” shall be as defined in Section 287.133, Florida Statutes.

3. Scrutinized Companies

a. Contractor hereby represents, warrants, and certifies that: Contractor is not on Florida’s “Scrutinized Companies that Boycott Israel List”, created pursuant to Section 215.4725, Florida Statutes, nor is it engaged in a boycott of Israel; and Contractor has read and reviewed the provisions, requirements, and prohibitions of Florida’s prohibition against contracting with scrutinized companies, as found in Section 287.135, Florida Statutes, and hereby affirms its compliance therewith.

b. If the Contract Amount meets or exceeds $1,000,000, then Contractor hereby additionally represents, warrants, and certifies that Contractor is not on the “Scrutinized Companies with Activities in Sudan List” or the “Scrutinized Companies with Activities in the Iran Terrorism Sectors List”, created pursuant to Section 215.473, Florida Statutes, and Contractor is not engaged in business operations in Cuba or Syria.

c. In accordance with Section 218.135, Florida Statutes, if any of the above certifications are found to have been false, if Contractor is later placed on any of the lists referenced in this Article, or if Contractor becomes engaged in business operations in Cuba or Syria or any boycott of Israel, Toho shall have the option to terminate this Contract and shall have the right to, notwithstanding anything to the contrary in this Contract, pursue all remedies available to it in equity and at law.

4. Discriminatory Vendors

Contractor hereby represents, warrants, and certifies that entering into this Contract will not violate Subsection 287.134, Florida Statutes, which provides that an entity or affiliate who has been placed on the discriminatory vendor list may not submit a bid, proposal, or reply on a contract to provide any goods or services to a public entity; may not submit a bid, proposal, or reply on a contract with a public entity for the construction or repair of a public building or public work; may not submit bids, proposals, or replies on leases of real property to a public entity; may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity; and may not transact business with any public entity.

FL-00200

v: 12/2024

Florida Vendor Eligibility Requirements Form Page

5. Anti-Trust Violators

Contractor hereby represents, warrants, and certifies that entering into this Contract will not violate Section 287.137, Florida Statutes, which provides that a person or an affiliate who has been placed on the antitrust violator vendor list following a conviction or being held civilly liable for an antitrust violation may not submit a bid, proposal, or reply for any new contract to provide any goods or services to a public entity; may not submit a bid, proposal, or reply for a new contract with a public entity for the construction or repair of a public building or public work; may not submit a bid, proposal, or reply on new leases of real property to a public entity; may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a new contract with a public entity; and may not transact new business with a public entity.

6. Countries of Foreign Concern

Contractor hereby represents, warrants, and certifies that entering into this Contract will not violate Section 287.138, Florida Statutes, which provides that Toho may not enter into a contract with an entity that gives access to an individual’s personal identifying information if the entity is owned, controlled, or organized under the laws of a Foreign Country of Concern which includes: the People’s Republic of China, the Russian Federation, the Islamic Republic of Iran, the Democratic People’s Republic of Korea, the Republic of Cuba, the Venezuelan regime of Nicolas Maduro, the Syrian Arab Republic, or any other entity or agency under the significant control of such Foreign Country of Concern.

7. Common Carrier

If Contractor meets the definition of “Common Carrier” under Section 908.111, Florida Statutes, then Contractor shall execute an attestation in conformity with Section 92.525, Florida Statutes, that the common carrier or contracted carrier is not willfully providing and will not willfully provide any service during the contract term in furtherance of transporting a person into the State of Florida knowing that the person is an unauthorized alien, except to facilitate the detention, removal, or departure of the person from this state or the United States. Such attestation must be provided to Toho prior to commencement of this Contract. In accordance with Section 908.111, Florida Statutes, Toho may terminate this Contract for cause if Contractor is found to be in violation of this provision or its attestation.

8. Human Trafficking Contractor hereby represents, warrants, and certifies that Contractor does not use coercion for labor or services as defined in Section 787.06, Florida Statutes and that Contractor has provided the affidavit attached hereto as TOH-240 to TOHO.

TOH-120

v: 03/2024

Affidavit of Non-Collusions and of Non-Interest of Toho Employees

Form Page

Instructions: “Vendor(s)”, defined as any person or entity responding to a formal solicitation issued by the Tohopekaliga Water Authority (“Toho”), must submit this form with their Solicitation Responses.

The terms “Contract” and “Agreement” may be interchangeably used.

Vendor Name (as on Sunbiz.org):

Solicitation/Contract Number:

Affidavit of Non-Collusion and of Non-Interest of Toho Employees

The undersigned hereby certifies that they are authorized to legally bind the Vendor of this Solicitation Response, that the only person(s) or party(s) interested in this Solicitation Response are those named in the Solicitation Response, that no officer, employee, or agent of the Tohopekaliga Water Authority or any other Vendor is interest in this Solicitation Response, that this Solicitation Response is made without fraud, that this Solicitation Response is made with no past or present collusion with any other person, firm, or corporation.

By submitting a Solicitation Response to the above-referenced Solicitation, Vendor also represents that this Solicitation Response has been prepared without collusion or fraud and in fair competition with other Vendors, without any restraint on free competition, and acknowledges that TOHO is acting in reliance upon that representation.

The undersigned hereby represents that they: make the above certifications based upon personal knowledge; are over the age of 18 years and otherwise competent to make the above certifications; and are authorized to legally bind and make the above certifications on behalf of Vendor.

Under penalties of perjury, the undersigned declares that they have read and understand the contents of the foregoing form. Pursuant to the authority granted to the undersigned by Vendor, the undersigned hereby acknowledges, affirms, and makes the above sworn statement.

By:

Authorized Representative on behalf of Vendor

Printed Name:

Official Title:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________________, 20____, by _______________________, as __________________ of __________________________, a ________________________________ authorized to do business in the State of Florida on behalf of the company/corporation. They ☐ are personally known to me or ☐ have produced ___________________________ as identification.

(Seal)

Signature of Notary Public

Name of Notary Typed, Printed or Stamped

TOH-140

v: 02/2025

Structural Records Acknowledgment

Instructions: “Vendor(s)”, defined as any person or entity responding to a formal solicitation issued by the Tohopekaliga Water Authority (“Toho”), must submit this form with their Solicitation Responses.

Structure Record Release Acknowledgement

THIS ACKNOWLEDGMENT shall apply to the dissemination of any and all information, data and/or records concerning plans, blueprints, schematic drawings, locations and diagrams, including draft, preliminary and final formats, which may depict the location, layout and structural elements of Toho Water Authority (“Toho”) utility and other such facilities ("Toho structures").

THE UNDERSIGNED acknowledges and understands that the requested Toho structures described in the attached Exhibit “A” and any updates or revisions to Exhibit “A” which may be subsequently provided, are exempt from review as public records under Chapter 119 and the State Constitution, and that by law such information may only be disclosed to the following:

(1) Another governmental entity if disclosure is necessary for the receiving entity/individual to perform its duties and responsibilities;

(2) A licensed architect, engineer or contractor who is performing work on or related to the requested Toho structures; or

(3) Upon a showing of good cause before a court of competent jurisdiction.

ADDITIONALLY, the undersigned acknowledges that entities or person(s) receiving such information are statutorily required to maintain the exempt status of information. In other words, it is unlawful to obtain information concerning Toho structures under false pretenses, and similarly, unlawful to share or otherwise disseminate such information concerning Toho structures for any reason other than the lawful purposes under which it was obtained.

THE UNDERSIGNED HEREBY CERTIFIES AND AFFIRMS UNDER PENALTY OF PERJURY THE FOLLOWING:

1. The undersigned is or duly acts on behalf of the following authority (check each that applies):

_______ A Governmental entity who must obtain information concerning Toho structures to perform its duties and responsibilities.

_______ A licensed architect, engineer, or contractor who is performing work on or related to the requested Toho structures (a license number or copy of license is required for file).

_______ A person or entity who, after providing notice to Toho, has shown good cause before a court of competent jurisdiction, and possesses an appropriate Order compelling review and copying of specific information concerning Toho structures.

2. The undersigned understands, certifies, acknowledges and agrees that:

(a) Any and all persons receiving any information based upon the foregoing representations are required by law (and shall act to so inform in writing any third party who may properly use or share such information) to maintain the exempt status of the information provided;

(b) Any and all information obtained does not carry with it any representation or certification, implied or express, of completeness, reliability or suitability for any purposes, or accuracy; that the recipient assumes all risks of reliance upon or use of such information; and

(c) The undersigned, to the maximum extent permitted by law and on behalf of itself, and any other persons with whom the information is shared legitimately or otherwise, holds Toho, it’s officials, officers, employees, agents, contractors and all other persons or entities affiliated with Toho harmless from any loss, claim, demand, or responsibility for adverse consequence of any conceivable nature resulting from the use, accuracy, or reliance upon the information for any purpose, including but not limited to the information being erroneous, incomplete, incorrect, or inaccurate.

IN WITNESS WHEREOF, I have hereunto set my hand and seal this ___ day of ____________ 202___.

By: ________________________________________ Printed Name: ______________________________ License Number: ____________________________

STATE OF FLORIDA

COUNTY OF ________________

The foregoing instrument was executed before me by means of [ ] physical presence or [ ] online notarization, this ___________ day of ____ 202___ by . He/She [ ] is personally known to me, or [ ] has produced as identification.

(Notary Seal below)

TOH-200

v: 03/2024

E-Verify Registration and Use Certification

Instructions: “Vendor(s)”, defined as any person or entity seeking to engage in business with the Tohopekaliga Water Authority (“Toho”), must certify that they are registered and use the U.S.

Department of Homeland Security’s E-Verify system using this form. The terms “Contract” and “Agreement” may be interchangeably used.

Section 448.095, Florida Statutes, Compliance Certification

Employment Eligibility

The undersigned, on behalf of the Vendor, hereby certifies as follows:

A. Vendor acknowledges that Section 448.09, Florida Statutes, makes it unlawful for any person to knowingly employ, hire, recruit, or refer, for private or public employment, an alien who is not duly authorized to work in the United States.

B. Vendor acknowledges that, in accordance with Section 448.095(5), Florida Statutes: (1) the Vendor, and any subcontractor thereof, are required register with and use the U.S. Department of Homeland Security’s E-Verify system to verify the work authorization status of all new employees of the Vendor or subcontractor; and (2) Toho may not enter into a contract unless each party to the contract registers with and uses the E-Verify system.

C. Vendor hereby certifies that the Vendor is registered with the U.S. Department of Homeland Security’s E-Verify system to verify the work authorization status of all employees hired during the term of the Contract.

D. Vendor hereby certifies that it does not and shall not employ, contract, or subcontract with an unauthorized alien, pursuant to Section 448.095, Florida Statutes, is otherwise in compliance with the requirements of Sections 448.09 and 448.095, Florida Statutes, and shall remain in compliance with such sections of Florida law during the term of any contract with Toho.

E. Vendor hereby acknowledges that the language of the Solicitation and/or Contract notwithstanding, a contract terminated under Section 448.095(5), Florida Statutes, is not a breach of contract and may not be considered as such.

F. Vendor hereby acknowledges and agrees that in the event that Vendor, or any subcontractor thereof, fails to comply with all applicable provisions of Sections 448.09 and 448.095, Florida Statutes, Toho reserves the right to exercise all remedies available to it at law and in equity, including without limitation recovery from the Vendor of the costs incurred by Toho as a result of termination of the Agreement under the aforementioned Florida statutes.

G. Attached to this form is a true and correct copy of the Vendor’s proof of registration in the E- Verify system.

H. Vendor shall ensure compliance with the requirements of Sections 448.09 and 449.095, Florida Statutes, by any and all of its subcontractors, and shall require all subcontractors performing work under the Contract to provide this same certification form, with party names changed as applicable.

Toho reserves the right to request copies of each such subcontractor’s form.

Initials: _____

TOH-200

v: 03/2024

E-Verify Registration and Use Certification

EXECUTION OF ABOVE CERTIFICATION

The undersigned hereby represents that they: make the above certification based upon personal knowledge; are over the age of 18 years and otherwise competent to make the above certification; and are authorized to legally bind and make the above certification on behalf of the Vendor.

Under penalties of perjury, the undersigned declares that they have read and understand the contents of the foregoing form. Pursuant to the authority granted to the undersigned by Vendor, the undersigned hereby acknowledges, affirms, and makes the certification provided above on behalf of Vendor.

Printed Name:

Official Title:

Date:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________________, 20____, by _______________________, as

__________________ of __________________________, a ________________________________

TOH-210

v: 03/2024

Certifications Regarding Vendor Eligibility for Contracts with Public Entities

Tohopekaliga Water Authority (“Toho”), must use this form to certify that they are eligible to solicit an award from and/or enter into a contract with a public entity under applicable Florida law. The terms “Contract” and “Agreement” may be interchangeably used.

Part 1: Section 287.133, Florida Statutes, Compliance Certification

Public Entity Crimes Act

The undersigned hereby certifies, on behalf of Vendor, that:

A. Neither Vendor, nor one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of Vendor, nor any affiliate of the entity, has been charged with and convicted of public entity crime subsequent to July 1, 1989;

B. Vendor has not been placed on any convicted vendor list by the State of Florida and that Vendor will not utilize any funding provided pursuant to this Contract to subcontract with any vendor that has been placed on any such convicted vendor list;

C. Vendor acknowledges that for the purposes of this certification, the terms “public entity crime,” “convicted,” and “affiliate,” are as defined in Section 287.133, Florida Statutes, which Vendor has reviewed prior to the execution of this certification;

D. Vendor acknowledges that Toho reserves the right to terminate this Contract immediately and take full advantage of any legal remedies available in equity or law should Vendor be found to: have falsified its certification of eligibility to bid on, submit a proposal for, or enter into or renew a contract with Toho for goods or services pursuant to Section 287.133, Florida Statutes; or have become ineligible to bid on, submit a proposal for, or enter into or renew a contract with Toho for goods or services pursuant to Section 287.133, Florida Statute subsequent to entering into this Contract with Toho; and

E. Vendor shall immediately notify Toho if at any point during the term of the Contract, Vendor’s status under Section 287.133, Florida Statutes, changes in any manner.

Part 2: Section 287.134, Florida Statutes, Compliance Certification Discriminatory Vendors

The undersigned hereby certifies, on behalf of Vendor, that:

A. Neither Vendor, in its capacity as an “entity”, as defined in Section 287.134, Florida Statutes, nor any of its “affiliates”, as defined in that same statute, have been placed on the discriminatory vendor list;

B. Vendor is eligible to submit an offer or proposal to, receive an award from, contract with, and otherwise transact business with public entities in the State of Florida under Section 287.134, Florida Statutes; and

C. Vendor shall immediately notify Toho if at any point during the term of the Contract, Vendor’s status under Section 287.134, Florida Statutes, changes in any manner.

Vendor’s Initials: _____ v: 03/2024

Certifications Regarding Vendor Eligibility for Contracts with Public Entities

Part 3: Section 287.137, Florida Statutes, Compliance Certification

Antitrust Violators

The undersigned hereby certifies, on behalf of Vendor, that:

A. Neither Vendor, in its capacity as an “entity”, as defined in Section 287.137, Florida Statutes, nor any of its “affiliates”, as defined in that same statute, have been placed on the antitrust violator vendor list following a conviction or being held civilly liable for an antitrust violation;

B. Vendor is eligible to submit an offer or proposal to, receive an award from, contract with, and otherwise transact business with public entities in the State of Florida under Section 287.137, Florida Statutes; and

C. Vendor shall immediately notify Toho if at any point during the term of the Contract, Vendor’s status under Section 287.137, Florida Statutes, changes in any manner.

Part 4: Section 287.135, Florida Statutes, Compliance Certification Prohibition Against Contracting with Scrutinized Companies

The undersigned hereby certifies, on behalf of Vendor, that:

A. Vendor has reviewed Section 287.135, Florida Statutes, and in accordance with such provision of Florida law, is eligible to bid on, submit a proposal for, or enter into or renew a contract with Toho for goods or services.

B. Vendor is not on the “Scrutinized Companies that Boycott Israel List”, created pursuant to Section 215.4725, Florida Statutes, and additionally is not engaged in a boycott of Israel.

C. If the value of the award, contract, or agreement for which this certification is being executed meets or exceeds $1,000,000.00 in value, Vendor additionally hereby certifies that Vendor is not: (1) on either the “Scrutinized Companies with Activities in Sudan List” or the “Scrutinized Companies with Activities in the Iran Terrorism Sectors List” created pursuant to Section 215.473, Florida Statutes; or

(2) engaged in business operations in Cuba or Syria.

D. Vendor acknowledges that Toho reserves the right to terminate this Contract immediately and take full advantage of any legal remedies available in equity or law should Vendor be found to: (1) have falsified its certification of eligibility to bid on, submit a proposal for, or enter into or renew a contract with Toho under Section 287.135, Florida Statutes; (2) have become ineligible to bid on, submit a proposal for, or enter into or renew a contract with Toho under Section 287.135, Florida Statutes, by having been added to any of the above-referenced “Scrutinized Companies” lists, or by engaging in any boycott of Israel or business operations in Cuba or Syria.

E. Vendor shall immediately notify Toho if at any point during the term of the Contract, Vendor’s status under Section 287.135, Florida Statutes, changes in any manner.

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v: 03/2024

Certifications Regarding Vendor Eligibility for Contracts with Public Entities

Part 5: Section 287.138, Florida Statutes, Compliance Certification

Foreign Countries of Concern

If being awarded the Contract, or otherwise entering into the Contract, would grant Vendor access to an individual’s personal identifying information, pursuant to section 287.138, Florida Statutes, the undersigned, on behalf of Vendor, hereby certifies, represents, and warrants that Vendor is not affiliated with a foreign country of concern, as such countries are identified in section 287.138(1), Florida Statutes.

The undersigned additionally certifies, represents, and warrants that: (A) Vendor is not owned by a foreign country of concern; (B) the government of a foreign country of concern does not have a controlling interest in Vendor; and (C) Vendor is not organized under the laws of or has its principal place of business in a foreign country of concern.

EXECUTION OF ABOVE CERTIFICATIONS

The undersigned hereby represents that they: make the above certifications based upon personal knowledge; are over the age of 18 years and otherwise competent to make the above certifications; and are authorized to legally bind and make the above certifications on behalf of Vendor.

Under penalties of perjury, the undersigned hereby certifies and declares that they have read and understand the contents of the foregoing form. Pursuant to the authority granted to the undersigned by Vendor, the undersigned hereby acknowledges, affirms, and makes the above-provided certifications on behalf of Vendor.

Printed Name:

Official Title:

Date:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________________, 20____, by _______________________, as __________________ of __________________________, a

________________________________ authorized to do business in the State of Florida on behalf of the company/corporation. They ☐ are personally known to me or ☐ have produced

___________________________ as identification.

TOH-220

v: 03/2024

Common Carrier Certification

Tohopekaliga Water Authority (“Toho”), must use this form to certify that they either: (1) are not a common carrier under applicable Florida law, or (2) are a common carrier and comply with applicable Florida law. The terms “Contract” and “Agreement” may be interchangeably used.

Section 908.111, Florida Statutes, Compliance Certification

Common Carriers

The undersigned, on behalf of the Vendor, hereby certifies as follows:

A. Vendor acknowledges that Section 908.111, Florida Statutes, which prohibits a local government such as Toho from executing, amending, or renewing a contract with a common carrier or contracted carrier if the carrier is willfully providing any service in furtherance of transporting a person into the State of Florida knowing that person is an unauthorized alien, except to facilitate detention, removal, or departure of the person from this state or the United States.

B. Vendor acknowledges that Section 908.111, Florida Statutes, defines “common carrier” as follows: “. .

. a person, firm, or corporation that undertakes for hire, as a regular business, to transport persons or commodities from place to place, offering his or her services to all such as may choose to employ the common carrier and pay his or her charges.”

C. Vendor hereby certifies that the following selected statement is true, correct, and accurate (select only one statement from below):

☐ Statement 1: Vendor is not a “common carrier”, as defined in Section 908.111, Florida Statutes.

☐ Statement 2: Vendor is a “common carrier”, as defined in Section 908.111, Florida Statutes.

D. If Vendor is a common carrier, as defined by Section 908.111, Florida Statutes, then Vendor hereby certifies that it is not willfully providing and will not willfully provide any service during the Contract term in furtherance of transporting a person into this state knowing that the person is an Unauthorized Alien, except to facilitate the detention, removal, or departure of the person from this state or the United States.

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TOH-220

v: 03/2024

Common Carrier Certification

The undersigned hereby represents that they: (A) make the above certification based upon personal knowledge; (B) are over the age of 18 years and otherwise competent to make the above certification; and

(C) are authorized to legally bind and make the above certification on behalf of the Vendor.

Under penalties of perjury, the undersigned declares that they have read and understand the contents of the foregoing form. Pursuant to the authority granted to the undersigned by Vendor, Printed Name:

Official Title:

Date:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________________, 20____, by _______________________, as

__________________ of __________________________, a ________________________________

TOH-230

v: 04/2024

Florida Trench Safety Act Affidavit

Tohopekaliga Water Authority (“Toho”), must use this form to certify that they either: (1) are not a common carrier under applicable Florida law, or (2) are a common carrier and comply with applicable Florida law. The terms “Contract” and “Agreement” may be interchangeably used.

FLORIDA TRENCH SAFETY ACT AFFIDAVIT

The undersigned hereby certifies, on behalf of Vendor, that Vendor will fully comply with the applicable trench safety standards and all requirements of the Occupational Safety and Health Administration's (OSHA) excavation safety standards as defined in 29 CFR 1926.650 Sub-Part P as required by the State of Florida Trench Safety Act, Section 553.63, Florida Statutes, and further that submittal of this Bid for the Project is full acknowledgment of the requirements and that the costs associated with said compliance have been included in the Bid.

The undersigned hereby represents that they: (A) make the above certification based upon personal knowledge; (B) are over the age of 18 years and otherwise competent to make the above certification; and

(C) are authorized to legally bind and make the above certification on behalf of the Vendor.

Under penalties of perjury, the undersigned declares that they have read and understand the contents of the foregoing form. Pursuant to the authority granted to the undersigned by Vendor, Printed Name:

Official Title:

Date:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________________, 20____, by _______________________, as

__________________ of __________________________, a ________________________________

TOH-240

v: 5/2025

Anti-Human Trafficking Affidavit

Instructions: “Nongovernmental Entity”, defined as any person or entity seeking to engage in business with the Tohopekaliga Water Authority (“Toho”), must complete the following form. The terms “Contract” and “Agreement” may be used interchangeably.

Nongovernmental Entity Name

Solicitation/Contract Number(s):

The undersigned, on behalf of the Nongovernmental Entity, hereby attests as follows:

A. The Nongovernmental Entity understands and affirms that Section 787.06(13), Florida Statutes, prohibits Toho from executing, renewing, or extending a contract with entities that use coercion for labor or services, as such terms are defined in Section 787.06, Florida Statutes.

B. The Nongovernmental Entity hereby attests, under penalty of perjury, that the Nongovernmental Entity does not use coercion for labor or services as defined in Section 787.06(2), Florida Statutes.

C. The Nongovernmental Entity understands and affirms that if at any time in the future, the

Nongovernmental Entity does use coercion for labor or services, the Nongovernmental Entity will immediately notify Toho and no contracts may be executed, renewed, or extended with Toho.

The undersigned hereby represents that they: make the above attestation based upon personal knowledge; are over the age of 18 years and otherwise competent to make the above attestation; and are authorized to legally bind and make the above attestation on behalf of the Nongovernmental Entity.

Under penalties of perjury, the undersigned declares that they have read and understand the contents of the foregoing document and that the facts stated in it are true.

Authorized Signature:

Printed Name:

Title:

Date:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________, 20____, by ____________________________, as __________________ on behalf of the Nongovernmental Entity. They ☐ are personally known to me or ☐ have produced ___________________ as identification.

Signature of Notary Public

My Commission Expires: _______________

TOH-300

v: 03/2024

Federal Suspension and Debarment Certification

Tohopekaliga Water Authority (“Toho”), must use this form to certify that they are not appear on the SAM.gov Exclusion list. For the purposes of this form, “Contract” and “Agreement” may be interchangeably used.

2 CFR Part 180, Subpart C, Compliance Certification

Federal Suspension and Debarment

The undersigned hereby certifies on behalf of Vendor, that:

(A) Vendor complies with 2 CFR Part 180, Subpart C (“Responsibilities of Participants Regarding Transactions Doing Business with Other Persons”).

(B) Neither Vendor, nor any owner, partner, director, officer, or principal of Vendor, nor any person in a position with management responsibility or responsibility for financial administration:

(1) Is presently debarred, suspend, proposed for debarment, or declared ineligible or voluntarily excluded from covered transactions by any federal or state department or agency;

(2) Has been convicted within the preceding three years of any of the offenses listed in 2 CFR 180.800(a) or had a civil judgment rendered against them for one of those offenses within that time period;

(3) Is presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses listed in 2 CFR 180.800(a);

or

(4) Have had one or more public transactions (federal, state, or local) terminated within the preceding three years for cause or default.

(C) Vendor does not appear on the System for Award Management (“SAM”) Exclusions list and shall notify Toho within five (5) business days if it is added to the SAM Exclusions list, or should its status under the SAM system change in any way during the term of this Agreement.

(D) Vendor understands and agrees that should Vendor be found to have falsified this certification or to have otherwise misrepresented its SAM Exclusion status in any manner, Toho shall have the right to partake in any number of the following actions: (1) instituting additional restrictions and conditions to this Contract; (2) terminating this Contract for default; and (3) pursuing any other remedy available under local, state, and federal law.

(E) Vendor acknowledges and agrees that it shall not enter into any lower tier transaction with a person or entity that is debarred, suspended, declared ineligible, or voluntary excluded from participation in this covered transaction. Vendor shall include a requirement to comply with 2 CFR Part 180, Subpart C in any lower tier covered transactions, including but not limited to subcontracts, into which it enters.

TOH-300

v: 03/2024

Federal Suspension and Debarment Certification

(F) Vendor acknowledges and agrees that this certification is a material representation of fact upon which reliance will be placed when Toho determines to award the covered transaction to Vendor.

If it is later determined that Vendor falsified this certification or otherwise fails to comply with this certification or 2 CFR Part 180, Subpart C, in addition to remedies available to Toho, the Federal Government may pursue available remedies, including but not limited to, suspension or debarment.

knowledge; are over the age of 18 years and otherwise competent to make the above certification;

and are authorized to legally bind and make the above certification on behalf of the Vendor.

Under penalties of perjury, the undersigned hereby certifies and declares that they have read and understand the contents of the foregoing form. Pursuant to the authority granted to the undersigned by Vendor, the undersigned hereby acknowledges, affirms, and makes the certification provided above on behalf of Vendor.

Printed Name:

Official Title:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________________, 20____, by

_______________________, as __________________ of __________________________, a

________________________________ authorized to do business in the State of Florida on behalf of the company/corporation. They ☐ are personally known to me or ☐ have produced

___________________________ as identification.

TOH-310

v: 03/2024

Byrd Anti-Lobbying Amendment Certification

Instructions: “Vendor(s)”, defined as person or entity seeking to engage in business with the Tohopekaliga Water Authority (“Toho”), must use this form to certify that they will take the requisite “affirmative steps” as discussed below. The terms “Contract” and “Agreement” may be

31 USC § 1352 Compliance Certification

Byrd Anti-Lobbying Amendment

Part 1: Certification for Contracts, Grants, Loans, and Cooperative Agreements

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

A. No Federal appropriated funds have been paid or shall be paid, by or on behalf of Vendor, 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.

B. If any funds other than Federal appropriated funds have been paid or shall 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, Vendor shall complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities", in accordance with its instructions.

C. Vendor 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.

Part 2: Statement for Loan Guarantees and Loan Insurance

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

If any funds have been paid or shall 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 commitment providing for the United States to insure or guarantee a loan, Vendor shall complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities", in accordance with its instructions.

Submission of this statement 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 statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Vendor’s Initials: _______

TOH-310

v: 03/2024

Byrd Anti-Lobbying Amendment Certification knowledge; are over the age of 18 years and otherwise competent to make the above certification; and are authorized to legally bind and make the above certification on behalf of the Vendor.

Under penalties of perjury, the undersigned declares that they have read and understand the contents of the foregoing form. Pursuant to the authority granted to the undersigned by Vendor, Printed Name:

Official Title:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________________, 20____, by _______________________, as

__________________ of __________________________, a ________________________________

TOH-320

v: 04/2024

Drug-Free Workplace Compliance Form

Instructions: “Vendor(s)”, defined as person or entity seeking to engage in business with the Tohopekaliga Water Authority (“Toho”), must use this form to certify that they will take the requisite “affirmative steps” as discussed below. The terms “Contract” and “Agreement” may be

Drug-Free Workplace Compliance Form

Contractor shall comply with all provisions of the Drug-Free Work Place Act of 1988, 41 U.S.C. §8101 et seq., as amended. The Contractor shall commit to comply with this requirement by completing this form and submitting it with its Bid. In order to have a drug-free workplace program, Contractor certifies that it will:

1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

2) Inform employees about the dangers of drug abuse in the workplace, the business’s policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

3) Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1).

4) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than 5 days after such conviction.

5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee’s community by, any employee who is so convicted.

6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of the Project.

Vendor’s Initials: _______

TOH-320

v: 04/2024

Drug-Free Workplace Compliance Form knowledge; are over the age of 18 years and otherwise competent to make the above certification; and are authorized to legally bind and make the above certification on behalf of the Vendor.

Under penalties of perjury, the undersigned declares that they have read and understand the contents of the foregoing form. Pursuant to the authority granted to the undersigned by Vendor, Printed Name:

Official Title:

STATE OF _________________

COUNTY OF _______________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of ________________________, 20____, by _______________________, as

__________________ of __________________________, a ________________________________