2-Attachment A.pdf

AFFIDAVIT

STATE OF ______________________ )

) SS.

COUNTY OF ____________________ )

_________________________________of the city of ________________________________ County of ____________________ State of __________________being duly sworn on her or his oath, deposes and says;

1. That I am the _________________________ (Title of Affiant) of __________________________________(Name of Bidder) and have been authorized by said Bidder to make this Affidavit upon my best information and belief, after reasonable inquiry as to the representations herein.

2. No Officer, Agent or Employee of Jackson County, Missouri is financially interested directly or indirectly what Bidder is offering to sell to the County pursuant to this Invitation (though no representation is made regarding potential ownership of publicly traded stock of bidder).

3. If Bidder were awarded any contract, job, work or service for Jackson County, Missouri, no Officer, Agent or Employee of the

County would be interested in or receive any benefit from the profit or emolument of such.

4. Either Bidder is duly listed and assessed on the tax rolls of Jackson County, Missouri and is not delinquent in the payment of any taxes due to the County or Bidder did not have on December 31, 2025, any property subject to taxation by the County and if bidder is duly listed and assessed on the tax rolls of Jackson County, Missouri, bidder agrees to permit an audit of its records, if requested by the Jackson County Director of Assessment, as they relate to the assessment of Business Personal Property.

5. Bidder has not participated in collusion or committed any act in restraint of trade, directly or indirectly, which bears upon anyone's response or lack of response to the Invitation.

6. Bidder certifies and warrants that Bidder or Bidder's firm/organization is not listed on the General Services Administration's Report of Debarred and/or Suspended Parties.

7. Bidder certifies and affirms its enrollment and participation in a federal work authorization program with respect to the employees working in connection with the contracted services.

8. Bidder certifies and affirms that it does not knowingly employ any person who is an unauthorized alien in connection with the contracted services.

_______________________________ (Name of Bidder)

By: ____________________________ (Signature of Affiant)

_______________________________ (Title of Affiant)

Subscribed and sworn to before me this ______ day of _________________, 20____

NOTARY PUBLIC in and for the County of _______________________________(SEAL)

State of _____________________________

My Commission Expires: ______________________________________________

OFFICE OF THE COUNTY AUDITOR

COMPLIANCE REVIEW OFFICE

415 E 12TH STREET, 2ND FLOOR

KANSAS CITY, MISSOURI 64106

(816) 881-3302

FAX (816) 881-3340

COMPLIANCE@JACKSONGOV.ORG

WWW.JACKSONGOV.ORG/AUDITOR

CERTIFICATE OF COMPLIANCE NOTICE:

All vendors doing business with Jackson County are required to obtain a Certificate of Compliance issued by the Jackson County Compliance Review Office.

A Certificate of Compliance is required to be submitted with any bid response.

Failure to comply with this requirement may result in the REJECTION of a bid.

Vendors may complete a

Certificate of Compliance Application by visiting https://www.jacksongov.org/Government/Departments/Com pliance-Review-Office/Certificate-of-Compliance

A Certificate of Compliance will certify that vendors meet the following requirements:

1. Are duly listed and assessed on the tax rolls of Jackson County and are not delinquent in the payment of any taxes due to the County, or do not have on December 31st of the previous year any property subject to taxation by Jackson

County.

2. Attest and agree to Chapter 6 of the Jackson County Code which prohibits discriminatory practices and promotes Equal Employment Opportunity by contractors doing business with Jackson County.

Certificate of Compliance Application must be submitted five (5) business days prior to a bid response deadline to allow sufficient time to process. A Certificate of

Compliance is not guaranteed if this timeline is not met.

QUESTIONS? Email compliance@jacksongov.org mailto:COMPLIANCE@JACKSONGOV.ORG http://www.jacksongov.org/AUDITOR https://www.jacksongov.org/Government/Departments/Compliance-Review-Office/Certificate-of-Compliance https://www.jacksongov.org/Government/Departments/Compliance-Review-Office/Certificate-of-Compliance mailto:compliance@jacksongov.org

STATEMENT OF CONTRACTOR'S QUALIFICATIONS

(Complete in full, Use attachments if necessary)

Name of Bidder:

Address with Zip Code:

Federal Tax I.D. Number:

Check One: Corporation Partnership Sole Proprietorship

If SOLE PROPRIETORSHIP, state name, address, and phone number of owner:

If CORPORATION:

Date of Incorporation:

Name of State(s) in which incorporated:

President's Name:

Vice-President's Name:

Secretary's Name:

Treasurer's Name:

If PARTNERSHIP:

Is the Partnership: General Limited Association (Check one)

Date of Organization:

Name and addresses of all partners:

1.

2.

3.

GENERAL INFORMATION:

Percent of work to be done under the proposed contract by your own staff:

No. of Permanent Employees:

Geographical Limits of Operation:

No. of years in business:

Have you ever done business under a different name: Yes No (Check one)

If Yes, give Name and Location:

Has contractor ever withdrawn or defaulted on a contractual obligation: Yes No (Check one)

If Yes, state where and why:

STATEMENT OF CONTRACTOR'S QUALIFICATIONS - Continued

Has Contractor ever been sued for breach of any contract? Yes No (Check one)

If Yes, Explain:

List Completed Contracts within the Past Three Years, Including Amount of Each:

List of Current Contracts, Including Amount of Each:

Customer Reference (state name, address, and phone number):

List each subcontractor you plan to use if awarded the contract. If no, so state.

SUBCONTRACTOR'S NAME & PHONE

ITEM OF WORK $ AMOUNT OF CONTRACT MBE/WBE

State any other relevant information concerning Contractor's history, credentials, responsibility, and capabilities (If none, so state):

DBE STATUS Indicate status claimed:

1. Minority Owned Business (MBE) YES____ NO____

African American____ Latino____ Native American____ Asian____ Pacific Islander____

2. Woman Owned Business (WBE) YES____ NO____

3. Small Business YES____ NO____

For consideration as an MBE, WBE or Small Business, a copy of any governmental entity or Minority Supplier Council certification must be attached.

Prepared by (print or type):

Title:

Signature:

Date:

ACKNOWLEDGMENT OF RECEIPT OF ADDENDA

We acknowledge the receipt # of Addenda ______________ for this Invitation to Bid. We understand that additional addenda may be issued up until the Question Response Deadline of 5:00 pm CDT April 7, 2026, and acknowledge that we will be responsible for checking the Bonfire Portal regularly for any new addenda issued.

Signature of Respondent Date

Company Name

Address

City, State, and Zip Phone

JACKSON COUNTY, MISSOURI INVITATION TO BID NO. 26-009 (CONCRETE CLEANING AND SEALING)

ATTACHMENT 1 - BIDDER’S QUOTATION

• Traffic Control if needed will be by Jackson County

• Bidder may add a sheet covering any other items they supply with units, pricing and installation info.

• Bidder may bid on items with the intent to subcontract that item.

• Water and Power by contractor unless otherwise arranged for at the site

• Bidder may bid items 1 and 2, or item 3, or all three items.

CERTIFICATION

SIGNATURE: DATE:

NAME: (Print or Type) PHONE:

TITLE: (Print or Type) MOBILE:

COMPANY NAME: (Print or Type) FAX:

EMAIL ADDRESS: (Print or Type)

Item No.

Description Units Qty Unit Price

Comments

1.

Concrete Cleaning by Power Washing

Sidewalks, drives, bridge decks, bridge rails, and other flatwork.

Mobilization

Each

One per site

Power Wash

SY

0-500

2000 to 3000 psi pressure 2-4 GPM water flow

500-10,000

Over 10,000

2. Concrete Sealing with Silane Aquanil 100 Plus or Approved

Equal

Apply Sealer per Manufacturer

Instructions

0-500

Approved Equal means owner must approve before use.

500-10,000

Over 10,000

3. Mobile Power Washing Equipment and Large Vehicle

Cleaning

½ Day

4-hour day water and power by contractor

Full Day

8-hour day water and power by contractor

BIDDER'S EXCEPTIONS

TO

SPECIFICATIONS/SCOPE OF SERVICES

OF

JACKSON COUNTY, MISSOURI INVITATION TO BID NO. 26-009

Respondent's attention is directed to Paragraph 4 of the General Conditions of this Invitation to Bid. READ THIS PARAGRAPH

CAREFULLY.

The following exceptions to the Specifications of Invitation to Bid No. 26-009 are requested by the undersigned Respondent: (Use additional pages as necessary.)

REFERENCE

PARA # & PAGE #

EXCEPTION REQUESTED

Name of Firm:

Signature of Bidder:

Harry S. Truman, Presiding Judge 1927-1934

JACKSON COUNTY, MISSOURI

MBE/WBE/VBE PARTICIPATION AFFIDAVIT

ITB/RFP/RFQ Number: 26-009

ITB/RFP/RFQ Title: Concrete Cleaning & Sealing Services

Contracting Department: Road & Bridge

Respondent:

I, ________________________________, of lawful age and upon my oath state as follows:

1. This Affidavit is made for the purpose of complying with the provisions of the MBE/WBE/VBE submittal requirements on the above ITB/RFP/RFQ and the MBE/WBE/VBE Program and is given on behalf of the Respondent listed above.

The goals set by Jackson County, Missouri are:

9.5 %MBE 11.7 %WBE 0 %VBE

2. Bidder stipulates that it will utilize a minimum of the following percentages of MBE/WBE/VBE participation in the above bid:

%MBE %WBE %VBE

***INTERNAL USE ONLY***

CUP RECEIVED: CUP APPROVED:

GFE RECEIVED: GFE APPROVED:

CUP REVISED: REVISION APPROVED:

APPROVED GOALS: MBE WBE VBE OTHER

RES/ORD: AMT AWARDED:

NOTES:

OFFICE OF THE COUNTY AUDITOR

COMPLIANCE REVIEW OFFICE

415 E 12TH STREET, 2ND FLOOR

KANSAS CITY, MISSOURI 64106

(816) 881-3302

FAX (816) 881-3340

COMPLIANCE@JACKSONGOV.ORG

WWW.JACKSONGOV.ORG/AUDITOR

ACKNOWLEDGMENT

Respondent acknowledges that it is responsible for considering the effect that any change order and/or amendments changing the total contract amount may have on its ability to meet or exceed the subcontractor participation goals.

List of Intended Subcontractors:

Respondent acknowledges that it is responsible for submitting a List of Intended Subcontractors (LIS) prior to receiving a contract award as a result of its response to the above ITB/RFP/RFQ. This affidavit in conjunction with the LIS constitutes the Contractor’s Utilization Plan (CUP), which sets out the Respondent’s plan to utilize MBE and/or WBE and/or VBE prime and subcontractors on the awarded contract. The CUP is contractually binding and any changes to either document must follow a modification process as described below.

Good Faith Effort:

Respondent further acknowledges that it is responsible for submitting a Good Faith Effort Form if it will be unable to meet the participation goals. A Good Faith Effort Form documents the efforts a respondent puts forth to achieve the MBE and/or WBE and/or VBE goals on a project. Simply stating that goals cannot be met is not considered sufficient.

Contractor Modification Form:

If, at any point during the life of the awarded contract, the contractor needs to substitute an approved subcontractor a Contractor Modification Form must be submitted to the Compliance Review Office.

Any Good Faith Effort or Contractor Modification Form must be approved by the Compliance Review Office.

***Contact the Compliance Review Office for assistance or to request forms. ***

I hereby certify that I am authorized to make this Affidavit on behalf of the Respondent named below and who shall abide by the terms set forth herein. I acknowledge that the assigned values determined by this CUP shall be enforceable under the contract terms and conditions.

Respondent Primary Contact (Print) :____________________________________________________

Title:_____________________________________ Email: ____________________________________

Date:_____________________________________ Phone: ____________________________________

Signature: _______________________________ Date:_______________________________

NOTARIZED:

Subscribed and sworn to before me this _______ day of ________________, 20___.

My Commission Expires: __________________________

NOTARY PUBLIC

Attach Corporate Seal if applicable

LIST OF INTENDED SUBCONTRACTORS

Complete this form and return to the Compliance Office. Attach additional pages as needed.

Contractor Name: _______________________ Bid Number: ____________________________

Description Bidder Response

Company Name: INTERNAL USE ONLY

A. Address line 1: Certifying Agency:

Address line 2 : ________ KCMO Telephone Number : ________ State of MO Contact Name: ________ Other

Email Address: Approved: Y N

Certified ( Check One) : __ MBE __ WBE __ VBE __DBE Approved By: _______

Expiration Date of Certification:

Scope of Work : Contract Value :

Percentage of Contract Award: $ __________________

B. Address line 1: Certifying Agency:

Address line 2 : ________ KCMO Telephone Number : ________ State of MO Contact Name: ________ Other

Email Address: Approved: Y N

Certified ( Check One) : __ MBE __ WBE __ VBE __DBE Approved By: _______

Expiration Date of Certification:

C. Address line 1: Certifying Agency:

Address line 2 : ________ KCMO Telephone Number : ________ State of MO Contact Name: ________ Other Email Address: Approved: Y N Certified ( Check One) : __ MBE __ WBE __ VBE __DBE Approved By: _______ Expiration Date of Certification:

D. Address line 1: Certifying Agency:

Address line 2 : ________ KCMO Telephone Number : ________ State of MO Contact Name: ________ Other

Email Address: Approved: Y N

Certified ( Check One) : __ MBE __ WBE __ VBE __DBE Approved By: _______

Expiration Date of Certification:

E. Address line 1: Certifying Agency:

Address line 2 : ________ KCMO Telephone Number : ________ State of MO Contact Name: ________ Other Email Address: Approved: Y N Certified ( Check One) : __ MBE __ WBE __ VBE __DBE Approved By: _______ Expiration Date of Certification:

F. Address line 1: Certifying Agency:

Address line 2 : ________ KCMO

Telephone Number : ________ State of MO Contact Name: ________ Other Email Address: Approved: Y N Certified ( Check One) : __ MBE __ WBE __ VBE __DBE Approved By: _______ Expiration Date of Certification:

INTERNAL USE ONLY

LIS RECEIVED: _________________________

LIS APPROVED:_______________ LIS NOT APPROVED: ______________

REASON LIS NOT APPROVED:_______________________________________

CHIEF OF COMPLIANCE X_____________________________________________

SIGNATURE