2-Attachment D1 - FTA Proposers.pdf

OFFICE OF CONTRACTING AND PROCUREMENT &

DETROIT DEPARTMENT OF TRANSPORTATION

ATTACHMENT D1: REQUIRED FTA PROPOSER’S FORMS

Any contract/purchase order resulting from this solicitation shall include the forms listed below.

Proposer/Bidder shall complete the required forms and return them, along with the checklist, with the signed bid/proposal document. Failure to submit the required forms shall be a basis for rejection of your bid/proposal.

FORM DESCRIPTION

A Proposer’s Certification Statement B Amendment/Riders D1 Non-Collusion Affidavit D2 Affidavit of Disclosure of Interests F Debarment & Suspensions G Disclosure of Lobbying Activities Q Responsibility of Bidder/Proposer Determination Q1 Respondent Questionnaire Q2 Proposer’s Representation R

S

Certification of Compliance with Drug and Alcohol Policy Testing Program Verification and Acknowledgment

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FORM A: PROPOSER'S CERTIFICATION STATEMENT

The Proposer, ____________________________________________________ (“Proposer”), (Complete Legal Name) hereby certifies the accuracy of the following statements:

1. That the Proposer (check one) is or is not: owned or controlled by a parent company, which owns fifty-one percent (51%) or more of the voting rights or assets of the Proposer; and, if there is a Parent company, that the complete legal name, main office address, and state of incorporation of said parent company is as follows:

Complete Legal Name:

Main Office Address:

State of Incorporation:

2. If the Proposer is a Corporation, that it (check one)_ is or is not: a Michigan

Corporation and, if not, the state in which it is incorporated is as follows:

State of Incorporation (if not Michigan):

3. That, to its knowledge, Proposer’s agents, officers, and employees have not directly or indirectly entered into any agreements, participated in any collusion, or otherwise taken any action in restraint of free and competitive bidding in connection with this bid.

4. That the work specified herein is to be performed in accordance with the affirmative action requirements of these contract documents, and that all of its subcontractors are aware of said requirements and also agree to comply with them.

FORM A 1/3

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5. That Proposer (check one) _____ does or _____ does not: have 50 or more employees and meet one of the following criteria:

a. Proposer has a contract of $50,000 or more, or which may reasonably be expected to total $50,000 or more in any 12-month period; or

b. Proposer is a financial institution that serves as a depository for Government funds in any amount, acts as an issuing or redeeming agent in U.S. savings bonds and notes in any amount, or subscribes to federal deposit of share insurance.

Instructions: Statement 6, below, is required only to the extent that Office of Federal Contract

Compliance Programs (“OFCCP”) affirmative action requirements set forth in 41 CFR Chapter 60, including in Parts 60-1, 60-2, 60-4, 60-20, 60-30, 60-50, 60-741, and 60-742, remain effective, pending

OFCCP’s promulgation of final rulemaking regarding the “Rescission of Executive Order 11246

Implementing Regulations,” (Docket No. OFCCP–2025–0001), initiated pursuant to Executive Order

14173, or similar regulatory action. To complete Statement 6:

• If Proposer “does not” meet the criteria in Statement 5, above, then check “Not Applicable” for both Statements 6a and 6b, below.

• If Proposer “does” meet the criteria in Statement 5, above, then check either “Yes” or “No” for each of Statements 6a and 6b, below, as applicable.

6. That Proposer is in compliance with OFCCP affirmative action requirements set forth in 41 CFR

Chapter 60, including in Parts 60-1, 60-2, 60-4, 60-20, 60-30, 60-50, 60-741, and 60-742, and that

Proposer will secure documentation of compliance with such regulations from its subcontractors, and that:

A. Standard Form 100 (EEO-1) is filed annually on or before the 31st day of March with the Joint Reporting Committee, the U.S. Office of Federal Contract Compliance, or the

U.S. Equal Employment Opportunity Commission.

Yes _____ No _____ Not Applicable _____

B. Proposer has participated in previous contracts or subcontracts subject to the OFCCP affirmative action requirements set forth in 41 CFR Chapter 60.

Yes _____ No _____ Not Applicable _____

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FORM A 2/3

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7. That Proposer will fully comply with applicable DBE requirements, and where possible exceed, such requirements for this project.

8. That Proposer provides a DBE/WBE liaison, as follows:

Name:

Address:

Phone:

Certification: By its duly authorized representative, Proposer hereby certifies the accuracy of the statements set forth above, as applicable to the Proposer and its subcontractors.

Proposer:

(complete legal name of entity)

By:

(signature)

Name:

Title:

(Authorized Representative)

Address:

I, _______________________________, Secretary for the Proposer, attest to the authority of

(Name)

_________________________________________ to execute this bid proposal on behalf of the

(Authorized Representative)

Proposer and its parent company if other than the Proposer.

By: ________________________________________________

(Secretary)

Name:

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FORM A 3/3

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AMENDMENTS/RIDERS

Solicitation No.: __________________________________

Solicitation Title: ______________________________________

The undersigned acknowledges receipt of the following amendments/riders to the request for

Solicitation

Amendment/Rider No. __________, Dated ________________

Company Name: _____________________________________________

Authorized Signature: _________________________________________

Name: _____________________________________________________

(Print)

Title: ______________________________________________________

Date: _____________________________________________________

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FORM B

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Instructions. Completing and submitting this disclosure affidavit fulfills the disclosure requirements of Section 2-

106.2 of the 2012 Detroit City Charter and Section 2-5-34 of the 2019 Detroit City Code of Ordinances, as well as Sections 200.212, .318(c) of the Uniform Guidance found at 2 C.F.R. 200 et seq. Please complete all applicable sections by typing or legibly printing. Where a section does not apply, please check the appropriate box and skip to the next section. If necessary, provide additional information on page 4 or attach additional documents to this disclosure affidavit. This disclosure affidavit must be signed, notarized, and filed with the applicable bid or response to a Notice of Funds Availability (NOFA), as well as with the City of Detroit Board of Ethics, 7737 Kercheval, Suite #213, Detroit, MI 48214 (City Code § 2-5-34(b)).

Note: An “immediate family member” of a person is that person’s spouse, domestic partner, an individual living in the person’s household, or an individual claimed as a dependent or spouse’s dependent under the Internal Revenue Code at 26 USC 1, et seq. (City Charter § 2-105.A.20; City Code § 2-5-3)

Section 1 - Identity of Disclosing Filer (Individual/Contractor/Vendor) (Charter § 2-106.2.2; Code § 2-5-34)

Provide the complete name of the filer (individual or business entity/organization seeking to do business with the City of Detroit) making this disclosure:

Name Street Address City State Zip code Telephone Fax Email

If the filer is a business entity, print the name, title, and contact information of the authorized individual making the disclosure and signing for the business entity, and include the certificate or resolution of authority authorizing the individual as an attachment to this affidavit.

Name Title

Telephone Fax Email

Section 2 - Financial Interests in Contracts or Matters Pending Before City (Charter § 2-106.2.1(a), (b); Code § 2-5- 34(a)(1), (2))

The above-named contractor or vendor; its direct and/or indirect owners, officers, directors, and managers; and/or an immediate family member of any owner, officer, director, or manager thereof has (if checked, complete rest of section below) does not have (if checked, skip to next section) a direct or indirect financial interest in the following matters that are pending before the Detroit City Council or the following office, department, or agency of the City

Matter

Interested Party (if an immediate family member, please provide an address and phone number and the nature of the relationship to the filer): Name

Street Address

City State Zip code

Telephone Relationship

FORM D1: DISCLOSURE OF INTERESTS (1/7)

AFFIDAVIT OF DISCLOSURE OF INTERESTS

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Nature of financial interest

Estimated value of the financial interest

Section 3 - Interests in Property Subject to Decision by City (City Charter § 2-106.2.1(c); City Code § 2-5-34(a)(3))

The above-named contractor or vendor; its direct and/or indirect owners, officers, directors, and managers; and/or an immediate family member of any owner, officer, director, or manager thereof has (if checked, complete rest of section below) does not have (if checked, skip to next section) an interest in real or personal property that is subject to a decision by the City regarding the purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement or a development agreement.

Interested Party (if an immediate family member, please provide an address and phone number and the nature of the relationship to the filer): Name

Street Address

City State Zip code

Telephone Relationship

Description of real or personal property

Nature of interest

Estimated value of the interest

Section 4 - Immediate Family Members Employed by or Seeking Employment with City (City Charter § 2- 106.2.1(e); City Code § 2-5-34(a)(5))

Please identify any immediate family member of the filer, including any immediate family members of a direct or indirect owner, officer, director, or manager thereof, who is currently employed by or applying for employment with the City of Detroit.

If none, check here and skip to next section; otherwise, complete rest of section below:

Name

Street address

City State Zip code

Phone

Nature of relationship to filer

Department/agency employed by or seeking employment with

Position held or sought

FORM D1: DISCLOSURE OF INTERESTS (2/7)

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Section 5 - Persons with Financial Interest in Contractor’s/Vendor’s Matters Pending Before City (City Charter § 2-106.2.2; City Code § 2-5-34(a)(6), (7))

Please identify all persons or entities having a direct or indirect financial interest in any matter the contractor or vendor has pending before the Detroit City Council or before any office, department, or agency of the City. Note that the term “financial interest” includes, but is not limited to receipt of a thing of value (either presently or in the future).

Complete on additional page(s), if necessary.

If none, check here and skip to next section; otherwise, complete rest of section below Name Street Address City State Zip code Contract or matter in which the person or entity named has a direct or indirect financial interest in the following matters that are pending before the Detroit City Council or the following office, department, or agency of the City:

Nature of financial interest Estimated value of the financial interest

Section 6 – Contractor/Vendor’s Role In The Solicitation Please identify whether the Contractor/Vendor contributed information, expertise or in any other way participated in the creation of the project underlying the Solicitation, including, but not limited to, participation in the creation of the scope of the project, the requirements of the project, or the budget required for the project.

Complete on additional page(s), if necessary.

If the Vendor answers this question in the negative, please check here and skip to the next section; otherwise, complete the rest of the section below. Please use extra sheets if necessary.

Describe the nature and extent of the Vendor’s contribution:

List the City employees with whom the Vendor assisted with the Solicitation:

Please list any of Vendor’s subcontractors or proposed subcontractors that contributed information, expertise or in any other way participated in the creation of the project underlying the Solicitation, including, but not limited to, participation in the creation of the scope of the project, the requirements of the project, or the budget required for the project, along with the nature and extent of the subcontractor’s contribution:

FORM D1:DISCLOSURE OF INTERESTS (3/7)

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Section 7 - Affirmation of Accuracy of Disclosure (City Charter § 2-106.2.3; City Code § 2-5-34(b))

I understand that the information provided in this disclosure will be relied upon by the City of Detroit in evaluating the proposed bid, solicitation, contract, or lease. I swear [or affirm] that the information provided is accurate. If I am signing on behalf of an entity, I swear [or affirm] that I have made a good faith and reasonable effort to verify the information provided herein, and further, that I have the authority to provide this disclosure on behalf of the entity.

Sign name:

Print name:

Sworn and subscribed to before me on , 20 by , the [name] [title] of the and am an authorized representative of that entity.

[legal entity/company]

Sign:

Print:

Notary Public, County, Michigan, Acting in County

My Commission Expires:

Notary Seal

FORM D1: DISCLOSURE OF INTERESTS (4/7)

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ADDITIONAL INFORMATION

FORM D1: DISCLOSURE OF INTERESTS (5/7)

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REFERENCES FOR DISCLOSURES BY CONTRACTORS AND VENDORS

2012 Detroit City Charter

Sec. 2-105. - Definitions and Rules of Construction.

A. As used in this Charter:

20. Immediate family member means a Public Servant’s spouse, domestic partner, individual who lives in the Public Servant’s household or an individual claimed by a Public Servant or a Public Servant’s spouse as a dependent under the United States Internal Revenue Code at 26 USC 1, et seq.

Sec. 2-106.2. - Disclosures.

1. Except as otherwise provided by applicable law, a Public Servant who exercises significant authority shall disclose:

a. Any financial interest, direct or indirect, that he or she or an immediate family member has in any contract or matter pending before City Council.

b. Any financial interest, direct or indirect, that he or she or an immediate family member has in any contract or matter pending before or within any office, department or agency of the City.

c. Any interest that he or she, or an immediate family member has in real and personal property that is subject to a decision by the City regarding purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement or a development agreement.

d. Campaign contributions and expenditures, in accordance with applicable laws.

e. The identity of any immediate family member employed by the City or who is making application to the City.

2. In addition to compliance with subsection (1) above, contractors and vendors shall disclose:

a. The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter the vendor or contractor has pending before City Council.

b. The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter the vendor or contractor has pending before or within any office, department, or agency of the City.

3. The above disclosures shall be made in writing and be made by sworn, notarized affidavit, in accordance with City ordinance and applicable laws.

FORM D1: DISCLOSURE OF INTERESTS (6/7)

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2019 Detroit City Code of Ordinances

Sec. 2-5-3 – Definitions.

Immediate family member means:

(1) A public servant’s spouse;

(2) A public servant’s domestic partner;

(3) An individual claimed by a public servant or a public servant’s spouse as a dependent under the United States Internal Revenue Code, being 26 USC 1 et seq.; or

(4) An individual who lives in the household of a public servant.

Sec. 2-5-34. - Disclosure of interests by contractors and vendors.

(a) Except as otherwise provided for by applicable law, all contractors and vendors doing business with the City of Detroit shall disclose the following:

(1) Any financial interest, direct or indirect, that the contractor or vendor or an immediate family member has in any contract or matter pending before City Council;

(2) Any financial interest, direct or indirect, that the contractor or vendor or an immediate family member has in any contract or matter pending before or within any office, department or agency of the City;

(3) Any interest that the contractor or vendor, or an immediate family member, has in real or personal property that is subject to a decision by the City regarding purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement, or a development agreement;

(4) Campaign contributions and expenditures in accordance with applicable law;

(5) The identity of any immediate family member employed by the City or who is making application to the City;

(6) The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter that the contractor or vendor has pending before City Council;

(7) The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter that the contractor or vendor has pending before or within any office, department, or agency of the City.

(b) All disclosures that are required under Subsection (a) of this section shall be made, in writing, on a form that is created by the Law Department and sworn to in the presence of a notary public. After completion, the form shall be filed with the Board of Ethics, which shall forward a complete copy of the form to the applicable department director or agency head.

FORM D1: DISCLOSURE OF INTERESTS (7/7)

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NON-COLLUSION AFFIDAVIT

Negotiation No.

Negotiation Title:

State of :

County of : s.s.

I state that I am of , and that I am authorized to make this affidavit on behalf of my firm, and its owners, directors, and, officers. I am the person responsible in my firm for the price(s) and the amount of this RFP.

I state that:

The price(s) and amount of this proposal has been arrived at independently and without consultation, influence, communication or agreement with (i) any other contractor, vendor or potential vendor, or (ii) the City of Detroit, including any of its departments, boards, commissions, officers, employee, or agents.

Neither the price(s) nor the amount of this proposal, and neither the approximate price(s) nor approximate amount of this proposal, have been disclosed to any other firm or person who is a vendor or potential vendor, and they will not be disclosed before the bid opening.

No attempt has been made or will be made to induce any firm or person to refrain from responding to this contract, or to submit a proposal higher than this proposal, or to submit any intentionally high or noncompetitive proposal or other form of complementary proposal.

The proposal of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit a complementary or other noncompetitive proposal, including, but not limited to, any agreement to circumvent any regulatory or City requirements that may be applicable.

, its affiliates, subsidiaries, officers, directors, and employees are not currently under investigation by any governmental agency and have not in the last five years been convicted or found liable for any act prohibited by state or federal law in any jurisdiction, involving conspiracy or collusion with respect to submitting a proposal on any public contract, except as follows:

I state that understands and acknowledges that the above representations are material and important, and will be relied on by the City of Detroit in awarding the contract(s)/ purchase order(s) for which this proposal is submitted. I understand and my firm understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from the City of Detroit’s Office of Contracting and Procurement of the true facts relating to the submission of this RFP.

Printed Name & Title of Authorized Representative:

Signature of Authorized Representative:

Date:

**This Document MUST be Notarized**

Signature of Notary:

Printed Name of Seal of Notary:

My Commission Expires: / /

FORM D2

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OFFICE OF CONTRACTING AND PROCUREMENT

AND THE

DETROIT DEPARTMENT OF TRANSPORTATION

DEBARMENT AND SUSPENSION

POLICY

Unless otherwise permitted by law, any person that is debarred, suspended, or voluntarily excluded may not take part in any covered transaction, either as a participant or a principal, during the period of debarment, suspension, or voluntary exclusion. Accordingly, DDOT as an FTA recipient, may not enter into any transaction with such debarred, suspended, or voluntarily excluded persons during such period.

A certification process has been established by 49 C.F.R Part 29, as a means to ensure that debarred, suspended or voluntarily excluded persons do not participate in a federally assisted project. The inability of a person to provide the required certification will not necessarily result in denial of participation in a covered transaction. A person that is unable to provide a positive certification as set forth in FTA Circular

4220.1G must submit a complete explanation attached to the certification. FTA will consider the certification and any accompanying explanation in determining whether or not to provide assistance for the project. Failure to furnish a certification or an explanation may disqualify that person from participating in the project. In addition, each potential contractor for a major third party contract must provide to DDOT, a certification for a primary participant. Each potential third party contractor and subcontractor under a major third party contract must provide to DDOT a certification for lower-tier participant. In general, lower level employees or procurements of less than $25,000 will not be covered by the certification procedures, except in the case of procurements with individuals that would have a critical influence on or substantive control over the project; nevertheless a participant is not authorized involve a lower employee or enter into a contract of less than $25,000 with a person actually known by the participant to be debarred, suspended or voluntarily excluded.

CERTIFICATION OF PRIMARY PARTICIPANT REGARDING DEBARMENT,

SUSPENSION, AND OTHER RESPONSIBILITY MATTERS

Proposers/Proposer’s Name __________________________________________________ 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 voluntarily excluded from covered transactions by any Federal Department or Agency;

2. Have not within a three-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 or 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 government entity

(Federal, State, or local) with commission of any of the offenses enumerated in paragraph (2) of this certification; and

4. Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State, or local) terminated for cause or default. If you are unable to certify to any of the statements in this certification, attach an explanation to this certification.

FORM F (1/2)

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DETROIT DEPARTMENT OF TRANSPORTATION

THE PROPOSER/PROPOSER _________________________________________________,

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. SECTIONS 3801 ET SEQ. ARE

APPLICABLE THERETO.

Signature and Title of Authorized Official

The undersigned chief legal counsel for ______________________________________ hereby certifies that the _______________________________ has authority under State and Local law to comply with the subject assurances and that the certification above has been legally made.

Signature of Applicant’s Attorney

CERTIFICATION OF LOWER-TIER PARTICIPANTS REGARDING DEBARMENT,

SUSPENSION, AND OTHER INELIGIBILITY AND VOLUNTARY EXCLUSION

The Lower Tier Participant (potential subcontractor under a major third party contract), ________________________________, 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.

(If the Lower-Tier Participant (potential subcontractor under a major third party contract) is unable to certify to any of the statements in this certification, such participant shall attach an explanation to this proposal).

THE LOWER-TIER PARTICIPANT (POTENTIAL SUBCONTRACTOR UNDER A THIRD

PARTY CONTRACT) _________________________________________, CERTIFIES OR

AFFIRMS THE TRUGHFULNESS AND ACCURACY OF THE CONTENTS OF THE

STATEMENTS SUBMITTED OR WITH THIS CERTIFICATION AND UNDERSTANDS

THAT THE PROVISIONS OF 31 U.S.C SECTION 3801 ET SEQ. ARE APPLICABLE

THERETO.

Signature and Title of Authorized Official

The undersigned chief legal counsel for the __________________ hereby certifies that the

_______________________ has authority under Stats and Local law to comply with the subject assurances and that the certification above has been legally made.

Signature of Applicant’s Attorney

Date

DEBARMENT AND SUSPENSIONS

FORM F (2/2)

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DETROIT DEPARTMENT OF TRANSPORTATION

DISCLOSURE OF LOBBYING ACTIVITIES

Section 319 of the Fiscal Year 1990 Department of the Interior and Related Agencies

Appropriation Act. Public Law 101-121 contains a prohibition on the use appropriated funds for

“influencing or attempting influence” federal officials in connection with grants, cooperative agreements or contracts.

The law became effective December 23, 1989 and requires that all FTA grantees and contractors, in order to remain eligible for federal funds, must certify that no federal funds are used to influence federal employee, Members of Congress and Congressional staff regarding specific grants and contracts. The law also requires that contractors who use non-federal funds for lobbying on behalf of specific projects and proposals submit disclosure documentation when these efforts are intended to influence the decision of federal officials. These provisions apply to grants, contracts and cooperative agreements of $100,000 or more.

The attached Form G “Disclosure of Lobbying Activities” must be completed and submitted to

DDOT in order for the Proposer to be considered eligible for a contract award.

CERTIFICATION OF RESTRICTIONS ON LOBBYING

(To be submitted with each bid or offer exceeding $100,000)

I, ____________________________________________________, hereby certify on behalf of

(Name and Title of Contractor’s Official)

_____________________________________ that:

(Name of Contractor)

(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 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.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for making lobbying contacts to an officer or employee of any agency, a Member of Congress, and 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 [as amended by “Government wide Guidance for New Restrictions on Lobbying” 61

Fed. Reg. 1413 (1/19/96), Note: Language in paragraph (2) herein has been modified in accordance with Section 10 of the Lobbying Disclosure Act of 1995 (P.L. 104-65, to be codified at 2 U.S.C. 1601, et seq.)]

FORM G (1/2)

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DETROIT DEPARTMENT OF TRANSPORTATION

DISCLOSURE OF LOBBYING ACTIVITIES

(3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients 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 31, U.SC. A 1352 (as amended by the Lobbying

Disclosure Act of 1995). 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. [Note:

Pursuant to 31 U.S.C. A 1352©(i)-(2)(a), any person who makes a prohibited expenditure or fails to file or amend a required certification or disclosure form shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each expenditure or failure.]

The Contractor, ____________________________________, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. A 3801, et seq., apply to this certification and disclosure, if any.

Signature of Contractor’s Authorized Official: ____________________________________

Name and Title of Contractor’s Authorized Official: _______________________________

Date: ____________________________

FORM G (2/2)

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DETROIT DEPARTMENT OF TRANSPORTATION

FORM Q (1/2)

INSTRUCTIONS

RESPONSIBILITY OF PROPOSER/PROPOSER

1. All Proposers/Proposers submitting a response to a Request for Proposals must complete and submit with its Proposal the attached “Q” Forms. If required for Request for Quote (RFQ), the apparent low Proposer shall receive written notification requesting submission of Forms Q-3 and

Q-4. Completed Forms Q-3 and Q-4 shall be submitted to the City of Detroit Office of Contracting and Procurement within 10 calendar days of the request.

2. Please state “not applicable” in questions clearly not applicable to Proposer/Proposer in connection with this solicitation. Do not omit any question. If any representation is not accurate and complete to the time Proposer/Proposer signs the “Q” Forms, Proposer/Proposer must, as a part of its Bid/Proposal, identify the provision and explain the reason in detail in the space provided below. If additional space is needed, add additional sheet(s) to the “Q” Forms. If this space is left blank, Proposer/Proposer shall be deemed to have represented and warranted the accuracy and completeness of the representations on these Forms:

3. All information must be legible.

4. Completed forms must be signed by a partner (if partnership), a duly authorized officer or individual (If a corporation), or a principal (If a sole proprietorship).

5. The term “Proposer” includes the term “Proposer” and also refers to the firm awarded the

Contract. The term “Proposal” includes the term “Bid”.

6. If during the performance of the Contract either of the following occurs, the Proposer shall promptly give notice of the situation, in writing, to the Chief Procurement Officer, and cooperate with the City of Detroit’s review investigation of such information

i) Proposer has reason to believe that any representation or answer to any question contained in the “Q” Forms was not accurate or complete at the time the Forms were signed; or

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DETROIT DEPARTMENT OF TRANSPORTATION

ii) Events occur of circumstances changes so that an answer to any question in Part

IV is no longer accurate or complete.

In the Office of Contracting and Procurement’s sole discretion, the following shall constitute grounds for the City of Detroit to take remedial action, up to and including immediate termination of the Contract for convenience without payment for profit and overhead for wok not performed, if, i) Proposer fails to notify the City of Detroit’s Chief

Procurement Officer as required by “6” above.

7. The City of Detroit reserves the right to inquire further with respect to the Proposer’s responses; and Proposer consents to such further inquiry and agrees to furnish all relevant documents and information as requested by the City of Detroit’s Office of Contracting and

Procurement. Any response to this document prior or subsequent to the Proposer’s Proposal which is or may be construed as unfavorable to the Proposer will not necessarily automatically result in a negative finding on the question of Proposer’s responsibility or a decision to terminate the Contract if it is awarded to Proposer.

FORM Q (2/2)

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DETROIT DEPARTMENT OF TRANSPORTATION

FORM Q1 (1/4)

Solicitation Number: _______________________________

Solicitation Title: __________________________________

IDENTITY OF PROPOSER

1. Proposer's Full Legal Name: __________________________________________

2. The Proposer represents that it operates as the following form of legal entity: (Check whichever applies and fill in any appropriate blanks.)

☐ an individual or sole proprietorship

☐ a general partnership

☐ a limited partnership

☐ a joint venture consisting of: ___________________________________ and _______________________________________________________

(List all joint ventures on a separate sheet, if this space is inadequate.)

☐ a non-profit organization

☐ a corporation organized or incorporated under the laws of the following state or country:

________________________ on the following date: ______________

3. Proposer's federal taxpayer identification number: ________________________

4. Proposer's legal address: ____________________________________________

Telephone Number: (____) _____________ Fax Number: (____) ____________

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DETROIT DEPARTMENT OF TRANSPORTATION

5. Proposer's local or authorized point of contact address:

Name:___________________________ Title:____________________________

Address: _________________________________________________________

Telephone Number: (____) _________________ Fax Number: (____) ________

6. a. If Proposer is a corporation, has the Certificate of Incorporation been previously filed with the Detroit Department of Transportation?

YES NO If answer is "NO", attach a certified copy.

b. Attach a certified copy of the By-Laws and Resolution of the Corporation giving the names and titles of the corporate officers other than President, as well as non-officer employees, who are authorized to sign contracts, bonds, bills of sale and other legal instruments in connection with the Contract, if the same have not been previously filed.

c. If a foreign corporation, has proof of authority to transact business in the State of

Michigan been previously filed with the City of Detroit’s Office of Contracting and Procurement?

_ _YES _NO If answer is "NO", attach a certified copy.

In the event that any of Proposer's previous submissions to Office of Contracting and Procurement in response to the above (questions a-c) no longer represent the

Proposer's current corporate status, Proposer must attach a certified copy of any documents amending its previous submissions.

7. a. How long has the Proposer been in business? _____________

b. Have Proposer's major shareholders, officers or principals been in business under another name? If so, identify name and dates used.

c. How many years’ experience as a prime contractor/consultant?________

FORM Q1 (2/4)

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DETROIT DEPARTMENT OF TRANSPORTATION

d. How many years’ experiences as a subcontractor/sub-consultant?

8. If your firm considers itself to be an MBE, WBE or DBE, then within the past three years has the Proposer had any MBE, WBE, or DBE certification certification) revoked or, if you made application for such certification during such period, was same denied?

YES NO If answer is "NO", attach a certified copy

9. List below the names, business addresses, titles, and telephone numbers of the following people: if a corporation, identify the president, executive officers, and any other officers directly responsible for this Proposal; if a partnership, identify the partners directly responsible for this Proposal; or, if another form of business entity, identify the principals directly responsible for this Proposal.

Name: _________________________________________________________________

Title:

Address:_______________________________________________________________

Phone Number: ( )___________________________________________

Name: _________________________________________________________________

Title:

Address:_______________________________________________________________

Phone Number: ( )___________________________________________

Name: _________________________________________________________________

Title:

Address:_______________________________________________________________

Phone Number: ( )___________________________________________

FORM Q1 (3/4)

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DETROIT DEPARTMENT OF TRANSPORTATION

Name: _________________________________________________________________

Title:

Address:_______________________________________________________________

Phone Number: ( )___________________________________________

Name: _________________________________________________________________

Title:

Address:_______________________________________________________________

Phone Number: ( )___________________________________________

Authorized Signature Date

Printed Name Title

Phone

UNSIGNED BIDS/PROPOSALS CANNOT BE CONSIDERED.

FORM Q1 (4/4)

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DETROIT DEPARTMENT OF TRANSPORTATION

FORM Q2

Solicitation Number: _______________________________

Solicitation Title: __________________________________

FORM Q2: PROPOSER’S REPRESENTATION

1. By submission of this Proposal, the undersigned, and each person signing on behalf of the undersigned, certifies that in the case of a joint proposal each party thereto certifies, as to its own organization, under penalty of perjury, that to the best of its knowledge and belief:

a. the prices in this Proposal have been arrived at independently without collusion, consultation, communication, or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other proposer or with any competitor;

b. unless otherwise required by law, the prices which have been quoted in this Proposal have not been knowingly disclosed by the Proposer and will not knowingly be disclosed by the undersigned prior to opening, directly or indirectly, to any other proposer or to any competitor prior to the closing date for proposals;

c. no attempt has been or will be made by the Proposer to induce any other person, partnership or corporation to submit or not to submit a proposal for the purpose of restricting competition;

A Proposal shall not be considered for award nor shall any award be made where a, b, and c, above, have not been complied with provided, however, that if in any case the Proposer cannot make the foregoing certification, the

Proposer shall so state and shall furnish with the Proposal a signed and notarized statement which sets forth in detail the reasons therefore.

Where a, b, and c, above, have not been complied with, the Proposal shall not be considered for award nor shall any award be made unless the Chief Procurement Officer, or his/her designee, determine that such disclosure was not made for the purpose of restricting competition.

The fact that a Proposer (i) has published price lists, rates, or tariffs covering items being procured; (ii) has informed prospective customers of proposed or pending publication of new or revised price lists for such items; or (iii) has sold the same items to other customers at the same prices being proposed, does not constitute, without more, a disclosure within the meaning of a, b, and c above.

1. It is the City of Detroit’s policy to award contracts to only those offerors whose objectivity is not impaired because of any related past, present, or planned interest, financial or otherwise, in organizations regulated by City of Detroit or in organizations whose interests may be substantially affected by Departmental activities.

a. No appointed or elected official, member or other officer or employee of the City of Detroit, during the performance of this Contract, or in the supplies, work or business to which it relates, or in any portion of the profits thereof, has been or will be offered or given any tangible consideration in connection with this

Proposal/Contract

b. Proposer covenants that neither Proposer nor, to the best of the Proposer’s knowledge after diligent inquiry, any director, officer, owner or employee of the Proposer has any interest nor shall they acquire any interest, directly in indirectly, which would conflict in any manner or degree with the faithful performance of the Contract hereunder.

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DETROIT DEPARTMENT OF TRANSPORTATION

FORM Q2

c. In the event Proposer has no prior knowledge of a conflict of interest as set forth in “a” and “b” above and hereafter acquires information which indicates that there may be an actual or apparent violation of any of the above, Proposer shall promptly bring such information to the attention of the Chief Procurement officer.

Proposer shall thereafter cooperate with City of Detroit review and investigation of such information and comply with any instruction it receives from the Chief Procurement Officer in regard to remedying the situation.

3. The following statements apply to any proposal or contract between Proposer and the City of Detroit: (In the event of a “Yes”, the City of Detroit reserves the right to inquire further with respect thereto.)

a. Statement (b) thru (o) below also apply to i) Proposer’s Parent, subsidiaries and affiliates (if any),

ii) any joint venture, including its individual members and any other form of partnership (including its individual members) which includes: Proposer or Proposer’s parent, subsidiaries, or affiliates; iii) Proposers directors, officers, principals, and managerial employees and any person or entity with a 10% or more interest in Proposer; iv) any legal entity controlled, or 10% or more of which is owned by Proposer, of by any director, officer, principal, or managerial employee of Proposer, or by any person or entity with a 10% or more interest in Proposer; or v) any parent, subsidiary or affiliate of any legal entity controlled, or 10% or more of which is owned by Proposer, or by any director, officer, principal or managerial employee of

Proposer, or any person or entity with a 10% or more interest in Proposer.

b. Has the Proposer been declared not responsible? (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

c. Has the Proposer been debarred, suspended, proposed for debarment, declared ineligible, voluntarily excluded, or otherwise disqualified from bidding, proposing, or contracting?

Yes ( ) No ( )

d. Has the Proposer been a defaulter, as principal, surety or otherwise.

Yes ( ) No ( )

e. Has the government or other public entity requested or required enforcement of any of its right under a surety agreement on the basis of a Proposer default or in lieu of declaring Proposer in default. (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

f. Is the Proposer in arrears upon a contract or debt. (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

g. Are there any proceedings pending relating to Proposer’s responsibility, debarment, suspension, voluntarily exclusion or qualifications to receive a public contract. (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

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DETROIT DEPARTMENT OF TRANSPORTATION

FORM Q2

h. List the name and address of each person or legal entity which has a 10% or more ownership or control interest in Proposer (attach additional pages as needed).

i. Has been convicted by plea or verdict of guilty of, or pleaded nolo contenders to, a misdemeanor or felony in any federal, state or local court. (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

j. Having pending any state or federal grand jury or court an indictment or information for the commission of a crime which has not been favorable terminated. (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

k. is the subject of any pending investigation by any grand jury, commission, committee or other entity or agency or authority of any state or the federal government in connection with the commission of a crime.

(Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

l. Is currently disqualified from selling or submitting bids/proposals to or receiving awards from or entering into any contract with any federal, state or local government entity, any public authority or any public entity. (Check

“Yes” or “No”, as appropriate.)

Yes ( ) No ( )

m. Within the past five years, has refused to testify or to answer and question concerning a bid or contract with any federal, state, or local government entity, any public authority or other public entity when called before a grand jury or other committee, agency or forum which is empowered to compel the attendance of witnesses and examine them under oath, upon being advised that neither the person’s statement nor any information or evidence derived from such statement will be used against that person in any subsequent criminal proceeding. (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

n. Is currently disqualified from selling or submitting a bid to, or receiving an award from, or entering into public entity or public authority within the State of Michigan because, within the past five years, such entity or person refused to testify or to answer any relevant question concerning a transaction or contract with the State of Michigan, any political subdivision of the State of Michigan, or a public authority or a public department, agency or official of the State of Michigan or of a political subdivision of the State of Michigan, when called before a grand jury or other state or local department, commission or agency which is empowered to compel the attendance of witnesses and examine them under oath, upon being advised that neither that person’s statement nor any information or evidence derived from such statement will be used against that person in any subsequent criminal proceeding. (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

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DETROIT DEPARTMENT OF TRANSPORTATION

FORM Q2

o. Has within a three 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. (Check “Yes” or “No”, as appropriate.)

Yes ( ) No ( )

p. Explain any “YES” answers to (a) thru (o) in the space provided below (attach additional pages as needed.

ADDITIONAL QUESTIONS

1. List all Proposer’s employees:

a. who are currently employees of the City of Detroit.

b. who within the past two years have been City of Detroit employees who were involved on behalf of Proposer with the preparation of this Proposal or would be involved in the performance of the

Contract if it is awarded to Proposer.

2. Does Proposer have a subsidiary or affiliate:

Yes ( ) No ( ) If answer is “Yes”, list firm name, address and affiliation

3. Is Proposer a subsidiary of another entity:

Yes ( ) No ( ) If answer is “Yes”, list firm name, address and affiliation

4.

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DETROIT DEPARTMENT OF TRANSPORTATION

FORM Q2

4. Does Proposer, and director, officer, principal or managerial employee of Proposer, or any other person or entity with a 10% or more interest in Proposer have an interest of 10% or more in any other firm or legal entity?

Yes ( ) No ( ) If answer is “Yes”, list individuals name and firm or entity

Signature: __________________________________

Title: ______________________________________

Firm:…