2026717 - RFP - Forms.pdf

PROPOSAL CERTIFICATION FORM

PROFESSIONAL SERVICES FOR

PALM BEACH COUNTY FLASHING YELLOW ARROW DEMONSTRATION

PROJECT ENGINEERING SERVICES - FEDERALIZED

PROJECT # 2026717

(Proposer must complete, sign and return with proposal)

I hereby certify that I am submitting my company’s proposal and understand that by virtue of executing and returning with this proposal this Proposal Certification Form, I certify that all information is correct and I understand the contents and accept the conditions of the Request for

Proposal and this Proposal Certification Form.

Acknowledgment of Supplements:

Proposer has checked the County’s on-line Vendor Self-Service (VSS) system at https://pbcvssp.co.palm-beach.fl.us/webapp/vssp/AltSelfServicehttps://pbcvssp.co.palm-beach.fl.us/webapp/vssp/AltSelfService for any Supplements to this RFP that may have been issued prior to the deadline for receipt of proposals and understands all supplements issued by the County.

The Proposer acknowledges the following supplement(s):

Supplement # dated Supplement # dated

PROPOSER (firm name):

PRINT NAME OF AUTHORIZED REPRESENTATIVE: ______

SIGNATURE OF AUTHORIZED REPRESENTATIVE: __________________

TITLE: _________ DATE: __________________

https://pbcvssp.co.palm/ https://pbcvssp.co.palm-beach.fl.us/webapp/vssp/AltSelfService https://pbcvssp.co.palm-beach.fl.us/webapp/vssp/AltSelfService

CONSULTANT RESPONSIBILITY DISCLOSURE FORM

BEFORE COMPLETING THIS FORM, READ

EACH QUESTION CAREFULLY AND ANSWER COMPLETELY

(This disclosure must be completed, signed and returned with proposal)

CONSULTANT RESPONSIBILITY DISCLOSURE

Entity Name: ___________________________________________________________________________________

Entity Address: _________________________________________________________________________________

City ____________________________________________ State __________ Zip ________-______

Phone Number (______) ______-________

E-MAIL: _____________________________

Contact Name: ______________________ Title __________________

Entity Classification: Corporation _____ , Partnership ___ Sole Proprietorship _____ , Other _____(please explain)

(If Corporation, State where incorporated _____ , Date of Incorporation ____/____/______) ________________

All applicants answer this:

1. How many years has your organization been operating under your present business name? ____________

2. List all previous business names of your organization:

3. How many years’ experience has your organization had as a:

Design Consultant _____________

4. Enter your Federal Employer Identification Number (FEIN): __________________________

Dunn & Bradstreet Number (D&B): ____________________________________

The term “affiliate” means a predecessor or successor of a firm under the same, or substantially the same, control or a group of business entities which are connected or associated so that one entity controls or has the power to control each of the other business entities. The term “affiliate” includes the officers, directors, and shareholders active in management. The ownership by one business entity of a controlling interest in another business entity or a pooling of income among business entities is evidence that one business entity is an affiliate of another.

PLEASE COMPLETE QUESTIONS 5 and 6 USING THE ABOVE DEFINITION OF “AFFILIATE”.

5. Has the firm, an affiliate, an officer, a director, an agent, an employee or a member of your firm, or that of an affiliate, ever been indicted, had criminal information filed against it, pled guilty, pled no contest, or been convicted of any act prohibited by state or federal criminal law which involves fraud, bribery, collusion, conspiracy, violation of state or federal antitrust laws, or material misrepresentation committed in any federal or state jurisdiction with respect to any public contract?

Yes ______ No ______ If yes, please explain in detail _________________________________________

6. Please state whether your firm or any of your affiliates are presently or have ever been barred or suspended from bidding, proposing or contracting on any public contract(s)?

Yes ______ No ______ If yes, please explain in detail _________________________________________

7. Within the past 10 years, has your firm failed to successfully complete any work awarded to you?

Yes ______ No ______ If yes, please explain in detail _________________________________________

8. Has your firm or any of its owners, officers and directors ever filed for protection of the bankruptcy court, have pending any petition in bankruptcy court or made an assignment for the benefit of creditors?

Yes ______ No ______ If yes, please explain in detail _________________________________________

9. Total number of full time, regular employees in your company: ___________ If this number has changed in the past 2 years, please explain ______________________________________________________________________________

10. Consultant hereby represents and warrants that, if selected, the firm has sufficient staff and financial resources to complete the Project.

Remainder of this page left blank intentionally

CERTIFICATION

I, the undersigned authority, hereby certify that the information submitted herewith, including any attachment hereto, is true and accurate to the best of my knowledge and belief under perjury of law.

By:

(Print)

(Signature)

Title:

Date:

STATE OF FLORIDA

COUNTY OF PALM BEACH

The foregoing instrument was acknowledged before me by means of ___ physical presence OR ___ online notarization, this day of , 20 , by , who is personally known to me or who has produced as identification and who did not take an oath.

Notary Public

CONFLICT OF INTEREST DISCLOSURE FORM

(Must be completed by Proposer and any subconsultants and returned with proposal)

PALM BEACH COUNTY CONFLICT OF INTEREST DISCLOSURE FORM

CONSULTANT/SUBCONSULTANT represents that it presently has no interest, either direct or indirect, which would or could conflict in any manner with the performance of services for the County, except as follows:

(Attach additional sheets as needed.)

CONSULTANT/SUBCONSULTANT further represents that no person having any interest shall be employed for said performance. By signing below, CONSULTANT/SUBCONSULTANT certifies that the information contained herein is true and correct and constitutes all current potential conflicts of interest which may influence or appear to influence CONSULTANT/SUBCONSULTANT’S judgment or quality of services being provided to the County.

CONSULTANT/SUBCONSULTANT shall promptly notify the COUNTY in writing by certified mail of all potential conflicts of interest that may arise in the future through any prospective business association, interest or other circumstance which may influence or appear to influence

CONSULTANT/SUBCONSULTANT’S judgment or quality of services being provided to the County.

Such written notification shall identify the prospective business association, interest or circumstance, the nature of work that CONSULTANT/SUBCONSULTANT may undertake and request an opinion of the

COUNTY as to whether the association, interest or circumstance would, in the opinion of the COUNTY, constitute an unacceptable conflict of interest if entered into by the CONSULTANT/SUBCONSULTANT.

If, in the sole opinion of the COUNTY, the prospective business association, interest or circumstance of

CONSULTANT/SUBCONSULTANT would constitute an unacceptable conflict of interest to the

COUNTY, the COUNTY shall so state in the notification and the CONSULTANT/SUBCONSULTANT shall not enter into said association, interest or circumstance.

This DISCLOSURE is submitted by (Name of Individual:) __________________________, as

(Title/Position:) ___________________________of (Name of Firm:) ____________________________ who hereby certifies that any misrepresentation by the CONSULTANT/SUBCONSULTANT on this

Disclosure is considered an unethical business practice and is grounds for sanctions against future County business with the CONSULTANT/SUBCONSULTANT.

Signature

Date

PRIME CONSULTANT QUALIFICATION QUESTIONNAIRE

(Proposer must complete, sign and submit with Proposal)

The detailed data requested herein must be submitted in this format only. Use as many pages as needed to provide the following required information:

A. Prime Consultant

Firm Name:

Office Location:

Address City State

Contact Person: Title:

Contact Person’s Email:

Telephone Number: Fax Number:

Number of Employees: CCNA Certified by PBC Engineering Department: ___yes ___no

The undersigned intends to perform in connection with the above project as (check one):

an individual a corporation a partnership a joint venture ___ a LLC

B. SBE Certifications: Check all that apply and attach copy of applicable certification letter(s) or certificates.

SBE (certified with Palm Beach County):

M/WBE (certified with State of Florida):

DBE Certification: _____________

C. 1. Prime’s “Total Project Participation” : %

(Note: can total 100% only if no sub-consultants are used.)

2. Scope of Services Description: (Consultant’s services must be described here) ______________________

D. Dollar Volume Award

List all Palm Beach County Projects with associated contracts and supplement fees awarded or funded by Palm

Beach County in the fiscal years indicated.

FY Period **Adjusted Fee Factor Fee Considered

(1) Current Fiscal Year: (Oct. 1 – Sept. 30) x 1.00

(2) Previous Fiscal Year: (Oct. 1 – Sept. 30) x 0.75

(3) Fiscal Year Once Removed: (Oct. 1 – Sept. 30) x 0.50

(4) Fiscal Year Twice Removed: (Oct. 1 – Sept. 30) x 0.25

Total:

**Palm Beach County Fees rendered to consultant, minus fees sub-contracted out by consultant to sub-consultants. Fees for which the consultant is a sub-consultant must be included. Reference may be made to the County's Consultant Considered Fees posted at http://www.pbcgov.com/engineering/roadwayproduction/. This site should not be used as a sole reference.

Project Name Consultant Firm

Project Number Signature

Title Date

SUB-CONSULTANT QUALIFICATION QUESTIONNAIRE

(subconsultant must complete and sign and submit with proposal)

The detailed data requested herein must be submitted in this format only. Proposer must submit a Subconsultant

Questionnaire on each subconsultant intended to be used for performance of the contract, if awarded. Use as many pages as needed to provide the following required information:

A. Sub-Consultant

Firm Name:

Office Location:

Address City State

Contact Person: Title:

Contact Person’s Email:

Telephone Number: Fax Number:

Number of Employees: CCNA Certified by PBC Engineering Department: ___yes ___no

The undersigned intends to perform in connection with the above project as (check one):

an individual a corporation a partnership a joint venture ___ a LLC

B. SBE Certifications: Check all that apply and attach copy of applicable certification letter(s) or certificates.

S/BE (certified with Palm Beach County):

M/WBE (certified with State of Florida):

DBE Certification:________________

C. 1. Sub.’s “Total Project Participation” : %

(Note: shall reflect the ACTUAL %, and must be less than 100%.)

2. Scope of Services Description: (Subconsultant’s services must be described here) ____________________

D. Dollar Volume Award

List all Palm Beach County Projects with associated contracts and supplement fees awarded or funded by County in the fiscal years indicated.

FY Period **Adjusted Fee Factor Fee Considered

1. Current Fiscal Year: (Oct. 1 – Sept. 30) x 1.00

2. Previous Fiscal Year: (Oct. 1 – Sept. 30) x 0.75

3. Fiscal Year Once Removed: (Oct. 1 – Sept. 30) x 0.50

4. Fiscal Year Twice Removed: (Oct. 1 – Sept. 30) x 0.25

Total:

**Palm Beach County Fees rendered to consultant, minus fees sub-contracted out by consultant to sub-consultant. Fees for which the consultant is a sub-consultant must be included. Reference may be made to the County's

Consultant Considered Fees posted at http://www.pbcgov.com/engineering/roadwayproduction/. This site should not be used as a sole reference.

Project Name Subconsultant Firm

Project Number Signature

Title Date

SUMMARY OF CONSULTANT AND SUBCONSULTANTS QUESTIONNAIRES

(Proposer must complete, sign and submit with Proposal)

Proposer must provide a tabular summary of the information that is provided on the consultant and subconsultants questionnaires. The table must be signed to confirm the accuracy of the attached information. All information for the table shall be derived from the signed

Consultant and Subconsultant Questionnaires.

1.Firm Name

Prime/

Subconsultant

(Questionnaire

Section A)

2. CCNA

Certified

By PBC

Yes/No

(Questionnaire

Section A)

3. PBC

Certified

SBE,

List

Certification

Type

(Questionnaire

Section B)

For informational purposes only

4. State

Certified

M/WBE,

List

Certification

Type

(Questionnaire

Section B)

For informational purposes only

5. DBE

(Questionnaire

Section B)

6. Services to be Provided

(Questionnaire

Section C2)

7. Project

Participation

(Questionnaire

Section C1)

8. Fee

Considered

(Questionnaire

Section D total)

TOTALS for Team 100% $________

Signature required, confirming that the above information exactly matches the information on the Consultant and Subconsultant

Questionnaires submitted by Proposer.

Print Name and Title Signature and Date

CERTIFICATION REGARDING DEBARMENT SUSPENSION, INELIGIBILITY

This Contract is a covered transaction for purposes of 2 CFR Parts 180 and 1200.

(a) The Consultant certifies to the best of its knowledge and belief that it and its principals:

(1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in 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, including a civil settlement, rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

(3) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity

(Federal, State or local) with commission of any of the offenses enumerated in paragraph (a)(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.

(b) The Consultant shall provide immediate written notice to the County if any time the Consultant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

(c) The Consultant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction.

(d) This certification is a material representation of fact relied upon by the County. If it is later determined that the

Consultant knowingly rendered an erroneous certification, or knowingly entered into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the County may terminate this transaction for cause of default.

(e) The Consultant agrees to comply with the requirements of 2 CFR Parts 180 and 1200 while this proposal is valid and throughout the period of any contract that may arise from this proposal. The Consultant further agrees to include a provision requiring such compliance in lower tier covered transactions, including submission to Consultant of this

Certification completed by its subconsultants.

(f) Where the Consultant is unable to certify to any of the statements in this certification, such Consultant shall attach an explanation to its proposal.

FIRM NAME:_______________________________________________________

ADDRESS:____________________________________________________________

FIRM’S AUTHORIZED OFFICIAL:

Name and Title Signature Date

CERTIFICATION REGARDING LOBBYING

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

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 influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-

LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

3. The undersigned 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 31, U.S.C. § 1352. 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.

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

Signature of Firm’s Authorized Official

Name and Title of Firm’s Authorized Official

Date

FEDERAL TAX LIABILITY AND RECENT FELONY CONVICTIONS

DISCLOSURE

The CONSULTANT certifies that:

1. The CONSULTANT does not have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability, where the awarding agency is aware of the unpaid tax liability, unless a Federal agency has considered suspension or debarment of the corporation and made a determination that suspension or debarment is not necessary to protect the interests of the Government; and

2. The CONSULTANT has not been convicted of the felony criminal violation under any Federal law within the preceding 24 months, where the awarding agency is aware of the conviction, unless a federal agency has considered suspension or debarment of the corporation and made a determination that suspension or debarment is not necessary to protect the interests of the Government.

3. Before entering into a subcontract with a subconsultant, the CONSULTANT shall check the System for

Award Management (the “SAM”) at http://www.sam.gov/ for an entry describing the subconsultant.

4. Before entering a subcontract with subconsultant, the CONSULTANT shall require the subconsultant to:

(a) certify whether the subconsultant has a tax delinquency and (b) certify whether the subconsultant has a felony conviction.

5. If the SAM entry for a subconsultant indicates that the subconsultant has a tax delinquency or a federal conviction, or if subconsultant provides an affirmative response to either certification in section 4 above, or if a subconsultant’s certification under section 4 above was inaccurate when made or became inaccurate after being made, then the CONSULTANT shall not enter or continue a subcontract with that subconsultant, unless the USDOT has determined in writing that suspension or debarment of that entity are not necessary to protect the interests of the Government; and the CONSULTANT shall notify the County in writing of such occurrence.

The CONSULTANT agrees to flow these requirements down to all lower tier participants (subcontractors), without regard of the value of any subcontract.

(Date) (Signature)

(Print Name)

(Title)

(Company)