25_054_LH_ Attachment A.pdf

Macon‐Bibb County

Summary of Attachment “A” Required Documents

• Bidder Qualification Form

• List of Sub‐Contractors

• Bidder Minority Participation Goal

• Financial & Legal Stability Statement

• Insurability Statement

• Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion

• Non‐Collusion Affidavit

• Macon‐Bibb County Vendor Application

• Form W‐9

• E‐Verify Affidavit

Attachment “A”

Required Submission Documents

BIDDER QUALIFICATION FORM

Company Name: ______________________________________________________________________

Address: ____________________________________________________________________________

When Organized: ______________ Where Incorporated: __________________________________

How many years have you engaged in business under the present firm name? _____________________

Credit available for this contract? ________________________________________________________

Contracts now in hand? ________________________________________________________________

Has bidder ever refused to execute a contract at the original bid amount? _________________________

Has bidder ever been declared in default on a contract? _______________________________________

Comments: __________________________________________________________________________

Company Name: _____________________________________________________________________

Authorized By (typed name): ____________________________________________________________

Authorized Signature: _________________________________________________________________

Title: ________________________________________ Date: ________________________________

References

Following is a reference list of contracts that are similar to this project:

NAME OF PROJECT/DATE LOCATION CONTACT PHONE #

My Commission Expires: _________________

[NOTARY SEAL]

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

______ DAY OF __________________, 202___

Notary Public

LIST OF SUB-CONTRACTORS

I do , do not , propose to sub-contract some of the work on this project. I propose to sub-contract work to the following contractors.

NAME/ADDRESS TYPE OF WORK % of Contract

Contractor Name

BIDDER MINORITY PARTICIPATION GOAL

(Attach additional pages if required.)

I do , do not , propose to employ the minority sub-contractors as listed below on some of the work on this project.

NAME/ADDRESS TYPE OF WORK % of Contract

Contractor Name

FINANCIAL & LEGAL STABILITY STATEMENT

Please check appropriate item(s):

__ Firm has the financial capability to undertake the work and assume the liability required if awarded this solicitation.

__ Firm has the legal capability to undertake the work and assume the responsibilities required if awarded this solicitation.

Pending litigations (if any) will not affect the firm’s ability to perform on this contract, if awarded.

Company Name: ____________________________________________________________________________

Authorized By (typed name): ___________________________________________________________________

Authorized Signature: ________________________________________________________________________

Title: ________________________________________ Date: _______________________________________

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

_____ DAY OF _________________, 202___ My Commission Expires: _____________

____________________________________ [NOTARY SEAL]

INSURABILITY STATEMENT

Please check appropriate item(s):

__ By submission of this form, this firm confirms the ability to acquire and maintain the required levels of insurance as outlined in the bid document. It is the understanding of this firm that proof of Insurance must be provided prior to contract execution and maintained throughout the entire term of the contract.

Company Name: ____________________________________________________________________________

Authorized By (typed name): ___________________________________________________________________

Authorized Signature: ________________________________________________________________________

Title: ________________________________________ Date: _______________________________________

My Commission Expires: _____________

[NOTARY SEAL]

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

_____ DAY OF _________________, 202___

Macon-Bibb County Procurement Department

700 Poplar Street, Suite 308 Macon, Georgia 31202-0247

Tel: (478) 803-0550 • Fax: (478) 751-7252 www.maconbibb.us

CERTIFICATION REGARDING DEBARMENT, SUSPENSION

INELIGIBILITY AND VOLUNTARY EXCLUSION

The Bidder/offer certifies, by submission of this Proposal or acceptance of this contract, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary excluded from participation in this transaction by any Federal department or agency. It further agrees by submitting this proposal that it will include this clause without modification in all lower tier, transactions, proposals, contracts, and subcontracts. Where the Bidder/offeror or any lower tier participant is unable to certify to this statement, it shall attach an explanation of this solicitation/proposal.

Dated at this________day of_______________________, 202_.

Signature of Contractor: ______________________________________

Title: ______________________________________________________

For Macon Bibb County Personnel Only:

Macon Bibb County Procurement Department will verify that the above bidder/offer certifies, by submission of this Proposal or acceptance of this contract, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary excluded from participation in this transaction by any Federal department or agency.

Signature of Procurement Officer ____________________________________ Date _____________

Printed Name ________________________________

NON COLLUSION AFFIDAVIT

Date:

Project: Bibb County, Georgia

Project #:

Project Description:

Services Provided:

General Contracting

State of: Georgia

County of: Bibb

I, ______________________________having first been duly sworn, deposes and states as follows:

I am the party making the foregoing Proposal or Bid; that such Proposal or Bid is genuine and not collusive or sham; that said Proposer or Bidder has not colluded, conspired, connived, or agreed, directly or indirectly, with any Proposer or Bidder or person, to put in a sham Proposal or Bid, or that such other person refrain from proposing or bidding, and has not in any manner, directly or indirectly sought by agreement or collusion, or communication or conference, with any person, to fix the Proposal Fee or Bid Price of affiant or any other Proposer or Bidder, or to fix any overhead, profit or cost element of said Proposal Fee or Bid Price, or that of any other Proposer or Bidder, or to secure any advantage against Bibb County, Georgia or any person interested in the proposed Contract; and that all statements in said Proposal or Bid are true; and further, that such Proposer or Bidder has not directly or indirectly submitted this Proposal or Bid, or the contents thereof, or divulged information or data relative thereto to any association or to any member or agent thereof.

Contractor:

(Signature) (Seal)

Attachment "A"

MACON-BIBB COUNTY

Vendor Application Date Submitted:

New Application Revised Application

RETURN THIS COMPLETED FORM TO:

Macon-Bibb County Procurement Department Phone: 478-803-0550 700 Poplar Street, Ste. 308 Fax: 478-751-7252 Macon, GA 31201 Email: procurement@maconbibb.us

Company Name:

Company Address:

Authorized By (Name):

Title:

Authorized Signature: Date:

Telephone Number: Fax Number:

Email Address:

Remit to Name:

Remit to Address:

Phone: Fax: Toll Free:

Contact: Email:

Business Type (choose one): Individual/Sole Proprietor Single member LLC

Business - incorporated Business - not incorporated/partnership LLC: C S P (circle one) Other (Specify):

Social Security #: Federal Tax ID #:

Purchase Order Name:

Purchase Order Address:

Phone: Fax: Toll Free:

Contact: Email:

Payment Terms: Discount % # Days Net Due Freight Terms: Ship Via FOB

Private Employer Affidavit is attached :

With E-Verify # _____ With E-Verify exemption selected ______ Contractor Affidavit is attached: (additional affidavit, if applicable) With E-Verify # _____ Without E-Verify # but a copy of my driver's license is attached since I have no employees and no intent to hire employees _____

Minority Owned (African American, Hispanic, Native American, Asian American) circle one _______ Woman Owned _________ Disabled________ Veteran_______ Not Applicable________

Do you maintain a local office in Macon-Bibb County? Yes______ No_______

GENERAL VENDOR INFORMATION

REMITTANCE INFORMATION (where payments should be sent)

PURCHASE ORDER INFORMATION (where purchase orders should be sent)

E-Verify Information

MBE/DBE/WBE STATUS (Select at least one)

Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the requester. Do not send to the IRS.

P ri n t o r ty p e

S ee

S p e c if ic

I n s tr u c ti o n s o n p ag e

3.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number or Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign Here

Signature of

U.S. person Date

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

Cat. No. 10231X Form W-9 (Rev. 10-2018)

E-VERIFY AND PRIVATE EMPLOYER AFFIDAVIT

Pursuant To O.C.G.A. § 36-60-6(d)

By executing this affidavit, the undersigned private employer verifies one of the following with respect to its application for an occupational tax certificate, alcohol license, or other document required to operate a business as referenced in O.C.G.A. § 36-60-6(d):

Business Name: __________________________________________________________________________________

SECTION 1 (Choose ONE of the following)

(A) ☐ On January 1 of the below-signed year, the individual, firm, or corporation employed ten (10) or less employees. (Proceed to Section 3)

(B) ☐ On January 1 of the below-signed year, the individual, firm, or corporation employed more than ten (10) employees and has registered with the E-Verify program. (Proceed to Section 2)

SECTION 2

The employer has registered with and utilizes the Federal Work Authorization program commonly known as E-Verify, in accordance with the applicable provisions and deadlines established in O.C.G.A. §36-60-6. The undersigned private employer also attests that its E-Verify number and date of authorization are as follows:

E-Verify Number: ________________________________________

Date of Authorization: ___________________________________ (Proceed to Section 3)

SECTION 3

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on ________________________, _______, 20______ in _____________________ (city), _________ (state)

Printed Name of Authorized Officer or Agent: ______________________________________________

Title of Authorized Officer or Agent: ________________________________________________________

Signature of Authorized Officer or Agent: ___________________________________________________

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE ________ DAY OF _____________________________, 20________

NOTARY PUBLIC

My Commission Expires: _________________________________

Form W-9

Non-Collusion Affidavit