25-10_Required_Forms.pdf

ADDENDUM ACKNOWLEDGEMENT

I acknowledge receipt of the following addenda:

ADDENDUM NO. DATED

ADDENDUM NO. DATED

ADDENDUM NO. DATED

ADDENDUM NO. DATED

ADDENDUM NO. DATED

Name of Firm:

Authorized Signature:

Printed Name:

Title:

Date:

It is the responsibility of the firm to ensure that they have received addendums if issued.

Call (850) 248-8270 or email Purchasing@baycountyfl.gov prior to submitting your bid to ensure that you have received addendums.

25-10 Steelfield Road Landfill Scrap Metal and Appliance Recycling Re-bid 12 of 37

AFFIDAVIT OF COMPLIANCE WITH SECTION 287.138, FLORIDA STATUTES,

CONTRACTING WITH FOREIGN ENTITIES OF CONCERN

Before me, the undersigned authority, personally appeared (Name of Affiant) _______________ ____________________, who, after being first duly sworn, deposes and says of his or her personal knowledge the following:

1, Affiant is the (Title) ___________________________ of (Business Name) _________________________________ which does business in the State of Florida, hereinafter called the “Nongovernmental Entity.”

2. Nongovernmental Entity, pursuant to § 287.138, Florida Statues, certifies that

(1) Nongovernmental Entity is not owned by a government of a foreign country of concern; (2) a government of a foreign country of concern does not have a “controlling interest” in Nongovernmental Entity, as defined by Section 287.138(1)(a), Florida Statutes; and (3) Nongovernmental Entity is not organized under the law of nor has its principal place of business in a foreign country of concern. For the purposes of this affidavit, foreign country of concern means the People’s Republic of China, the Russian Federation, the Islamic Republic of Iran, the Democratic People’s Republic of Korea, the Republic of Cuba, the Venezuelan regime of Nicolás Maduro, or the Syrian Arab Republic, including any agency of or any other entity of significant control of such foreign country of concern, as defined in § 287.138(1)(c), Florida Statutes.

3. This Affidavit is executed by the Nongovernmental Entity accordance with § 287.138, Florida Statutes, for the purposes of preventing Bay County, Florida, from entering contracts with foreign entities of concern which would provide Nongovernmental Entity access to an individual’s personal identifying information.

Signed and Delivered on this _____ day of __________, 2024.

Signature of Affiant Printed Name of Affiant

STATE OF__________________

COUNTY OF________________________

Sworn to (or affirmed) and subscribed before me by means of □ physical presence or □ online notarization, this ______ day of _____________, 2024, by

Personally Known OR Produced Identification Type of Identification Produced________ ____________________________ (Notary Signature)

(SEAL)

25-10 Steelfield Road Landfill Scrap Metal and Appliance Recycling Re-bid 13 of 37

AFFIDAVIT OF COMPLIANCE WITH SECTION 787.06, FLORIDA STATUTES,

HUMAN TRAFFICKING ATTESTATION

Before me, the undersigned authority, personally appeared (Name of Affiant) _________________________________, who, after being first duly sworn, deposes and says of his or her personal knowledge the following:

1. Affiant is the (Title) ______________________________ of (Business Name) __________________________________ which does business in the State of Florida, hereinafter called the “Nongovernmental Entity.”

2. Nongovernmental Entity, pursuant to § 787.06(13), Florida Statues, certifies that 1) neither Nongovernmental Entity nor any of its subsidiaries or affiliates uses coercion for labor or services, as terms are defined in § 787.06, Fla. Stat., as may be amended from time to time; (2) Nongovernmental Entity will immediately notify Bay County, Florida, if, at any time in the future, Nongovernmental Entity does use coercion for labor or services, and understands that pursuant to such notification no contracts may be executed, renewed, or extended between the parties; and (3) Nongovernmental Entity has read the foregoing attestation, confirms the facts stated in it are true, ad are made for the benefit of, and reliance by, Bay County, Florida.

Signed and Delivered on this _____ day of __________, 2024.

Signature of Affiant Printed Name of Affiant

STATE OF ___________

COUNTY OF ______________

Sworn to (or affirmed) and subscribed before me by means of □ physical presence or □ online notarization, this ____ day of _____________, 2024, by ___________________.

Personally Known OR Produced Identification

Type of Identification Produced______ _______________________________ (Notary Signature)

(SEAL)

25-10 Steelfield Road Landfill Scrap Metal and Appliance Recycling Re-bid 14 of 37

ANTI-COLLUSION CLAUSE

Firm certifies that their response is made without prior understanding, agreement or connection with any Corporation, Firm or person submitting a response for the same services and is in all respects fair and without collusion or fraud.

Name of Firm:

Authorized Signature:

Printed Name:

Title:

Date:

25-10 Steelfield Road Landfill Scrap Metal and Appliance Recycling Re-bid 15 of 37

CERTIFICATION REGARDING SCRUTINIZED COMPANIES LIST

Respondent Vendor Name:

Vendor FEIN:

Vendor's Authorized Representative Name and Title:

Address:

City: State: ZIP:

Phone Number:

Email Address:

Section 287.135, Florida Statutes prohibits agencies from contracting with companies, for goods or services over $1,000,000, that are participating in a boycott of Israel, are on the Scrutinized Companies that Boycott Israel list, the Scrutinized Companies with Activities in Sudan List, the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or has been engaged in business operations in Cuba or Syria.

Both lists are created pursuant to Section 215.473, Florida Statutes.

As the person authorized to sign on behalf of Respondent, I hereby certify that the company identified above in the sector entitled "Respondent Vendor Name" is not participating in a boycott of Israel, is not listed on the Scrutinized Companies that Boycott Israel List, the Scrutinized Companies with Activities in Sudan List, or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List and has not been engaged in business operations in Cuba or Syria. I understand that pursuant to Section 287.135, Florida Statutes, the submission of false certification may subject company to civil penalties, attorney's fees, and/or costs.

Certified By:

AUTHORIZED SIGNATURE

Print Name and Title:

25-10 Steelfield Road Landfill Scrap Metal and Appliance Recycling Re-bid 16 of 37

CONFLICT OF INTEREST DISCLOSURE FORM

For purposes of determining any possible conflict of interest, all firms, must disclose if any Bay County Board of County Commissioner(s), employee(s), elected officials(s), or any of its agencies is also an owner, corporate officer, agency, employee, etc., of their firm.

Indicate either “yes” (a county employee, elected official, or agency is also associated with your firm), or “no”. If yes, give person(s) name(s) and position(s) with your firm.

YES NO

NAME(S) POSITION(S)

Name of Firm:

Authorized Signature:

Printed Name:

Title:

25-10 Steelfield Road Landfill Scrap Metal and Appliance Recycling Re-bid 17 of 37

IDENTICAL TIE BIDS/DRUG FREE WORKPLACE

Preference shall be given to businesses with drug-free workplace programs. Whenever two or more submittals, which are equal with respect to price, quality, and service, are received by the County for the procurement of commodities or contractual services, a submittal received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process.

Established procedures for processing tie bids will be followed if none of the tied firms have a drug-free workplace program. To have a drug-free workplace program, a business shall:

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

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

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

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

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

Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.

As the person authorized to sign the statement, I certify the following:

(Check one and sign in the space provided.)

This firm complies fully with the above requirements.

This firm does not have a drug free work place program at this time.

Name of Firm:

Authorized Signature:

Printed Name:

Title:

25-10 Steelfield Road Landfill Scrap Metal and Appliance Recycling Re-bid 18 of 37

SUB-CONTRACTORS

As the bidder, I submit a listing of the Sub-Contractors which I shall use to accomplish the Work. Sub-Contractors are listed by name, address, amount of work and item of work. If none, please state so.

Subcontractor Name and Address:

Work to be performed and $ amount:

Subcontractor Name and Address:

Work to be performed and $ amount:

Subcontractor Name and Address:

Work to be performed and $ amount:

Subcontractor Name and Address:

Work to be performed and $ amount:

Name of Firm:

Authorized Signature:

Printed Name:

Title:

25-10 Steelfield Road Landfill Scrap Metal and Appliance Recycling Re-bid 19 of 37