25CS0058_-_CUF_Certification_Form_-_CV_012.pdf

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Attached to
25CS0058 - *SB & MB Only* - Window and Window Screen
Solicitation number
0000037322
Issued by
Imperial County, Los Angeles County, Orange County, Riverside County, San Bernardino County, San Diego County, Orange Cove City, Imperial City, East Los Angeles CDP, Lake Los Angeles CDP, Los Angeles City, Orange City, Lake Riverside CDP, Riverside City, Orangevale CDP, San Bernardino City, Imperial Beach City, Rancho San Diego CDP, San Diego City, San Diego Country Estates CDP, Orange Blossom CDP, California

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This is a Commercially Useful Function (CUF) Certification Form CV 012 issued by the State of California Department of Veterans Affairs for solicitation 25CS0058, which pertains to Window and Window Screen Repair and Replacement Services at the Veterans Home of California, Chula Vista. The form must be completed by all certified Small Business (SB), Micro Business (MB), and Disabled Veteran Business Enterprise (DVBE) firms that will perform any element of the work under this solicitation. The document requires bidders to certify that their business will execute a distinct element of the work, carry out contract obligations through actual performance, management, or supervision, perform work normal to their business functions, and not subcontract work beyond normal industry practices. Bidders must also confirm that their role is not limited to being an extra participant for the purpose of obtaining the appearance of SB or DVBE participation.

The certification form requires bidders to provide a written statement detailing the role, services, and goods their company will provide to meet CUF requirements. All responses to the five certification questions must be answered with "Yes" responses for questions 1-3, and "No" for question 4, or the quote may be deemed non-responsive and subject to disqualification. The authorized signatory, identified as the certified business owner or authorized corporate representative, must sign the form under penalty of perjury, certifying that all information provided is truthful and accurate in accordance with California law. The State reserves the right to request additional clarifying information prior to contract award.

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State of California Department of Veterans Affairs

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM

CV 012 (REV. 08/2023) Page 1 of 2

Solicitation Number:

Every certified SB, MB & DVBE must complete this form if they will perform an element of the work.

1. CONTRACTOR NAME (Completing Form) "DOING BUSINESS AS" (DBA) NAME: OSDS REF # (Currently certified firms only): Expiration Date:

2. COMMERCIALLY USEFUL FUNCTIONS (CUF)

All certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code, Section 14837 (d)(4) (for SB) and Military and Veterans Code, Section 999(b)(5)(B) (for DVBE).

Please answer the following questions, as they apply to your company for the goods and services being acquired in this solicitation:

Mark all that apply: DVBE Small Business Micro Business

1 If awarded a contract, will your business be responsible for the execution of a distinct element of the resulting work? Yes No

2 If awarded a contract, will your business carry out the obligation of the contract by actually performing, managing, or supervising the work involved? Yes No

3 If awarded a contract, will you perform work that is normal for your business, service and functions? Yes No

4 If awarded a contract, will your business subcontract a portion of the work greater than would be expected by normal industry practices? Yes No

5 If awarded a contract, will your business role be limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation? Yes No

A response of "No" in questions 1-3 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.

3. WRITTEN STATEMENT

Provide a written statement below detailing the role, services and goods your company will provide to meet the commercially useful function requirement. At the State's option prior to award, you may be required to submit additional clarifying information

State of California Department of Veterans Affairs

CV 012 (REV. 08/2023) Page 2 of 2

AUTHORIZING SIGNATURE (REQUIRED)

The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.

AUTHORIZED REPRESENTATIVE SIGNATURE: TITLE:

PRINTED NAME: DATE:

State of California Department of Veterans Affairs

CV 012 (REV. 08/2023) Page 1 of 2 Every certified SB, MB & DVBE must complete this form if they will perform an element of the work.

1. CONTRACTOR NAME (Completing Form)

2. COMMERCIALLY USEFUL FUNCTIONS (CUF)

All certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code, Section 14837 (d)(4) (for SB) and Military and Veterans Code, Section 999(b)(5)(B) (for DVBE).

Please answer the following questions, as they apply to your company for the goods and services being acquired in this solicitation:

Mark all that apply:

If awarded a contract, will your business be responsible for the execution of a distinct element of the resulting work?

If awarded a contract, will your business carry out the obligation of the contract by actually performing, managing, or supervising the work involved?

If awarded a contract, will you perform work that is normal for your business, service and functions?

If awarded a contract, will your business subcontract a portion of the work greater than would be expected by normal industry practices?

If awarded a contract, will your business role be limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation?

A response of "No" in questions 1-3 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.

3. WRITTEN STATEMENT

State of California Department of Veterans Affairs

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM

CV 012 (REV. 08/2023) Page 2 of 2

AUTHORIZING SIGNATURE (REQUIRED)

The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.

9.0.0.2.20101008.1.734229

SolicitationNumber: 25CS0058
DoingBusinessAs:
OSDSRefNumber:
ExpirationDate:
:
Yes:
No:
ProvideAWrittenStatement:
AuthorizedRepresentative:
Title:
PrintedName:
Date:

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