25YS0004-_Bidders_Checklist_and_Required_Documents.pdf

State of California Solicitation Number: 25YS0004 Department of Veterans Affairs

BIDDER’S CHECKLIST

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The checklist below is a summary of documents to be submitted based on requirements in the Invitation for Bid. This checklist should be returned with your bid. Place a check-mark or “X” next to each document being submitted.

Signatures are required on the documents where specified.

The company name listed on all documents submitted (ex. licenses, permits, certifications, and insurance) must be identical to the company name on the Payee Data Record (STD 204). Failure to submit these documents in the manner prescribed may delay award of Agreements.

Bidder’s Checklist

Bidder Certification

Bid Rate Sheet

Signed Payee Data Record - STD 204

Bidder Declaration - GSPD-05-105

Commercially Useful Function (CUF) Certification, if applicable

Disabled Veteran Business Enterprise (DVBE) Declarations – DGS PD 843, if applicable

Iran, if applicable

Darfur Contracting Act

California Civil Rights Laws

Contractor Certification Clauses (CCC-4/2017) - The CCC-4/2017 can be found on the Internet at https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List- Folder/Standard-Contract-Language

Valid California city or county business license; or, if a corporation located within the State of California, incorporation documents or letter from the Secretary of State; or, if not a California business, an affidavit that business is in good standing with the State, Province, or Country in which business is headquartered.

Sample Invoice

BID/BIDDER CERTIFICATION SHEET

This Bid/Bidder Certification Sheet must be signed and returned along with all the "required attachments" as an entire package. The bid must be transmitted in accordance with IFB instructions.

A. I have read and understand the DVBE participation requirements and have included documentation demonstrating that I have met the participation goals, if goals are included.

B. The undersigned signature certifies under penalty of perjury that they are a duly authorized representative and in compliance with all the requirements of this bid document. The signature below authorizes the verification of this certification.

An Unsigned Bid/Bidder Certification Sheet May Be Cause For Rejection.

1. Company Name 2. Telephone Number 2a. Fax Number

2c. E-MAIL

3. Address

Indicate your organization type:

4. Sole Proprietorship 5. Partnership 6. Corporation

Indicate the applicable employee and/or corporation number:

7. Federal Employee ID No. (FEIN) 8. California Corporation No.

9. Bidder’s Name (Print) 10. Title

11. Signature 12. Date

13. Are you certified with the Department of General Services, Office of Small Business and Disabled Veteran Business Enterprise Services (OSDS) as:

a. California Small Business Yes No

If yes, enter certification number:

b. Disabled Veteran Business Enterprise Yes No If yes, enter your service code below:

NOTE: A copy of your Certification should be included if either of the above items is checked “Yes”.

Date application was submitted to OSDS, if an application is pending:

Completion Instructions for Bid/Bidder Certification Sheet

Complete the numbered items on the Bid/Bidder Certification Sheet by following the instructions below.

Item Numbers Instructions

1, 2, 2a, 3 Must be completed. These items are self-explanatory.

Check if your firm is a sole proprietorship. A sole proprietorship is a form of business in which one person owns all the assets of the business in contrast to a partnership and corporation. The sole proprietor is solely liable for all the debts of the business.

Check if your firm is a partnership. A partnership is a voluntary agreement between two or more competent persons to place their money, effects, labor, and skill, or some or all of them in lawful commerce or business, with the understanding that there shall be a proportional sharing of the profits and losses between them. An association of two or more persons to carry on, as co-owners, a business for profit.

Check if your firm is a corporation. A corporation is an artificial person or legal entity created by or under the authority of the laws of a state or nation, composed, in some rare instances, of a single person and his successors, being the incumbents of a particular office, but ordinarily consisting of an association of numerous individuals.

7 Enter your federal employee tax identification number.

Enter your corporation number assigned by the California Secretary of State’s Office. This information is used for checking if a corporation is in good standing and qualified to conduct business in California.

9, 10, 11, 12 Must be completed. These items are self-explanatory.

If certified as a California Small Business, place a check in the "Yes" box, and enter your certification number on the line. If certified as a Disabled Veterans Business Enterprise, place a check in the "Yes" box and enter your service code on the line. If you are not certified to one or both, place a check in the "No" box. If your certification is pending, enter the date your application was submitted to OSDS.

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STATE OF CALIFORNIA- DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

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Section 1 - Payee Information NAME (This is required. Do not leave this line blank. Must match the payee's federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE

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E-MAIL ADDRESS

Section 2 - Entity Type Check one (1} box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on oaoe 2)

□ SOLE PROPRIETOR / INDIVIDUAL CORPORATION (see instructions on page 2)

□ SINGLE MEMBER LLC Disregarded Entity owned by an individual □ MEDICAL (e.g., dentistry, chiropractic, etc.)

□ PARTNERSHIP □ LEGAL (e.g., attorney services)

□ ESTATE OR TRUST □ EXEMPT (e.g., nonprofit)

□ ALL OTHERS

Section 3 - Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN. Social Security Number (SSN) or The TIN is a 9-digit number. Note: Payment will not be processed without a TIN. Individual Tax Identification Number (ITIN)

• For Individuals, enter SSN.

• If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

• Granter Trusts (such as a Revocable Living Trust while the granters are alive) may not have a separate FEIN. Those trusts must enter the individual grantor's SSN.

• For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

• For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity's FEIN. Do not use the disregarded entity's FEIN.

• For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity's FEIN.

OR

Federal Employer Identification Number

(FEIN)

Section 4 - Payee Residency Status (See instructions)

□ CALIFORNIA RESIDENT - Qualified to do business in California or maintains a permanent place of business in California.

□ CALIFORNIA NONRESIDENT - Payments to nonresidents for services may be subject to state income tax withholding.

□ No services performed in California

□Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 - Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE

Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE

Department of Veterans Affairs

MAILING ADDRESS

1227 0 Street

CITY STATE

Sacramento CA

DATE

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TELEPHONE (include area code)

Section 6 - Paying State Agency

UNIT/SECTION

CBO/ Contracts Unit

FAX TELEPHONE (include area code)

(916)651-2159

ZIP CODE

95814

E-MAIL ADDRESS

ophelia.deollas@calvet.ca.gov

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Agreement Number: 25YS0004

CCC 04/2017

CERTIFICATION

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective Contractor to the clause(s) listed below. This certification is made under the laws of the State of California.

Contractor/Bidder Firm Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County of

CONTRACTOR CERTIFICATION CLAUSES

1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the nondiscrimination program requirements. (Gov. Code §12990 (a-f) and CCR, Title 2, Section 11102) (Not applicable to public entities.)

2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free workplace by taking the following actions:

a. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations.

b. Establish a Drug-Free Awareness Program to inform employees about:

1) the dangers of drug abuse in the workplace;

2) the person's or organization's policy of maintaining a drug-free workplace;

3) any available counseling, rehabilitation and employee assistance programs; and,

4) penalties that may be imposed upon employees for drug abuse violations.

c. Every employee who works on the proposed Agreement will:

1) receive a copy of the company's drug-free workplace policy statement; and,

2) agree to abide by the terms of the company's statement as a condition of employment on the Agreement.

Failure to comply with these requirements may result in suspension of payments under the Agreement or termination of the Agreement or both and Contractor may be ineligible for award of any future State agreements if the department determines that any of the following has occurred: the Contractor has made false certification, or violated the

State of California-Department of General Services, Procurement Division

GSPD-OS-1 OS (REV 08/09)

Solicitation Number: 25YS0004

BIDDER DECLARATION

1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form):

a. Identify current California certification(s) (MB, SB, NVSA, DVBE): _____ or None 0_ (If "None'; go to Item #2)

b. Will subcontractors be used for this contract? Yes D No D (If yes, indicate the distinct element of work your firm will perform in this contract e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary.

c. If you are a California certified DVBE: (1) Are you a broker or agent? Yes D No D

(2) If the contract includes equipment rental, does [Jr co[Jany own at least 51 % of the equipment provided in this contract (quantity and value)? Yes No NtAO

2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary):

Subcontractor Name, Contact Person, Subcontractor Address CA Certification (MB, SB, Work performed or goods provided Corresponding Good 51%

Phone Number & Fax Number & Email Address NVSA, DVBE or None) for this contract % of bid price Standing? Rental?

CER TIFICATION: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct.

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State of California Department of Veterans Affairs

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM

CV 012 (REV. 08/2016) Page 1 of2

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:

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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)(S)(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 0 Small Business □ Micro Business □

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

Yes f"l No r resulting work?

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

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

If awarded a contract, will your business subcontract a portion of the work greater than would be

Yes D No □ 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, Yes f"l No r 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

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

DARFUR CONTRACTING ACT CERTIFICATION

DGS PD 1 (Rev. 12/19)

Agreement Number: 25YS0004

Public Contract Code Sections 10475 -10481 applies to any company that currently or within the previous three years has had business activities or other operations outside of the United States. For such a company to bid on or submit a proposal for a State of California contract, the company must certify that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit a proposal.

If your company has not, within the previous three years, had any business activities or other operations outside of the United States, you do not need to complete this form.

OPTION #1 - CERTIFICATION

If your company, within the previous three years, has had business activities or other operations outside of the United States, in order to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete the certification below.

I, the official named below, CERTIFY UNDER PENAL TY OF PERJURY that a) the prospective proposer/bidder named below is not a scrutinized company per Public Contract Code 10476; and b) I am duly authorized to legally bind the prospective proposer/bidder named below. This certification is made under the laws of the State of California.

CompanyNendor Name (Printed) Federal ID Number

By (Authorized Signature) Date

Printed Name and Title of Person Signing

OPTION #2 - WRITTEN PERMISSION FROM DGS

Pursuant to Public Contract Code Section 10477(b), the Director of the Department of General Services may permit a scrutinized company, on a case-by-case basis, to bid on or submit a proposal for a contract with a state agency for goods or services, if it is in the best interests of the state. If you are a scrutinized company that has obtained written permission from the DGS to submit a bid or proposal, complete the information below.