26_36001_002 Complete Bid Package_Remount Amb.pdf

SOLICITATION

26-36001-002

REMOUNT AMBULANCE

Putnam County Board of Commissioners 117 Putnam Drive, Suite A

Eatonton, GA 31024

MAY 7, 2026

10:05 A.M.

PUTNAM COUNTY BOARD OF COMMISSIONERS

117 Putnam Drive, Suite A ◊ Eatonton, GA 31024 Tel: 706-485-5826 ◊ www.putnamcountyga.us

PUTNAM COUNTY

SOLICITATION # 26-36001-002

Remount Ambulance

The Putnam County Board of Commissioners requests sealed bids, good for 90 business days, for a Remount Ambulance.

Prospective bidders must obtain a bid package from the Putnam County Board of Commissioners via the county website:

www.putnamcountyga.us/rfps

Proposals must be submitted on the proposal form issued by Putnam County and contained in the bid package.

Proposals must be received by Thursday, May 7, 2026 at 10:05 a.m. The proposals will be read at that time.

LOCAL AND MINORITY OWNED/OPERATED AND/OR WOMEN

OWNED/OPERATED BUSINESSES ARE ENCOURAGED TO SUBMIT PROPOSALS.

PUTNAM COUNTY RESERVES THE RIGHT TO REJECT ANY AND ALL BIDS, TO

WAIVE ANY AND ALL TECHNICALITIES AND TO AWARD THE BID BASED ON

THE LOWEST AND/OR BEST INTEREST OF PUTNAM COUNTY.

04/16/2026 & 04/23/2026 http://www.putnamcountyga.us/

Putnam County BOC Page 1 of 5 Instructions

117 Putnam Drive, Suite A ◊ Eatonton, GA 31024 Tel: 706-485-5826 ◊ www.putnamcountyga.us

INSTRUCTIONS AND SPECIFICATIONS FOR BIDDERS:

SOLICITATION # 26-36001-002

REMOUNT AMBULANCE

PUTNAM COUNTY, GEORGIA

SECTION 1 – GENERAL NOTICE

Sealed proposals for an AMBULANCE REMOUNT (SOLICITATION: 26-36001-002) will be received by the office of the Board of Commissioners of Putnam County, Georgia, up to the hour of 10:05 A.M.

local time, on Thursday, May 7, 2026, at which time and place they will be publicly opened and read aloud. Bidders are invited to be present.

SECTION 2 – BID DOCUMENTS

Copies of the Proposal, Specifications, Plans (if required) and other document forms may be obtained from the office of the County Commissioners. Bidders are required to examine the same and satisfy themselves that all requirements are fully understood.

SECTION 3 – BIDDING PROCEDURE

Bids shall be presented in a sealed envelope with the bid number (26-36001-002) and the name of the company or firm submitting clearly marked on the outside of the envelope. IF

SUBMITTING A PHYSICAL BID, TWO PAPER COPIES AND ONE ELECTRONIC COPY MUST

BE SUBMITTED. IF SUBMITTING ELECTRONICALLY, ONE ELECTRONIC COPY MAY BE

SUBMITTED VIA THE COUNTY WEBSITE. Bids will not be accepted verbally, by fax or email. All appropriate blanks shall be completed. Any interlineations, alteration, or erasure on the specification document shall be initialed by the signer of the bid. Bidder shall not change the proposal form nor make additional stipulations on the specification document. Any amplified or qualifying information shall be on the bidder’s letterhead and firmly attached to the bid document.

Items in RED are requirements for bid consideration.

Bid prices shall be submitted on the Proposal Form included in the bid document.

Each bid must be legibly printed in ink or by printer, include the full name, business address, and telephone number of the bidder and be signed in ink by the bidder, or signed electronically.

A bid by a firm or organization other than a corporation must include the name and address of each member.

A bid by a corporation must be signed in the name of such corporation by a duly authorized official thereof.

No bidder shall submit more than one proposal nor submit two or more proposals under different names.

Putnam County BOC Page 2 of 5 Instructions

In order to be considered, the outside of the sealed envelope must be clearly marked with the offeror’s name, address and phone number, the project number, name of the project for which the proposal is being submitted, and the bid opening date and time of Thursday, May 7, 2026 at 10:05 a.m. All proposals shall be delivered by a delivery service or in person to Putnam County Board of Commissioners, 117 Putnam Drive, Suite A, Attn: County Manager, Eatonton, GA 31024, or submitted electronically, on or before the time and date prescribed above.

For your convenience, please use the label on the enclosed “Submittal Requirement” page.

Bids received after the time and date established for receiving bids will be rejected.

SECTION 4 – QUALIFICATION OF BIDDERS

All bidders shall provide a Work Resume and file it with their bid. The resume shall include projects which are similar to the type of work being bid for which the bidder had direct control over and was charged with full responsibility of the outcome.

SECTION 5 – ADDENDA

Addenda are written instruments issued by the County prior to the date for receipt of bids which modify or interpret the specification document by addition, deletion, clarification, or correction.

Addenda will be mailed or delivered to all who are known by the County to have received a complete set of specification documents. Potential bidders may return the “Potential Bidder Form” to ensure they are notified of any addenda issued.

Copies of addenda will be posted on the county website and will also be available for inspection at the office of the County Clerk.

No addendum will be issued later than forty-eight (48) hours prior to the date and time for receipt of bids, except an addendum withdrawing the invitation to bid or an addendum which includes postponement of the bid.

Bidders shall ascertain prior to submitting their bid that they have received all addenda issued and they shall acknowledge receipt of addenda on the proposal form.

SECTION 6 – BIDDER’S REPRESENTATION

Each bidder by signing and submitting a bid, represents that the bidder has read and understands the specification documents and the bid has been made in accordance therewith.

Each bidder for services further represents that the bidder is familiar with the local conditions under which the work is to be done and has correlated the observations with the requirements of the bid documents.

NON-COLLUSION AFFIDAVIT: By submitting a proposal, the bidder represents and warrants that such bid is genuine and not a sham or collusion or made in the interest or in behalf of any person not therein named, and that the bidder has not directly or indirectly induced or solicited any other bidder to put in a sham bid, or any other firm, person or corporation to refrain from bidding and that the bidder has not in any manner sought by collusion to secure to that bidder any advantage over any other bidder.

INTEREST OF: By submitting a proposal, the bidder represents and warrants that neither a commissioner, administrator, manager, employee, nor any other person employed by PUTNAM COUNTY or in any other way connected with the county has, in any manner, an interest, either directly or indirectly, in the bid or in the contract which may be made under it, or in any expected profits to arise therefrom.

Putnam County BOC Page 3 of 5 Instructions

CERTIFICATE OF INDEPENDENT PRICE DETERMINATION: By signing and submitting this bid, the bidder certifies that the prices in this bid have been arrived at independently, without consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor; unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder prior to bid opening directly or indirectly to any other bidder or to any competitor; no attempt has been made, or will be made, by the bidder to induce any person or firm to submit, or not to submit, a bid for the purpose of restricting competition.

Various professions within the building industry are required by state law to be licensed. These professions include electricians, plumbers, conditioned air contractors, low voltage contractors, utility contractors, and certain residential and general contractors. Putnam County will be complying with state laws and board rules regarding licensure. No bid or proposal for projects that require a licensed professional will be accepted from unlicensed persons. In addition, the licensed contractor must be the prime contractor on the project. It is not permissible for an unlicensed individual/firm to subcontract with a licensed contractor. The validity of all licenses will be checked.

SECTION 7 – BIDDER’S SECURITY

BID BOND: No required.

PERFORMANCE BOND: Not required.

SECTION 8 – EQUAL OPPORTUNITY

Each bidder agrees that it shall not discriminate against any employee or applicant for employment because of race, color, religion, sex, disability, national origin, age, or marital status. In the employment of persons, bidder shall take affirmative action to ensure that applicants are employed and that employees are treated during employment without regard to race, color, religion, sex, disability, national origin, age, or marital status.

SECTION 9 – CLARIFICATION OF SPECIFICATION DOCUMENTS

Bidders shall promptly notify the County Manager of any ambiguity, inconsistency, or error which they may discover upon examination of the specification documents.

Bidders desiring clarification or interpretation of the Specification documents shall make a written request which must reach the County Manager at least seven (7) calendar days prior to the date and time for receipt of bids.

Interpretations, corrections, and changes made to the Specification Documents will be made by written addenda. Oral interpretations or changes to the Specification Documents made in any other manner, will not be binding on the County; and bidders shall not rely upon such interpretations or changes.

SECTION 10 – SCHEDULE

The ambulance shall be delivered to Putnam County as soon as possible following the Notice of Award, but in no event later than that date which is 150 days from the date of the Notice of Award- unless delayed from the specified chassis manufacturer. The bidder shall state the estimated delivery time on the Official Bid Form in the space provided. Putnam County shall be notified at least forty-eight (48) hours in advance of the delivery date and time.

SECTION 11 – BID EVALUATION AND AWARD

The signed bid proposal shall be considered an offer on the part of the bidder. Such offer shall be deemed accepted upon issuance, by the County, of purchase orders, contract award notifications, or other contract documents appropriate to the work.

No bid shall be modified or withdrawn for a period of ninety (90) calendar days after the time and date established for receiving bids and each bidder so agrees in submitting the bid.

Putnam County BOC Page 4 of 5 Instructions

Award will be made to the vendor submitting the lowest responsive and responsible bid. The Putnam County Board of Commissioners reserves the right to reject any or all bids, to waive technicalities and to re-advertise or make an award as deemed in its best interest. The written bid documents supersede any verbal or written prior communication between the parties.

SECTION 12 – CONTRACT AND BOND

After the acceptance of the bid, the successful bidder must execute a written Contract between the bidder and the County; such contract will incorporate the County’s contract documents and be on forms provided by the County.

SECTION 13 – INSURANCE

All bidders shall take special note of the attached insurance sheet titled “Insurance Clause for all County Contracts.”

The successful bidder must provide proof of insurance in accordance with the contract documents.

SECTION 14 – INDEMNIFICATION

The bidder shall indemnify and hold harmless the County, its members, its officers, and employees from and against all claims, damages, losses, and expenses, including, but not limited to attorney’s fees arising out of or resulting from the performance of the contract, provided that any such claim, damage, loss, or expense is attributable to bodily injury, sickness, disease, or death, or to injury to or destruction of tangible property other than goods, materials, and equipment furnished under this contract, including the loss of use resulting therefrom; is caused in whole or part by any negligent act or omission of the bidder, any subcontractor, or anyone directly or indirectly employed by any one of them or anyone for whose acts made by any of them may be liable, regardless of whether or not it is caused by a party indemnified hereunder.

In any and all claims against the County or its members, officers or employees by an employee of the bidder, any subcontractor, anyone directly or indirectly employed by any of them or by anyone for whose acts made by any of them may be liable, the indemnification obligation listed above shall not be limited in anyway by any limitation of the amount or type of damages, compensation, or benefits payable by or for the bidder or any subcontractor under worker’s or workmen’s compensation acts, disability benefit acts, or other employee benefit acts.

SECTION 15 – LAWS

The Laws of the State of Georgia shall govern the rights, obligations, and remedies of the Parties under this proposal and any agreement reached as a result of this process.

SECTION 16 – INDEPENDENT CONTRACTOR

It is the express intent of the parties that this Contract shall not create an employer-employee relationship, and the Contractor, or any employee or other person acting on behalf of Contractor in the performance of this Contract, shall be deemed to be independent contractor(s) during the entire term of this Contract or any renewals thereof. Contractor shall be responsible for all compensation and benefits payable to Contractor’s employee(s) under this Contract and Contractor’s employees shall not be entitled to any compensation from County or to any benefits made to their employees, including, but not limited to, overtime, vacation, retirement benefits, workers’ compensation, sick leave, or injury leave. Contractor shall also be responsible for maintaining workers’ compensation insurance, unemployment insurance, and for payment of all federal, state, local and any other payroll taxes with respect to the employee’s compensation.

SECTION 17 – CERTIFICATION

By signing and submitting a proposal, the bidder certifies that they have carefully examined the plans for this project and the applicable federal, state, and local regulations and the special provisions included in and made a part of this proposal, and have also personally examined the site of the work. If awarded, the bidder further proposes to execute the contract agreement described in the specifications as soon as the work is awarded.

Putnam County BOC Page 5 of 5 Instructions

SECTION 18 - DRUG-FREE WORK PLACE CERTIFICATION

By signing and submitting a proposal, the bidder certifies that the provisions of Code Sections 50-24-1 through 50-24-6 of the Official Code of Georgia Annotated, relating to the "Drug-free Work Place Act”, have been complied with in full. The bidder further certifies that:

(1) A drug-free work place will be provided for the contractor's employees during the performance of the contract; and

(2) Each contractor who hires a subcontractor to work in a drug-free work place shall secure from that subcontractor a written certification that a drug free work place will be provided for the subcontractor's employees during the performance of this contract pursuant to paragraph (7) of subsection (b) of Code Section 50-24-3.

Also, they further certify that they will not engage in the unlawful manufacture, sale, distribution, dispensation, possession, or use of a controlled substance or marijuana during the performance of the contract.

SECTION 19 – SECURITY AND IMMIGRATION COMPLIANCE

It is further certified that pursuant to O.C.G.A. §13-10-91 I and all contractors and sub-contractors performing work under this Agreement are in compliance with the Federal Work Authorization Program.

Prime contractors and sub-contractors may participate in any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (“IRCA”). Contractor Affidavit, Subcontractor Affidavit (if applicable), and Sub-subcontractor Affidavit (if applicable) must be completed and turned in with your bid.

It is further certified that pursuant to O.C.G.A. §50-36-1 I am a United States citizen, a legal permanent resident of the United States, or a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency. Affidavit must be completed and turned in with your bid, along with a copy of your driver’s license.

SECTION 20 – PAYMENTS

Contractor shall be paid by and in accordance with Putnam County payment regulations. Putnam County will strive to take advantage of all discounts offered for prompt payment, therefore, indicate all discounts on monthly invoices. Invoices shall not be submitted more frequently than once a month.

SECTION 21 – SPECIFICATIONS

Putnam County is seeking proposals for an Ambulance Remount as described on the following pages.

PUTNAM COUNTY GEORGIA

REMOUNT - DODGE B4500 4X2 DIESEL - 12 FT BODY

CHASSIS - DODGE B4500 4X2 order with OEM Aluminum wheels

STANDARD CONVERSION

CHASSIS ADD-ON

MUD FLAPS- DRW - NO LOGO

RUNNING BOARDS- Black Luverne Grip Step

LIQUID SPRING SUSPENSION

REMOUNT

BASE REMOUNT

RE-PAINT BODY

SCORPION FINISH or SIMILAR - ALL COMPARTMENTS

REPLACE ALL ALUMINUM DIAMOND PLATE - BLACK

REPLACE REAR BUMPER/STEP - BLACK

NEW FENDERETTES - BLACK

NEW "C" CHANNEL RUB RAIL W/REFLECTIVE TAPE - BLACK

NEW WEATHERSTRIPPING ALL DOORS

ELECTRICAL

12V ELECTRICAL

BACK UP ALARM

FRONT CONSOLE- SCORPION COATED GRAY

SIREN SPEAKERS, Whelen SA315

NEW FRONT & REAR SWITCH PANELS Reuse

NEW BATTERY SWITCH

NEW DOOR SWITCHES

WIRE ENGINE BLOCK HEATER - SHORLINE SUPPLIED & SWITCHED

LIGHTING – EMERGENCY

(6) WHELEN ION LED W/BEZELS - (4) on GRILLE (2) on brush guard

(2) WHELEN ION LED W/FLANGES - FRONT INTERSECTION - RED

LIGHTING - NON-EMERGENCY

ICC MARKER LIGHTS-LED

S-T-T LIGHTS - WHELEN M6 / ARROW TURN / LED REVERSE

TAG LIGHT - LED

HVAC

NEW HVAC SYSTEM WITH AUX. CONDENSER

OXYGEN / SUCTION

CHECK SYSTEMS ONLY

PATIENT COMPARTMENT

NEW FLOOR COVERING

DECALS/GRAPHICS/LETTERING

SOL DECALS

OPTIONS

Replace door handles with TriMark. On Entry doors replace interior handle as well.

Install over the top of existing countertop - New Countertops - White - Soft Edge Trim

Seat - Attendant Child 3 Point Safety - Desert Rose w Swivel Base - Wise

Recover pads next to CPC seat Desert Rose

New upper and lower ALS windows Austin Hardware

Replace plexi windows above squad bench

New Vanner inverter

Add 110V upper ALS

Add 110V behind driver seat

Back Up Camera - OEM - Dodge

Replace connectors on scene lights

Ranch Hand full bumper replacement

LED Fog lights mounted in the cutouts of the Ranch Hand grille guard 6"-wired to upfitter switch

Siren - Dual Tone Self Contained

Howler CP-SRN-H-U

Reinstall forward facing Camera

Install radios

Adjustable arm rest

Graphics, lettering and rear Chevron to match Fleet

Paint stripes Vermillion to match fleet

Shoreline - 20A/120V - Auto Eject - Yellow Cover

(2) New 600 Whelen LED Clear lens backups

R3 Compartment add Backboard divider vertical and strap DP

Add Stair Chair bracket on L3 Door

Add Power for Stryker plate

NON power Stryker Stair Chair

Stryker MTS POWER LOAD

IMPORTANT

SUBMITTAL REQUIREMENT

Submittals must be properly labeled to ensure they are not inadvertently opened before the designated time. Affix the label below to the outside of the sealed submittal envelope or delivery package.

If this label is not used (i.e. in case of some delivery services), it is the bidder’s responsibility to ensure that all required information (offeror’s name, address and phone number, the project number, name of the project for which the proposal is being submitted, and the bid opening date and time) is on the OUTSIDE of the delivery package. Submissions that do not comply may be rejected.

FROM:

Company Name _________________________________________

Address: _______________________________________________

Phone: ________________________________________________

Bid/Proposal #: 26-36001-002

Bid/Proposal Name: Remount Ambulance

Bid Opening Date/Time: Thursday, May 7, 2026, 10:05 AM

TO:

ATTN: COUNTY MANAGER

117 PUTNAM DRIVE

SUITE A

EATONTON, GA 31024

Putnam County BOC Page 1 of 2 Insurance

Tel: 706-485-5826 ◊ www.putnamcountyga.us

INSURANCE CLAUSE

FOR ALL COUNTY CONTRACTS

The Contractor shall indemnify and hold harmless, to the fullest extent allowed by law, Putnam County, Georgia, its members, its officers and employees from and against all losses, claims, damages and expenses, including court-ordered attorney’s fees, arising out of or resulting from the performance of the contract that results in bodily injury, sickness, disease, death or injury to or destruction of tangible property, including the loss of use resulting therefrom and is caused in whole or in part by the Contractor, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable.

Contractor shall not commence work under this contract until he has obtained all insurance required under this Section and such insurance has been approved by PUTNAM COUNTY, nor shall the Contractor allow any subcontractor to commence work on his subcontract until all similar insurance required of the subcontractor has been so obtained and approved.

A. Workers’ Compensation Insurance and Employer’s Liability Insurance:

The Contractor shall take out and maintain during the life of this contract the applicable statutory Worker’s Compensation Insurance, and in the case of any work sublet, the Contractor shall require the subcontractor similarly to provide statutory Worker’s Compensation Insurance for the latter’s employees. Coverage shall be provided by an insurance company authorized to write such insurance in all states where the Contractor will have employees located in the performance of this contract, and the Contractor shall require each of his subcontractors similarly to maintain Employer’s Liability Insurance similarly to the Contractor.

Worker’s Compensation – Required limits:

Coverage A – Coverage will include Statutory requirements Coverage B – Employers Liability $100,000 Each Person $100,000 Each Person by Disease $500,000 Policy Limit – Disease

B. General Liability Insurance

1. The Contractor shall maintain during the life of this contract, Commercial General Liability Insurance, naming and protecting him and Putnam County against claims for damages resulting from (a) bodily injury, including wrongful death, and (b) property damage which may arise from operations under this contract whether such operations be by himself or by any subcontractor or anyone directly or indirectly employed by either of them. The insurance requirements are:

Putnam County BOC Page 2 of 2 Insurance

Commercial General Liability with limits of:

$1,000,000 Each Occurrence $1,000,000 Personal Injury $2,000,000 Products/Completed Operations $2,000,000 General Aggregate

2. Coverage shall include Contractual Liability coverage insuring the contractual exposure as addressed in this contract.

3. There shall be no exclusion or limitation for the Explosion (X), Collapse (C) and Underground (U) hazards.

4. Putnam County shall be named as Additional Insured.

5. The Commercial General Liability coverage shall be endorsed with the Designated Construction

Project(s) General Aggregate Limit endorsement.

C. Automobile Liability Insurance: The Contractor shall take out and maintain during the life of the contract such Automobile Liability Insurance as shall protect him against claims for damages resulting from (a) bodily injury, including wrongful death, and (b) property damage which may arise from the operations of any owned, hired, or non-owned automobiles used by or for him in any capacity in connection with the carrying out of this contract. The minimum acceptable limits of liability to be provided by such Automobile Liability Insurance shall be as follows:

Bodily Injury and Property Damage $1,000,000 Combined Single Limit

D. Builder’s Risk Insurance: (For Building Construction Contracts Only) Unless otherwise specified where buildings are to be constructed under this contract, the Contractor shall provide coverage for all direct physical loss (also known as “Special Causes of Loss”). Such insurance shall be written on a Replacement Cost basis covering such building in the amount equal to one-hundred percent (100%) of the contract amount (minimum) as specified herein. Losses, if any, shall be made payable to PUTNAM COUNTY and Contractor as their interest may appear. A certificate of insurance evidencing such insurance coverage shall be filed with PUTNAM COUNTY by the time work on the building begins and such insurance shall be subjected to the approval of PUTNAM COUNTY.

E. Minimum Scope of Insurance: All Liability Insurance policies shall be written on an “Occurrence” basis only. All insurance coverage is to be placed with insurers authorized to do business in the State of Georgia.

F. Certificate of Insurance: All Certificates of Insurance shall be filed with PUTNAM COUNTY on the standard ACCORD CERTIFICATE OF INSURANCE form showing the specific limits of insurance, coverage modifications and endorsements required by the preceding Sections A, B, C, D and showing PUTNAM COUNTY as an additional insured where required. Such certificate shall specifically state that insurance policies are to be endorsed to require the insurer to provide PUTNAM COUNTY thirty days notice of cancellation, non-renewal or any material reduction of insurance coverage.

The original certificate shall be provided to the Putnam County Board of Commissioners as designated and mailed to: 117 Putnam Drive, Suite A, Eatonton, GA 31024.

Putnam County BOC Page 1 of 2 Proposal Form

Tel: 706-485-5826 ◊ www.putnamcountyga.us

PROPOSAL FORM

SOLICITATION 26-36001-002

REMOUNT AMBULANCE

To: The Putnam County Board of Commissioners

Pursuant to the invitation to bid and the instructions to Bidders and according to the specifications attached, the below stated bidder proposes the following prices for a New Ambulance:

____________________________________________ does hereby propose the following:

(Name of Bidder)

$_________________________________ (Base Bid)

OPTIONS:

a) ______________________________________________ $ _____________________

b) ______________________________________________ $ _____________________

c) ______________________________________________ $ _____________________

Grand Total: $_____________________________________________________________

Estimated Delivery Time: ____________________________________________________

Additional sheet may be attached for detailed breakdown.

MARK OUTSIDE OF BID ENVELOPE AS FOLLOWS:

The offeror’s name, address, telephone number, the Solicitation # and name, the date Thursday, May 7, 2026 at 10:05 a.m. and addressed as follows:

Remount Ambulance Attn: Paul Van Haute, County Manager

I hereby acknowledge receipt of the following checked amendments of the Proposal, Plans and/or Specifications, etc.:

Amendment No's: 1___, 2___, 3___, 4___, 5___, I understand that failure to confirm the receipt of amendments is cause for rejection of bids.

Signatures on the following page

Putnam County BOC Page 2 of 2 Proposal Form

The undersigned signatory for the bidder represents and warrants that he has full and complete authority to submit this proposal to the County and to enter into contract with Putnam County.

COMPANY NAME BY (SIGNATURE)

STREET ADDRESS or P. O. BOX (PRINT NAME)

CITY, STATE ZIP CODE (TITLE)

TELEPHONE NO. FAX NO. (DATE)

EMPLOYERS FEDERAL I.D. NO or Email

SOCIAL SECURITY NUMBER

The Bidder(s) whose signature(s) appears on this document, having personally appeared before me, and being duly sworn, deposes and says that the above statements are true and correct.

Sworn to and subscribed before me this _______day of__________________, 20_____.

Notary signature: ________________________________________________

My commission expires: ____________________ (seal)

706-485-5826 ◊ www.putnamcountyga.us

SAVE Affidavit

(U.S. Citizens are only required to provide this affidavit one time)

By executing this affidavit under oath, as bidder to Putnam County Georgia as referenced in O.C.G.A. § 50-36-1, the undersigned applicant verifies one of the following with respect to my application for a public benefit:

Please check one box only

1) I am a United States citizen

2) I am a legal permanent resident of the United States

3) I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency

My alien number issued by the Department of Homeland Security or other federal immigration agency is:

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.

The secure and verifiable document provided with this affidavit can best be classified as:

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statue.

Executed in ________________________________________ (city), ____________________________________ (state).

Signature of Applicant: ______________________________________________________________________________

Printed Name: ______________________________________________________________________________________

Date _____________________________________________________________________________________________

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE

__________ DAY OF ____________________, 20_______

Notary Public Signature: _________________________________ Affix Notary stamp/seal here

My Commission Expires: _________________________________

Contractor Affidavit Under O.C.G.A. § 13-10-91(b)(1)

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of the Putnam County Board of Commissioners has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number Date of Authorization

Name of Contractor

Name of Project

Putnam County Board of Commissioners Name of Public Employer

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

Executed on the __________ day of _______________________, 20_____ in

______________________________(city), _________________________(state).

Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE

_______ DAY OF ________________, 20_______

Notary Public Signature

My Commission Expires:

Subcontractor Affidavit Under O.C.G.A. § 13-10-91(b)(3)

By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with __________________________(name of contractor) on behalf of the Putnam County Board of Commissioners has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned subcontractor will contract for physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the subcontractor with the information required by O.C.G.A. § 13-10-91(b). Additionally, the undersigned subcontractor will forward notice of the receipt of an affidavit from a sub-subcontractor to the contractor within five business days of receipt.

If the undersigned subcontractor receives notice of receipt of an affidavit from any sub-subcontractor that has contracted with a sub-subcontractor to forward, within five business days of receipt, a copy of such notice to the contractor.

Subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number Date of Authorization

Name of Subcontractor Name of Project

Putnam County Board of Commissioners Name of Public Employer

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

Executed on the __________ day of _______________________, 20_____ in

______________________________(city), _________________________(state).

Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE

_______ DAY OF ________________, 20_______

Notary Public Signature My Commission Expires:

Sub-subcontractor Affidavit Under O.C.G.A. § 13-10-91(b)(4)

By executing this affidavit, the undersigned sub-subcontractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with __________________________(name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract) and _____________________________ (name of contractor) on behalf of the Putnam County Board of Commissioners has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned sub-subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned sub-subcontractor will contract for the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the sub-subcontractor with the information required by O.C.G.A. § 13-10- 91(b). The undersigned sub-subcontractor shall submit, at the time of such contract, this affidavit to _______________________________ (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract). Additionally, the undersigned sub-subcontractor will forward notice of the receipt of an affidavit from a sub-subcontractor to ________________________ (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract). Sub-subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number Date of Authorization

Name of Sub-subcontractor Name of Project

Putnam County Board of Commissioners Name of Public Employer

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

Executed on the __________ day of _______________________, 20_____ in

______________________________(city), _________________________(state).

Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE

_______ DAY OF ________________, 20_______

Notary Public Signature My Commission Expires: