26FS0002_-_CV_012_CUF_Certification_Form.pdf
PDF 179 KB Posted
- Attached to
- 26FS0002 - Sanitation System Pumping Services
- Solicitation number
- 0000038538
- Issued by
- Fresno County, Inyo County, Kings County, Madera County, Mariposa County, Merced County, Mono County, Monterey County, San Benito County, Tulare County, Fremont City, Fresno City, Kingsburg City, Inyokern CDP, Monterey Park City, Madera City, Madera Acres CDP, Madera Ranchos CDP, Corte Madera Town, Mariposa CDP, Merced City, University of California-Merced CDP, Mono City CDP, Monterey City, Kings Beach CDP, Monterey Park Tract CDP, East Tulare Villa CDP, Tulare City, Mono Vista CDP, California
About this file
This is a Commercially Useful Function (CUF) Certification Form issued by the State of California Department of Veterans Affairs for Solicitation Number 26FS0002, which concerns Sanitation System Pumping Services at the Veterans Home of California at Fresno. The form must be completed by every certified Small Business (SB), Micro Business (MB), and Disadvantaged Veteran Business Enterprise (DVBE) that will perform any element of the work. The certification requires bidders to confirm that their business will be responsible for executing a distinct element of work, will carry out contract obligations through actual performance or management, will perform work normal to their business operations, and will not subcontract beyond normal industry practices. Bidders must also confirm that their role is not limited to being an extra participant merely passing through funds to create an appearance of small or veteran business participation.
The form requires a written statement detailing the role, services, and goods the company will provide to meet CUF requirements. Responses of "No" to questions one through three or "Yes" to question four regarding excessive subcontracting may result in the quote being deemed non-responsive and disqualified from consideration. The form must be signed by the certified business owner or authorized corporate representative under penalty of perjury, certifying that all information provided is truthful and accurate. The State of California reserves the right to request additional clarifying information prior to contract award.
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Text version
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: 26FS0002 |
| DoingBusinessAs: |
| OSDSRefNumber: |
| ExpirationDate: |
| : |
| Yes: |
| No: |
| ProvideAWrittenStatement: |
| AuthorizedRepresentative: |
| Title: |
| PrintedName: |
| Date: |
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