26WS0010_-_CUF_Certification_Form.pdf
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- Solicitation number
- 0000039350
About this file
This is a Commercially Useful Function (CUF) Certification Form issued by the State of California Department of Veterans Affairs for solicitation 26WS0010, which pertains to Temporary/Relief Physician/Surgeon and Chief Medical Officer Services at the Veterans Home of California at West Los Angeles. The form is mandatory for all certified Small Businesses (SB), Micro Businesses (MB), and Disabled Veteran Business Enterprises (DVBE) that will perform any element of the work under this contract. Bidders must certify their role and demonstrate that they meet commerciall useful function requirements by answering five specific questions regarding their responsibility for executing distinct work elements, their direct involvement in performing, managing, or supervising the work, the alignment of work with normal business functions, subcontracting practices, and their substantive participation beyond mere financial pass-through.
The CUF certification requires that responding businesses answer affirmatively to questions one through three and negatively to question four to remain responsive; responses indicating no responsibility for distinct work elements, no direct performance or management involvement, work outside normal business functions, or excessive subcontracting beyond industry norms will result in disqualification. Respondents must provide a written statement detailing their specific role, services, and goods, and the authorized business owner or representative must sign the form under penalty of perjury, certifying the accuracy and truthfulness of all information provided.
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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: 26WS0010 |
| DoingBusinessAs: |
| OSDSRefNumber: |
| ExpirationDate: |
| : |
| Yes: |
| No: |
| ProvideAWrittenStatement: |
| AuthorizedRepresentative: |
| Title: |
| PrintedName: |
| Date: |
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