3-2024-BRP-008 REQUIRED DOCUMENTS - affidavits and compliance.pdf

Contractor Affidavit of Eligibility

, being first duly sworn, deposes and says that he is

Of (sole owner, partner, president, secretary, etc) (Name of Firm) and that he is authorized to make this affidavit on behalf of the firm, and its owners, directors, and officers. He is the person responsible in my firm for accurate submission of this bid.

1. , its affiliates subsidiaries, officers, directors, (Name of Firm) and employees are not currently under investigation by any governmental agency and have not in the last four years been convicted or found liable for any act prohibited by State or Federal law in any jurisdiction with respect to bidding on any public contract, except as follows:

2. , its affiliates subsidiaries, officers, directors, and employees are not debarred, suspended, proposed for debarment, excluded or disqualified under the nonprocurement common rule, or otherwise declared ineligible from receiving Federal contracts, certain subcontracts, and certain Federal assistance and benefits.

3. I state that , understand and acknowledges that the above representations are material and important, and will be relied on by Steel Rivers

Council of Governments in awarding the contract(s) for which this bid is submitted. I understand and my firm understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from Steel Rivers Council of Governments of the true facts relating to the submission of bids for this contract.

Signed:

By:

Title:

Sworn to and subscribed before me this Day of

20 .

Notary Public

Date My Commission Expires

Non Collusion Affidavit To Be Executed by Each Bidder

State of: Municipality:

County of: Contract Name:

, being first duly sworn, deposes and says that he is

Of (sole owner, partner, president, secretary, etc) and that he is authorized to make this affidavit on behalf of the firm, and its owners, directors, and officers. He is the person responsible in my firm for the price (s) and the amount of this bid.

To state that:

1. The price(s) and amount of this bid have been arrived at independently and without consultation, communication or agreement with any other contractor, bidder or potential bidder.

2. That such bid is not made in the interest of or on behalf of any undisclosed person, partnership, company association, organization, or corporation; that such bid is genuine and not collusive or sham;

3. The bid of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit an complementary or other noncompetitive bid.

4. That said bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of said bidder or of any other bidder, nor to fix any overhead, profit, or cost element of such bid price nor of that of any other bidder, nor to secure any advantage against the public body awarding the contract to anyone interested in the proposed contract;

5. No attempt has been made or will be made to induce any firm or person to refrain from bidding on this contract, or to submit a bid higher than this bid, or to submit any intentionally high or noncompetitive bid or other form of complementary bid.

6. That said bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and has not directly or indirectly induced or solicited any other bidder connived, or agreed with any bidder or anyone else to put in a sham bid.

7. Neither the price(s) nor the amount of this bid, and neither the approximate price(s) nor approximately amount of this bid, have been disclosed to any other firm or person who is a bidder or potential bidder, and they will not be disclosed before bid opening.

8. That all statements contained in such bid are true; and, further, that said bidder has not directly or indirectly, submitted his bid price or any breakdown thereof, nor the contents there of, nor divulged information or data relative thereto, nor paid and will not pay fee in connection therewith to any corporation, partnership, company, association, organization, bid depository, nor to any member or agent thereof, nor to any other individual except to such person or persons as have a partnership or other financial interest with said bidder in his general business.

9. , its affiliates subsidiaries, officers, directors, and employees are not currently under investigation by any governmental agency and have not in the last four years been convicted or found liable for any act prohibited by

State or Federal law in any jurisdiction involving conspiracy or collusion with respect to bidding on any public contract, except as follows:

10. I state that , understand and acknowledges that the above representations are material and important, and will be relied on by Steel

Rivers Council of Governments in awarding the contract(s) for which this bid is submitted. I understand and my firm understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from Steel Valley Council of

Governments of the true facts relating to the submission of bids for this contract.

Signed:

By:

Sworn to and subscribed before me this Day of

20 .

Notary Public

Date My Commission Expires

Qualification Statement (Type or Print Legibly)

1. Name of Bidder: Federal ID#

2. Address of Bidder:

Business Telephone Number: Cell Number: Fax Number:

Email address:

3. Date When Organized:

4. Type of Organization

(Individual) (Partnership) (Corporation)

5. Years Engaged in Contracting Business

6. Experience Record: Name, address, phone number and contact person of four (4) organizations you have performed similar work.

1)

2)

3)

4)

7. Contracts on Hand: Anticipated

Project Gross Amount Completion Date

8. Ever fail to complete any work awarded to you?

9. If so, where and why?

10. Most Important Contracts recently Completed by You:

Project Gross Amount Completion Date

11. Background and Experience of Principal Members of your Company:

12. Major Equipment Available for this Contract:

13. Do you agree to submit a detailed financial statement if requested?

Contractor Name:

Signed By:

Date:

INCLUDE IN BID

SPECIFICATIONS Procurement Compliance / Bid Package Documents

NOTICE TO PRIME CONTRACTORS/SUBCONTRACTORS

PROJECT NAME_ #

Acknowledgement by Prime Contractor Subcontractor

Company Name_

Authorized Official:

Signature: Date:

PROJECT LOCATION

GRANTEE_

All contractors for the above-named project understand that any payment request for the project will not be processed by until all requirements are met. It is the responsibility of the Grantee to make sure that all the paperwork is submitted by everyone on the project before request for payments are submitted.

It is further understood that the Prime Contractor is responsible for collecting all paperwork for each Subcontractor hired and must submit it to the Grantee, along with a signed agreement between the Prime and Subcontractor . Both Prime and Subcontractors are required to retain copies of all paperwork for this State-funded project for a period of three years after completion of the project.

The contractor understands that no basic wage can be lower than the wage issued: if fringe benefits are not paid into a special fund, the fringe benefits listed for any particular trade in the wage decision is added to, and becomes part of, the basic hourly wage for the employee performing the work.

All payrolls must be forwarded within seven days after the pay period. Payrolls must be certified on the reverse side and the signatures must be hand written in blue i

This form must be signed by the Prime Contractor or Subcontractor

Revised January 022

Procurement Compliance / Bid Package Documents

AFFIRMATIVE ACTION /MWBE CERTIFICATION

PRIME / SUBCONTRACTOR AFFIRMATIVE ACTION CERTIFICATION

PRIME/SUBCONTRACTOR Agrees to comply with the U.S. Department of Labor Model Affirmative Action (41-CFR-60- 1.4) Plan.

MINORITY BUSINESS AND FEMALE UTILIZATION CERTIFICATION

Company Name , Contractor, will abide by and initiate all of my subcontracts to the greatest extent feasible, the requirements of Executive Order 11625 and Executive Order 12138 regarding utilization of Minority and Female Business on this project.

SIGNATURE _DATE

NAME_ TITLE

NUMBER_ PHONE#

PROJECT NAME_

LOCATION PROJECT #

INCLUDE IN BID

SPECIFICATIONS

IN

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J an ua ry

Allegheny County Economic Development

AWARD VERIFICATION FOR PRIME/ SUBCONTRACTORS - PL3/PL4

INCLUDE IN BID

SPECIFICATIONS

This portion to be completed by Prime Contractor / Subcontractor:

SCHEDULE OF SUBCONTRACTORS

PRIME CONTRACTORS: This form must be submitted to the GRANTEE no more than ten days after you have received a bid award letter notifying you that you have been awarded the contract. Failure to submit this form could disqualify your bid.

PROJECT NAME

PROJECT LOCATION PROJECT #

IRS ID#_ DATE

COMPANY NAME

ADDRESS

CITY

IRS ID#TELEPHONE#

Is Subcontractor a MBE? Yes Is Subcontractor a WBE? Yes Is Subcontractor a DBE? Yes Is Subcontractor a VOSB? Yes

Type of Work

COMPANY NAME

ADDRESS

CITY ZIP

IRS ID#

No No No No

TELEPHONE#

Is Subcontractor a MBE? Yes Is Subcontractor a WBE? Yes Is Subcontractor a DBE? Yes Is Subcontractor a VOSB? Yes

Type of Work

COMPANY NAME

ADDRESS

CITY ZIP

IRS ID#

No No No No

TELEPHONE#

Is Subcontractor a MBE? Yes Is Subcontractor a WBE? Yes Is Subcontractor a DBE? Yes Is Subcontractor a VOSB? Yes

Type of Work

COMPANY NAME

ADDRESS

CITY ZIP

IRS ID#

No No No No

TELEPHONE#

Is Subcontractor a MBE? Yes Is Subcontractor a WBE? Yes Is Subcontractor a DBE? Yes Is Subcontractor a VOSB? Yes

Type of Work

INCLUDE IN BID

AGENCY PRIME CONTRACTOR / SUBCONTRACTOR VERIFICATION

(Agency/Prime/Subcontractor Legal Name) has an agreement with

(Prime/Subcontractor Legal Name) to work on the

(Project Name)_ located in the area of , PA.

If awarded the contract, the above Agency/Prime Contractor/Subcontractor intends to have a binding contract with the above Prime Contractor or Subcontractor to perform the following work:

(Provide Brief Description of the Type of Work Agreed Upon)

Signature:_____________________________________________ Date:

Name:___________________________________________________ Title:

Prime Contractor Signature:_____________________________________ Date:

Name: __________________________________________ Title:

Signature:_______________________________________ Date:

Printed Name: _____________________________________________ Title

INCLUDE IN BID

SPECIFICATIONS

The contract dollar amount $

THIS FORM MUST BE SUBMITTED FOR EVERY PRIME / SUBCONTRACTOR HIRED FOR THIS

PROJECT AND SUBMITTED TO THE AGENCY. THIS FORM IS TO BE SUBMITTED 10 DAYS AFTER CONTRACT IS AWARDED.

Revised January 2022

FRINGE BENEFIT LETTER

Wage Decision

IRS ID#

City State

Project Name_

Project #

Contract Amount $

Prime/Subcontractor Company Name (Circle One)_

Address:

FRINGE BENEFITS:

All Fringe Benefits will be paid as follows:

_Fringes will be included in the basic hourly wage rates.

_Fringes will be paid into the following Benefit Plans: (List Hourly Fringe Benefit Rate)

Name of Plan:

Address:

City:

Classification: Hourly Fringe Benefit Rate

Name of Plan:

Address:

City:

Classification: Hourly Fringe Benefit Rate

Name of Plan:

Address:

City:

Classification: Hourly Fringe Benefit Rate

Signature

Printed Name: Date:

INCLUDE IN BID

As a contractor/subcontractor for the above referenced public works contract, I hereby affirm that as of the above date, our company is in compliance with the Public Works Employment Verification Act through utilization of the federal Program (EVP) operated by the United States Department of Homeland Security. To the best of my/our knowledge, all employees hired post January 1, 2013 are authorized to work in the United States.

It is also agreed to that all public works contractors/subcontractors will utilize the federal EVP to verify the employment eligibility of each new hire within five (5) business days of the employee start date throughout the duration of the public works contract. Documentation confirming the use of the federal EVP upon each new hire shall be maintained in the event of an investigation or audit.

I, , authorized representative of the company above, attest that the information contained in this verification form is true and correct and understand that the submission of false or misleading information in connection with the above verification shall be subject to sanctions provided by law.

COMMONWEALTH OF PENNSYLVANIA

PUBLIC WORKS EMPLOYMENT VERIFICATION FORM

Date

Business or Organization Name (Employer)

Address

City State Zip Code

Contracting Public Body

Contract/Project No

Project Description

Project Location

Authorized Representative Signature

INCLUDE IN BID