3-Appendix A.pdf

Appendix A

SUBMISSION FORMS

The following forms must be submitted and uploaded with the proposal. Failure to include these forms may lead to rejection of the proposal as non-responsive. Each form must be signed by a person authorized to bind the company. Electronic signatures are acceptable.

PUBLIC DISCLOSURE STATEMENT

Provide a YES or NO answer to the following three (3) questions. If you responded “yes” to any question, please explain (responding “yes” does not necessarily disqualify you from doing business with the County).

In the past five (5) years,

1. Has your firm referred any business (whether or not compensated) or otherwise had any financial dealings with any County elected official or County officer?

2. Have any officers or principals of your firm engaged in any dealings of a financial or personal nature with any County elected official or County officer?

3. Have any officers or principals of your firm been solicited for a campaign contribution by or on behalf of any County elected official or County officer?

[ ] Confirm that you will comply in all respects with the Pennsylvania Public Official and Employees Ethics Act. 65 Pa.C.S.. § 1101 et seq.

Signature & Date

Typed/Printed Name

Title

CERTIFICATION AND REPRESENTATIONS OF OFFERORS

1. Certification of Eligibility

a. The bidder certifies that neither the offeror, nor any person or firm which has an interest in the proposal or the offeror’s firm:

(1) Has been suspended, debarred or otherwise restricted by the County or any Department or Agency of the Federal Government or of any State Government from doing business with such County, Department, Agency or State for the period beginning 5 years prior to the date of this certification;

(2) Has experienced default or noncompliance under any contract with any governmental agency with which it has contracts for the period beginning 10 years prior to the date of this certification; or

(3) Has unresolved findings raised as a result of federal, state or local government audits, or any other governmental investigations concerning the offeror or any person or firm which has an interest in the offeror's firm under any of the offeror's contracts;

(4) Has defaulted on an obligation covered by a bond, and has not been the subject of a claim under any fidelity bond.

(5) Has been found by the Commonwealth of Pennsylvania to be in noncompliance with any applicable civil rights laws.

(6) Is a County Commissioner, County employee, or otherwise prohibited or limited by law from contracting with the County.

(7) Has been convicted of a felony and is not presently the subject of a complaint or indictment charging a felony. (A felony is any offense punishable by imprisonment for more than one year, but does not include any offense classified as a misdemeanor under the laws of a State and punishable by imprisonment of two years or less.)

(8) Has been convicted or found liable for any act prohibited by state or federal law involving conspiracy or collusion with respect to proposing or bidding on any public contract within the last three years. If offeror has been convicted of any act prohibited by State or Federal law involving collusion with respect to proposing or bidding on any public contract within the past three years, offeror should attach an explanation of the circumstances surrounding that conviction.

b. Statements above to which the offeror cannot certify (if any) have been deleted by striking through the words with a pen. The offeror has initialed each deletion (if any) and has attached a true and accurate signed statement (if applicable) to explain the facts and circumstances which qualify the offeror as a responsible offeror for participation in this project.

c. The certification in paragraph (a) above is a material representation of fact upon which reliance was placed when making the award. If it is later determined that the offeror knowingly rendered an erroneous certification, the contract may be terminated for default.

2. Contingent Fee Representation and Agreement

a. The bidder/offeror represents and certifies as part of its bid/offer that, except for full-time bona fide employees working solely for the bidder/offeror, the bidder/offeror:

(1) [ ] has, [ ] has not employed or retained any person or company to solicit or obtain this contract; and

(2) [ ] has, [ ] has not paid or agreed to pay to any person or company employed or retained to solicit or obtain this contract any commission, percentage, brokerage, or other fee contingent upon or resulting from the award of this contract.

b. If the answer to either (a) (1) or (a) (2) above is affirmative, the bidder/offeror shall make an immediate and full written disclosure to the Chief Procurement Officer.

c. Any misrepresentation by the bidder/offeror shall give the County the right to (1) terminate the resultant contract; (2) at its discretion, to deduct from contract payments the amount of any commission, percentage, brokerage, or other contingent fee; or (3) take other remedy pursuant to the contract.

3. Certificate of Independent Price Determination

a. The bidder/offeror certifies that:

(1) The prices in this bid/offer have been arrived at independently, without, for the purpose of restricting competition, any consultation, communication, or agreement with any other bidder/offeror or competitor relating to (i) those prices,

(ii) the intention to submit a bid/offer, or (iii) the methods or factors used to calculate the prices offered;

(2) The prices in this bid/offer have not been and will not be knowingly disclosed by the bidder/offeror, directly or indirectly, to any other bidder/offeror or competitor before bid opening (in the case of a sealed bid solicitation) or contract award (in the case of a negotiated solicitation) unless otherwise required by law;

(3) No attempt has been made or will be made by the bidder/offeror to induce any other concern to submit or not to submit a bid/offer for the purpose of restricting competition; and

b. Each signature on the bid/offer is considered to be a certification by the signatory that the signatory:

(1) Is the person in the bidder/offeror’s organization responsible for determining the prices being offered in this bid or proposal, and that the signatory has not participated and will not participate in any action contrary to subparagraphs (a)(l) through (a)(3) above; or

(2) (i) Has been authorized, in writing, to act as agent for the following principals in certifying that those principals have not participated, and will not participate in any action contrary to subparagraphs (a)(l) through (a)(3) above.

_______________________________________________________ [insert full name of person(s) in the bidder/offeror’s organization responsible for determining the prices offered in this bid or proposal, and the title of his or her position in the bidder/offeror’s organization];

(ii) As an authorized agent, does certify that the principals named in subdivision (b)(2)(i) above have not participated, and will not participate, in any action contrary to subparagraphs (a)(l) through (a)(3) above; and

(iii) As an agent, has not personally participated, and will not participate in any action contrary to subparagraphs (a)(l) through (a)(3) above.

c. If the bidder/offeror deletes or modifies subparagraph (a)2 above, the bidder/offeror must furnish with its bid/offer a signed statement setting forth in detail the circumstances of the disclosure.

4. Organizational Conflicts of Interest Certification

a. The Contractor warrants that to the best of its knowledge and belief and except as otherwise disclosed, it does not have any organizational conflict of interest which is defined as a situation in which the nature of work under a proposed contract and a prospective contractor’s organizational, financial, contractual or other interest are such that:

(1) Award of the contract may result in an unfair competitive advantage;

(2) The Contractor’s objectivity in performing the contract work may be impaired; or

(3) That the Contractor has disclosed all relevant information and requested the County to make a determination with respect to this Contract.

b. The Contractor agrees that if after award he or she discovers an organizational conflict of interest with respect to this contract, he or she shall make an immediate and full disclosure in writing to the County which shall include a description of the action which the Contractor has taken or intends to eliminate or neutralize the conflict. The County may, however, terminate the Contract for the convenience of the County if it would be in the best interest of the County.

c. In the event the Contractor was aware of an organizational conflict of interest before the award of this Contract and intentionally did not disclose the conflict to the County, the County may terminate the Contract for default.

d. The Contractor shall require a disclosure or representation from subcontractors and consultants who may be in a position to influence the advice or assistance rendered to the County and shall include any necessary provisions to eliminate or neutralize conflicts of interest in consultant agreements or subcontracts involving performance or work under this Contract.

[ ] In the absence of any actual or apparent conflict, I hereby certify that to the best of my knowledge and belief, no actual or apparent conflict of interest exists with regard to my possible performance of this procurement.

5. Authorized Negotiators

The offeror represents that the following persons are authorized to negotiate on its behalf with the County in connection with this request for proposals:

(list names, titles, and telephone numbers of the authorized negotiators):

6. Conflict of Interest

In the absence of any actual or apparent conflict, the offeror, by submission of a proposal, hereby warrants that to the best of its knowledge and belief, no actual or apparent conflict of interest exists with regard to my possible performance of this procurement, as described in the clause in this solicitation titled “Organizational Conflict of Interest.”

Offeror’s Signature

The offeror hereby certifies that the information contained in these certifications and representations is accurate, complete, and current.

Typed/Printed Name

LOCAL, SMALL, AND DISADVANTAGED BUSINESS CONCERN CERTIFICATION

Submit if any below are applicable

The Provider represents and certifies as part of its proposal that it:

[ ] is a local business concern. A “Local business concern” as used in this provision, means a person, partnership, corporation or other business entity authorized to transact business in this County and having a bona fide establishment for transacting business in this County at which it was transacting business on the date when bids or proposals for the public contract were first solicited.

[ ] is a small business concern. “Small business concern,” as used in this provision, means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding, and qualified as a small business under the criteria and size standards in 13 CFR 121.

Certifying Agency & Certification Number (if applicable):______________

[ ] is a women-owned small business concern. “Women-owned,” as used in this provision, means a small business that is at least 51 percent owned by a woman or women who are U.S. citizens and who also control and operate the business.

Certifying Agency & Certification Number (if applicable):______________

[ ] is a minority enterprise which, pursuant to Executive Order 11625, is defined as a business which is at least 51 percent owned by one or more minority group members or, in the case of a publicly owned business, at least 51 percent of its voting stock is owned by one or more minority group members, and whose management and daily operations are controlled by one or more such individuals.

For the purpose of this definition, minority group members are:

(Check the block applicable to you) [ ] Black Americans [ ] Asian Pacific Americans [ ] Hispanic Americans [ ] Asian Indian Americans [ ] Native Americans [ ] Hasidic Jewish Americans

Certifying Agency & Certification Number (if applicable) ______________

Typed/Printed Name

LOCAL, SMALL, AND DISADVANTAGED BUSINESS CONCERN CERTIFICATION