3-Attachment A Forms.pdf

AFFIDAVIT

STATE OF ______________________ )

) SS.

COUNTY OF ____________________ )

_________________________________of the city of ________________________________ County of ____________________ State of __________________being duly sworn on her or his oath, deposes and says;

1. That I am the _________________________ (Title of Affiant) of __________________________________(Name of Supplier) and have been authorized by said Supplier to make this Affidavit upon my best information and belief, after reasonable inquiry as to the representations herein.

2. No Officer, Agent or Employee of Jackson County, Missouri is financially interested directly or indirectly what Supplier is offering to sell to the County pursuant to this Invitation (though no representation is made regarding potential ownership of publicly traded stock of supplier).

3. If Supplier were awarded any contract, job, work or service for Jackson County, Missouri, no Officer, Agent or Employee of the County would be interested in or receive any benefit from the profit or emolument of such.

4. Either Supplier is duly listed and assessed on the tax rolls of Jackson County, Missouri and is not delinquent in the payment of any taxes due to the County or Supplier did not have on December 31, 2025, any property subject to taxation by the County and if Supplier is duly listed and assessed on the tax rolls of Jackson County, Missouri, supplier agrees to permit an audit of its records, if requested by the Jackson County Director of Assessment, as they relate to the assessment of Business Personal Property.

5. Supplier has not participated in collusion or committed any act in restraint of trade, directly or indirectly, which bears upon anyone's response or lack of response to the Invitation.

6. Supplier certifies and warrants that Supplier or Supplier’s firm/organization is not listed on the General Services Administration's Report of Debarred and/or Suspended Parties.

7. Supplier certifies and affirms its enrollment and participation in a federal work authorization program with respect to the employees working in connection with the contracted services.

8. Supplier certifies and affirms that it does not knowingly employ any person who is an unauthorized alien in connection with the contracted services.

_______________________________ (Name of Supplier)

By: ____________________________ (Signature of Affiant)

_______________________________ (Title of Affiant)

Subscribed and sworn to before me this ______ day of _________________, 20____

NOTARY PUBLIC in and for the County of _______________________________(SEAL)

State of _____________________________

My Commission Expires: ______________________________________________

(816) 881-3302

FAX (816) 881-3340

COMPLIANCE@JACKSONGOV.ORG

WWW.JACKSONGOV.ORG/AUDITOR

CERTIFICATE OF COMPLIANCE NOTICE:

All vendors doing business with Jackson County are required to obtain a Certificate of Compliance issued by the Jackson County Compliance Review Office.

A Certificate of Compliance is required to be submitted with any bid response.

Failure to comply with this requirement may result in the REJECTION of a bid. In the event a Respondent has been recommended for a contract award during this time, it will be the understanding of the Respondent that no contract will be awarded by County Legislature or approved by the Compliance Review Office without a current Certificate of Compliance on file.

Vendors may complete a

Certificate of Compliance Application by visiting www.jacomocompliance.com

A Certificate of Compliance will certify that vendors meet the following requirements:

1. Are duly listed and assessed on the tax rolls of Jackson County and are not delinquent in the payment of any taxes due to the County, or do not have on

December 31st of the previous year any property subject to taxation by Jackson County.

2. Attest and agree to Chapter 6 of the Jackson County Code which prohibits discriminatory practices and promotes Equal Employment Opportunity by contractors doing business with Jackson County.

Certificate of Compliance Application must be submitted five (5) business days prior to a bid response deadline to allow sufficient time to process. A Certificate of Compliance is not guaranteed if this timeline is not met.

QUESTIONS? Email compliance@jacksongov.org

OFFICE OF THE COUNTY AUDITOR

COMPLIANCE REVIEW OFFICE

415 E 12TH STREET, 2ND FLOOR

KANSAS CITY, MISSOURI 64106

mailto:COMPLIANCE@JACKSONGOV.ORG http://www.jacksongov.org/AUDITOR http://www.jacomocompliance.com/ mailto:compliance@jacksongov.org

STATEMENT OF CONTRACTOR'S QUALIFICATIONS

(Complete in full, Use attachments if necessary)

Name of Bidder:

Address with Zip Code:

Federal Tax I.D. Number:

Check One: Corporation Partnership Sole Proprietorship

If SOLE PROPRIETORSHIP, state name, address, and phone number of owner:

If CORPORATION:

Date of Incorporation:

Name of State(s) in which incorporated:

President's Name:

Vice-President's Name:

Secretary's Name:

Treasurer's Name:

If PARTNERSHIP:

Is the Partnership: General Limited Association (Check one)

Date of Organization:

Name and addresses of all partners:

1.

2.

3.

GENERAL INFORMATION:

Percent of work to be done under the proposed contract by your own staff:

No. of Permanent Employees:

Geographical Limits of Operation:

No. of years in business:

Have you ever done business under a different name: Yes No (Check one)

If Yes, give Name and Location:

Has contractor ever withdrawn or defaulted on a contractual obligation: Yes No (Check one)

If Yes, state where and why:

STATEMENT OF CONTRACTOR'S QUALIFICATIONS - Continued

Has Contractor ever been sued for breach of any contract? Yes No (Check one)

If Yes, Explain:

List Completed Contracts within the Past Three Years, Including Amount of Each:

List of Current Contracts, Including Amount of Each:

Customer Reference (state name, address, and phone number):

List each subcontractor you plan to use if awarded the contract. If no, so state.

SUBCONTRACTOR'S NAME & PHONE

ITEM OF WORK $ AMOUNT OF CONTRACT MBE/WBE

State any other relevant information concerning Contractor's history, credentials, responsibility, and capabilities (If none, so state):

DBE STATUS Indicate status claimed:

1. Minority Owned Business (MBE) YES____ NO____

African American____ Latino____ Native American____ Asian____ Pacific Islander____

2. Woman Owned Business (WBE) YES____ NO____

3. Small Business YES____ NO____

For consideration as an MBE, WBE or Small Business, a copy of any governmental entity or Minority Supplier Council certification must be attached.

Prepared by (print or type):

Title:

Signature:

Date:

ACKNOWLEDGMENT OF RECEIPT OF ADDENDA

We acknowledge the issuance and receipt # of Addenda for this ITB. We understand that additional addenda may be issued up until the Question Response Deadline of [insert date], 2026 and we will be responsible for checking the Bonfire Portal regularly for any new addenda issued.

Signature of Respondent Date

Company Name

Address

City, State, and Zip Phone

Invitation to Bid No. 26-032 Attachment 1

Bidder’s Quotation Sheet

Line-Item No.

Description Hourly Wage Rate (Regular)

Hourly Wage Rate (Weekends, Holidays)

1.

Regular Time (Work Hours – 8:00am to 4:30pm Monday – Friday) n/a

2.

Weeknight/Overtime (4:30pm to 8:00 am Monday – Friday)

3.

Weekend/Overtime/Holidays (4:30pm to 8:00 am Friday – Monday including Jackson County observed holidays)

Company Name: ____________________________________

Print Name: ________________________________________

Signature: _________________________________________

Date: _____________________________________________

BIDDER'S EXCEPTIONS

TO

SPECIFICATIONS

OF

JACKSON COUNTY, MISSOURI INVITATION TO BID NO. 26-032

Respondent's attention is directed to Paragraph 4 of the General Conditions of this Invitation to Bid. READ THIS PARAGRAPH

CAREFULLY.

The following exceptions to the Specifications of Invitation to Bid No. 26-032 are requested by the undersigned Respondent: (Use additional pages as necessary.)

REFERENCE

PARA # & PAGE #

EXCEPTION REQUESTED

Name of Firm:

Signature of Bidder: