3-Consolidated Forms Pack Appendices A-F.pdf

Cherokee County Standard Solicitation Term and Conditions, Page 9 of 20

APPENDIX “A”

Solicitation # and Title

INFORMATION & ADDENDA ACKNOWLEDGEMENT FORM

Name of Company

Address - City, State and Zip Code

Name & Title of Primary Contact (for proposal clarifications/questions)

Phone of Primary Contact

Email of Primary Contact

Addenda Acknowledgement: Proposer acknowledges receipt of the following addenda (as applicable):

Proposer’s Signature Date

Addendum Number: Date:

Addendum Number: Date:

Addendum Number: Date:

No Addenda Issued

Cherokee County Standard Solicitation Term and Conditions, Page 10 of 20

APPENDIX “B”

NON-COLLUSION AFFIDAVIT

I state that I am authorized to make this AFFIDAVIT on behalf of my company, and its owners, directors and officers and I further state that:

1. The price(s) shown in this Qualification/bid/proposal has/have been arrived at independently and without consultation, communication or agreement with any other contractor, responder or potential responder to the Request for Bids (RFB)/Request for Proposals (RFP); and

2. Neither the price(s) nor the amount of the Qualification/bid/proposal, and neither the approximate budgets nor approximate amounts in this Qualification/bid/proposal, have been disclosed to any other company or person who is a responder or potential responder to this RFP, and they will not be disclosed before the Qualification/bid/proposal opening; and

3. No attempt has been made or will be made to induce any company or person to refrain from responding to this RFB/RFP, or to induce them to submit a budget that is higher than the budget in this Qualification/bid/proposal, or to submit any intentionally high or noncompetitive Qualification/bid/proposal or other form of nonresponsive Qualification/bid/proposal; and

4. The price(s), proposal and budget prepared are made in good faith and not pursuant to any agreement, discussion with or inducement from any agency, company or person to submit a complementary or other noncompetitive Qualification/bid/proposal.

I state that understands and acknowledges that

(Name of Company) the above representations are material and important and will be relied on by the Cherokee County Board of Commissioners (CCBOC) in awarding the contract(s) for which this Qualification/bid/proposal is submitted. I understand, and my company understands, that any misstatement in this Affidavit is and shall be treated as fraudulent concealment from CCBOC of the true facts relating to the submission of Bids/Proposals for this contract.

Signature Date

Printed Name

Title

Sworn to and subscribed before me this day of , 20

[SEAL REQUIRED]

(Notary Public)

My Commission Expires:

Cherokee County Standard Solicitation Term and Conditions, Page 11 of 20

APPENDIX “C”

CONTRACTOR AFFIDAVIT UNDER O.C.G.A. § 13-10-91(b)(l)

The undersigned contractor ("Contractor") executes this Affidavit to comply with O.C.G.A § 13-10-91 related to any Contract to which Contractor is a party that is subject to O.C.G.A. § 13-10-91 and hereby verifies its compliance with O.C.G.A. § 13-10-91, attesting as follows:

(a) The Contractor has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program;

(b) The Contractor will continue to use the federal work authorization program throughout the contract period, including any renewal or extension thereof;

(c) The Contractor will notify the public employer in the event the Contractor ceases to utilize the federal work authorization program during the contract period, including renewals or extensions thereof;

(d) The Contractor understands that ceasing to utilize the federal work authorization program constitutes a material breach of Contract;

(e) The Contractor will contract for the performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the Contractor with the information required by O.C.G.A. § 13-10- 91(a), (b), and (c);

(f) The Contractor acknowledges and agrees that this Affidavit shall be incorporated into any contract(s) subject to the provisions of O.C.G.A. § 13-10- 91 for the project listed below to which Contractor is a party after the date hereof without further action or consent by Contractor; and

(g) Contractor acknowledges its responsibility to submit copies of any affidavits, drivers' licenses, and identification cards required pursuant to O.C.G.A. § 13-10-91 to the public employer within five business days of receipt.

E-Verify Company ID Number (4 to 7 numbers) Date of Authorization

Name of Contractor Name of Project

Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on _______________________ ,________, 20___ in____________________(city), _____________(state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE _______ DAY OF _____________ , 20______.

NOTARY PUBLIC

My Commission Expires:

o Not Applicable by Statute for labor less than $2500

NOTE: The E-Verify Company ID number is not a Federal Identification Number, Tax ID Number, or Social Security Number. It will be a 4 to 7 digit number included in the E-Verify MOU (Federal program paperwork).

Cherokee County Board of Commissioners

Cherokee County Standard Solicitation Term and Conditions, Page 12 of 20

APPENDIX “D”

REFERENCES (Include a minimum of 3 unless otherwise directed)

1. Company

City/State

Contact Name

Phone/Email

2. Company

3. Company

4. Company

5. Company

Cherokee County Standard Solicitation Term and Conditions, Page 13 of 20

APPENDIX “E”

ACCEPTANCE OF COUNTY AGREEMENT

The Agreement used for the solicitation will be the “Sample” Agreement posted with the solicitation.

Using this form, please indicate either the willingness to sign the Agreement included in the solicitation, as is, upon award and/or recommendation of award or list all exceptions. This form is to be filled out, signed and returned as part of a responsive qualification/bid/proposal. The County is under no obligation to accept exceptions or modifications suggested by the Supplier (or any Third Parties/subcontractors). Any exceptions or modifications may be considered during evaluation and may result in rejection of the qualification/bid/proposal or a lower score. Such a determination shall not be a cause of action by the bidder/proposer against Cherokee County.

If the Supplier (or any Third Parties/subcontractors) does wish to suggest exceptions or modifications, all such exceptions or modifications must be submitted with the qualification/bid/proposal; no exceptions or modifications to the contract will be considered after qualification/bid/proposal review by the County (i.e. after the opening). All exceptions to the County’s contract must be listed on the provided form as only those exceptions listed on the form provided will be evaluated. Any material exceptions may result in the rejection of the proposal and the Supplier will not receive further consideration.

CHECK AND INITIAL ONE OF THE FOLLOWING STATEMENTS:

I and my legal advisor and insurance carrier representatives have read, understand and accept all the terms and conditions of the Agreement, and if awarded this Project, I will promptly execute and furnish all required statements, exhibits and certification of insurance coverage within five (5) business days.

OR

I and my legal advisor and insurance carrier representatives have read and understand all the terms and conditions of the Agreement, BUT HAVE NOTED THE FOLLOWING EXCEPTIONS AND/OR QUALIFICATIONS:

Proposers may provide additional sheets written on their own letterhead to supplement this page, if necessary.

I CERTIFY that the above information is true and correct.

Signed: Date:

Printed Name & Title:

Cherokee County Standard Solicitation Term and Conditions, Page 14 of 20

APPENDIX “F”

This certification is required by the regulations implementing Executive Order 12549, Debarment and

Suspension, 13 CFR Part 145. The regulations were published as Part VII of the May 26, 1988 Federal Register

(pages 19160-19211). Copies of the regulations are available from local offices of the U.S. Small Business

Administration.

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 2)

(1) The prospective primary participant certifies to the best of its knowledge and belief that it and its principals:

(a) Are not presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

(b) Have not within a five-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of

Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and

(d) Have not within a five-year period preceding this application had one or more public transactions (Federal, State, or local) terminated for cause or default.

(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective primary participant shall attach an explanation to this proposal.

Business Name

Date By

Name and Title of Authorized Representative

Signature of Authorized Representative

SBA Form 1623 (10-88)

This form was electronically produced by Elite Federal Forms, Inc.