IFB-BW-26-048

OFFEROR INFORMATION/CERTIFICATION FORM

This form MUST BE:

• INCLUDED DOWNLOADED, COMPLETED AND UPLOADED INTO BONFIRE WITH OFFEROR’S

SUBMISSION

• FULLY executed with original authorized signature and notarized signature

1. "We offer to sell/provide Pasco County, Florida, the above item(s) and/or service(s) at the price(s) stated, in accordance with the terms and conditions contained herein. In addition, the item(s) and/or service(s) offered above meet all specifications contained herein or attached, unless otherwise stipulated by exception. This offer to sell/provide is firm for ninety (90) days."

MUST BE SIGNED BY THE PRESIDENT OF THE CORPORATION, OR A MEMBER OF A MEMBER-MANAGED

LIMITED LIABILITY COMPANY, OR THE MANAGER OF A MANAGER-MANAGED LIMITED LIABILITY

COMPANY; OR INCLUDE WRITTEN PROOF THAT THE INDIVIDUAL SIGNING HAS THE AUTHORITY TO

OBLIGATE THE FIRM.

OFFEROR MUST BE REGISTERED ON SUNBIZ ( http://www.sunbiz.org/index.html ), FLORIDA

DEPARTMENT OF STATE DIVISION OF CORPORATIONS.

2. Legal Name of Offeror. Indicate if the Offeror is a Corporation, Joint Venture, Partnership, etc.:

(This name must match the name on your current W9 Form. The W9 will be requested at the time of award.)

3. Name/title of contact person for the Offeror:

4. Business and mailing address: (If claiming Local Vendor Preference, a valid Local Business Tax Receipt must be provided at the time the response is submitted in order to qualify for such consideration)

5. Primary business and mailing address (if different):

6. Telephone number: ( ) Fax: ( )

Email Address:

The above‐named Offeror affirms and declares:

A. That the Offeror understands all requirements of this request and states that as a serious Offeror they will comply with all the stipulations included in this request.

http://www.sunbiz.org/index.html

B. That the Offeror is of lawful age and that no other person, firm or corporation has any interest in this Proposal or in the contract proposed to be entered into except as expressly stated below:

C. That this proposal is made without any understanding, agreement, or connection with any other person, firm or corporation making a proposal for the same purpose, and is in all respects fair and without collusion or fraud except as expressly stated below:

D. That the Offeror is not in arrears to the Pasco County Board of County Commissioners upon debt or contract and is not a defaulter, as surety or otherwise, upon any obligation to the Pasco County Board of County Commissioners except as expressly stated below:

E. That the Offeror is in compliance with Section 448.095(2), Florida Statutes, requiring Contractor and its Subcontractors to register with and utilize the U.S. Department of Homeland Security’s E‐Verify program to verify the work authorization status of all newly hired employees and acknowledges that it will be required to maintain such compliance throughout the term of any Contract entered between the parties. The Offeror also confirms that no public employer has terminated a contract with the Offeror for failure to comply with Section 448.095(2), Florida Statutes, within the 12 months preceding the date this Certification Form is signed by the Offeror.

F. That no officer or employee or person whose salary is payable in whole or in part from the County is, will be or become interested, directly, or indirectly, surety or otherwise in this response; in the performance of the resulting contract; in the purchase of supplies, materials, equipment, work and/or labor to which they relate; or in any portion of the profits thereof.

G. That the Offeror has received and carefully examined all Addenda issued prior to uploading its Response and its Response will be in accordance with all Addenda prior to Response Opening.

H. That by submitting a response, the Offeror certifies that it is not currently debarred from submitting proposals for contracts issued by any political subdivision or agency of the State of Florida and that it is not an agent of a person or entity that is currently debarred from submitting proposals for contracts issued by any subdivision or agency of the State of Florida.

I. That pursuant to Section 287.087, Florida Statutes, Offerors understands that they may certify in their response that they have implemented a drug free workplace program. If two or more responses are deemed equal, preference will be given in the award process to the Offeror who has furnished such certification with their response.

J. If claiming Local Vendor Preference, the Offeror certifies that they satisfy each of the following criteria at the time of their submission of a response to the solicitation necessary to qualify as a “Local Business”: a) a vendor, supplier, or contractor who does business in Pasco County by providing goods, services, or construction; and b) maintains a physical business address located within the jurisdictional limits of Pasco County in an area zoned for the conduct of such business; and c) which the vendor, supplier or contractor operates or performs business on a daily basis; and d) has for at least twelve (12) months prior to the bid or proposal opening date;

and (e) a copy of their local business tax receipt or qualifies as a business in a neighboring county as listed in the County’s Purchasing Ordinance. Post office boxes shall not be used for the purpose of establishing said physical address.

Please put an “X” in the applicable box or mark N/A Local Business located in Pasco County Business located within Hillsborough, Pinellas, Polk, or Hernando County

This local preference provision is not applicable to those solicitations involving the use of either State or Federal funds as indicated below:

State/Federal Funds Involved: N (Y if applicable, N if not applicable)

Note: If claiming Local Vendor Preference, a valid Local Business Tax Receipt must be provided at the time the response is submitted in order to qualify for such consideration.

K. By signing this Certification, I represent that I am of lawful age and have the authority to bind the Offeror for contract purposes. If someone other than the President of the corporation, or a member of a member-managed limited liability company, or the manager of a manager managed limited liability company, then one of the following must be submitted with this Certification:

1. If Offeror is a corporation (includes incorporated or company, or abbreviations thereof, in its name), and if other than the President of the corporation is signing this Certification, then one of the following must be submitted with this Certification:

a. a current corporate resolution naming the officer or person signing this Certificate as authorized to sign contracts on behalf of the company or,

b. a copy of the Board of Directors’ resolution or meeting minutes designating the officer or person signing this Certificate as authorized to sign contracts for the corporation, certified by the secretary of the corporation.

2. If Offeror is a limited liability company, then the following must be submitted with this Certification: a copy of the Operating Agreement of the limited liability company showing that that person signing this Certificate is authorized to sign contracts for the limited liability company.

L. Attached to this response is a copy of the Certificate of Status from the Florida Secretary of State, Division of Corporations, which can be downloaded from https://dos.myflorida.com/sunbiz/search/.

https://dos.myflorida.com/sunbiz/search/

M. Exceptions to any Contract Provisions and Miscellaneous Declarations (attach additional sheets, if necessary):

(The remainder of this page intentionally left blank).

(SIGNATURES FOLLOW ON NEXT PAGE)

IN WITNESS WHEREOF, this proposal is hereby signed and sealed as of the date indicated.

OFFEROR:

BY:

(Authorized Signature in Ink)

(Printed name of Signatory)

(Printed Title of Signatory)

(Signature Date)

NOTARY ACKNOWLEDGMENT

STATE OF }

} ss

COUNTY OF }

The foregoing instrument was acknowledged before me on ________________, 20_____, by means of:

[___] physical presence, or [___] online notarization

[as applicable, complete one (1) of the four (4) choices below]:

(1) FOR A CORPORATION OR LIMITED LIABILITY COMPANY:

[Name] , who executed the foregoing instrument as [Title] ____ of [Corporation or Company Name] , a:

[___] corporation, or [___] limited liability company organized under the laws of [State] __ , and who severally and duly acknowledged the execution of such instrument as aforesaid on behalf of the corporation or limited liability company.

(2) FOR AN INDIVIDUAL ACTING IN HIS OR HER OWN RIGHT:

[Name] _____________________________________________________________.

(3) FOR A PARTNERSHIP:

[Name] ______Partner (or Agent), on behalf of [Name of Partnership] , a [State] partnership.

(4) FOR AN INDIVIDUAL ACTING AS PRINCIPAL BY AN ATTORNEY IN FACT:

[Name] , as attorney in fact.

Said person is (check one below):

[___] Personally known to me, or [___] Has produced as identification.

Signature of person taking acknowledgment

[Notary Stamp or Seal] Print Notary’s Name (This line is required to be completed by §117.05, F.S.)

PASCO COUNTY, FLORIDA

HUMAN TRAFFICKING AFFIDAVIT

Florida law requires completion of this form to execute, renew, or extend a contract with Pasco County (see section 787.06(13), Florida Statutes). This form must be completed by an officer or representative of the company or individual entering into, renewing, or extending a contract with Pasco County.

Under penalty of perjury, I hereby attest that based upon my personal knowledge, the below-named company or individual does not use coercion1 for labor2 or services,3 as those terms are defined in section 787.06, Florida Statutes.

Signature

Printed Name

Title

Name of Company if applicable

Date

STATE OF FLORIDA

COUNTY OF_____________________

The foregoing Human Trafficking Affidavit is sworn to (or affirmed) and subscribed before me under penalty of perjury by means of ☐ physical presence or ☐ online notarization, this ______day of________, (month) ________ (year), by _____________________________________________(name of person making statement).

(Signature of Notary Public - State of Florida)

(Print Commissioned Name of Notary Public)

☐ Personally Known OR ☐ Produced Identification

Type of Identification Produced

Definitions

1 “Coercion” means the following:

1. Using or threatening to use physical force against any person;

2. Restraining, isolating, or confining or threatening to restrain, isolate, or confine any person without lawful authority and against her or his will;

3. Using lending or other credit methods to establish a debt by any person when labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt, the length and nature of the labor or services are not respectively limited and defined;

4. Destroying, concealing, removing, confiscating, withholding, or possessing any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person;

5. Causing or threatening to cause financial harm to any person;

6. Enticing or luring any person by fraud or deceit; or

7. Providing a controlled substance as outlined in Schedule I or Schedule II of section 893.03, Florida Statutes, to any person for the purpose of exploitation of that person.

2 “Labor” means work of economic or financial value.

3 “Services” means any act committed at the behest of, under the supervision of, or for the benefit of another. The term includes, but is not limited to, forced marriage, servitude, or the removal of organs.

http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String&URL=0800-0899/0893/Sections/0893.03.html