3-Westview PS (31214) - Bid Packet.pdf

BID PACKET

Project No. 31214

Westview Pump Station Upgrade

PRE-BID CONFERENCE:

April 8, 2026

9:00 am Jefferson City Regional Water Reclamation Facility, 401

Mokane Road, Jefferson City, Missouri 65101

BID DATE:

April 30, 2026

1:30 pm

City of Jefferson, Missouri

TABLE OF CONTENTS

• Bid Form *

• Bid Bond *

• Certification Regarding Lobbying *

• Certification of Nonsegregated Facilities *

• Domestic Products Procurement Act *

• American Iron and Steel Certification *

• Certification Regarding Debarment and Suspension *

• Business Entity Certification *

• Anti-Collusion Statement *

• Contractor's Affidavit *

• Minority Business Enterprise Statement

• Minority Business Utilization Agreement *

• Affidavit of Compliance with Prevailing Wage Law *

• Prevailing Wage Determination

• Affidavit of Compliance Public Works Contracts Law *

• Federal Work Authorization Program Affidavit *

BID FORM

Name of Bidder______________________________________________________________

Address of Bidder_____________________________________________________

PROJECT IDENTIFICATION:

City of Jefferson Project No. 31214 Westview Pump Station Upgrade Jefferson City, Missouri

THIS BID IS SUBMITTED TO:

CITY OF JEFFERSON

Office of the Purchasing Agent

320 East McCarty Street Jefferson City, Missouri 65101

1.01 THE UNDERSIGNED BIDDER, having examined the plans, specifications, regulations of the Contract, Special Conditions, other proposed contract documents and all addenda thereto; and being acquainted with and fully understanding (a) the extent and character of the work covered by this Bid; (b) the location, arrangement, and specified requirements for the proposed work; (c) the location, character, and condition of existing streets, roads, highways, railroads, pavements, surfacing, walks, driveways, curbs, gutters, trees, sewers, utilities, drainage courses, structures, and other installations, both surface and underground which may affect or be affected by the proposed work; (d) the nature and extent of the excavations to be made and the type, character, and general condition of materials to be excavated; (e) the necessary handling and rehandling of excavated materials; (f) the location and extent of necessary or probable dewatering requirements; (g) the difficulties and hazards to the work which might be caused by storm and flood water; (h) local conditions relative to labor, transportation, hauling, and rail delivery facilities; and (i) all other factors and conditions affecting or which may be affected by the work.

1.02 The undersigned Bidder proposes and agrees, if this Bid is accepted, to enter into a Construction Contract with Owner in the form included in the Bidding Documents to perform all Work as specified or indicated in the Bidding Documents for the prices and within the times indicated in this Bid and in accordance with the other terms and conditions of the Bidding Documents.

2.01 Bidder accepts all of the terms and conditions of the Official Notice to Bidders and

Information for Bidders, including without limitation those dealing with the disposition of Bid security. Bidder has not added any conditions or qualifying statements to the Bid. The Bid will remain subject to acceptance for the bid withdrawal time stated in the Official Information for Bidders, or for such longer period of time that Bidder may agree to in writing upon request of Owner. Bidder will sign and deliver the required number of counterparts of the Agreement with the Bonds, evidence of insurance coverage, and other documents required by the Bidding Requirements within 15 days after the date of Owner’s Notice of Award.

3.01 In submitting this Bid, Bidder represents, as set forth in the Construction Contract, that:

A. Bidder has examined and carefully studied the Bidding Documents, the other related data identified in the Bidding Documents, and the following Addenda, receipt of all which is hereby acknowledged.

Addendum No. Addendum Date

B. Bidder has visited the Site and become familiar with and is satisfied as to the general, local and Site conditions that may affect cost, progress, and performance of the Work.

C. Bidder is familiar with and is satisfied as to all federal, state and local Laws and Regulations that may affect cost, progress and performance of the Work.

D. Bidder has carefully studied all reports of explorations and test of subsurface conditions at or contiguous to the Site and all drawings of physical conditions in or relating to existing surface or subsurface structures at or contiguous to the site (except Underground Facilities), if any.

E. Bidder has considered and correlated the information known to the Bidder;

information commonly known to bidders doing business in the locality of the Site;

information and observations obtained from visits to the Site; the Contract Documents; and all additional or supplementary examinations, investigations, explorations, tests, studies, and data with respect to the effect of such information, observations, and documents on (1) the cost, progress, and performance of the Work; (2) the means, methods, techniques, sequences, and procedures of construction to be employed by Bidder, including any specific means, methods, techniques, sequences, and procedures of construction expressly required by the Contract Documents; and (3) Bidder’s safety precautions and programs.

F. Bidder does not consider that any further examinations, investigations, explorations, tests, studies, or data are necessary for the determination of this

Bid for performance of the Work at the price(s) bid and within the times and in accordance with the other terms and conditions of the Bidding Documents.

G. Bidder is aware of the general nature of work to be performed by Owner and others at the Site that relates to the Work as indicated in the Bidding Documents.

H. Bidder has given Engineer written notice of all conflicts, errors, ambiguities, or discrepancies that Bidder has discovered in the Bidding Documents, and confirms that the written resolution thereof by Engineer is acceptable to Bidder.

I. The Bidding Documents are generally sufficient to indicate and convey understanding of all terms and conditions for the performance of the Work for which this Bid is submitted.

J. The submission of this Bid constitutes an incontrovertible representation by Bidder that Bidder has complied with every requirement of this Article, and that without exception the Bid and all prices in the Bid are premised upon performing and furnishing the Work required by the Bidding Documents.

K. Bidder will submit written evidence of its authority to do business in the state where the Project is located not later than the date of its execution of the Construction Contract.

L. In connection with the performance of Work under this Contract, Bidder agrees not to discriminate against any employee or applicant for employment because of age, race, religion, color, handicap, sex, physical condition or developmental disability. This provision shall include, but not be limited to, the following:

employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation;

and selection for training including apprenticeship. Bidder further agrees to take affirmative action to ensure equal employment opportunities for persons with disabilities.

4.01 Bidder further represents that:

A. This Bid is genuine and not made in the interest of or on behalf of any undisclosed individual or entity and is not submitted in conformity with any collusive agreement or rules of any group, association, organization or corporation;

B. Bidder has not directly or indirectly induced or solicited any other Bidder to submit a false or sham bid;

C. Bidder has not solicited or induced any individual or entity to refrain from bidding;

and

D. Bidder has not engaged in corrupt, fraudulent, collusive, or coercive practices in competing for the Contract. For the purposes of this paragraph 4.01.D:

a. “corrupt practice” means the offering, giving, receiving, or soliciting of any thing of value likely to influence the action of a public official in the bidding process;

b. “fraudulent practice” means an intentional misrepresentation of facts made

(a) to influence the bidding process to the detriment of Owner, (b) to establish bid prices at artificial non-competitive levels, or (c) to deprive Owner of the benefits of free and open competition;

c. “collusive practice” means a scheme or arrangement between two or more Bidders, with or without the knowledge of Owner, purposes of which is to establish bid prices at artificial, non-competitive levels; and

d. “coercive practice” means harming or threatening to harm, directly or indirectly, persons or their property to influence their participation in the bidding process or affect the execution of the Contract.

5.01 Bidder will furnish all required materials, supplies, equipment, tools, and plant; to perform all necessary labor and supervision; and to construct, install, erect, and complete all work stipulated, required by, and in accordance with the proposed contract documents and the drawings, specifications, and other documents referred to therein (as altered, amended, or modified by addenda), complete the Work in accordance with the Contract Documents for the following price:

UNIT PRICE SCHEDULE

No. Section Item Qty Unit Bid Unit Price Bid Price

All

Sections

All Work Except For Items No. 2 and No. 3

1 LS $ per LS $

31 22 00 31 23 00 31 23 33

Rock Excavation

3,500 CY $ per CY $

Sheet 54 Thoenen Park Pipe Replace

30-inch Storm Sewer Removal and Replacement

160 LF $ per LF $

TOTAL OF ALL BID PRICES (Sum of Bid Price for Each Item)

(figures)

Dollars (words)

Qty = Estimated Quantity

Bid Price (for each Item) = Qty x Bid Unit Price (for each item)

LF = Linear Feet LS = Lump Sum CY = Cubic Yard

Unit Prices have been computed in accordance with the General Provisions.

Bidder acknowledges that estimated quantities are not guaranteed, and are solely for the purpose of comparison of Bids, and final payment for all Unit Price Bid items will be based on actual quantities, determined as provided in the Contract Documents.

SUBCONTRACTORS AND MAJOR SUPPLIERS

6.01 If the Bidder intends to use any subcontractors in the course of the construction, he shall list them below.

6.02 The names of Major Equipment Suppliers to be used for the Work shall be clearly indicated by an “X” in the column preceding “Manufacturer”. Upon award of the contract, the named Suppliers and equipment shall be used and furnished.

Equipment substitutions will be permitted only if named equipment does not meet the requirements of the Contract Documents; the Supplier is unable to meet the delivery requirements of the construction schedule; the Supplier is dilatory in complying with the requirements of the Contract Documents; or for other reasons specified in the General Conditions. Substitutions shall be subject to concurrence of the Owner and shall be confirmed by Change Order.

Preliminary acceptance of equipment listed by Supplier’s name shall not in any way constitute a waiver of the specifications covering such equipment; final acceptance will be based on full conformity with the Contract Documents.

Specification

Section Major Equipment Item “X” Manufacturer

Div 5

05 50 00 Hatches

Bilco

Halliday

Or Equal_______________

Div 23

23 81 19

Self-Contained Air Source Heat

Pumps

Bard

Marvair

Bebco Environmental Controls

Or Equal_______________

Div 26

26 29 23

Variable Frequency Drive

Equipment

Rockwell Automation

ABB

Or Equal_______________

Div 40

40 63 43

Programmable Logic

Controllers

Allen Bradley

Or Equal_______________

Div 43 43 25 13

Submersible Centrifugal Pumps

Flygt

KSB

Sulzer

Or Equal_______________

TIME OF COMPLETION

7.01 The undersigned hereby agrees to complete the project within 365 days, subject to the stipulations of the regulations of the Contract and the Special Provisions.

It is understood and agreed that if this bid is accepted, the prices quoted above include all applicable state taxes and that said taxes shall be paid by the Contractor.

The undersigned, as Bidder, hereby declares that the only persons or firms interested in the bid as principal or principals is or are named herein and that no other persons or firms than herein mentioned have any interest in this bid or in the Contract to be entered into; and this bid is made without connection with any other person, company, or parties making a bid; and that it is in all respects fair and in good faith, without collusion or fraud.

The undersigned agrees that the accompanying bid deposit shall become the property of the Owner, should he fail or refuse to execute the Contract or furnish Bond as called for in the specifications within the time provided.

If written notice of the acceptance of this bid is mailed, telegraphed, or delivered to the undersigned within sixty (60) days after the date of opening of bids, or any time thereafter before this bid is withdrawn, the undersigned will, within ten (10) days after the date of such mailing, telegraphing, or delivering of such notice, execute and deliver a Contract in the form of Contract attached.

The undersigned hereby designates as his office to which such notice of acceptance may be mailed, telegraphed, or delivered:

It is understood and agreed that this bid may be withdrawn at any time prior to the scheduled time for the opening of bids or any authorized postponement thereof.

8.01 The following documents are attached to and made a condition of this Bid:

A. Required Bid security in the form of _________________________________ (Certified Check or Bid Bond)

If certified check, make payable to the City of Jefferson.

in the amount of _______________________________________________.

(Dollars or Percent of Lump Sum Bid Price)

B. List of proposed Subcontractors having a direct contract with the Contractor.

C. The following forms included in Clean Water State Revolving Fund Specification Requirements:

1. EPA Certification Regarding Lobbying

2. EPA Certification of Nonsegregated Facilities

3. Domestic Products Procurement Certification

4. American Iron and Steel Certification

5. Certification Regarding Debarment and Suspension

6. Business Entity Certification, Enrollment Documentation, and Affidavit of Work Authorization

D. The following forms included at the end of the Bid Form:

1. Anti-Collusion Statement

2. Contractor’s Affidavit

3. Minority Business Utilization Agreement

4. Affidavit – Compliance with Prevailing Wage Law

5. Affidavit of Compliance Public Works Contracts Law

6. Federal Work Authorization Program Affidavit

Signature of Bidder:

If an individual,________________________________________, doing business as_______________________________________________.

If a partnership,_______________________________________, member of firm.

by_______________________________________________.

If corporation,________________________________________________________ by ______________________________________________.

Title ______________________________________________

SEAL

Business Address of Bidder_____________________________________________

If Bidder is a corporation, supply the following information:

State in which incorporated_____________________________________

Name and Address of its:

President ___________________________________________

Secretary ____________________________________________

Date_______________________________

BID BOND

KNOW ALL MEN BY THESE PRESENTS, that we, the undersigned,__________________________________________________as Principal, and______________________________________________as Surety, are hereby held and firmly bound unto the CITY OF JEFFERSON, MISSOURI , as owner, in the penal sum of____________________________________________for the payment of which, well and truly to be made, we hereby jointly and severally bind ourselves, our heirs, executors, administrators, successors and assigns, this______day of___________, 20 ____.

The condition of the above obligation is such that whereas the Principal has submitted to the CITY OF JEFFERSON, MISSOURI a certain Bid, attached hereto and hereby made a part hereof to enter into a contract in writing, for the project entitled:

"Project No 31214, Westview Pump Station Upgrade"

NOW, THEREFORE,

(a) If said Bid shall be rejected, or in the alternate,

(b) If said Bid shall be accepted and the Principal shall execute and deliver a contract in the Form of Contract attached hereto (properly completed in accordance with said Bid) and shall furnish a bond for his faithful performance of said contract, and for the payment of all persons performing labor or furnishing materials in connection therewith, shall in all other respects perform the agreement created by the acceptance of said Bid, then this obligation shall be void, otherwise the same shall remain in force and effect; it being expressly understood and agreed that the liability of the Surety for any and all claims hereunder shall, in no event, exceed the penal amount of this obligation as herein stated.

The Surety, for value received, hereby stipulates and agrees that the obligations of said Surety and its bond shall be in no way impaired or affected by the extension of the time within which the Owner may accept such Bid; and said Surety does hereby waive notice of any such extension.

IN WITNESS WHEREOF, the Principal and the Surety have hereunto set their hands and seals, and such of them as are corporations have caused their corporate seals to be hereto affixed and these presents to be signed by their proper officers, the day and year first set forth above.

_________________________________(L.S.)

Principal

By:_________________________________

SEAL

Surety

By: _________________________________

OMB Control No. 2030-0020 Approval expires 06/30/2024

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

EPA Form 6600-06 (Rev. 06/2014) Previous editions are obsolete.

EPA Project Control Number

CERTIFICATION REGARDING LOBBYING

CERTIFICATION FOR CONTRACTS, GRANTS,

LOANS AND COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including sub-contracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31 U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Typed Name & Title of Authorized Representative

Signature and Date of Authorized Representative

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0020).

Responses to this collection of information are required to obtain an assistance agreement (40 CFR Part 30, 40 CFR Part 31, and 40 CFR Part 33 for awards made prior to December 26, 2014, and 2 CFR 200, 2 CFR 1500, and 40 CFR Part 33 for awards made after December 26, 2014). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

The public reporting and recordkeeping burden for this collection of information is estimated to be 0.25 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046

(See reverse for public burden disclosure.)

1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:

a. contract a. bid/offer/application a. initial filing

b. grant b. initial award b. material change

c. cooperative agreement c. post-award For Material Change Only:

d. loan year _________ quarter _________

e. loan guarantee date of last report ______________

f. loan insurance

4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address of Prime:

Tier ______, if known :

Congressional District, if known : Congressional District, if known :

6. Federal Department/Agency: 7. Federal Program Name/Description:

CFDA Number, if applicable: _____________

8. Federal Action Number, if known : 9. Award Amount, if known :

10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if ( if individual, last name, first name, MI): different from No. 10a )

(last name, first name, MI ):

11. Signature:

Print Name:

Title:

Telephone No.: _______________________

Authorized for Local Reproduction

Standard Form LLL (Rev. 7-97)

Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be available for public inspection.

required disclosure shall be subject to a not more than $100,000 for each such failure.

Prime Subawardee

Federal Use Only:

Date:

who fails to file the Any person $10,000 and than civil penalty of not less

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employeeof any agency, a Member of Congress, an officer or employeeof Congress, or an employeeof a Member of Congress in connectionwith a coveredFederalaction. Completeall items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. Identify the appropriateclassification of this report. If this is a followup report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action.

4. Enter the full name, address, city, State and zip code of the reporting entity. Include CongressionalDistrict, if known. Check the appropriateclassification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee,e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known.

6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizationallevel below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance

(CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number;

Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001."

9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.

10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and Middle Initial (MI).

11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503.

U.S. ENVIRONMENTAL PROTECTION AGENCY

WATER QUALITY OFFICE

CERTIFICATION OF NONSEGREGATED FACILITIES

(Applicable to federally assisted construction contracts and related sub-contracts exceeding $10,000 which are not exempt from the Equal Opportunity clause.)

The federally assisted construction contractor certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The federally assisted construction contractor certifies further that he will not maintain or provide for his employees any segregated facilities at any of his establishments, and that he will not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The federally assisted construction contractor agrees that a breach of this certification is a violation of the Equal Opportunity clause in this contract. As used in this certification, the term “segregated facilities” means any waiting rooms, work areas, rest rooms and wash rooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, creed, color, or national origin, because of habit, local custom, or otherwise. The federally assisted construction contractor agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, and that he will retain such certifications in his files.

Signature _______________________________________

Name and Title of Signer

Date____________________

(Print or Type)

Firm Name

NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.

Domestic Products Procurement Act – RSMo 34.350 – 34.359 Certification

Each contract for the purchase or lease of manufactured goods or commodities by any public agency, and each contract made by a public agency for construction, alteration, repair, or maintenance of any public works shall contain a provision that any manufactured goods or commodities used or supplied in the performance of that contract or any subcontract thereto shall be manufactured or produced in the United States. (34.353.1 RSMo)

Project Name: _____________________________________________________________________

Project Number: ___________________________________________________________________

Contract Name: ____________________________________________________________________

Please check one of the following and sign where indicated.

All of the iron, steel, and manufactured goods used in the project are produced in the United States.

A waiver is being requested from the ____________________________ to the domestic (owner) products provision due to the following exception:

The specified products are not manufactured or produced in the United States in sufficient quantities or manufactured or produced in the United States within the necessary time frames in sufficient quantities.

The cost for the specified products would increase the contract by more than 10 percent*;

or

Only one line of a product is manufactured or produced in the United States.

Documentation of at least one of the cases above must be provided. List below the materials that cannot comply with the Domestic Product Procurement Act provisions.

Additional sheets (attach if necessary)

Name of Contracting Firm Signature Date

Name and Title of Signer (Please type)

*In accordance with the Federal Water Pollution Control Act, Section 608, all iron and steel products used in a State Revolving Fund project should be produced in the United States. This requirement does not apply where the inclusion of iron and steel products produced in the United States will increase the cost of the overall project by more than 25 percent.

Missouri DNR CWSRF (03/31/15)

American Iron and Steel Certification

The Contractor acknowledges to and for the benefit of _______________________ and the State of Missouri that it understands the goods and services under this Agreement are being funded with monies made available by the Clean Water State Revolving Fund and/or Drinking Water State Revolving Fund that have statutory requirements (see attached) commonly known as “American Iron and Steel;” that requires all of the iron and steel products used in the project to be produced in the United States (“American Iron and Steel Requirement”) including iron and steel products provided by the Contactor pursuant to this Agreement. The Contractor hereby represents and warrants to and for the benefit of the Purchaser and the State that (a) the Contractor has reviewed and understands the American Iron and Steel Requirement, (b) all of the iron and steel products used in the project will be and/or have been produced in the United States in a manner that complies with the American Iron and Steel Requirement, unless a waiver of the requirement is approved, and (c) the Contractor will provide any further verified information, certification or assurance of compliance with this paragraph, or information necessary to support a waiver of the American Iron and Steel Requirement, as may be requested by the Purchaser or the State.

Notwithstanding any other provision of this Agreement, any failure to comply with this paragraph by the Contractor shall permit the Purchaser or State to recover as damages against the Contractor any loss, expense, or cost (including without limitation attorney’s fees) incurred by the Purchaser or State resulting from any such failure (including without limitation any impairment or loss of funding, whether in whole or in part, from the State or any damages owed to the State by the Purchaser). While the Contractor has no direct contractual privity with the State, as a lender to the Purchaser for the funding of its project, the Purchaser and the Contractor agree that the State is a third-party beneficiary and neither this paragraph (nor any other provision of this Agreement necessary to give this paragraph force or effect) shall be amended or waived without the prior written consent of the State.

Name of Contracting Firm

Signature Date

Name and Title of Signer (Please type)

MISSOURI DEPARTMENT OF NATURAL RESOURCES

FINANCIAL ASSISTANCE CENTER

CERTIFICATION REGARDING DEBARMENT AND SUSPENSION

1. APPLICANT/CONTINUING AUTHORITY

NAME OF APPLICANT/CONTINUING AUTHORITY

PROJECT NAME PROJECT NUMBER

2. CERTIFICATION

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

a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any governmental (federal, state, or local) entity;

b) Have not within a three-year period preceding this certification been convicted of or had a civil judgment rendered against them for:

1) 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;

2) Violation of federal or state antitrust statutes relating to the submission of offers; or

3) 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 three-year period preceding this certification, had one or more public transactions (federal, state, or local) terminated for cause or default.

I understand that a false statement on this certification may be grounds for rejection of this proposal or termination of the award.

I am able to certify to the above statements.

I am unable to certify to the above statements and attached my explanation.

NAME OF AUTHORIZED REPRESENTATIVE (PRINT OR TYPE) TITLE OF AUTHORIZED REPRESENTATIVE (PRINT OR TYPE)

SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE

EMAIL (PREFERRED) OR MAIL COMPLETED APPLCATION TO:

Missouri Department of Natural Resources Financial Assistance Center P.O. Box 176 Jefferson City, MO 65102-0176 800-361-4827 or 573-751-1192 fac@dnr.mo.gov

MO 780-3043 (07-24) PAGE 1 of 1 mailto:fac@dnr.mo.gov

CERTIFICATION REGARDING DEBARMENT AND SUSPENSION INSTRUCTIONS

Potential applicants should contact the Missouri Department of Natural Resources’ Financial Assistance Center prior to completing and submitting this form, unless already directed to do so.

The Missouri Department of Natural Resources receives assistance from the federal government, and the funds provided to a community constitute a sub-agreement. Accordingly, each prospective recipient of a grant, loan, or cooperative agreement and any contractor or subcontractor must agree to fully comply with Executive Order 12549, 2 C.F.R. Part 180, and 2 C.F.R. Part 1532 regarding debarment and suspension.

1. APPLICANT/CONTINUING AUTHORITY: The applicant is the entity that will receive the loan funds, if awarded. A continuing authority is a company, business, entity, or person(s) that will be operating the facility and/or ensuring compliance with the permit requirements. A continuing authority is not, however, an entity or individual that is contractually hired by the permittee to sample or operate and maintain the system for a defined period, such as a certified operator or analytical laboratory. One can find the regulatory requirement regarding continuing authority at 10 CSR 20-6.010 (2). Please visit https://s1.sos.mo.gov/cmsimages/adrules/csr/current/10csr/10c20-6.pdf.

A continuing authority’s name must be listed exactly as it appears on the Missouri Secretary of State’s (SoS’s) webpage https://bsd.sos.mo.gov/BusinessEntity/BESearch.aspx?SearchType, unless the continuing authority is an individual(s), government, or otherwise not required to register with the SoS.

Print or type the applicant’s name as well as the project name and number.

2. CERTIFICATION: The authorized representative of the prospective grant, loan, or cooperative agreement recipient must sign the certification, and provide an explanation, if needed. Print or type the authorized representative’s name and title. Make a copy of the completed form for your records.

“Principals,” for the purposes of this certification, means officers; directors; owners; partners; and persons having primary management or supervisory responsibilities within an entity (e.g., general manager; plant manager; head of a subsidiary, division, or business segment, and similar positions).

The recipient of funding should also obtain a certification from their consulting engineer and prime contractor.

The funding recipient shall also check the status on the System for Award Management (SAM) located online at https://www.sam.gov/portal/public/SAM/.

Each prospective subcontractor should submit a completed certification or explanation to the prime contractor for the project.

Form Submittal: Submit the completed form and any attachments via email to fac@dnr.mo.gov (preferred), or mail to:

Missouri Department of Natural Resources Financial Assistance Center P.O. Box 176 Jefferson City, MO 65102-0176

For More Information:

Missouri Department of Natural Resources Financial Assistance Center P.O. Box 176 Jefferson City, MO 65102-0176 800-361-4827 or 573-751-1192

FAX: 573-751-9396

Email: fac@dnr.mo.gov https://dnr.mo.gov/water/business-industry-other-entities/financial-opportunities/financial-assistance-center https://s1.sos.mo.gov/cmsimages/adrules/csr/current/10csr/10c20-6.pdf https://bsd.sos.mo.gov/BusinessEntity/BESearch.aspx?SearchType https://www.sam.gov/portal/public/SAM/ mailto:fac@dnr.mo.gov mailto:fac@dnr.mo.gov https://dnr.mo.gov/water/business-industry-other-entities/financial-opportunities/financial-assistance-center

Attachment 6

EXHIBIT _

BUSINESS ENTITY CERTIFICATION, ENROLLMENT DOCUMENTATION,

AND AFFIDAVIT OF WORK AUTHORIZATION

BUSINESS ENTITY CERTIFICATION:

The bidder/contractor must certify their current business status by completing either Box A or Box B or Box C on this Exhibit.

BOX A: To be completed by a non-business entity as defined below.

BOX B: To be completed by a business entity who has not yet completed and submitted documentation pertaining to the federal work authorization program as described at http://www.dhs.gov/files/programs/gc_1185221678150.shtm.

BOX C: To be completed by a business entity who has current work authorization documentation on file with a Missouri state agency including Division of Purchasing and Materials Management.

Business entity, as defined in section 285.525, RSMo, pertaining to section 285.530, RSMo, is any person or group of persons performing or engaging in any activity, enterprise, profession, or occupation for gain, benefit, advantage, or livelihood. The term “business entity” shall include but not be limited to self-employed individuals, partnerships, corporations, contractors, and subcontractors. The term “business entity” shall include any business entity that possesses a business permit, license, or tax certificate issued by the state, any business entity that is exempt by law from obtaining such a business permit, and any business entity that is operating unlawfully without such a business permit. The term “business entity” shall not include a self-employed individual with no employees or entities utilizing the services of direct sellers as defined in subdivision (17) of subsection 12 of section 288.034, RSMo.

Note: Regarding governmental entities, business entity includes Missouri schools, Missouri universities (other than stated in Box C), out of state agencies, out of state schools, out of state universities, and political subdivisions. A business entity does not include Missouri state agencies and federal government entities.

BOX A – CURRENTLY NOT A BUSINESS ENTITY

I certify that (Company/Individual Name) DOES NOT CURRENTLY MEET the definition of a business entity, as defined in section 285.525, RSMo pertaining to section 285.530, RSMo as stated above, because: (check the applicable business status that applies below)

I am a self-employed individual with no employees; OR The company that I represent employs the services of direct sellers as defined in subdivision

(17) of subsection 12 of section 288.034, RSMo.

I certify that I am not an alien unlawfully present in the United States and if (Company/Individual Name) is awarded a contract for the services requested herein under

(Bid/SFS/Contract Number) and if the business status changes during the life of the contract to become a business entity as defined in section 285.525, RSMo, pertaining to section 285.530, RSMo, then, prior to the performance of any services as a business entity, (Company/Individual Name) agrees to complete Box B, comply with the requirements stated in Box B and provide the documentation required in Box B of this exhibit.

(insert agency name) with all

Authorized Representative’s Name (Please Print) Authorized Representative’s Signature

Company Name (if applicable) Date http://www.uscis.gov/e-verify http://www.uscis.gov/e-verify

Attachment 6

EXHIBIT _, continued

(Complete the following if you DO NOT have the E-Verify documentation and a current Affidavit of Work Authorization already on file with the State of Missouri. If completing Box B, do not complete Box C.)

BOX B – CURRENT BUSINESS ENTITY STATUS

I certify that (Business Entity Name) MEETS the definition of a business entity as defined in section 285.525, RSMo, pertaining to section 285.530.

Authorized Business Entity Representative’s Name (Please Print)

Authorized Business Entity Representative’s Signature

Business Entity Name Date

E-Mail Address

As a business entity, the bidder/contractor must perform/provide each of the following. The bidder/contractor should check each to verify completion/submission of all of the following:

Enroll and participate in the E-Verify federal work authorization program (Website:

http://www.uscis.gov/e-verify; Phone: 888-464-4218; Email: e- verify@dhs.gov) with respect to the employees hired after enrollment in the program who are proposed to work in connection with the services required herein; AND

Provide documentation affirming said company’s/individual’s enrollment and participation in the E- Verify federal work authorization program. Documentation shall include EITHER the E-Verify Employment Eligibility Verification page listing the bidder’s/contractor’s name and company ID

OR a page from the E-Verify Memorandum of Understanding (MOU) listing the bidder’s/contractor’s name and the MOU signature page completed and signed, at minimum, by the bidder/contractor and the Department of Homeland Security – Verification Division. If the signature page of the MOU lists the bidder’s/contractor’s name and company ID, then no additional pages of the MOU must be submitted; AND

Submit a completed, notarized Affidavit of Work Authorization provided on the next page of this Exhibit.

https://www.e-verify.gov/

EXHIBIT _, continued Attachment 6

AFFIDAVIT OF WORK AUTHORIZATION:

The bidder/contractor who meets the section 285.525, RSMo, definition of a business entity must complete and return the following Affidavit of Work Authorization.

Comes now (Name of Business Entity Authorized Representative) as (Position/Title) first being duly sworn on my oath, affirm (Business Entity

Name) is enrolled and will continue to participate in the E-Verify federal work authorization program with respect to employees hired after enrollment in the program who are proposed to work in connection with the services related to contract(s) with the State of Missouri for the duration of the contract(s), if awarded in accordance with subsection 2 of section 285.530, RSMo. I also affirm that (Business Entity Name) does not and will not knowingly employ a person who is an unauthorized alien in connection with the contracted services provided under the contract(s) for the duration of the contract(s), if awarded.

In Affirmation thereof, the facts stated above are true and correct. (The undersigned understands that false statements made in this filing are subject to the penalties provided under section 575.040, RSMo.)

Authorized Representative’s Signature Printed Name

Title Date

E-Mail Address E-Verify Company ID Number

Subscribed and sworn to before me this of

(DAY) (MONTH, YEAR)

. I am commissioned as a notary public within the County of

, and my commission expires on

, State of

(NAME OF COUNTY)

(NAME OF STATE) (DATE)

Signature of Notary Date

EXHIBIT _, continued Attachment 6

(Complete the following if you have the E-Verify documentation and a current Affidavit of Work Authorization already on file with the State of Missouri. If completing Box C, do not complete Box B.)

BOX C – AFFIDAVIT ON FILE - CURRENT BUSINESS ENTITY STATUS

I certify that (Business Entity Name) MEETS the definition of a business entity as defined in section 285.525, RSMo, pertaining to section 285.530, RSMo, and have enrolled and currently participates in the E-Verify federal work authorization program with respect to the employees hired after enrollment in the program who are proposed to work in connection with the services related to contract(s) with the State of Missouri. We have previously provided documentation to a Missouri state agency or public university that affirms enrollment and participation in the E-Verify federal work authorization program. The documentation that was previously provided included the following.

The E-Verify Employment Eligibility Verification page OR a page from the E-Verify Memorandum of Understanding (MOU) listing the bidder’s/contractor’s name and the MOU signature page completed and signed by the bidder/contractor and the Department of Homeland Security – Verification Division

A current, notarized Affidavit of Work Authorization (must be completed, signed, and notarized within the past twelve months).

Name of Missouri State Agency or Public University* to Which Previous E-Verify Documentation Submitted:

(*Public University includes the following five schools under chapter 34, RSMo: Harris-Stowe State University – St. Louis;

Missouri Southern State University – Joplin; Missouri Western State University – St. Joseph; Northwest Missouri State University

– Maryville; Southeast Missouri State University – Cape Girardeau.)

Date of Previous E-Verify Documentation Submission:

Previous Bid/Contract Number for Which Previous E-Verify Documentation Submitted:

(if known)

Authorized Business Entity Representative’s Authorized Business Entity Name (Please Print) Representative’s Signature

E-Verify MOU Company ID Number E-Mail Address

Business Entity Name Date

FOR STATE USE ONLY

Documentation Verification Completed By:

Buyer Date

ANTI-COLLUSION STATEMENT

STATE OF _______________________________)

COUNTY OF _____________________________)

___________________________________________________ being first duly sworn, deposes and says that he is ________________________________ of

TITLE OF PERSON SIGNING

NAME OF BIDDER

that all statements made and facts set out in the bid for the above project are true and correct; and that the bidder (the person, firm, association, or corporation making said bid) has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with such bid or any contract which result from its acceptance.

Affiant further certifies that bidder is not financially interested in, or financially affiliated with, any other bidder for the above project.

(BY)___________________________________

(BY)___________________________________

Sworn to before me this _______day of ___________________, 20 ___.

NOTARY PUBLIC

My commission expires:________________________________

CONTRACTOR'S AFFIDAVIT

This affidavit is hereby made a part of the Bid, and an executed copy thereof shall accompany each Bid submitted.

STATE OF _________________________)

) ss

COUNTY OF _______________________)

The undersigned, _______________________________________________, of lawful age, being first duly sworn states upon oath that he is

______________________________________________________________ of the contractor submitting the attached bid, that he knows of his own knowledge and states it to be a fact that neither said bid nor the computation upon which it is…