4-1.3 Fillable Forms.pdf

ANTI-COLLUSION STATEMENT

Suwannee County, FL

I hereby attest that I am the person responsible within my company for the final decision as to the price(s) and amount of this RFP or, if not, that I have written authorization, enclosed herewith, from that person to make the statements set out below on his or her behalf and on behalf of my company.

I further attest that:

1. The price(s) and amount of this RFP have been arrived at independently, without consultation, communication, or agreement for the purpose or with the effect of restricting competition with any other company or person who is a responder or potential prime responder.

2. Neither the price(s) nor the amount of this RFP have been disclosed to any other company or person who is a responder or potential prime responder on this project, and will not be so disclosed prior to RFP opening.

3. Neither the prices nor the amount of the RFP of any other company or person who is a responder or potential prime responder on this project have been disclosed to me or my company.

4. No attempt has been made to solicit, cause or induce any company or person who is a responder or potential prime responder to refrain from bidding on this project, or to submit a RFP higher than the RFP of this company, or any intentionally high or noncompetitive RFP or other form of complementary RFP.

5. No agreement has been promised or solicited for any other company or person who is a responder or potential prime responder on this project to submit an intentionally high, noncompetitive or other form of complementary RFP on this project.

6. The RFP of my company is made in good faith and not pursuant to any consultation, communication, agreement or discussion with, or inducement or solicitation by or from any company or person to submit any intentionally high, noncompetitive or other form of complementary RFP.

7. My company has not offered or entered into a subcontract or agreement regarding the purchase or sale of materials or services from any company or person, or offered, promised or paid cash or anything of value to any company or person, whether in connection with this or any other project, in consideration for an agreement or promise by any company or person to refrain from bidding or to submit any intentionally high, noncompetitive or other form of complementary RFP or agreeing or promising to do so on this project.

8. My company has not accepted or been promised any subcontract or agreement regarding the sale of materials or services to any company or person and has not been promised or paid cash or anything of value by any company or person, whether in connection with this or any other project, in consideration for my company's submitting any intentionally high, noncompetitive or other form of complementary RFP, or agreeing or promising to do so, on this project.

9. I have made a diligent inquiry of all members, officers, employees, and agents of my company with responsibilities relating to the preparation, approval or submission of my company's RFP on this project and have been advised by each of them that he or she has not participated in any communication, consultation, discussion, agreement, collusion, or other conduct inconsistent with any of the statements and representations made in this affidavit.

10. I understand and my company understands that any misstatement in this affidavit is and shall be treated as a fraudulent concealment from the Florida Department of Transportation, of the true facts relating to submission of RFPs for this contract.

ANTI-COLLUSION STATEMENT - SIGNATURE

I DECLARE UNDER PENALTY OF PERJURY IN THE SECOND DEGREE, AND ANY OTHER

APPLICABLE STATE OR FEDERAL LAWS, THAT THE STATEMENTS MADE ON THIS DOCUMENT

ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Signature Company Name

Title Address

Date Phone Number

CONFLICT OF INTEREST DISCLOSURE FORM

Please mark which of the following applies to you/your company:

I hereby attest that no Suwannee County Board of County Commissioners employee(s), elected officials(s), of if any of its agencies is also an owner, corporate officer, agency, employee, etc., of their corporation/partnership/individual business.

The following person(s) name(s) and position(s) with your business.

NAME(S) POSITION(S)

(Signature)

Title/Date: ___________________________

Business Name: ____________________________________________

DEBARMENT

Contractor Covered Transactions

(1) The prospective contractor, _______________________________, of the Sub-Recipient certifies, by submission of this document, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(2) Where the Sub-Recipient’s subcontractor is unable to certify to the above statement, the prospective subcontractor shall attach an explanation to this form.

Contractor Name:

By:

Signature

Name and Title

Street Address

City, State, Zip

Date

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion

Failure to Perform Questionnaire

Name of Company: ______________________________________________________

1. Has the company been involved in any litigation within the last (5) five years for failure to perform?

Yes _____ No_____

If yes, explain:

2. Has a bond company or other insurance been utilized to complete a project for the company within the last (5) five years?

Yes _____ No _____

If yes, explain:

Draft 1 2025-07 RFQ Master Planning Svcs @ Regional Shelter

Draft 1 2025-07 RFQ Master Planning Svcs @ Regional Shelter

Draft 1 2025-07 RFQ Master Planning Svcs @ Regional Shelter

Draft 1 2025-07 RFQ Master Planning Svcs @ Regional Shelter