4-4. Appendix B - Required Forms.pdf

Appendix B.01

DISADVANTAGE BUSINESS ENTERPRISE

If a Proposer desires to qualify as a Disadvantage Business Enterprise (DBE), the web address for the California Unified Certification Program (UCP) is:

http://dot.ca.gov/hq/bep/find_certified.htm. If you are a DBE, please provide a copy of your UCP certificate.

AFFIDAVIT FOR DISADVANTAGED BUSINESS ENTERPRISE

STATE OF _____________________:

COUNTY (CITY) OF _____________:

I HEREBY DECLARE AND AFFIRM THAT I AM THE ___________________(Title) and duly authorized representative of ______________________ (name of corporation/firm) whose address is _________________________________. I hereby declare and affirm that my firm is a certified Disadvantaged Business Enterprise or Women-Owned Business Enterprise as defined and approved by California Unified Certification Program. The above, named firm will provide MST with a copy of the document from the California Unified Certification Program so affirming their DBE status.

I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY

THAT THE CONTENTS OF THE FOREGOING DOCUMENT ARE TRUE AND

CORRECT, AND THAT I AM AUTHORIZED, ON BEHALF OF THE ABOVE FIRM, TO

MAKE THIS AFFIDAVIT.

_______________________(AFFIANT)________________________(DATE)

STATE OF_____________________:

COUNTY (CITY) OF_____________:

On this__________ day of ______________, 20____, Appendix B.02

CERTIFICATION OF CONTRACTOR REGARDING DEBARMENT, SUSPENSION,

AND OTHER RESPONSIBILITY MATTERS

The Contractor, _________________________, certifies to the best of its knowledge and belief, that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

2. Have not within a three (3) year period preceding this proposal 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;

3. 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 offense enumerated in paragraph (2) of this certification; and

4. Have not within a three (3) year period preceding this application/proposal had one (1) or more public transactions (Federal, State, or Local) terminated for cause or default.

If the above-named Contractor is unable to certify to any of the statements in this certification, the Contractor shall attach an explanation to this certification.

The Contractor, _________________________, certifies or affirms the truthfulness and accuracy of the contents of the statements submitted on or with this certification and understands that the provision of 31 U.S.C. Section 3801 et seq. are applicable thereto.

Signature and Title of Authorized Official

Notary Public Name (Printed)

Notary Public Signature County of Expiration Date

Appendix B.03

Federal Tax Delinquency and Conviction Certification

The Contractor must complete the following two certification statements.

The Contractor must indicate its current status as it relates to tax delinquency and felony conviction by indicating in following spaces below the applicable response. The

Contractor agrees that, if awarded a contract resulting from this solicitation, it will incorporate this provision for certification in all lower tier subcontracts.

Certifications

Delinquency: The Contractor represents that it is or is not , a corporation that has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

Conviction: The Contractor represents that it is or is not , a corporation that was convicted of a criminal violation under any Federal law within the preceding 24 months.

Note

If a Contractor responds in the affirmative to either of the above representations, the Contractor is ineligible to receive an award.

Term Definitions

Felony conviction: Felony conviction means a conviction within the preceding twenty-four

(24) months of a felony criminal violation under any Federal law and includes conviction of an offense defined in a section of the U.S. code that specifically classifies the offense as a felony and conviction of an offense that is classified as a felony under 18

U.S.C. § 3559.

Tax Delinquency: A tax delinquency is any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted, or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

Date Signature

Company Name Title

NOTE: No award can be made without this form being completed

Appendix B.04

CERTIFICATION OF RESTRICTIONS ON LOBBYING

I, __________________________ , ________________________ , hereby certify on (Name) (Title) behalf of ________________________________________ that:

(Firm)

(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, an officer or employee of Congress, or an employee of 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.

This certification is a material representation of fact upon which reliance is 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 or not less than $10,000 and not more than $100,000 for each such failure.

Dated ____________________ ______________________________

(Name)

(Title)

(Firm)

Appendix B.05

MONTEREY-SALINAS TRANSIT BIDDER FORM

All bidders/proposers are required to provide the following information for DBE & non-DBE firms:

MST requires all prime contractors bidding on DOT-assisted contracts to submit, at the time of bid opening, the following information pertaining to the prime contractor and subcontractors who provided a bid or who were contacted by the prime contractor. Monterey-Salinas Transit will use this information to maintain and update a "Bidders List" to assist in MST's DBE goal-setting process. To the extent permitted by law, all information submitted will be held in strict confidence.

Firm Name: Firm Owner or Primary Contact:

Phone: Fax: Email:

Firm Address: City: State: Zip:

Is the firm currently certified as a *DBE by the California Unified Certification Program?

Yes or No (Circle one) NAICS Code:

*A copy of Bidder’s DBE Certification, if applicable, must be included with this form.

List the type(s) of work/services/materials provided by the firm:

How many years has your firm been in business? ______________

Provide your DBE minority status:

Provide your firm's Gross Annual Receipts for the previous year:

Less than $1 million

Less than $5 million

Less than $10 million

Less than $15 million

More than $15 million

Black American

Hispanic American

Native American

Asian Pacific American

Subcontinent Asian-Pacific American

Other (state DBA eligibility designation)

Provide your DBE gender status:

Woman Owned

Male Owned

This form may be duplicated to report all bidders' (DBE and non-DBE) information.

Monterey-Salinas Transit

Attn: DBE Liaison Officer

19 Upper Ragsdale Dr., Suite 200

Monterey, CA 93940

Appendix B.06

NON-COLLUSION AFFIDAVIT

STATE OF CALIFORNIA )

COUNTY OF ________________________________)

___________________________________________, being first duly sworn, deposes and says that he or she is of (position or title)

(the Contractor) the party making the foregoing contract that the contract price is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the bid is genuine and not collusive or sham; that the Contractor, and has not directly or indirectly colluded, conspired, connived, or agreed with any Contractor or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the Contractor has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the Contractor or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other Contractor, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true; and, further, that the Contractor has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or date relative thereto, or paid, and will not pay, any free to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid.

Dated:____________________ By:_____________________

Appendix B.07

PROPOSER'S STATEMENT

REGARDING INSURANCE COVERAGE

To Be Submitted with Proposal

PROPOSER HEREBY CERTIFIES that the Proposer has reviewed and understands the insurance coverage requirements specified in the Request for Proposals (RFP) #26- 01 for Digital Content Management System. Should the Proposer be awarded the contract for the work, Proposer further certifies that the Proposer can meet the specified requirements for insurance, including insurance coverage of the subcontractors, and agrees to name MST as Additional Insured for the work specified.

Name of Proposer (Person, Firm, or Corporation)

Signature of Proposer's Authorized Representative

Name & Title of Authorized Representative

Date of Signing

INSURANCE REQUIREMENTS AND LIMITS

General:

CONTRACTOR, at its sole cost and expense, for the full term of this Contract (and any extensions thereof), shall obtain and maintain at minimum all of the following insurance coverage. Such insurance coverage shall allow and be endorsed primary coverage as respects MST and any insurance or self-insurance maintained by MST shall be excess of CONTRACTOR's insurance coverage and shall not contribute to it.

Types of Insurance and Minimum Limits

CONTRACTOR shall obtain and maintain during the term of this Contract:

(a) Worker's Compensation and Employer's Liability Insurance in conformance with the laws of the State of California (not required for CONTRACTOR 's or sub-

CONTRACTORs providing MST written confirmation of having no employees) with limits of not less than one million dollars ($1,000,000) each accident, $1,000,000 by disease-policy, and $1,000,000 disease-each employee.

(b) CONTRACTOR’s vehicles used in the performance of this Contract, including owned, non-owned (e.g. owned by CONTRACTOR's employees), leased or hired vehicles, shall each be covered with Commercial Automobile, Liability Insurance using Insurance Services Office (ISO) Business Automobile Coverage form CA 00

01 (or equivalent) in the minimum amount of one million dollars ($1,000,000) combined single limit per accident for bodily injury and property damage.

(c) CONTRACTOR shall obtain and maintain Commercial General Liability Insurance coverage with coverage at least as broad as Insurance Services Office (ISO) form

CG 00 01 in the minimum amount of one million dollars ($1,000,000) per occurrence, two million dollars ($2,000,000) general aggregate, and one million dollars ($1,000,000) products and completed operations aggregate. The policy shall include a per project or per location general aggregate endorsement. If a per project/location endorsement is not available, the limit for the general aggregate shall be doubled. If CONTRACTOR maintains higher limits than the specified minimum limits, MST requires and shall be entitled to coverage for the higher limits maintained by CONTRACTOR.

(d) CONTRACTOR shall obtain and maintain Professional Liability insurance that insures against professional errors and omissions that may be made in performing professional services in the minimum amount of two million dollars ($2,000,000) per claim and in the aggregate. Any policy inception date, continuity date, or retroactive date must be before the effective date of the start of work, and

CONTRACTOR agrees to maintain continuous coverage through a period no less than three (3) years after completion of the work.

(e) CONSUTANT shall provide Cyber Liability Insurance with limits not less than one million dollars ($1,000,000) per claim. Coverage shall be sufficiently broad to respond to the duties and obligations as is undertaken by CONTRACTOR in this agreement and shall include, but not be limited to, claims involving infringement of intellectual property, including but not limited to infringement of copyright, trademark, trade dress, invasion of privacy violations, information theft, damage to or destruction of electronic information, release of private information or personally identifiable information (PII), alteration of electronic information, extortion, and network security. The policy shall provide coverage for breach response costs as well as regulatory fines and penalties, and credit monitoring expenses with limits sufficient to respond to these obligations.

Other Insurance Provisions

(a) As to all insurance coverage required herein, any deductible or self-insured retention exceeding $5,000.00 shall be disclosed to and be subject to written approval by MST.

(b) Except Professional Liability, each insurance coverage required hereunder is to be provided as an “occurrence” form basis only.

(c) All required Automobile Liability Insurance and Commercial General Liability

Insurance shall contain the following endorsement as a part of each policy: “MST is hereby added as an additional insured as respects the operations of the named insured."

(d) All the insurance required herein shall include and contain the following clause: "It is agreed that this insurance shall not be canceled until thirty (30) days after MST shall have been given written notice of such cancellation or reduction." If a carrier will not provide the required notice of cancellation, the CONTRACTOR shall provide written notice to MST of a cancellation no later than five (5) business days before cancellation.

(e) All required Workers’ Compensation, Automobile Liability Insurance and

Commercial General Liability shall contain and be endorsed with a waiver of subrogation in favor of MST.

(e) CONTRACTOR shall notify MST in writing at least thirty (30) days in advance of any reduction in any insurance policy required under this Contract.

(f) CONTRACTOR agrees to provide MST at or before the effective date of this

Contract with a certificate of insurance of the coverage and amendatory endorsements required.

(g) If CONTRACTOR, for any reason, fails to maintain insurance coverage, which is required pursuant to this Contract, the same shall be deemed a material breach of contract. MST, at its sole option, may terminate this Contract and obtain damages from the CONTRACTOR resulting from said breach.

Appendix B.08

Proposer Information Sheet

A. PROPOSER QUALIFICATIONS AND REFERENCES

The Proposer is required to state what work of similar magnitude or character they have done. Give references to enable MST to judge experience, skill and business standing and provide information to assess the ability to perform the services as completely and as rapidly as is required under the terms of the contract. All questions must be answered and the data given must be clear and comprehensive. Provide the nature of the work performed, for whom, amount of contract, dates of work, and the name of a point of contact for the Transit Agency, Firm or other Public Agency. If necessary, questions may be answered on separate attached sheets.

B. GENERAL PROPOSER INFORMATION:

When organized? ___________________________________________________

If a Corporation, where incorporated? ___________________________________

How many years in business under your current firm or trade name? ___________

Has the firm ever defaulted on a contract? __________ If so, where and why?

How was it resolved? ___________________________________________________

Has there ever been a failure to complete any work? ___________ If so, where and why?

How was it resolved?

Any claims for labor code violations? ___________________________________

PROPOSER QUALIFICATIONS AND REFERENCES CONTINUED

A. List three (3) current projects to include the, contract value, scheduled completion date, and the contact person, e-mail address and telephone number.

B. List three (3) similar work experiences to this contract requirement. Provide contract value, date completed, and a contact name and phone number.

C. Is there any legal action filed or threatened pertinent to this contract work? __

If yes, please list the title of the action, whether it is pending or resolved, and explain the circumstances:

D. The undersigned hereby authorizes and requests any person, firm, or corporation to furnish any credit history and financial condition or other information required by MST in verification of the information provided in this statement of PROPOSERS qualifications.

I hereby certify that the above information is true and correct to the best of my knowledge and that MST may rely on the information provided.

THIS STATEMENT MUST BE NOTARIZED.

Attach the “California All-Purpose Acknowledgement” duly notarized.

NAME OF CONTRACTOR:_______________________________________________

BY: __________________________________________________________________

Signature Title

Type/Print Name Date

Appendix B.09

RFP COMPLIANCE OR EXCEPTION

(Proposer must complete and submit with their proposal)

PLEASE ONLY SELECT ONE

COMPLIANCE OR EXCEPTION TO THE TERMS AND CONDITIONS OF THE RFP

A. COMPLIANCE:

This is to certify that Proposer agrees and shall comply with the terms and conditions of the RFP.

Firm Name: ___________________________________________________________

Proposer Signature: _____________________________________________________

Title: _________________________________________________________________

Date: _________________________________

B. EXCEPTION:

This is to certify that Proposer takes exception to the following terms and conditions of the RFP. Proposer must identify and list the terms and conditions by Section, page number and title. Proposer must identify what its exception is.

Firm Name: ___________________________________________________________

Proposer Signature: _____________________________________________________

Title: _________________________________________________________________

Date: _________________________________

Proposer shall list and attach to this form proposer’s exception(s):

Appendix B.10

SUBCONTRACTOR'S STATEMENT OF ELIGIBILITY

Contractor to provide a signed Statement of Eligibility from each of its subcontractors listed on the Designation of Subcontractors form.

__________________________________________________ (Subcontractor Name) hereby certifies that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in any federal project by any federal department or agency.

Where the subcontractor is unable to certify any of the statements in this certification, such subcontractor shall attach an explanation with this form.

The subcontractor certifies or affirms the truthfulness and accuracy of the contents of the statements submitted on or with this certification and understands that the provisions of 31 U.S.C. Section 3801, et. seq. are applicable.

Signature of Bidder: _____________________________ Date: _________________

(SIGN HERE)

Appendix B.11

PROPOSER’S LIST OF SUBCONTRACTORS (DBE AND NON-DBE) PART 1

In accordance with Title 49, Section 26.11 of the Code of Federal Regulations, and Section 4104 of the Public Contract Code, as amended, the following information is required for each subcontractor who will perform work amounting to more than one half of one percent (0.5%) of the Total Base Amount for Preconstruction Services or $10,000 (whichever is greater). Photocopy this form for additional firms.

PROPOSER’S LIST OF SUBCONTRACTORS (DBE AND NON-DBE) PART 2

In accordance with Title 49, Section 26 of the Code of Federal Regulations, the Proposer shall list all subcontractors who provided a quote or bid but were not selected to participate as a subcontractor on this project. Photocopy this form for additional firms.

Appendix B.12

COST PROPOSAL

In compliance with Monterey-Salinas Transit District’s (MST’s) Request for Proposals, we propose to furnish all labor, equipment, and services necessary in an amount not to exceed:

$____________________________________ for the Digital Content Management System.

$____________________________________ annually for the maintenance agreement.

$____________________________________ annually for the option year number one (1) of the maintenance agreement (only fill this part out if different from the initial fee).

$____________________________________ annually for the option year number two (2) of the maintenance agreement (only fill this part out if different from the initial fee or the initial option year).

TOTAL CONTRACT VALUE: $____________________________________________

(Including Option Years)

*Please also include a cost breakdown on a separate page.

Signature: ____________________________

Name: _______________________________

Title: ________________________________

Company Name: _______________________