4-D. Required Forms.docx

PROPOSAL SUBMISSION FORM

This Proposal is submitted by:

The representative signing above hereby certifies and agrees that the following information is correct:

1. In preparing its Proposal, the Company has considered all proposals submitted from qualified, potential subcontractors and suppliers, and has not engaged in or condoned prohibited discrimination.

2. For purposes of this Section, discrimination means discrimination in the solicitation, selection, or treatment of any subcontractor, vendor or supplier on the basis of race, ethnicity, gender, age or disability or any otherwise unlawful form of discrimination. Without limiting the foregoing, discrimination also includes retaliating against any person or other entity for reporting any incident of discrimination.

3. Without limiting any other provision of the solicitation for proposals on this project, it is understood and agreed that, if this certification is false, such false certification will constitute grounds for the City to reject the Proposal submitted by the Company on this Project and to terminate any contract awarded based on such Proposal.

4. As a condition of contracting with the City, the Company agrees to maintain documentation sufficient to demonstrate that it has not discriminated in its solicitation or selection of subcontractors. The Company further agrees to promptly provide to the City all information and documentation that may be requested by the City from time to time regarding the solicitation and selection of subcontractors. Failure to maintain or failure to provide such information constitutes grounds for the City to reject the Proposal submitted by the Company or terminate any contract awarded on such proposal.

5. As part of its Proposal, the Company shall provide to the City a list of all instances within the past ten years where a complaint was filed or pending against the Company in a legal or administrative proceeding alleging that the Company discriminated against its subcontractors, vendors or suppliers, and a description of the status or resolution of that complaint, including any remedial action taken.

6. The information contained in this Proposal or any part thereof, including its Exhibits, Schedules, and other documents and instruments delivered or to be delivered to the City, is true, accurate, and complete. This Proposal includes all information necessary to ensure that the statements therein do not in whole or in part mislead the City as to any material facts.

7. None of Company’s or its subcontractors’ owners, employees, directors, or contractors will be in violation of the City’s Conflict of Interest Policy for City, Secondary and Other Employment Relationships (HR 13) if a Contract is awarded to the Company.

8. It is understood by the Company that the City reserves the right to reject any and all Proposals, to make awards on all items or on any items according to the best interest of the City, to waive formalities, technicalities, to recover and resolicit this RFP.

9. This Proposal is valid for one hundred and eighty (180) calendar days from the Proposal due date.

ADDENDA RECEIPT CONFIRMATION

Please acknowledge receipt of all addenda by including this form with your Proposal. All addenda will be posted to the City’s Bonfire eProcurement Portal at https://charlottenc.bonfirehub.com/ and the City’s Contract Opportunities Site at http://charlottenc.gov/DoingBusiness/Pages/ContractOpportunities.aspx.

I certify that this proposal complies with the Specifications and conditions issued by the City except as clearly marked in the attached copy.

EXCEPTIONS FORM

The undersigned Proposer agrees to provide all Products and Services requested in the RFP for the price(s) set forth in the Pricing Sheet, all in strict conformity with the terms, conditions and specifications set forth in the RFP and the Sample Contract (including any addenda or amendments), subject only to the exceptions stated in the chart below. Exceptions representing material changes to Proposal terms are grounds for rejection of the Proposal.

RFP/Contract Section Number RFP/Contract Section Title Exception and Proposed Change to RFP and/or Sample Contract

I, the undersigned, hereby acknowledge that my company was given the opportunity to provide exceptions to the Sample Contract as provided in the RFP. As such, I have elected to do the following:

___ Include exceptions to the Sample Contract in the following section of my Proposal: _______ ___ Not include any exceptions to the Sample Contract.

I, the undersigned, hereby acknowledge that my company was given the opportunity to indicate any Trade Secret materials or Personally Identifiable Information (“PII”) as detailed in Section 1.6.3. I understand that the City is legally obligated to provide my Proposal documents, excluding any appropriately marked Trade Secret information and PII, upon request by any member of the public. As such, my company has elected as follows:

___ The following section(s) of the of the Proposal are marked as Trade Secret or PII: ________ ___ No portion of the Proposal is marked as Trade Secret or PII.

Date:

Company:

By:

Signature:

Print name and title of signatory

NON-DISCRIMINATION PROVISION

All requests for Proposals issued for City contracts shall include a certification to be completed by the Bidder or Proposer in substantially the following form:

The undersigned Bidder or Proposer hereby certifies and agrees that the following information is correct:

NAME OF COMPANY:

BY: TITLE:

SIGNATURE OF AUTHORIZED OFFICIAL:

DATE:

REFERENCES FORM

Company Name: ____________________________________________________________ List three (3) clients excluding the City of Charlotte, for whom you have provided services similar to those outlined in this Request for Proposal, for reference check:

NAME OF FIRM:

ADDRESS OF FIRM:

CONTACT PERSON:

TELEPHONE NUMBER:

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS

The bidder, contractor, or subcontractor, as appropriate, certifies to the best of its knowledge and belief that neither it nor any of its officers, directors, or managers who will be working under the Contract, or persons or entities holding a greater than (ten percent) 10% equity interest in it (collectively “Principals”):

1. Are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal or state department or agency in the United States;

2. Have within a three-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 anti-trust or procurement statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are presently indicted for or otherwise criminally or civilly charged by a government entity, (federal, state or local) with commission of any of the offenses enumerated in paragraph 2 of this certification; and

4. Have within a three-year period preceding this application/proposal 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 or in some instances, criminal prosecution.

· I hereby certify as stated above:

(Print Name) Signature

Title Date

· I am unable to certify to one or more the above statements. Attached is my explanation. [Check box if applicable]

(Print Name) Signature

BYRD ANTI-LOBBYING CERTIFICATION

The undersigned certifies, to the best of their 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 an 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 and 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 making lobbying contacts to an officer or employee of an 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 [as amended by "Government wide Guidance for New Restrictions on Lobbying," 61 Fed. Reg. 1413 (1/19/96)].

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including all subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients 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 by 31 U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). 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.

___________________________________ (the “Company”) certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Company understands and agrees that the provisions of 31 U.S.C. A 3801, et seq., apply to this certification and disclosure, if any.

(Print Name) Company Name

Authorized Signature Address

List of Subcontractors – FORM A Instructions Note: A correctly completed Form A will list all subcontractors and suppliers a bidder plans to directly utilize. Each company who will have 2nd or 3rd tier subcontractors or suppliers should submit individual Form A’s. Only DBEs certified by NCDOT may be submitted to meet the contract goal. Note: These instructions and the signed Forms A and resulting forms D, will be incorporated actually and by reference into the selected firm’s contract with the City of Charlotte.

Form A‐ Instructions to fill out form

1. Bidder’s Name is the name of the company that will be entering into contract agreements or purchasing supplies and materials from the subcontractors listed in the document

2. Project Name is the name of the is listed on the solicitation

3. Name and address of each subcontractor/supplier that is intended to do work on the project :

a. “Annual Gross Receipts range” must be identified for each company according to the ranges provided

4. Contact Person and Phone Number (plus email address if available).

5. Age of the Firm approximate age of firm

6. Description of the Work or supplies to be provided by the subcontractor

7. NAICS Code (if available) for the work provided by the subcontractor

8. NCDOT Reporting number # (specifically for the DBE subcontractors and suppliers).

9. Total Project $ dollars that are projected to be spent with each subcontractor/supplier (Dollars committed to DBE subcontractor) Note: for DBE suppliers only 60% of the total amount to be spent may be counted. Supplier entries must include both the total amount listed with “100%” indicated, and the committed amount listed with 60% indicated. Regardless firms must achieve 100% utilization to remain compliant with the 60% commitment (as determined by the City of Charlotte).

10. % of the total Bid Amount is the percent of dollars to be spent with each subcontractor or supplier.

a. Calculation = Total Projected $ divided by Total Bid Amount

b. DBE supplier utilization may only count 60% toward DBE goal, but 100% must be spent with the DBE supplier to get the 60% credit.

c. Total Bid Amount includes the contingency amount

11. Your company must acknowledge that you have confirmed that each DBE submitted is certified as such in the NCDOT database https://www.ebs.nc.gov/VendorDirectory/search.html?s=fn&a=new . Note: this database includes DBE and Non‐DBE Firms, you must check in the system “DBE”.

12. Print additional copies of the extended Form‐ A to list all subcontractors or suppliers which do not fit on one page. On each sheet the company with subcontractors and suppliers must Print:

a. The company name under “Bidders Name”

b. The solicitation title next to “Project Name”.

13. The project totals including for all vendors listed on a company’s Form A and extended Form A’s must be listed on the 1st page including the following.

a. The Total DBE Utilization in $ dollars

b. The Total Bid Amount in $ dollars

c. Percentage % of total DBE Utilization (Total DBE Utilization/Total Bid Amount including contingency)

14. Read the “Certification statement” before signing your Form A.

15. An Authorized Official from your company must sign the Form. That official must then Print:

a. Name

b. Title

c. Submittal Date.

16. Note by submitting this form the prime will be contractually held to the amounts listed on the Forms A and tiered forms A submitted their subcontractors, as well the Forms D letters of intent submitted will be considered both the commitments by the prime and subcontractors (should the subcontractors not comply with DBE commitments/requirements) on this contract.

17. Additional questions on filling relating to the completion of the form should be directed to the contact provided included with the solicitation.

Note: NCDOT DBE certified Primes ,submitting bids/proposals, must include entries of their own utilization and their subcontractors utilization on the Form A. This includes if they will be utilizing other NCDOT certified DBE firms on the contract.

LIST OF SUBCONTRACTORS/SUPPLIERS ‐ FORM A

Project DBE and non‐DBE Subcontractor/Supplier Utilization Commitment Federal Disadvantaged Business Opportunity Program. Note: This MUST be submitted with your Bid. Make copies as needed.

If you fail to meet the DBE Goal for this Project, you MUST complete FORM C and attach documentation of your Good Faith Efforts with your Bid package.

Bidders Name: Project Name:

Below list ALL SUBCONTRACTORS AND SUPPLIERS (including DBEs) that you intend to use on this Contract. Continue listing on the supplemental form. Only utilization listed on the same row as the DBEs listed below will be considered utilization commitments. Note: Both the 100% DBE supplier utilization & the 60% commitment to those DBE suppliers must be listed below to be considered compliant. The 60% DBE supplier commitment applies toward meeting the goal calculation, but the 100% utilization is required to be listed to achieve to credit for that 60% commitment.

Subcontractor/Supplier’s Name & Address

Contact Person & Phone #

Age of Firm

Description of Work

NAICS

Code

NCDOT

Reporting # Total Projected Utilization/Commitment or 100% DBE Supplier Utilization commitment in dollars $ DBE Suppliers 60% credit in $ dollars

% of Bid Amount

I acknowledge that I have confirmed the certification of each DBE listed above on https://www.ebs.nc.gov/VendorDirectory/search.html?s=fn&a=new%

Total DBE Utilization

Total Bid Amount

Percent DBE Utilization (Total DBE Utilization/Total Bid Amount)

Please read the following “Certification” statement before signing. “The undersigned certifies that he/she has read, understands, and agrees to be bound by the DBE Program Requirements, including these accompanying FORM(s) A, and the other terms and conditions in the Notice to Bidders. The undersigned further certifies that he/she is legally authorized by the Bidder to make the statements and representations and that said statements and representations are true and correct to the best of his/her knowledge and belief. It is the intent by the undersigned to enter into formal agreement(s) with subcontractors/suppliers named on this Form conditioned upon execution of a contract with the City. All subcontractors/suppliers submitted to the City of Charlotte for DBE commitments on this document and for this solicitation/resulting contract by the signed party, at bid/proposal open or as replacements, must be listed at time of open/replacement in the North Carolina Department of Transportation’s vendor database as federally certified DBEs. The must be reconfirmed by submission of a form D to City’s Civil Rights Officer for review and approval prior to contract award. The dollar and % commitment levels as confirmed from this document by the DBLEO and assigned responsible staff as documented during compliance evaluation will contractually bound as commitments by the submitting prime, and will incorporated into said agreement. The undersigned understands and agrees that if any of the statements and representations are made by the Bidder knowing them to be false, or if there is a failure of the successful Bidder (i.e., the Contractor) to implement any of the stated agreements, intentions, objectives, goals, commitments and substitutions set forth herein without prior approval by the Civil Rights Officer or a designee, then in any of such events the Contractor's act or failure to act, as the case may be, shall constitute a material breach of the contract, entitling the City to terminate the contract for default. The right to so terminate shall be in addition to, and not in lieu of, any other rights and remedies the City may have for other defaults under the contract, or otherwise. Additionally, the Contractor will be subject to the loss of any future contract awards”.

Signature of Authorized Official Printed Name Title Submittal Date

COMPANY’S BACKGROUND RESPONSE

Companies shall complete and submit the form below as part of their response to this RFP. Additional pages may be attached as needed to present the information requested.

1. Company’s legal name.

2. Company Location (indicate corporate headquarters and location that will be providing the Services).

3. How many years has your company been in business? How long has your company been providing the Services as described in Section 3?

4. How many public sector (cities or counties) clients does your company have? How many are using the Services? Identify by name some of the clients similar to City (e.g., similar in size, complexity, location, type of organization).

5. List any projects or services where your company was terminated or removed. Please disclose the entity that terminated and explain the reason for the termination.

6. List any litigation that your company has been involved with during the past two (2) years for Services similar to those in this RFP.

7. Provide an overview and history of your company.

8. Describe the key individuals along with their qualifications, professional certifications and experience that would comprise your company’s team for providing the Services.

9. Provide information regarding the level of staffing at your organization’s facilities that will be providing the Services, as well as the level of staffing at subcontractors’ facilities, if known or applicable.

10. What steps will your organization take to ensure that the transition of Services runs smoothly?

11. Describe the communications scheme that your organization will use to keep the City informed about the Services.

12. Describe the risks associated with this Contract. What contingencies have been built in to mitigate those risks?

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