4-D. Required Forms.docx

BID SUBMISSION FORM

This Bid is submitted by:

Company Legal Name:

Representative (printed):

Address:

City/State/Zip:

Email address:

Telephone:

By signing above, the Bidder agrees that the City reserves the right to reject any and all Bids, to award multiple Contracts by line item, combination of items, or grand total according to the best interest of the City, to waive formalities, technicalities, to recover and re-bid this ITB. Bids are valid for one hundred twenty (120) calendar days from Bid Opening.

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

1. Bid/Bid document has been signed by authorized bidder/proposer official.

2. Bid/Bid package has been properly labeled per the instructions. (See Section 1.6)

3. Bid/Bid package contains all of the Bid/Bid Response Package Forms:

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

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 Bid 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 Bid are marked as Trade Secret or PII:

No portion of the Bid is marked as Trade Secret or PII.

Representative (signed):

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, 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.

Phone # Age of Firm

Code

NCDOT

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

Annual Gross Receipts: Less than $500,000 $ 500,000 - $1M $1-2M $2-5M Over$5M

Annual Gross Receipts: Less than $500,000

Annual Gross Receipts: Less than $500,000

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”.

NON-DISCRIMINATION PROVISION

All requests for bids or Bids 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 Invitation to Bid, for reference check:

NAME OF FIRM:

ADDRESS OF FIRM:

CONTACT PERSON:

TELEPHONE NUMBER:

EXCEPTIONS FORM

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

ITB Section Number ITB Section Title Exception and Proposed Change to ITB

Date:

Company:

By:

Signature:

Print name and title of signatory

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

BUY AMERICA CERTIFICATION

ITB # 269-2026-2045A

CATS Bus OPerations WHEELCHAIR LIFT PARTS

COMPLIANCE FORM

Certificate for Compliance with 49 U.S.C. 5323(j)(1) (Procurement of Steel, Iron, or Manufactured Products)

The Bidder hereby certifies that it will comply with the requirements of 49 U.S.C. 5323(j)(1) and the applicable regulations in 49 CFR Part 661.

Date:

Signature:

Company Name:

Title:

NON COMPLIANCE FORM

Certificate for Non-Compliance with 49 U.S.C. 5323(j)(1) (Procurement of Steel, Iron, or Manufactured Products)

The Bidder hereby certifies that it cannot comply with the requirements of 49 U.S.C. 5323(j)(1) and the applicable regulations in 49 CFR 661, but it may qualify for an exception pursuant to 49 U.S.C. 5323(j)(2)(A), 5323(j)(2)(B), or 5323(j)(2)(D), and 49 CFR 661.7.

Date:

Signature:

Company Name:

Title:

Identify items that are non-compliant in the space below:

NOTICE TO BIDDERS:

Your bid cannot be considered unless one of the above certifications is signed and returned with the bid. If you submit an incomplete Buy America certificate or an incorrect certificate of non-compliance through an inadvertent or clerical error, you may submit to the FTA Chief Counsel, on the day of the Bid Opening, a written explanation of the circumstances surrounding the submission of the incomplete or incorrect certification.

ADDENDA RECEIPT CONFIRMATION

RFP # 269-2026-2045A

Please acknowledge receipt of all addenda by including this form with your Proposal. All addenda will be posted to the Bonfire Website.

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