4._26YS0058_-_IFB_Checklist_and_Bidder_Certification.pdf

State of California Solicitation Number: 26YS0058 Department of Veterans Affairs

BIDDER’S CHECKLIST

SUPPLEMENTAL WATER TREATMENT OPERATOR LABOR SERVICES

The checklist below is a summary of documents to be submitted based on requirements in the Invitation for Bid. This checklist should be returned with your bid. Place a check-mark or “X” next to each document being submitted.

Signatures are required on the documents where specified.

The company name listed on all documents submitted (ex. licenses, permits, certifications, and insurance) must be identical to the company name on the Payee Data Record (STD 204). Failure to submit these documents in the manner prescribed may delay award of Agreements.

Bidder’s Checklist

Bidder Certification

Bid Rate Sheet

Signed Payee Data Record - STD 204

Bidder Declaration - GSPD-05-105

Commercially Useful Function (CUF) Certification, if applicable

Disabled Veteran Business Enterprise (DVBE) Declarations – DGS PD 843, if applicable

Iran, if applicable

Darfur Contracting Act

California Civil Rights Laws

Contractor Certification Clauses (CCC-4/2017) - The CCC-4/2017 can be found on the Internet at https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List- Folder/Standard-Contract-Language

Valid California city or county business license; or, if a corporation located within the State of California, incorporation documents or letter from the Secretary of State; or, if not a California business, an affidavit that the business is in good standing with the State, Province, or Country in which the business is headquartered. Submit all Licenses and insurance required by this solicitation with your bid package.

Certificate of Insurance

Sample Invoice https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language

Bidders'

BID/BIDDER CERTIFICATION SHEET

This Bid/Bidder Certification Sheet must be signed and returned along with all the "required attachments" as an entire package. The bid must be transmitted in accordance with IFB instructions.

A. I have read and understand the DVBE participation requirements and have included documentation demonstrating that I have met the participation goals, if goals are included.

B. The undersigned signature certifies under penalty of perjury that they are a duly authorized representative and in compliance with all the requirements of this bid document. The signature below authorizes the verification of this certification.

An Unsigned Bid/Bidder Certification Sheet May Be Cause For Rejection.

1. Company Name 2. Telephone Number 2a. Fax Number

2c. E-MAIL

3. Address

Indicate your organization type:

4. Sole Proprietorship 5. Partnership 6. Corporation Indicate the applicable employee and/or corporation number:

7. Federal Employee ID No. (FEIN) 8. California Corporation No.

9. Bidder’s Name (Print) 10. Title

11. Signature 12. Date

13. Are you certified with the Department of General Services, Office of Small Business and Disabled Veteran Business Enterprise Services (OSDS) as:

a. California Small Business

Yes No If yes, enter certification number:

b. Disabled Veteran Business Enterprise Yes No If yes, enter your service code below:

NOTE: A copy of your Certification should be included if either of the above items is checked “Yes”.

Date application was submitted to OSDS, if an application is pending:

Completion Instructions for Bid/Bidder Certification Sheet

Complete the numbered items on the Bid/Bidder Certification Sheet by following the instructions below.

Item Numbers Instructions

1, 2, 2a, 3 Must be completed. These items are self-explanatory.

Check if your firm is a sole proprietorship. A sole proprietorship is a form of business in which one person owns all the assets of the business in contrast to a partnership and corporation. The sole proprietor is solely liable for all the debts of the business.

Check if your firm is a partnership. A partnership is a voluntary agreement between two or more competent persons to place their money, effects, labor, and skill, or some or all of them in lawful commerce or business, with the understanding that there shall be a proportional sharing of the profits and losses between them. An association of two or more persons to carry on, as co-owners, a business for profit.

Check if your firm is a corporation. A corporation is an artificial person or legal entity created by or under the authority of the laws of a state or nation, composed, in some rare instances, of a single person and his successors, being the incumbents of a particular office, but ordinarily consisting of an association of numerous individuals.

7 Enter your federal employee tax identification number.

Enter your corporation number assigned by the California Secretary of State’s Office. This information is used for checking if a corporation is in good standing and qualified to conduct business in California.

9, 10, 11, 12 Must be completed. These items are self-explanatory.

If certified as a California Small Business, place a check in the "Yes" box, and enter your certification number on the line. If certified as a Disabled Veterans Business Enterprise, place a check in the "Yes" box and enter your service code on the line. If you are not certified to one or both, place a check in the "No" box. If your certification is pending, enter the date your application was submitted to OSDS.

State of California-Department of General Services, Procurement Division

GSPD-OS-1 OS (REV 08/09)

Solicitation Number: 26YS0058

BIDDER DECLARATION

1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form):

a. Identify current California certification(s) (MB, SB, NVSA, DVBE): _____ or None 0_ (If "None': go to Item #2)

b. Will subcontractors be used for this contract? Yes D NoO (If yes, indicate the distinct element of work your firm will perform in this contract e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary.

c. If you are a California certified DVBE: (1) Are you a broker or agent? Yes O No D

(2) If the contract includes equipment rental, does ror COplPiany o�at least 51 % of the equipment provided in this contract (quantity and value)? Yes No LJ. N/A LJ

2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary):

Subcontractor Name, Contact Person, Subcontractor Address CA Certification (MB,SB, Work performed or goods provided Corresponding Good 51%

Phone Number & Fax Number & Email Address NVSA, DVBE or None) for this contract %of bid price Standing? Rental?

CERTIFICATION: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct.

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State of California Department of Veterans Affairs

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM

CV 012 (REV. 08/2016)

Solicitation Number:

Page 1 of2

26YS0058

Every certified SB, MB & DVBE must complete this form if they will perform an element of the work.

1. CONTRACTOR NAME (Completing Form)

"DOING BUSINESS AS" (DBA) NAME: OSDS REF# (Currently certified firms only): Expiration Date:

I I I

2. COMMERCIALLY USEFUL FUNCTIONS (CUF)

All certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code, Section 14837 (d)(4) (for SB) and Military and Veterans Code, Section 999(b)(S)(B)

(for DVBE).

Please answer the following questions, as they apply to your company for the goods and services being acquired in this solicitation:

Mark all that apply: DVBE 0 Small Business □ Micro Business □

If awarded a contract, will your business be responsible for the execution of a distinct element of the

Yes D No □ resulting work?

If awarded a contract, will your business carry out the obligation of the contract by actually performing, Yes n No n managing, or supervising the work involved?

3 If awarded a contract, will you perform work that is normal for your business, service and functions? Yes D No □

If awarded a contract, will your business subcontract a portion of the work greater than would be

Yes n No n expected by normal industry practices?

If awarded a contract, will your business role be limited to that of an extra participant in a transaction, contract, Yes D No □ or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation?

A response of "No" in questions 1-3 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.

3. WRITTEN STATEMENT

Provide a written statement below detailing the role, services and goods your company will provide to meet the commercially useful function requirement. At the State's option prior to award, you may be required to submit additional clarifying information

26YS0058

4. 26HS0013 - SFQ Attachments