5-0040 Forms and Supplements.pdf

00 40 00 – BID FORMS AND SUPPLEMENTS

Bid Form – The bid form is located on the Procurement Portal at https://charlottenc.bonfirehub.com in Microsoft Excel format.

https://charlottenc.bonfirehub.com/

EXECUTION OF BID

NON-COLLUSION AFFIDAVIT, DEBARMENT CERTIFICATION AND GIFT BAN CERTIFICATION

The person executing the bid, on behalf of the Bidder, being duly sworn, solemnly swears (or affirms) that neither he, nor any official, agent or employee of the Bidder has entered into any agreement, participated in any collusion, or otherwise taken any action which is in restraint of free competitive bidding in connection with any bid or contract, that the Bidder has not been convicted of violating North Carolina General Statute 133-24 within the last three years, and that the Bidder intends to do the work with its own bona fide employees or subcontractors and is not bidding for the benefit of another contractor.

In addition, execution of this bid in the proper manner also constitutes the Bidder’s certification of status under penalty of perjury under the laws of the United States in accordance with the Debarment Certification attached, provided that the Debarment Certification also includes any required statements concerning exceptions that are applicable.

NC General Statute 133-32 prohibits the offer to, or acceptance by, any City Employee of any gift from anyone with a contract with the City or State, or from any person seeking to do business with the City of Charlotte. By execution of any response in this procurement, you attest, for your entire organization and its employees or agents, that you are not aware that any such gift has been offered, accepted, or promised by any employees of your organization.

Affixing the corporate seal to this document is only intended to verify the officer signing on behalf of the corporation has the authority to do so.

The undersigned, having carefully examined the site and familiarized himself with the existing conditions on the Project area affecting the cost of work and hereby proposes to furnish all supervision, labor, equipment, materials and services required to construct and complete the Project in accordance with the Bidding Documents at and for the Total Bid Amount.

Submitted by: Subscribed and sworn before me this _____ day of ______________, 20____

Signature of Notary Public of ____________________________County

State of _____________________________

My commission expires_________________

Signature Title

Printed Name

Contractor (Legal) Name

Street Address

City State Zip Code

Telephone Fax

E-Mail Address

City Vendor Number License Number

Individual Corporation (State: ___________ )

Partnership LLC (State: __________________ )

COMMERCIAL NON-DISCRIMINATION CERTIFICATION

Project: Axle Counter System Upgrade

Name of Company (Bidder):

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

1. In preparing its Bid, the Bidder has considered all bids submitted from qualified, potential subcontractors and suppliers, and has not engaged in or condoned discrimination, as defined in Section 2 below.

2. For purposes of this form, discrimination means discrimination in the solicitation, selection, or treatment of any subcontractor, vendor, supplier or commercial customer on the basis of a person's race, color, gender, religion, national origin, ethnicity, age, familial status, sex (including sexual orientation, gender identity and gender expression), veteran status, pregnancy, natural hairstyle 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 remedies that the City may have for a false certification, it is understood and agreed that, if this certification is false, such false certification will constitute grounds for the City to reject the bid submitted with this certification and terminate any contract awarded based on such bid. It shall also constitute a violation of the City’s Commercial Non-Discrimination Ordinance and shall subject the Bidder to any remedies allowed thereunder, including possible disqualification from participating in City contracts or bid process for up to two years.

4. As a condition of contracting with the City, the Bidder 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 in connection with this solicitation process. Failure to maintain or failure to provide such information shall constitute grounds for the City to reject the bid submitted by the Bidder and terminate any contract awarded on such bid. It shall also constitute a violation of the City’s Commercial Non-Discrimination Ordinance and shall subject the Bidder to any remedies allowed thereunder.

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

6. As a condition of submitting a bid to the City, the Bidder agrees to comply with the City’s Commercial Non-Discrimination

Policy as described in Section 2, Article V of the Charlotte City Code, and consents to be bound by the award of any arbitration conducted thereunder.

By:

Signature of Company’s Authorized Representative

Title:

Date:

BUY AMERICA CERTIFICATION

BUY AMERICA CERTIFICATE

FOR

COMPLIANCE WITH TITLE 49 USC § 5323(J)(1)

(For Procurement of Steel, Iron, or Manufactured Products)

The Contractor hereby certifies that it will comply with the requirements of Title 49 USC §5323(j)(1) and the applicable regulations in 49 CFR Part 661.

__________________________ Signature of Contractor's Authorized Official

__________________________ Name and Title of Contractor's Authorized Official

__________________________ Date

BUY AMERICA CERTIFICATE

FOR

NON-COMPLIANCE WITH TITLE 49 USC § 5323(J)(1)

The Contractor hereby certifies that it cannot comply with the requirements of Title 49 USC §5323(j)(1), but it may qualify for an exception pursuant to Title 49 USC § 5323(j)(2)(B) or (j)(2)(D) and the regulations in 49 CFR 661.7.

__________________________ Signature of Contractor's Authorized Official

__________________________ Name and Title of Contractor's Authorized Official

__________________________ Date

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS

RFP # 269-2026-1894

Axle Counter System Upgrade

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

Title Date

BID FORM AND SUPPLIMENTS

City of Charlotte Charlotte Area Transit System (CATS)

BYRD ANTI-LOBBYING CERTIFICATION

RFP # 269-2026-1894

Axle Counter System Upgrade

The undersigned certifies, to the best of his or her 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

Date City/State/Zip

SUSPENSION & DEBARMENT CERTIFICATION (Prime Bidder)

ONLY APPLICABLE TO CONTRACTS EQUAL TO OR EXCEEDING $25,000.

CERTIFICATION OF PRIMARY PARTICIPANT REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY

MATTERS

The Primary Participant (potential Contractor for a major third party Contract), ______________________ _____________________________________ 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 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, of Local) with commission of any of the offenses 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 primary participant is unable to certify to any of the statements in this certification, the participant shall attach an explanation to this certification.)

THE PRIMARY PARTICIPANT (POTENTIAL CONTRACTOR FOR A MAJOR THIRD PARTY CONTRACT)

____________________________ , 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. SECTIONS 3801 ET SEQ. ARE APPLICABLE THERETO.

Signature and Title of Authorized Official

Date

SUSPENSION & DEBARMENT CERTIFICATION (Subcontractor)

CERTIFICATION OF LOWER-TIER PARTICIPANTS REGARDING DEBARMENT, SUSPENSION, & OTHER INELIGIBILITY

AND VOLUNTARY EXCLUSION

The Lower-Tier Participant (potential sub-Contractor under a major third party Contract), ______________ ____________________________________, certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(If the Lower-Tier Participant is unable to certify to any of the statements in this certification, such participant shall attach an explanation to this proposal.)

IF LOWER-TIER PARTICIPANT (POTENTIAL CONTRACTOR UNDER A MAJOR THIRD PARTY CONTRACT) ____________________________ , 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. SECTIONS 3801 ET SEQ. ARE APPLICABLE THERETO.

Signature and Title of Authorized Official

Date

CONFLICT OF INTEREST

Except as may be identified and explained below, the undersigned hereby certifies that, no member of the Charlotte City Council, Mecklenburg Board of County Commissioners, Metropolitan Transit Commission, officer, employee, or former employee of the City, AND no elected, appointed, or employed official or employee of the State of North Carolina or of a governing body, instrumentality, or political subdivision within the territory comprising Mecklenburg County, AND no relative of persons described above, AND no member of or delegate to the Congress of the United States has an interest whatsoever (regardless of how indirect and how remote that interest may be) in the Bidder’s organization and/or in the proceeds of any contract and/or agreement which might be made between the Bidder and the City as result of the successful bid/proposal accompanied by this certification; no person who is or who during the past twelve (12) months has been a member of the Charlotte City Council, Mecklenburg Board of County Commissioners, Metropolitan Transit Commission, an officer or employee of the City is employed by or on behalf of the Bidder’s organization; and that until acceptance of all work or services to be performed under any resulting contract or agreement, the Bidder shall not enter into any contract involving services or property, whether or not related to the performance of any resulting contract or agreement, with any of the aforementioned persons or with any business in which any such person has an interest, direct or indirect.

Except as identified and explained below and with City’s prior approval the Bidder shall not engage in any activity, or accept any employment, interest or contribution that would create an appearance of a conflict of interest (personal or organizational) or reasonably appear to compromise the Bidder’s judgment with respect to all work or services to be performed under any resulting contract or agreement.

The undersigned certifies that he is legally authorized by the Bidder to make the above representation, and that the representation is true to the best of his knowledge and belief and without deliberate omission of any inquiry which would to the best of his belief tend to change the above representation. The undersigned understands that any representation made knowing it to be false may be cause to disqualify the Bidder from competing for award for the contract at hand, may be cause to terminate the resulting contract and disqualify the Bidder from being awarded future contracts by the City.

The Bidder certifies that neither he nor any agent, representative, or other party acting on his behalf has offered or given any gratuity or gratuities, in the form of gifts, entertainment, or otherwise, to any director, officer, or employee of the City or of any person, firm, consultant or contractor retained by the City, with a view to securing the contract or of securing favorable treatment with respect to the award hereof, and the Bidder further certifies that neither he nor any agent, representative, or other party acting on his behalf will offer or give any such gratuity to any director, officer, or employee of the City or of any such consultant or contractor with a view to securing favorable treatment with respect to any change or amendment to the contract, or to any other action with respect to the performance hereof.

The Bidder further understands that in addition to submitting this certification at the time of bid/proposal submission to the City, the Bidder shall also be required to submit a similar certification at the time of execution of any resulting contract.

NOTE: THIS CERTIFICATION MUST BE SIGNED AND SUBMITTED WITH THE BID/PROPOSAL

Signature:

Title: Date of Signing: _______ Firm or Corporate Name: _______ Address:

Telephone Number:

INSTRUCTIONS TO COMPLETE FORM A

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. Only DBEs certified by NCDOT may be submitted to meet the Contract goal.

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 project 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).

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

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

b. DBE supplier utilization may only count 60% toward DBE goal

c. Total Amount Bid 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 http://partner.ncdot.gov/VENDORDIRECTORY/default.

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 Amount Bid in $ dollars

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

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

http://partner.ncdot.gov/VENDORDIRECTORY/default

LIST OF SUBCONTRACTORS - 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.

Subcontractor/Supplier’s Name & Address Contact

Person & Phone #

Age of

Firm Description of Work NAICS

Code

NCDOT

Reporting # Total Projected

% of Amount

Bid

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

I acknowledge that I have confirmed the certification of each DBE listed above on https://partner.ncdot.gov/VendorDirectory/default.html

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

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 DBE subcontractors/suppliers must provide proof of their DBE status or receive confirmation of their status from the City’s Civil Rights Officer prior to contract award. 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 https://partner.ncdot.gov/VendorDirectory/default.html

LIST OF SUBCONTRACTORS/SUPPLIERS - FORM A - Continuation 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:

Subcontractor/Supplier’s Name & Address Contact

Person & Phone #

Age of Firm Description of Work NAICS Code NCDOT

Reporting # Total Projected

% of Amount

Bid