5-Attachment D Forms.pdf

Attachment D

FORMS, AFFIDAVITS AND DOCUMENTATION CHECKLIST

Any contract/purchase order resulting from this solicitation shall include the forms indicated below.

Contractor shall complete the required forms and return them, along with the required documentation and the checklist, with the signed bid/proposal document. Failure to submit the completed forms and documentation may be a basis for rejection of your proposal.

Forms and Affidavits ☐ 1. Certificate of Authority -complete only one (1) ☐ 2. Amendment Form ☐ 3.Consolidated Affidavits

I. HIRING POLICY COMPLIANCE

II. SLAVERY ERA RECORDS AND INSURANCE, AND PRISON INDUSTRY AND

IMMIGRATION DETENTION SYSTEM RECORDS AND INTERESTS DISCLOSURE

III. COVENANT OF EQUAL OPPORTUNITY

IV. STATEMENT OF POLITICAL CONTRIBUTIONS AND EXPENDITURES

Documentation Instructions for Completion ☐ 4. Sample Employment Application Attach a copy of a sample employment application attesting that the employer will not inquire or consider the criminal convictions of applicants for employment needed to fulfill the terms of any City contract.

☐ 5. Income and Revenue Tax Clearance Approved clearances are not required to submit a response to the RFP but will be required of the successful respondent prior to City Council approval.

Submit requests for clearances electronically via a link in the bid response Requirement Section in the Supplier

Portal. Attach evidence showing you have submitted or received clearances. Please use the below URL to complete the Income Tax and Account Receivables Clearance process:

http://bit.ly/detroitclearances ☐ 6. Three (3) years Financial Information Attach your organization’s financial statements (Balance

Sheets, Income Statements and Statement of Cash Flows) for the previous three (3) years. Please do not submit your tax returns.

☐ 7. System of Awards Management (SAM) Attach a PDF screenshot to show proof of registration, or of SAM documentation. Instructions for registering are provided in this Attachment, “SAM.GOV Registration Steps”)If using Grant funds.

CERTIFICATE OF AUTHORITY

CORPORATION CERTIFICATE OF AUTHORITY

I, , Corporate Secretary of (name of corporate secretary)

, a

(complete name of corporation) (state of incorporation) corporation (the “Corporation”), DO HEREBY CERTIFY that the (non-profit or for profit) following is a true and correct excerpt from the minutes of the meeting of the Board of Directors duly called and held on , and that the same is now in full force and effect:

(date of meeting)

“RESOLVED, that the Chairman, the President, each Vice President, the Treasurer, and the Secretary and each of them, is authorized to execute and deliver, in the name of and on behalf of the Corporation and under its corporate seal of otherwise, any agreement or other instrument or document (‘Contract’) in connection with any matter or transaction that shall have been duly approved; and the execution and delivery of any Contract by any of the aforementioned officers shall be conclusive evidence of such approval.”

FURTHER, I CERTIFY that is Chairman is President, is/are Vice President(s), is Treasurer, is Secretary, is Executive Director, and is .

FURTHER, I CERTIFY that any of the aforementioned officers or employees of the

Corporation are authorized to execute and commit the Corporation to the conditions, obligations, stipulations and undertakings contained in the foregoing Contract between the City and the above-referenced Corporation and that all necessary corporate approvals have been obtained in relationship thereto.

IN WITNESS THEREOF, I have set my hand this day of , 20 .

CORPORATE SEAL

(if any)

Corporation Secretary

PLEASE NOTE THAT THE PERSON WHO SIGNS THE CONTRACT ON BEHALF OF

YOUR CORPORATION MUST BE ONE OF THE INDIVIDUALS LISTED ABOVE AS

PERSON AUTHORIZED TO EXECUTE CONTRACTS IN THE NAME OF AND ON

BEHALF OF THE CORPORATION.

LIMITED LIABILITY COMPANY

I, , a Manager or Member of (name of manager)

, L.L.C, a limited liability company (the “Company”), DO HEREBY (name of company)

CERTIFY that I am a Manager or Member of the Company who has the authority to act as an agent of the Company in executing this Certificate of Authority. I further certify that the following individuals are Managers or Members of the Company who have the authority to execute and commit the Company to the conditions, obligations, stipulations and undertakings contained in the foregoing Contract between the City and the Company:

FURTHER, I CERTIFY that all necessary approvals by the Managers or Members of the Company have been obtained with respect to the execution of said Contract.

COMPANY SEAL

( if any )

Manager or Member

YOUR LIMITED LIABILITY COMPANY MUST BE ONE OF THE INDIVIDUALS

LISTED ABOVE AS A PERSON AUTHORIZED TO EXECUTE CONTRACTS IN THE

NAME OF AND ON BEHALF OF THE LIMITED LIABILITY COMPANY.

PARTNERSHIP

I, , A General Partner in , (name of general partner) a County, Partnership (“the Partnership”)

(county of registration) (state in which county lies)

DO HEREBY CERTIFY that I am a General Partner in the Partnership formulated pursuant to a Partnership Agreement dated , and that the following is a true and (date of meeting) correct excerpt from the minutes of the meeting of the General Partnership held on and that the same is now in full force and effect:

“RESOLVED, that each General Partner is authorized to execute and deliver, in the name and on behalf of the Partnership, any agreement or other instrument or document (‘Contract’) in connection with any matter or transaction that shall have been duly approved; and the execution and delivery of any Contract by a general partner shall be conclusive evidence of such approval.”

FURTHER, I CERTIFY that the following persons are General Partners:

FURTHER, I CERTIFY that any of the aforementioned General Partners of the Partnership are authorized to execute and commit the Partnership to the conditions, obligations, stipulations and undertakings contained in the foregoing Contract between the City and the above-referenced partnership that all necessary approvals have been obtained in relationship thereto.

CORPPORATE SEAL

General Partner

YOUR PARTNERSHIP MUST BE ONE OF THE INDIVIDUALS LISTED ABOVE AS A

PERSON AUTHORIZED TO EXECUTE CONTRACTS IN THE NAME OF AND ON

BEHALF OF THE PARTNERSHIP.

UNINCORPORATED ASSOCIATION

I, , Secretary of , (name of association secretary) an unincorporated association (the “Association”), DO HEREBY CERTIFY that the following is a true and correct excerpt from the minutes of the meeting of the Board of

Directors duly called and held on , and that the same is now in full (date of meeting)

Force and effect:

“RESOLVED, that the Chairman, the President, each Vice President, the Treasurer, and the Secretary and each of them, is authorized to execute and deliver, in the name of an on behalf of the Association and under its Association seal or otherwise, any agreement or other instrument or document (‘Contract”) in connection with any matter or transaction that shall have been duly approved; and the execution and delivery of any Contract by any of the aforementioned officers shall be conclusive evidence of such approval.”

FURTHER, I CERTIFY that is Chairman is President, is/are Vice President(s), is Treasurer, is Secretary, is Executive Director, and is .

FURTHER, I CERTIFY that any of the aforementioned officers of the Association are authorized to execute or guarantee and commit the Association to the conditions, obligations, stipulations, and undertakings contained in the foregoing Contract between the City and the above-referenced Association and that all necessary Association approvals have been obtained in relationship thereto.

CORPORATE SEAL

Association Secretary

PLEASE NOTE THAT THE PERSON WHO SIGNS THE CONTRACT ON

BEHALF OF YOUR ASSOCIATION MUST BE ONE OF THE INDIVIDUALS

LISTED ABOVE AS A PERSON AUTHORIZED TO EXECUTE CONTRACTS IN

THE NAME OF AND ON BEHALF OF THE ASSOCIATION.

AMENDMENT FORM

Project/ RFP No.:

Project Title:

The undersigned acknowledges receipt of the following amendments to the request for Proposal (RFP) document:

Amendment No. , Dated _ Company

Name:

Authorized Signature:

Name: (Print)

Title:

Date:

I. HIRING POLICY COMPLIANCE

SLAVERY ERA RECORDS AND INSURANCE, AND PRISON INDUSTRY

AND IMMIGRATION DETENTION SYSTEM RECORDS AND INTERESTS

DISCLOSURE. YOU MUST COMPLETE EACH ITEM (4,5, 6 AND 7).

II.

City of Detroit Office of Contracting and Procurement

CONSOLIDATED AFFIDAVITS

The following attestations must be provided to the City of Detroit as part of the contract approval process. Please fill out required information, attach required supplemental documents and have it notarized before uploading

I , being duly sworn, state that I am the of

, and that I have reviewed the hiring policies of this employer, I affirm that these policies are in compliance with the requirements of Chapter 17, Article V, Division 6 of the 2019 Detroit City Code, being Sections 17-5-261 through 17-5-266 thereof. I further affirm that this employer will not inquire or consider the criminal convictions of applicants for employment needed to fulfill the terms of any City contract that may result from the competitive procedure in connection with which this affidavit is submitted, until such times as the employer interviews the applicant or determines that the applicant is qualified.

In support of this affidavit, I HAVE ATTACHED A COPY OF THE APPLICATION that will be used to hire employees needed to fulfill the terms of any City contract that may result from the competitive procedure in connection with which this affidavit is submitted.

1. Name of Contractor:

2. Address of Contractor:

3. Name of Predecessor Entities (ifany):

4. Prior Affidavit Submission? No Yes, on:

(Date of prior submission)

5. Contractor was established in (year) and did not exist during the slavery era in the United

States, is not a successor in interest to any entity that existed during such time, and therefore has no relevant records to search, or any pertinent information to disclose.

OR

Contractor has searched its records and those of any predecessor entity, and has found no record that Contractor or any predecessor(s) made any investments in, or derived profits from, the slave industry or slave holder insurance policies.

Contractor has found records that Contractor or its predecessor(s) made investments in, or derived profits from, the slave industry or slave holder insurance policies. The nature of the investment, profits, or insurance policies, including the names of any slaves or slave holders, is disclosed in the attached document(s).

6. Contractor has searched its records and those of any and all predecessor entities, and has found no record that indicate Contractor or its predecessor(s) have used inmate labor, or have derived income directly from, or have had any investments in, the construction, operations, services or activities of prisons.

Contractor has found records that indicate Contractor or its predecessor(s) have used inmate labor, or have derived income directly from, or have had any investments in, the construction, operations, services or activities of prisons. The nature of the use of inmate labor, profits, or investments is disclosed in the attached document(s).

7. Contractor has searched its records and those of any and all predecessor entities, and has found no record that indicates Contractor or its predecessor(s) have derived any income directly from, or have had any investments in, the construction, operations, services, or activities of facilities in the United States that are used for the detention of persons who are not citizens or nationals of the United States.

Contractor has found records that indicate Contractor or its predecessor(s) have derived any income directly from, or have had any investments in, the construction, operations, services, or activities of facilities in the United States that are used for the detention of persons who are not citizens or nationals of the United States. The nature of the profits or investments is disclosed in the attached document(s).

I declare that the representations made in this Affidavit are accurate to the best of my knowledge and are based upon a diligent search of records in the Contractor’s possession or knowledge, and that all documentation attached to this Affidavit reflects full disclosure of all records that are required to be disclosed to the City of Detroit. I also acknowledge that any failure to conduct a diligent search, or to make a full and complete disclosure, shall render this contract voidable by the City of Detroit.

I, being a duly authorized representative of , (hereinafter “Contractor”), am hereby authorized to enter into a Covenant of Equal Opportunity, (hereinafter “Covenant”) with the City of Detroit, (“hereinafter” City); obligating the Contractor and all sub-contractors, not to discriminate against any employee or application for employment, training, education, or apprenticeship connected directly or indirectly with the performance of the contract, with respect to his/her hire, promotion, job, assignment, tenure, terms, conditions, or privileges of employment because of race, color, religious beliefs, public benefit status, national origin, age, marital status, disability, sex, sexual orientation, or gender identity or expression; except as otherwise exempted under Section 23-2-6 of the 2019 Detroit City Code.

Contractor will ensure that the City of Detroit Human Rights Department shall receive notification of all potential sub-contractors and a copy of their Covenant prior to the commencement of work on any City of Detroit contract. Contractor further agrees that the City of Detroit reserves the right to require additional information prior to, during, and at any time until after the Covenant is fully executed.

Furthermore, Contractor agrees that this Covenant is valid for the life of the contract and/or for a specified period of time as indicated below and that a breach of this Covenant shall be deemed a material breach of contract and be subject to damages pursuant to Section 23-4-11(e) of the 2019 Detroit City Code.

RFP/Contract No.: (if applicable)

City Charter Sec. 4-122: For purposes of conflicts of interest, the City shall require in all of its contractual agreements, including, but not limited to, leases, service and equipment agreements and including contract renewals, that the contractor provide a statement listing all political contributions and expenditures (“Statement of Political Contributions and Expenditures”), as defined by the Michigan Campaign Finance Act, MCL 169.201, et seq., made by the contractor, its affiliates, subsidiaries, principals, officers, owners, directors, agents or assigns to elective city officials within the previous four (4) years. Individuals shall also list any contributions or expenditures from their spouses.”

Instructions: In accordance with Sec. 4-122 of the 2012 Detroit City Charter, please provide the following information. If additional space is needed, please enter “see additional sheet(s)” on the last row and attach

III. COVENANT OF EQUAL OPPORTUNITY

IV. STATEMENT OF POLITICAL CONTRIBUTIONS AND EXPENDITURES

additional sheets.

In Column A, enter the name of the person or company that made the contribution or expenditure. If there were no political contributions or expenditures made, enter NONE.

In Column B, enter the relationship of the donor to the contractor or vendor, that is, contractor, affiliate, subsidiary, principal, officer, owner, director, agent, assignee, or spouse of any of the foregoing who are individuals.

In Column C, enter the name of the recipient, an elective city official which under Charter § 3-107, includes only the Mayor, the City Clerk, and members of the City Council and the Board of Police Commissioners.

In Column D, enter the amount of the contribution or expenditure, as defined in the Michigan Campaign Finance Act, 1976 PA 388, MCL 169.204 and MCL 169.206.

In Column E, enter the date of the contribution or expenditure. This statement must include all contributions and expenditures within the previous four years.

A B C D E

Donor

Relationship to Contractor/Vendor

Recipient

Amount of Contribution or Expenditure

Date

Except as set forth above, I certify that no contributions or expenditures were made to elective city officials within the previous four (4) years by the contractor, its affiliates, subsidiaries, principals, officers, owners, directors, agents, assigns, and, if any of the foregoing are individuals, their spouses.

SIGNATURES AND ACKNOWLEDGEMENT:

I understand that the information provided in this consolidated affidavit will be relied upon by the City of Detroit in awarding the proposed bid, solicitation, contract, or lease. I swear or affirm that I have read this document, that I the authority to provide these disclosures and to bind the Contractor, and that the information provided herein is accurate. I have attached all required supplemental documents.

Sign name:

Print name:

Title:

STATE OF MICHIGAN

COUNTY

Sworn and subscribed to before me on ,20 , by , Date Name the of .

Title Contractor

Sign:

Print:

Notary Public, County, Michigan

Acting in County

My Commission Expires:

Sample Employment Application

Income and Revenue Tax Clearance

Three (3) Years Financial Information

System of Awards Management

Required Documentation

Attach a copy of a sample employment application attesting that the employer will not inquire or consider the criminal convictions of applicants for employment needed to fulfill the terms of any City contract

Approved clearances are not required to submit a response to the RFP but will be required of the successful respondent prior to City Council approval. Submit requests for clearances electronically via a link in the bid response Requirement Section in the Supplier Portal. Attach evidence showing you have submitted or received clearances.

Attach your organization’s financial statements (Balance Sheets, Income Statements and Statement of Cash Flows) for the previous three (3) years. Please do not submit your tax returns.

Attach a PDF screenshot to show proof of registration, or of SAM documentation.(grant funds only).

Please use the below URL to complete the Income Tax and Account Receivables Clearance process:

http://bit.ly/detroitclearances