_6 SRTA_27_001_Offer Documents (002).pdf

OFFER DOCUMENT #1 - COMPLETE PROPOSAL CHECKLIST

SRTA Solicitation No. 27-001

The undersigned certifies that all of the Offer Documents listed below have been fully, completed, properly signed, arranged in the proper order, and submitted with this proposal in response to SRTA Solicitation No. 27-001.

Offer Document #1 - Complete Proposal Checklist Offer Document #2 - Proposal Letter Offer Document #3 - Acknowledgement of Addenda to RFQ Offer Document #4 - Proposer Information Form Offer Document #5 - Proposer Certifications Offer Document #6 - Statement of Qualifications Offer Document #7 - Contractor Affidavit under O.C.G.A. 13-10-91(b)(1) Offer Document #8 - Subcontractor Affidavit Offer Document #9 - Subcontractor and DBE Listing Form Offer Document #10 - Certification Regarding Debarment and Suspension Offer Document #11 - Certification Regarding Lobbying Offer Document #12 - Non-Collusion Affidavit Offer Document #13 - Anti-Boycott, Divestment and Sanctions Against Israel Offer Document #14 - Statement of Responsibility Certification Offer Document #15 - Sales and Use Tax Compliance Form Offer Document #16 - Litigation History Offer Document #17 - Termination for Failure to Complete Offer Document #18 - Financial History

Company Name

Authorized Representative Name

Title Date

Authorized Representative Signature

OFFER DOCUMENT #2 - PROPOSAL LETTER

In response to SRTA Solicitation No. 27-001, the undersigned ("Proposer") hereby proposes to furnish to SRTA the necessary materials, labor, equipment, and supervision and to perform operations, duties, and obligations necessary to complete the Services required by the Contract Documents.

By submitting this proposal, Proposer agrees that all information received by SRTA from Proposer, as a result of this Request for Qualifications and subsequent thereto, shall become the property of SRTA, to be used and disclosed at its sole discretion without further obligation to Proposer, copyright or other restrictive legend notwithstanding.

SRTA reserves the right to reject any and all proposals. No obligation, either expressed or implied, exists on the part of SRTA to make a contract award or for the cost incurred by Proposer in the preparation of the proposal.

Proposer certifies that it has examined and fully understands all of the provisions of the Request for Qualifications (RFQ) and is satisfied that they are accurate; that it has carefully checked all numbers and statements made in this proposal; that it has satisfied itself with respect to the actual site conditions, nature and location of the engagement; the general and local conditions to be encountered in the performance of the contract; and other matters which in any way may affect the contract or the cost thereof. Proposer hereby agrees that SRTA will not be responsible for any errors or omissions in the proposal.

Proposer certifies that it is able to sign and comply with all provisions of the Contract that is attached as Part of this RFQ without any changes. The undersigned hereby certifies that he/she is authorized to bind Proposer to this proposal and to a contract resulting therefrom.

Attached hereto and made a part of this proposal are the required proposal data and all other information which Proposer desires to be considered as part of this proposal. Proposer acknowledges that SRTA, at its option, may incorporate any of the information submitted by Proposer into a resulting contract.

Proposer acknowledges receipt of all addenda to this RFQ.

OFFER DOCUMENT #3 - ACKNOWLEDGEMENT OF ADDENDA TO

SRTA Solicitation No. 27-001

The undersigned acknowledges either receipt of the following addenda to SRTA Solicitation No. 27-001 or acknowledges that no addenda were issued:

Addendum No. Dated

Addendum No.

OR

Dated

No addenda were issued to SRTA Solicitation No. 27-001.

OFFER DOCUMENT #4 - PROPOSER INFORMATION FORM

Contractor must provide all of the information requested below:

Legal Name

Mailing Address

Physical Address (if different from above)

Phone # Fax #

Website Address

Title

Email Address

Atlanta-Based Contact Name

Proposer is a (choose one):

Corporation State of Incorporation

Partnership Sole Proprietorship Joint Venture (attach names)

Proposer is a (choose one):

Not a Certified Disadvantaged Business Enterprise (DBE)

Certified Disadvantaged Business Enterprise (DBE)

Certifying Agency

Provide the following information for three (3) project references for which Proposer has provided products and services of similar scope and cost in the last five (5) years:

Reference #1

Name

Address

Contact Person

Phone # Fax #

Email Address

Total Contract Amount

Date of Contract Completion

Georgia

Reference #2

Name

Address

Contact Person

Total Contract Amount

Reference #3

Name

Address

Contact Person

Total Contract Amount

If Proposer is a wholly-owned subsidiary of a parent company, provide the legal name and form of the parent company.

The undersigned certifies that the information provided above is true and correct.

OFFER DOCUMENT #5

PROPOSER CERTIFICATIONS

This document must be fully completed, signed by an authorized representative of the Proposer, notarized and submitted with the Proposer's technical proposal.

1. I certify that, if awarded a contract, the Proposer will deliver goods and services which will meet or exceed the specifications set forth in this RFQ, the Proposal and the terms of the final contract between the Proposer and SRTA.

2. I certify on behalf of the Proposer that this Proposer is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a proposal for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud. I understand that collusive behavior surrounding formal solicitations is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards. I agree to abide by all conditions of the Proposal and certify that I am authorized to sign this Proposal for the Proposer.

3. I certify that the Proposer has not violated and will not violate the provisions of the Official Code of

Georgia Annotated, Section 45-10-20 et. seq.

4. I certify that this Proposal is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a Proposal for the same materials, supplies, services, or equipment and is in all respects fair and without collusion or fraud. I understand collusive behavior surrounding formal solicitations is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards. I agree to abide by all conditions of this RFQ and certify that I am authorized to sign this Proposal for the Proposer.

Authorized Representative's Name

Authorized Representative's Signature

Date

OFFER DOCUMENT #7 - E-VERIFY AFFIDAVIT

By executing this affidavit, the undersigned Proposer verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in in the physical performance of services on behalf of the State Road & Tollway Authority has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number

Date of Authorization

Name of Proposer

Name of Project

Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , , 2026 in (city) , (state) .

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF 2026.

NOTARY PUBLIC

My Commission Expires:

OFFER DOCUMENT #8 – Subcontractor Affidavit SRTA Solicitation #27-001

Subcontractor Affidavit under O.C.G.A. § 13-10-91(b)(3)

By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with (name of prime contractor) on behalf of SRTA has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned subcontractor will contract for the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the subcontractor with the information required by O.C.G.A.

§ 13-10-91(b). Additionally, the undersigned subcontractor will forward notice of the receipt of an affidavit from a sub-subcontractor to the contractor within five business days of receipt. If the undersigned subcontractor receives notice that a sub-subcontractor has received an affidavit from any other contracted sub-subcontractor, the undersigned subcontractor must forward, within five business days of receipt, a copy of the notice to the contractor. Subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number

Date of Authorization

Name of Subcontractor

Name of Project

Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , , 20 in (city), _ (state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE DAY OF , 2026.

NOTARY PUBLIC

OFFER DOCUMENT #9 - SUBCONTRACTORS AND DBEs

This document must be fully completed, signed by an authorized representative of the Contractor, notarized, and submitted with the technical proposal.

Subcontractor Name, Address, Description of and Phone# Subcontractor's Role

% of Contract

DBE?

(Y/N)

1 I II ICJ□

2 I 11 II�□

3 I 11 ICJ□

4 I I !CJD

OR

D No subcontractors or DBEs

Is the prime contractor a DBE? □ Yes □ No

Authorized Representative Name

OFFER DOCUMENT #10 - CERTIFICATION REGARDING SUSPENSION

AND DEBARMENT SRTA Solicitation No. 27-001

1. By signing and submitting this bid or proposal, the Proposer is providing the signed certification set out below.

2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the bidder or proposer knowingly rendered an erroneous certification, in addition to remedies available to SRTA, the Federal Government may pursue available remedies, including but not limited to suspension and/ or debarment.

3. The Proposer shall provide immediate written notice to SRTA if at any time the Proposer learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms “covered transaction,” “debarred,” “suspended,” “ineligible,” “lower tier covered transaction,” “participant,” “persons,” “primary covered transaction,” “principal,” “proposal,” and “voluntarily excluded,” as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549 [49 CFR Part 29].

5. The Proposer agrees by submitting this proposal that, should the proposed transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR Part 9, Subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized in writing by ATL.

6. The Proposer further agrees by submitting this proposal that it will include the clause titled “Debarment and Suspension Certification Requirements” and the certificate form without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely upon a certification of a prospective participate in a lower tier covered transaction that is not proposed for debarment under 48 CFR Part 9, Subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Excluded Parties List issued by U.S. General Service Administration.

8. Nothing contained in the forgoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

9. Except for transactions authorized under Paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR Part 9, Subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from participation in this transaction, in addition to remedies available to SRTA, the Federal Government may pursue available remedies, including but not limited to suspension and/or debarment.

The prospective lower tier participant (Proposer) certifies, by submission of this Offer, that neither it nor its “principals” as defined by 49 CFR § 29.105(p) is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

If the prospective lower tier participant (Proposer) is unable to certify to the statement above, it shall attach an explanation, and indicate that it has done so, by placing an “X” in the following space .

(name of company) certifies or affirms the truthfulness and accuracy of each statement of its certification and explanation, if any. in addition, the bidder or offeror understands and agrees that the provisions of 31 U.S.C. §§ 3801 et seq. apply to this certification and explanation, if any.

Name of Authorized Representative

Title of Authorized Representative

Signature of Authorized Representative

Certification Regarding Lobbying - Page 1

OFFER DOCUMENT NO. 11 - CERTIFICATION REGARDING LOBBYING

SRTA Solicitation No. 27-001

APPENDIX A, 49 CFR PART 20--CERTIFICATION REGARDING LOBBYING

Certification for Contracts, Grants, Loans, and Cooperative Agreements

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 any 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 any 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). Note: Language in paragraph (2) herein has been modified in accordance with Section 10 of the Lobbying Disclosure Act of 1995 (P.L. 104-65, to be codified at 2 U.S.C.

1601, et seq.)]

(3) The undersigned shall require that the language of this certification be included in the award documents for all sub awards at all tiers (including subcontracts, sub grants, and contracts under grants, loans, and cooperative agreements) and that all sub recipients 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 imposed 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.

[Note: Pursuant to 31 U.S.C. § 1352(c)(1)-(2)(A), any person who makes a prohibited expenditure or fails to file or amend a required certification or disclosure form shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such expenditure or failure.]

Certification Regarding Lobbying - Page 2

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

Company Name

Authorized Representative Name

OFFER DOCUMENT #12

Non-Collusion Affidavit

SRTA Solicitation No. 27-001

Now here appeared before the undersigned officer duly authorized by the State of Georgia to administer oaths (Authorized Company Representative) and after being first duly sworn, depose and say that, they are all the officers, agents, persons or employees who have acted for (Company Name) on the State Road and Tollway Authority proposal 27-001, and that said Representative has not by (himself, themselves) or through any persons, officers, agents or employees prevented or attempted to prevent by any means whatsoever, competition in such solicitation, or by any means whatever prevented or endeavored to prevent anyone from making a proposal therefore, or induced or attempted to induce another to withdraw proposal from said work.

Signature of Affiant

Name of Affiant

Title of Affiant

Sworn to and subscribed to me this day of , 20 .

Notary Public

(Seal)

Note: See O.C.G.A. § 36-91-27(e)

OFFER DOCUMENT #13

Certification of No Boycott of Israel

SRTA Solicitation No. 27-001

Contractor/Vendor certifies and verifies that it: (i) does not boycott Israel and (ii) will not boycott Israel during the Term of this Agreement.

Form requirements:

• This certification is required by O.C.G.A. § 50-5-85.

• This form is required to be attached to all Contracts (services), regardless of whether Contract requires the creation of a Purchase Order.

Pursuant to O.C.G.A. §50-5-85, the state shall not enter into a contract with a total value of $1,000 or greater with an individual or company if the contract is related to construction or the provision of services, supplies, or information technology unless the contract includes a written certification that such individual or company is not currently engaged in, and agrees for the duration of the contract not to engage in, a boycott of Israel.

Vendor/Contractor Name or Company Name

Street Address

City

State

Zip Code

Phone Number

Printed Name of Authorized Representative Title of Authorized Representative Signature of Authorized Representative

OFFER DOCUMENT #14

STATEMENT OF RESPONSIBILITY

CERTIFICATION

A responsible proposer is one that SRTA believes to be responsible based on responses provided in the Contractor's proposal and/or based on Contractor's responses to the requirements of the solicitation document. Responsibility shall generally be presumed. In order for a Contractor to be deemed non-responsible, SRTA must make an affirmative determination of non-responsibility. SRTA reserves the right to conduct additional due diligence into any Contractor's responsibility status.

Such due diligence may include investigations into one or more of the following areas:

1. Whether Contractor has adequate financial resources to perform the contract, or the ability to obtain them.

This includes, but is not limited to, the ability to obtain required bonds (if any) and insurance from sureties and insurance companies authorized to do business in Georgia.

2. Whether Contractor is able to comply with the contract requirements, considering the Contractor's other business obligations.

3. Whether Contractor is registered to do business in the State of Georgia and is listed as "ACTIVE/ COMPLIANCE" with the Office of the Georgia Secretary of State.

4. Whether Contractor is not presently debarred or suspended from bidding by any Federal or State governmental entity;

5. Whether Contractor has within a three year period preceding this proposal has 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 antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

6. Whether Contractor is presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated above.

7. Whether Contractor has had a contract terminated for default in the last 3 years.

8. Whether Contractor is currently under investigation for any possible breach of contract, or fraud or allegations of criminal activity related to the types of Services requested within this solicitation document.

(And if yes, the circumstances, nature and magnitude of such investigation shall be considered in any possible non-responsibility determination).

9. Whether Contractor has a satisfactory performance record.

10. Whether Contractor has a satisfactory record of integrity and business ethics.

11. Whether Contractor has satisfactory organization, experience, accounting and operational controls, and managerial and technical skills.

Statement of Responsibility Certification Continued

Instructions:

THIS FORM MUST BE COMPLETED, SIGNED, NOTARIZED AND SUBMITTED WITH YOUR BID/

PROPOSAL.

Please complete this form, answering every question. A “Yes” answer to any of the subparts of QUESTION NO. 3 requires a written explanation attached to the completed form, submitted on your company letterhead and signed by an authorized representative of the company. A “Yes” answer to any of the subparts of Question No. 3 will not necessarily result in denial of award, but will be considered in determining Contractor responsibility in the event SRTA undertakes an investigation into Firm's responsibility status. For any explanation, indicate to whom it applies; identify the initiating agency and the dates of action.

Contractors are responsible for updating any information submitted in their Statement of Responsibility Certification Form if a change occurs prior to the award of the contract.

Questions:

1. Does the Contractor certify that it has, or has the ability to obtain, adequate financial resources to perform the Services identified in the Agreement? This includes, but is not limited to, the ability to obtain required bonds (if applicable) and insurance from sureties and insurance companies authorized to do business in Georgia.

Yes No

2. Does the Contractor certify that it is able to comply with all contractual requirements and fulfill all of its contractual obligations, considering Offeror's other business obligations?

3. Within the past three (3) years, has Contractor, or any principal of the Contractor (e.g., any owner, partner, officer, or major stockholder with 10% or more shares) been the subject of any of the following:

(a) a judgment or conviction for any conduct constituting a felony under local, state or federal law, including, but not limited to, fraud, extortion, bribery, racketeering, labor, anti-trust, price-fixing, or bid collusion?

(b) a criminal investigation or indictment for any conduct constituting a felony under local, state or federal law, including, but not limited to, fraud, extortion, bribery, racketeering, price-fixing, or bid collusion (to the best of Firm's knowledge*)?

(c) an unsatisfied judgment, injunction or lien obtained by a Georgia state government agency including, but not limited to, judgments based on taxes owed and fines and penalties assessed by any Georgia state government agency?

(d) an investigation for a civil violation by any local, state or federal agency (to the best of Offeror's knowledge*)?

(e) a suspension, debarment or termination for cause from any local, state or federal government procurement process?

(f) a suspension or termination for cause prior to the completion of the term of any local, state or federal government contract?

(g) a denial of award for non-responsibility determination made by any local, state or federal government?

(h) an agreement to a voluntary exclusion from bidding/contracting on any local, state or federal procurement?

(i) an administrative proceeding or civil action seeking specific performance or restitution in connection with any local, state or federal procurement (to the best of Firm's knowledge*)?

(j) any bankruptcy proceeding?

(Company Representative Initials) I further certify that in regards to Audit and Accounting System requirements, that the submitting firm 1) has an accounting system in place to meet requirements of 48 CFR Part 31, and in the case of non-profit organizations, OMB Circular A-122; 2) has submitted its yearly CPA overhead audit if it currently has an aggregate contract amount over $250,000; has no significant outstanding deficient audit findings from SRTA or GDOT that have not been resolved;

and is reasonably assured that all sub-consultant(s) presented as part of the proposed team are similarly in compliance with the aforementioned requirements.

The undersigned: (i) recognizes that this questionnaire is submitted for the express purpose of assisting the State Road and Tollway Authority (SRTA) to make a determination regarding the eligibility for award of a contract, or to approve a subcontract;

(ii) acknowledges that SRTA, the State of Georgia, its agencies and political subdivisions may, in their sole discretion, by means which they may choose, verify the truth and accuracy of all statements made herein; (iii) acknowledges that submissions of false or misleading information may constitute fraud, may result in ineligibility for contract award, may be used as grounds for termination for default of any contract awarded in relation to this certification, may be considered by SRTA, the State of Georgia, its agencies and political subdivisions in making responsibility determinations in other procurements, and may subject the Contractor or its representatives to criminal liability; (iv) as the authorized representative of the Firm, states that the information submitted on this certification form and any attached pages is true, accurate and complete.

The undersigned hereby attests that he/she is duly authorized by the Firm to make the statements and representations contained herein and/or attached hereto, on behalf of such Firm.

Legal Name of Firm/Company

Firm/Company Street Address

City, State, Zip

Signature of Offeror's Authorized Representative

State Of County of

Sworn to and subscribed before me on this: Date

Notary Public Signature Field

Note: *As used herein, the term “to the best of Contractor's knowledge” shall refer to the current actual knowledge of Contractor and shall be construed, by imputation or otherwise, to refer to the knowledge of any agent, manager, representative or employee of Contractor but does not impose upon Contractor any duty of inquiry or investigation of the matter to which such actual knowledge, or the absence thereof, pertains. The fact that Contractors (or their principals) are under investigation will not necessarily result in a determination of non-responsibility; rather, SRTA will determine if the information and circumstances regarding such investigation are of such a nature or magnitude as to cause SRTA to deem the Contractor non-responsible in order to protect the interests of SRTA and/or the State.

Revised: 12/22/2010 SPD-SP045

Offer Document #15 Sales and Use Tax Compliance Form

TAX COMPLIANCE

INSTRUCTIONS TO SUPPLIERS

Please complete the following information:

• Supplier’s Name:

• Physical Location Address:

• Federal Identification Number (FEI):

• Have you ever been registered in the State of Georgia?

• If so, please provide the following information, if applicable:

o State Taxpayer Identification Number (STI):

o Sales and Use Tax Number:

o Withholding Tax Number:

• What type of service will you perform?

• Will you sell any tangible personal property or goods?

• Supplier’s Affiliate’s Name:

o FEI:

o STI:

o Sales and Use Tax Number:

o Withholding Tax Number:

If there is more than one affiliate, please attach a separate sheet listing the information above.

• Person responsible for handling supplier’s tax issues (such as the CFO, the company tax officer, etc.):

o Name:

o Telephone Number:

o E-mail Address:

NOTICE TO SUPPLIER:

In the event the supplier is considered for contract award, the information provided in the form will be submitted by the State Entity to the Georgia Department of Revenue (“DOR”) for a determination as to whether the supplier is a “prohibited source” (as defined by O.C.G.A. §50-5-82) or whether there are any other outstanding tax issues. MISSING, INCOMPLETE, OR ERRONEOUS DATA MAY

DELAY OR PROHIBIT VERIFICATION OF YOUR ELIGIBILITY FOR CONTRACT AWARD.

NO PROHIBITED SOURCE MAY RECEIVE CONTRACT AWARD; THEREFORE, YOU ARE

STRONGLY ENCOURAGED TO CHECK YOUR TAX STATUS NOW AND RESOLVE ANY

OUTSTANDING TAX LIABILITIES AND/OR MISSING TAX RETURNS.

STATE ENTITY: Please submit this form via email to DOR at tsd-state-contractors@dor.ga.gov for processing in accordance with the Georgia Procurement Manual.

mailto:tsd-state-contractors@dor.ga.gov