7-CIZ25-TRN-3193 - EXHIBIT A - City Forms.pdf

EXHIBIT A

REQUIRED FORMS

PROPOSAL FORMS REQUIRED FOR BID SUBMISSION

(ALL HANDWRITING MUST BE NEAT AND LEGIBLE)

Contractor's MUST submit their completed and signed BID Sheet along with Forms 1 through 9 and Form 1-0001. Incomplete submittal packages may cause the contractor's BID submittal to be rejected as nonresponsive. ALL addendums published through the life of the open procurement must also be signed and submitted as part of the BID package.

• BID Tabs (completed and MUST be signed (excel and PDF version available)

• Time of Completion (completed and MUST be signed)

• Bid Bond – Form 1

• Cashier’s Check or attached Bid Bond, payable to the City of Dallas in an amount not less than 5% of the total Bid submitted must accompany the Bid.

City reserves the right to reject any or all Bids.

• NOTE: Using another Form of Bid Bond other than the one included in these Specifications may result in rejection of your Bid.

• Form 1295

• Conflict of Interest Form – Form 2

• Non-Collusion Affidavit – Form 3

• Disclosure of Lobbying Activities – Form 4

• Prohibition on Contracts with Companies Boycotting Israel & Prohibition on Contracts with Foreign

Terrorist Organizations – Acknowledgement – Form 1-0001

• Bidder’s Safety Affidavit – Form 5

• Environmental Record Affidavit – Form 6

• Cement Certification – Form 7

• Statement of Insurability Form – Form 8

• Suspension/Debarment Certification Form - Form 9

The Following Forms are Required Upon Request for Contract Award

• Sample Civil Construction Services Contract – Form 10

• Davis-Bacon Wage Rates – Form 11

• Sample Performance Bond – Form 12

• Sample Payment Bond – Form 13

• Street Excavation Data Form – Form 14

• Concrete/Cement Delivery Certification – Form 15

• Inspection Overtime Request Form – Form 16

• Sample Certificate of Insurance (COI) – Form 17

• Invoice Example - Form 18

• Affidavit Statement of Partial Payment and Release Rights - Form 19

• Contractor's Affidavit of Final Payment and Release - Form 20

• Quantity Verification Sheet - Form 21

• OPS-BID-FRM-640 - Team Make-Up and Local Workforce

*Please note, failure to submit a BID Bond, on the City's provided BID Bond form (Form 1) or the appropriate allowed alternative (see note under BID Bond above), WILL result in the rejection of bid as per NCTCOG Standard Specifications 5th Edition - 2021 Addendum.

ITEM NO. DESCRIPTION UNIT EST. QTY BID PRICE BID TOTAL

1 MOBILIZATION (MINIMUM LUMP SUM PER WORK ORDER)

(SEE ITEM 1 IN SPECIFICATIONS)

LS 1 $ -

2 PROCUREMENT AND INSTALLATION OF BASE-MOUNTED CONTROLLER CABINET

AND CONTROLLER

EA 3 $ -

5 PROCUREMENT AND INSTALLATION OF TRAFFIC SIGNAL HEAD EA 37 $ -

6 PROCUREMENT AND INSTALLATION OF SINGLE SECTION TRAFFIC SIGNAL

HEAD

EA 17 $ -

10 PROCUREMENT AND INSTALLATION OF PEDESTRIAN SIGNAL HEAD EA 20 $ -

14 PROCUREMENT AND INSTALLATION OF ACCESSIBLE PEDESTRIAN SIGNAL UNIT EA 20 $ -

A. PROCUREMENT AND INSTALLATION OF ACCESSIBLE PEDESTRIAN SIGNAL

CABINET CONSOLE

EA 3 $ -

19 PROCUREMENT AND INSTALLATION OF TXDOT DALLAS STYLE MAST ARM

SIGNAL POLE ASSEMBLY (SMA, 20' TO 32')

A. GALVANIZED WITH LUMINAIRE EXTENSION EA 3 $ -

20 PROCUREMENT AND INSTALLATION OF TXDOT DALLAS STYLE MAST ARM

SIGNAL POLE ASSEMBLY (SMA, 36' TO 48')

A. GALVANIZED WITH LUMINAIRE EXTENSION EA 6 $ -

B. GALVANIZED, NO LUMINIARE EXTENSION EA 1 $ -

22 PROCUREMENT AND INSTALLATION OF TXDOT DALLAS STYLE CLAMP ARM

FOR SMA (DMA, 20' TO 36')

A. GALVANIZED EA 1 $ -

24 PROCUREMENT AND INSTALLATION OF PEDESTAL SIGNAL POLE .

A. ALUMINUM, TYPE I, 15 FOOT EA 7 $ -

DEPARTMENT OF TRANSPORTATION

TRANSPORTATION OPERATIONS DIVISION

Bid Sheet

CIZ25-TRN-3193 – Traffic Signal Construction – Augsut 2025 - Ferndale Rd at Walnut Hill Ln, Hampton Rd at Leath St, Masters Dr (N) at Old Segoville Rd

DEPARTMENT OF TRANSPORTATION

TRANSPORTATION OPERATIONS DIVISION

Bid Sheet

CIZ25-TRN-3193 – Traffic Signal Construction – Augsut 2025 - Ferndale Rd at Walnut Hill Ln, Hampton Rd at Leath St, Masters Dr (N) at Old Segoville Rd

C. ALUMINUM, TYPE II, 10 FOOT EA 1 $ -

25 PROCUREMENT AND INSTALLATION OF DAMPING PLATE ON MAST ARM EA 11 $ -

34 INSTALLATION OF TXDOT DALLAS DISTRICT STYLE TRAFFIC SIGNAL

FOUNDATION

A. TYPE 24A LF 48 $ -

B. TYPE 30-A LF 33 $ -

C. TYPE 36-A LF 78 $ -

D. TYPE 36-B LF 16 $ -

36 INSTALLATION OF BASE MOUNTED TRAFFIC SIGNAL CONTROLLER CABINET

FOUNDATION

EA 3 $ -

37 PROCUREMENT AND INSTALLATION OF RIGID METAL CONDUIT .

C. 2 INCH LF 10 $ -

38 PROCUREMENT AND INSTALLATION OF PVC CONDUIT (BORED OR TRENCHED) .

A. 2 INCH (TRENCHED) LF 234 $ -

B. 2 INCH (BORED) LF 217 $ -

C. 3 INCH (TRENCHED) LF 307 $ -

D. 3 INCH (BORED) LF 1230 $ -

E. 4 INCH (TRENCHED) LF 1536 $ -

TRANSPORTATION OPERATIONS DIVISION

Bid Sheet

CIZ25-TRN-3193 – Traffic Signal Construction – Augsut 2025 - Ferndale Rd at Walnut Hill Ln, Hampton Rd at Leath St, Masters Dr (N) at Old Segoville Rd

F. 4 INCH (BORED) LF 1220 $ -

41 PROCUREMENT AND INSTALLATION OF ELECTRICAL POWER SERVICE WITH

INSPECTION PERMIT OBTAINED BY VENDOR

B. PEDESTAL SERVICE EA 3 $ -

43 PROCUREMENT AND INSTALLATION OF GROUND BOX .

A. SMALL GROUND BOX (12X12X12) EA 2 $ -

C. LARGE GROUND BOX (16X28X18) EA 16 $ -

44 PROCUREMENT AND INSTALLATION OF MULTICONDUCTOR SIGNAL CABLE .

A. 2 CONDUCTOR LF 2791 $ -

D. 12 CONDUCTOR LF 1253 $ -

G. 25 CONDUCTOR LF 1166 $ -

45 PROCUREMENT AND INSTALLATION OF ELECTRICAL POWER WIRE LF 4227 $ -

46 PROCUREMENT AND INSTALLATION OF MULTICONDUCTOR VEHICLE DETECTOR

OR COMMUNICATION CABLE

A. RADAR DETECTOR CABLE LF 1931 $ -

C. CAT5E ETHERNET CABLE LF 363 $ -

PROCUREMENT AND INSTALLATION OF RADAR DETECTION CABINET CONTROL

UNIT (5 OR 6 SENSORS) EA 3 $ -

53 PROCUREMENT AND INSTALLATION OF RADAR VEHICLE PRESENCE DETECTOR EA 11 $ -

TRANSPORTATION OPERATIONS DIVISION

Bid Sheet

CIZ25-TRN-3193 – Traffic Signal Construction – Augsut 2025 - Ferndale Rd at Walnut Hill Ln, Hampton Rd at Leath St, Masters Dr (N) at Old Segoville Rd

54 PROCUREMENT AND INSTALLATION OF RADAR VEHICLE ADVANCE DETECTOR EA 6 $ -

60 INSTALLATION OF TRAFFIC SIGN .

A. TRAFFIC SIGNAL MOUNTED EA 23 $ -

C. GROUND MOUNTED ON CITY-PROVIDED SIGN POST EA 19 $ -

61 INSTALLATION OF CONCRETE SIDEWALK SY 146 $ -

62 INSTALLATION OF BARRIER FREE SIDEWALK RAMP SY 271 $ -

64 INSTALLATION OF CONCRETE CURB (6") LF 730 $ -

65 INSTALLATION OF CONCRETE CURB AND GUTTER (6") LF 12 $ -

66 INSTALLATION OF CONTINUOUSLY REINFORCED RIGID PAVEMENT NOT TO

EXCEED 10-INCHES IN DEPTH

SY 977 $ -

67 INSTALLATION OF CONTINUOUSLY REINFORCED RIGID PAVEMENT GREATER T SF 82 $ -

74 PROCUREMENT AND INSTALLATION OF ROADWAY LUMINAIRE (LED) .

A. STANDARD COBRA HEAD LUMINAIRE EA 9 $ -

75 PROCUREMENT AND INSTALLATION OF 4-INCH REFLECTORIZED PAVEMENT

MARKER

EA 281 $ -

76 PROCUREMENT AND INSTALLATION OF 4-INCH THERMOPLASTIC PAVEMENT

MARKING

A. WHITE LF 1511 $ -

B. YELLOW LF 1366 $ -

TRANSPORTATION OPERATIONS DIVISION

Bid Sheet

CIZ25-TRN-3193 – Traffic Signal Construction – Augsut 2025 - Ferndale Rd at Walnut Hill Ln, Hampton Rd at Leath St, Masters Dr (N) at Old Segoville Rd

77 PROCUREMENT AND INSTALLATION OF 6-INCH THERMOPLASTIC PAVEMENT

MARKING

A. WHITE LF 1933 $ -

79 PROCUREMENT AND INSTALLATION OF 12-INCH THERMOPLASTIC

PAVEMENT MARKING

A. WHITE LF 496 $ -

80 PROCUREMENT AND INSTALLATION OF 18-INCH THERMOPLASTIC PAVEMENT

MARKING

A. WHITE LF 335 $ -

81 PROCUREMENT AND INSTALLATION OF 24-INCH THERMOPLASTIC PAVEMENT

MARKING

A. WHITE LF 1142 $ -

82 PROCUREMENT AND INSTALLATION OF WHITE THERMOPLASTIC FOR

PAVEMENT LEGEND MARKING

SF 199 $ -

84 REMOVAL OF CONTROLLER CABINET EA 2 $ -

85 REMOVAL OF CONTROLLER CABINET FOUNDATION EA 2 $ -

86 REMOVAL OF PULL BOX EA 5 $ -

89 REMOVAL OF TRAFFIC SIGNAL POLE FOUNDATION - PARTIAL EA 6 $ -

90 REMOVAL OF TRAFFIC SIGNAL POLE FOUNDATION - COMPLETE .

A. MAST ARM FOUNDATION, 36" DIAMETER OR LESS EA 6 $ -

91 REMOVAL OF MAST ARM POLE ASSEMBLY EA 8 $ -

TRANSPORTATION OPERATIONS DIVISION

Bid Sheet

CIZ25-TRN-3193 – Traffic Signal Construction – Augsut 2025 - Ferndale Rd at Walnut Hill Ln, Hampton Rd at Leath St, Masters Dr (N) at Old Segoville Rd

93 REMOVAL OF PEDESTAL TRAFFIC SIGNAL POLE EA 2 $ -

94 REMOVAL OF VEHICULAR OR PEDESTRIAN TRAFFIC SIGNAL HEAD EA 32 $ -

96 REMOVAL OF PEDESTRIAN PUSH BUTTON EA 4 $ -

97 REMOVAL OF TRAFFIC SIGN EA 16 $ -

101 REMOVAL OF PRESSURE PAD DETECTOR EA 2 $ -

102 REMOVAL OF RIGID PAVEMENT SY 219 $ -

103 REMOVAL OF CONCRETE SIDEWALK SY 469 $ -

TRANSPORTATION OPERATIONS DIVISION

Bid Sheet

CIZ25-TRN-3193 – Traffic Signal Construction – Augsut 2025 - Ferndale Rd at Walnut Hill Ln, Hampton Rd at Leath St, Masters Dr (N) at Old Segoville Rd

104 REMOVAL OF CONCRETE CURB (6") LF 265 $ -

105 REMOVAL OF CONCRETE CURB AND GUTTER (6") LF 549 $ -

109 REMOVAL OF RAISED REFLECTORIZED MARKER AND CERAMIC BUTTON EA 17 $ -

111 REMOVAL OF PAVEMENT MARKING LINE LF 4269 $ -

142 PROCURE AND INSTALL TRAFFIC MONITORING SYSTEM EA 3 $ -

0100-7010 PREP ROW (TREE PRUNE AND TRIM) STA 0.3 $ -

0112-7001 SUBGR WIDEN (OC) STA 1.58 $ -

0160-7001 FURN & PLACE TOPSOIL (3") CY 5 $ -

0247-7067 FL BS (CMP IN PLC)(TY A GR 1-2)(8") SY 226 $ -

0260-7017 LIME TRT (NEW BASE)(12") SY 226 $ -

0416-7043 DRILL SHAFT (RDWY ILL POLE) (30 IN) LF 8 $ -

0610-7072 IN RD IL (TY SA) 30T-8 (250W EQ) LED EA 1 $ -

7004-7055 REMOVE AND RELOCATE METERS AND BOXES EA 1 $ -

7023-7032 ADJUST WATER METER AND BOX EA 1 $ -

7030-7038 ADJ OF WV COVERS AND VALVE STACKS EA 1 $ -

7030-7055 ADJUSTMENT OF WASTEWATER LAT CLEANOUT EA 1 $ -

TRANSPORTATION OPERATIONS DIVISION

Bid Sheet

CIZ25-TRN-3193 – Traffic Signal Construction – Augsut 2025 - Ferndale Rd at Walnut Hill Ln, Hampton Rd at Leath St, Masters Dr (N) at Old Segoville Rd

200 PROCURE AN INSTALL TXDOT ITS GROUND BOX (TYPE 1) (24X36X48) EA 1 $ -

500 EXTRA WORK EA 1 $ 60,000.00 $ 60,000.00

GRAND TOTAL BID . 60,000.00$

NAME OF CONTRACTOR: ______________________________________

PRINTED NAME OF AUTHORIZED SIGNER: ________________________

SIGNATURE OF AUTHORIZED SIGNER: ___________________________

(FORM 3)

CONTRACT TIME

TIME OF COMPLETION: The undersigned agrees to complete ALL WORK on or before 240 Working Days. The Work Order will be issued in accordance with Item 103.2 COD, "AWARD AND EXECUTION OF CONTRACT," of the COD 2021 Addendum to the Standard Specifications and Special Provision A.5, "CONTRACT TIME." The undersigned further declares that he will provide all necessary tools and apparatus, do all the work, furnish all materials, and do everything required to carry out the above mentioned work covered by this proposal, in strict accordance with the contract documents, and the requirements pertaining thereto, for the sum or sums above set forth.

Submitted:

By:

Signature

Printed Name

Address

City State Zip

Code (SEAL- If the bidder is a Corporation)

NOTE: DO NOT DETACH bid from other papers.

Fill in with ink and submit complete with attached papers.

(Form 1)

BID BOND

STATE OF TEXAS }

} KNOW ALL MEN BY THESE PRESENTS

COUNTY OF DALLAS }

That we , as Principal, and . a Corporation duly organized under the laws of the State of and fully authorized to transact business in the State of Texas, as Surety, are held and firmly bound unto the

CITY of DALLAS, TEXAS, a municipal corporation, as Obligee, in the penal sum of FIVE PERCENT (5%) OF THE GREATEST AMOUNT BID, lawful money of the United States of America; for the payment of which sum, well and truly to be made, we hereby bind ourselves, our heirs, executors, administrators, and successors and assigns, jointly and severally, firmly by these presents.

SIGNED, SEALED, and DATED this day of , .

WHEREAS, the Principal is herewith submitting its proposal for:

THE CONDITION OF THE ABOVE OBLIGATIONS ARE SUCH, that if the aforesaid Principal shall be awarded the Contract, the said Principal will, within the time required, enter into a Contract and give Bonds, if required, for the faithful performance of the Contract and the prompt payment for labor and materials in the prosecution thereof, then this obligation shall be null and void, otherwise the Principal and Surety will pay unto the Obligee the full penal sum thereof, as liquidated damages, it being difficult and impractical to determine accurately the actual amount of damages occurring to Obligee by reason of Principal’s failure to execute said Contract and Bonds.

PROVIDED FURTHER, that if any legal action be filed upon this Bond, venue shall lie exclusively in Dallas, County, Texas.

The Resident Agent of the Surety in Dallas County, Texas for delivery of notice and service of process is:

NAME: ADDRESS:

TELEPHONE: E-MAIL ADDRESS:

ATTEST: PRINCIPAL:

By Secretary Name/Title

ATTEST: SURETY:

By Secretary Name/Title

NOTE: CERTIFIED COPY OF POWER-OF-ATTORNEY MUST BE ATTACHED HERETO.

PROPOSAL FORMS

The bidder must complete this form regardless of whether or not the same information is given in the Bidder’s Bond:

1. Complete name and address of the Surety Company for Performance and Payment Bonds:

2. Name of the Attorney-In-Fact for the Surety Company:

3. The name of the resident agent of the Surety Company in Dallas County, Texas, (this name must be the name of a natural person residing in Dallas County, Texas):

4. Address of the resident agent of the Surety Company in Dallas County, Texas, (this must be a street address and not a post office box number):

Name of Bidder

Address of Bidder

(Form 1 contd.)

PROVIDE THE FOLLOWING INFORMATION:

1. If the Contractor is a corporation:

State of Incorporation:

If other than Texas, provide copy of a Certificate of Authority to do business in Texas.

2. Street Address:

Suite, Room or Building

Street Address

City, County, State, Zip Code

3. Mailing Address:

Suite, Room or Building

Street Address

City, County, State, Zip Code

4. If the contractor is a corporation:

A. Name of the Contractor’s President:

B. Name of the Contractor’s Corporate Secretary:

C. If other than A and B are to sign contract provide:

NAME TITLE

Attach a notarized copy of legal authorization granting contract signing authority.

5. All notices under the contract should be sent to:

Name Title

6. Provide information for a person who may be contacted concerning the proposal or other required documents:

Name Telephone Number

PROPOSAL GUARANTY FORM

The undersigned further agrees that the proposal guaranty may be retained by the City of Dallas, Texas, provided the undersigned is one of three lowest and most advantageous bidders, and that said proposal guaranty shall remain with the City of Dallas until the contract has been signed, and the bond required for the faithful performance of the contract has been made by one of the three lowest responsible bidders; otherwise, proposal guaranty may be obtained from the City Secretary after forty-eight hours from the time of opening the bids. The undersigned hereby declares that he has visited the sites, has had sufficient time to make all tests and investigations to arrive at an intelligent estimate of the cost of doing the work, and has carefully examined the details, specifications and contract documents relating to the work covered by his bid or bids, that he agrees to do the work, and that no representations made by the City are in any sense a warranty, but are mere estimates for the guidance of the Contractor. Upon receipt of notice of the acceptance of the bid, the Contractor will execute the formal contract attached in quintuplicate, within ten days, and will deliver a Surety Bond for the faithful performance of this contract, and such other bonds as may have been required in the specifications. The bid security attached, in the sum of:

is to become the property of the City of Dallas if a cashier’s check, and if a bond, the principal amount shall be paid to the City, in the event the contract and bond are not executed within the time above set forth, and to be considered as liquidated damages because the delay and additional work caused thereby are incapable of accurate ascertainment.

Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 12/22/2017

FORM 1295CERTIFICATE OF INTERESTED PARTIES

OFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLYYYYY

6 UNSWORN DECLARATION

My name is _______________________________________________________, and my date of birth is _______________________________.

My address is ________________________________________________, ___________________, _______, __________, ______________.

(street) (city) (state) (zip code) (country)

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

Executed in ___________________ County, State of ______________ , on the _______ day of _______________, 20______.

(month) (year)

Signature of authorized agent of contracting business entity (Declarant)

ADD ADDITIONAL PAGES AS NECESSARY

Name of Interested Party Nature of Interest (check applicable)City, State, Country

(place of business) Controlling Intermediary

Name of governmental entity or state agency that is a party to the contract for which the form is being filed.

3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract.

Complete Nos. 1 - 4 and 6 if there are interested parties.

Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.

1 Name of business entity filing form, and the city, state and country of the business entity's place of business.

Check only if there is NO Interested Party.

Mus t fi le on lin e a t w ww.et hic s.s tat e.t x.u s/F ile

Form 2

Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

FORM CIQ

This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.

This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a).

By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code.

A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor.

OFFICE USE ONLY

Date Received

[TI Name of vendor who has a business relationship with local governmental entity.

Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)

W

Name of local government officer about whom the information is being disclosed.

Name of Officer

Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.

Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIQ as necessary.

A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor?

Oves No

B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity?

Oves No

Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more.

Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).

[zJ

Signature of vendor doing business with the governmental entity Date

Form 2

Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

A complete copy of Chapter 176 of the Local Government Code may be found at http://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form.

Local Government Code§ 176.001(1-a): "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on:

(A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity;

(B) a transaction conducted at a price and subject to terms available to the public; or

(C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency.

Local Government Code§ 176.003(a)(2)(A) and (B):

(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:

(2) the vendor:

(A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that

(i) a contract between the local governmental entity and vendor has been executed;

or

(ii) the local governmental entity is considering entering into a contract with the vendor;

(B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that:

(i) a contract between the local governmental entity and vendor has been executed; or

(ii) the local governmental entity is considering entering into a contract with the vendor.

Local Government Code§ 176.00G(a) and (a-1)

(a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and:

(1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A);

(2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or

(3) has a family relationship with a local government officer of that local governmental entity.

(a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of:

(1) the date that the vendor:

(A) begins discussions or negotiations to enter into a contract with the local governmental entity; or

(B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or

(2) the date the vendor becomes aware:

(A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a);

(B) that the vendor has given one or more gifts described by Subsection (a); or

(C) of a family relationship with a local government officer.

(FORM 3)

NON-COLLUSION AFFIDAVIT

The undersigned bidder or agent, being duly sworn on oath, says that he/she has not, nor has any other member, representative, or agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to include anyone to refrain from bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or combination with any other person in reference to such bidding.

He/She further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee gift, commission or thing of value on account of such sale.

OATH AND AFFIRMATION

I HEREBY AFFIRM UNDER THE PENALTIES FOR PERJURY THAT THE FACTS

AND INFORMATION CONTAINED IN THE FOREGOING BID FOR

DEPARTMENT OF TRANSPORTATION ARE TRUE AND CORRECT.

Dated this day of , (Name of Organization)

(Title of Person Signing)

(Signature)

ACKNOWLEDGEMENT

STATE OF )

COUNTY OF )

) ss

Before me, a Notary Public, personally appeared the above named and swore that the statements contained in the foregoing document are true and correct.

Subscribed and sworn to me this day of , .

Notary Public Signature

My Commission Expires:

Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

(See reverse for public burden disclosure)

(Form 4) Approved by OMB

0348-0046

1. Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

2. Status of Federal Action:

a. bid/offer/application

b. initial award

c. post-award

3. Report Type:

a. initial filing

b. material change

For material change only:

Year quarter Date of last report

4. Name and Address of Reporting Entity:

Prime Subawardee

Tier , if Known:

Congressional District, if known:

5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime:

Congressional District, if known:

6. Federal Department/Agency: 7. Federal Program Name/Description:

CFDA Number, if applicable:

8. Federal Action Number, if known: 9. Award Amount, if known:

10. a. Name and Address of Lobbying Registrant (if individual, last name, first name, MI):

b. Individuals Performing Services (including address if different from No. 10a)

(last name, first name, MI):

11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature:

Print Name:

Title:

Telephone No.: Date:

Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97)

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action.

4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier.

Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in item 4 checks “Subawardee,” then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known.

6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., “RFP-DE-90-001.”

9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.

10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a).

Enter Last Name, First Name, and Middle Initial (MI).

11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503

(Form 4)

FORM 1-0001 – Prohibition on Contracts with Companies Boycotting Israel & Prohibition on Contracts with Foreign Terrorist Organizations - Acknowledgement

“FAILURE TO SIGN YOUR BID MAY RESULT IN A REJECTION OF

YOUR BID.

Bidder’s Acknowledgement of Prohibition on Contracts with Companies Boycotting Israel Effective September 1, 2017, Bidder acknowledges, in accordance with Chapter 2270 of the Texas Government Code, that Bidder does not boycott Israel and will not boycott Israel during the term of any contract with the City of Dallas to provide goods and services to the City. Bidder further acknowledges that this provision is hereby incorporated by reference, as if written word for word, into any subsequent contract entered into between City and Bidder for goods and services.”

“FAILURE TO SIGN YOUR BID MAY RESULT IN A REJECTION OF

YOUR BID.

Bidder’s Acknowledgement of Prohibition on Contracts with Foreign Terrorist Organizations Effective September 1, 2017, Bidder acknowledges, in accordance with Chapter 2252 of the Texas Government Code, that (a) Bidder does not engage in business with Iran, Sudan or any foreign terrorist organization and (b) Bidder is not listed by the Texas Comptroller as a terrorist organization as defined by Chapter 2252 of the Texas Government Code. Bidder further acknowledges that this provision is hereby incorporated by reference, as if written word for word, into any subsequent contract entered into between City and Bidder for (1) professional or consulting services subject to the Professional Services Act - Chapter 2254 of the Texas Government Code, (2) general construction, (3) an improvement, (4) a service, (5) a public works project, or (5) for a purchase of supplies, materials or equipment.”

Company Name

Signature of Authorized Official

Printed Name and Title of Authorized Official

Date

(Form 1-0001)

Date of Bid Opening

BIDDER'S SAFETY AFFIDAVIT

The following information is required by City Council Resolution No. 89-1132.

Failure or refusal to complete this form my result in bid rejection.

The undersigned certifies that safety records from the Dallas OSHA office or the local OSHA office in which this firm does business does not reflect penalties for six (6) or more serious violations, none of which may be repeat violation, nor may it reflect three (3) or more willful violations, none of which may be repeat violations, within the preceding three

(3) years.

Name of Signatory Title Address

Corporate Authorized Title Address Signatory (Only) The above signature must be by a Corporate Officer.

Legal Name of Bidder Address

SWORN TO AND SUBSCRIBED BEFORE ME on this _____ day of ______________, 20______, to certify which witness my hand and seal of this office.

NOTARY PUBLIC, STATE OF ___________

Printed Name of Notary

(FORM 5)

ENVIRONMENTAL RECORD AFFIDAVIT

For purposes of this Affidavit:

(A) the term “Bidder/Proposer” includes any and all authorized officers, employees, agents, or other representatives of Bidder/Proposer working in that capacity on behalf of Bidder/Proposer within the past three (3) years prior to the date of this Affidavit;

(B) the term “Environmental Laws” includes any and all State, Federal, or local statutes, laws, rules, codes, regulations, or ordinances developed to regulate activities that impact human health and the environment including, but not limited to, those intended to control land, air, and water pollution, conserve natural resources, prevent damaging practices, and regulate chemical hazards.

By signing below, I, ______________________, the authorized representative of

________________ (hereinafter called the “Bidder/Proposer”), affirm, on behalf of

Bidder/Proposer, the following:

(1) That Bidder/Proposer has received and read the Contractor Environmental Packet.

Bidder/Proposer also understands that the Contractor Environmental Packet is not intended to be all inclusive, but rather a guideline for environmental responsibility.

[Strike the item indicated below that does NOT apply in this Affidavit.]

(2) That Bidder/Proposer has not been served with any notices of violation or notices of enforcement or had any civil or criminal fines or penalties imposed by any regulatory authority for a violation of any Environmental Laws within the past three (3) years prior to the date of this Affidavit.

(3) That Bidder/Proposer has been served with notices of violation or notices of enforcement or had any civil or criminal fines or penalties imposed by any regulatory authority for a violation of any Environmental Laws within the past three (3) years prior to the date of this Affidavit as follows:

[If Item (3) applies, use a separate sheet to list the notices of violation or enforcement, and any adjudications of actual violations, along with copies of any compliance documents issued by the regulatory authority in connection with the notices or actual violations, and attach the separate sheet to this affidavit.]

COMPANY NAME SIGNATURE

DATE TITLE

Environmental Record Affidavit [032311 Edition]

(FORM 6)

CEMENT CERTIFICATION

I, , the [state title of officer of company] of [legal name of bidder company], do hereby certify that my bid for concrete products utilizes Portland cement produced by vendors who:

(1) are in compliance with all applicable state and federal environmental standards relating to the emission of NOx, including all applicable TCEQ and EPA rules and regulations; and

(2) operate kilns with emissions that exceed the standards for NOx emissions set out in 30 Tex.

Admin. Code § 117.3110(a)(1)-(4) (as provided presently and as may be amended in the future) by the following percentage amounts:

(a) for each long wet kiln, 10 percent lower than the standard for long wet kilns located in Ellis County, Texas as set out in 30 Tex. Admin. Code § 117.310(a)(1)(B) [As of 3-9- 11, wet kiln NOx emissions can NOT exceed 3.6 lbs per ton of clinker produced.];

(b) for each long dry kiln, 20 percent lower than the standard for long dry kilns located in Ellis County, Texas, as set out in 30 Texas. Admin. Code § 117.3110(a)(2) [As of 3-9- 11, dry kiln NOx emissions can NOT exceed 4.1 lbs per ton of clinker produced.];

(c) for each preheater kiln, 20 percent lower than the standard for preheater kilns located in Ellis County, Texas, as set out in 30 Tex. Admin. Code § 117.3110(a)(3) [As of 3-9- 11, preheater kiln NOx emissions can NOT exceed 3.0 lbs per ton of clinker produced.]; and

(d) for each preheater-precalciner or precalciner kiln, 35 percent lower than the standard for preheater-precalciner and precalciner kilns located in Ellis County, Texas, as set out in 30 Tex. Admin. Code § 117.3110(a)(4) [As of 3-9-11, preheater-precalciner or precalciner kiln NOx emissions can NOT exceed 1.8 lbs per ton of clinker produced.].

BIDDER:

Print Name and Title

SUBSCRIBED and SWORN TO before me this day of , 20 .

[Seal] Notary Public, State of Texas

My commission expires:

Form 8

OFFICE OF PROCUREMENT SERVICES

STATEMENT OF INSURABILITY AND QUOTE

SOLICITATION INFORMATION

I, as the person(s) legally authorized to sign contracts for my company, hereby attest that I have reviewed the insurance requirements for this contract and agree to produce a valid certificate of insurance meeting all the insurance requirements within 15 days of award notification. If the 15-day requirement is not met, the City of Dallas has the right to reject the award.

Furthermore, I have sent the requirements to my insurance agent or broker, and I have attached a copy of the quote for the cost of the required insurance, or proof of coverage.

By submitting a bid or proposal, I certify the above statements are true.

INSURANCE INFORMATION

I, as the authorized representative of the insurance agency or brokerage firm, have reviewed the attached insurance requirements, provided a quote, and attest that the bidder or proposer listed above is able to obtain the required insurance.

Signature, name, and title of Insurance Representative:

Agency Name:

Signature Date

Printed Name Title

Questions concerning these requirements?

Please contact the City of Dallas Risk Management Division at (214) 671-9041.

OPS-04 1/14/2020

Rev. 0 - 12/05/2019 Page 1 of 1

Business Name:

Insurance Requirements

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SECTION A.

CONTRACTOR shall procure, pay for and maintain the following insurance written by companies approved by the State of Texas and acceptable to CITY. The insurance shall be evidenced by delivery to the CITY, at the address shown in SECTION C (a), certificates of insurance executed by the insurer or its authorized agent stating coverages, limits, expiration dates and compliance with all applicable required provisions. The CITY shall be named as an additional insured by endorsement to the policy and thus will be entitled to notice of cancellation of the policy in accordance with Section 1811 of the Texas Insurance Code.

Upon request, the CITY shall be entitled to receive without expense, copies of the policies and all endorsements. CITY HAS NO DUTY TO PAY CONTRACTOR UNTIL SUCH

CERTIFICATE HAS BEEN DELIVERED TO THE CITY.

SECTION B.

The CITY reserves the right to review the insurance requirements of this section during the effective period of the services or work performed by CONTRACTOR and to modify insurance coverages and their limits when deemed necessary and prudent by City's Office of Risk Management based upon changes in statutory law, court decisions or other relevant factors. The CONTRACTOR shall acquire and ensure execution of requests for deletions, revisions or modifications of particular policy terms, conditions, limitations, or exclusions (except where policy provisions are established by law or regulation binding upon either CITY or CONTRACTOR).

SECTION C. REQUIRED PROVISIONS

The CONTRACTOR agrees, with respect to the required insurance as documented below, all certificate(s) of insurance will contain and state, in writing, the following required provisions:

a) The certificate of insurance or policy and endorsements shall be evidenced by delivery to:

(i) Transportation, Attention: Amber Ellis, 1500 Marilla St, Dallas, Texas 75201 and

(ii) Director, Office of Risk Management, 1500 Marilla, 6A-South, Dallas, Texas 75201.

b) All certificates of insurance shall identify the service or product being provided, by including the bid number and contract or solicitation name.

c) All certificates of insurance shall name the City of Dallas as the Certificate Holder.

SECTION D. INSURANCE COVERAGE REQUIRED

Subject to CONTRACTOR’S right to maintain reasonable deductibles, CONTRACTOR shall obtain and maintain in full force and effect for the duration of its engagement with the CITY and any extension hereof, at CONTRACTOR’S sole expense, insurance coverage in the following type(s) and amounts:

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1. WORKERS’ COMPENSATION and EMPLOYERS’ LIABILITY Workers’ Compensation within the regulations of the Texas Workers’ Compensation Act. The minimum policy limits for Employers Liability are:

Bodily Injury by Accident: $500,000 Each Accident Bodily Injury by Disease: $500,000 Each Employee Bodily Injury by Disease: $500,000 Policy Limit

The policy shall include:

a) An endorsement to waive subrogation in favor of the City of Dallas, its officers, employees and elected representatives, for bodily injury (including death) or any other loss.

b) An endorsement to provide thirty (30) days prior written notice in the event of cancellation to the address as shown in Section C, a (i) and (ii), or in accordance with Section 1811.155 of the Texas Insurance Code, Notice of Cancellation in accordance with the Notice of Insured in the policy for cancellation due to non-payment of premium.

NOTES:

i. If CONTRACTOR will not be providing services under the contract at a City facility, has no employees and/or is operating as a sole owner and single operator, CONTRACTOR shall provide a signed letter, with the current date, on official letterhead stating such to meet the requirement.

ii. If CONTRACTOR is a non-subscriber or is self-insured, CONTRACTOR shall provide a copy of its Certificate of Authority to Self-Insure from the Texas Department of Insurance, Division of Workers’ Compensation Self Insurance Regulation Program, evidence of alternative coverage and internal safety and injury coverage policies and procedures.

2. BUSINESS AUTOMOBILE LIABILITY INSURANCE

Business Automobile Liability Insurance covering owned, hired, and non-owned vehicles, with a minimum combined single limit for bodily injury (including death) and property damage limit of $500,000 per occurrence.

The policy shall include:

a) An endorsement naming the City of Dallas and its officers, employees and elected representatives as additional insureds.

b) An endorsement to waive of subrogation in favor of the City of Dallas, its officers and employees, for bodily injury (including death), property damage or any other loss.

c) An endorsement to provide thirty (30) days prior written notice in the event of cancellation to the address as shown in Section C, a (i) and (ii), or in accordance with Section 1811.155 of the Texas Insurance Code, Notice of Cancellation in accordance with the Notice of Insured in the policy for cancellation due to non-payment of premium.

d) Provide that CONTRACTOR’S insurance is primary insurance as respects the CITY, its officers, employees and elected representatives.

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NOTE:

i. If CONTRACTOR has no owned, hired and non-owned autos or vehicles and/or no autos or vehicles will not be used in the performance of services under the contract, CONTRACTOR shall provide a signed letter, with the current date, on official letterhead stating such to meet the requirement for owned autos.

3. COMMERCIAL GENERAL LIABILITY INSURANCE

Commercial General Liability Insurance including, but not limited to, Premises/Operations, Personal & Advertising Injury, Products/Completed Operations, Independent Contractors and Contractual Liability with minimum combined bodily injury (including death) and property damage limits of $1,000,000 per occurrence, $2,000,000 products/completed operations aggregate, $2,000,000 general aggregate.

The policy shall include:

a) Coverage extended to apply to products/completed operations and XCU (explosion, collapse and underground) hazards.

b) An endorsement naming the City of Dallas, its officers, employees and elected representatives as additional insured using the broadest form of endorsement available, with such status extended to include the extension of the completed operations coverage as described above.

c) An endorsement to waive subrogation in favor of the City of Dallas, its officers and employees, for bodily injury (including death), property damage or any other loss.

d) An endorsement to provide thirty (30) days prior written notice in the event of cancellation to the address as shown in Section C, a (i) and (ii), or in accordance with Section 1811.155 of the Texas Insurance Code, Notice of Cancellation in accordance with the Notice of Insured in the policy for cancellation due to non-payment of premium.

e) The policy shall include endorsement CG2503 Amendment of limits (designated project or premises) in order to extend the policy’s limits specifically to the project in question.

f) The Completed Operations coverage must be maintained for a minimum of one

(1) year after final completion and acceptance of the Work, with evidence of same filed with the City of Dallas.

g) Provide that CONTRACTOR’S insurance is primary insurance as respects the CITY, its officers, employees and elected representatives.

h) If this insurance is written on a claims-made form, coverage shall be continuous (by renewal or extended reporting period) for not less than twenty-four (24) months following completion of the contract and acceptance by the City.

Coverage, including any renewals, shall have the same retroactive date as the original policy.

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SECTION E. SELF-INSURED RETENTION (SIR)

Contractor may satisfy all or part of the insurance requirements under the Contract by means of self-insurance so long as:

(a) the SIR is permitted under all laws applicable to Contractor at the time Contractor submits its bid or proposal;

(b) Contractor maintains a net worth (as shown by its financial statements audited in accordance with generally accepted accounting principles) of not less than One Hundred Million Dollars ($100,000,000);

(c) if the Contractor is using their balance sheet to back the SIR, the SIR cannot exceed 10% of their net worth;

(d) Contractor, not less than annually, provides the City an audited financial statement, prepared by an independent certified public accountant in accordance with generally accepted accounting principles consistently applied, showing the net worth requirements outlined herein; and

(e) the SIR provides for loss reserves that are actuarially derived in accordance with accepted standards of the insurance industry and accrued (i.e., charged against earnings) or otherwise funded.

Any self-insured exposure shall be deemed to be an insured risk under the Contract. The beneficiaries of such insurance shall be afforded no less insurance protection than if such self-insured portion was fully insured by an insurance company of the quality and caliber required hereunder (including, without limitation, the protection of a legal defense, by attorneys reasonably acceptable to beneficiaries, and the payment of claims within the same time period that a third party insurance carrier of the quality and caliber otherwise required hereunder would have paid such claims).

The waiver of subrogation provided for hereunder shall be applicable to any self-insured exposure. All SIRs must be acceptable to and approved in writing by the City prior to implementation and the insurance required under the Contract must be maintained in excess of such SIRs. Any and all deductibles and/or SIRs for the insurance policies described in this Exhibit shall be assumed by and for the account of Contractor or any Contractor’s subcontractors, as applicable, at its sole risk and expense.

SECTION F. SUBCONTRACTING LIABILITY

(1) Without limiting any of the other obligations or liabilities of the CONTRACTOR, the…