7-H. OFFEROR FORM 103025.pdf

RSQ-TPR-26-031

OFFEROR INFORMATION/CERTIFICATION FORM

(MUST BE INCLUDED WITH OFFEROR’S SUBMISSION)

(This form must be FULLY executed with original authorized signature and notary signature)

1. Legal Name of Offeror. Indicate if the Offeror is a Corporation, Joint Venture, Partnership, etc.:

(This name must match the name on your current W9 Form. The W9 will be requested at the time of award.)

2. Name/title of contact person for the Offeror:

3. Local business and mailing address:

4. Primary business and mailing address:

5. Telephone number: ( ) Fax: ( )

Email Address: ______________________________________________________________

The above-named Offeror affirms and declares:

A. That the Offeror understands all requirements of this request and states that as a serious Offeror they will comply with all the stipulations included in this request.

B. That the Offeror is of lawful age and that no other person, firm or corporation has any interest in this response or in the contract proposed to be entered into except as expressly stated below:

C. That this response is made without any understanding, contract, or connection with any other person, firm or corporation making a response for the same purpose, and is in all respects fair and without collusion or fraud except as expressly stated below:

D. That the Offeror is not in arrears to the Pasco County Board of County Commissioners upon debt or contract and is not a defaulter, as surety or otherwise, upon any obligation to the Pasco County Board of County Commissioners except as expressly stated below:

E. That the Offeror is in compliance with Section 448.095(2), Florida Statutes, requiring Offeror and its Subcontractors to register with and utilize the U.S. Department of Homeland Security’s

E-Verify program to verify the work authorization status of all newly hired employees and acknowledges that it will be required to maintain such compliance throughout the term of any Contract entered between the parties. The Offeror also confirms that no public employer has terminated a contract with the Offeror for failure to comply with Section 448.095(2), Florida Statutes within the 12 months preceding the date this Certification Form is signed by the Offeror.

F. That no officer or employee or person whose salary is payable in whole or in part from the County is, will be or become interested, directly or indirectly, surety or otherwise in this response; in the performance of the resulting contract; in the purchase of supplies, materials, equipment, work and/or labor to which they relate; or in any portion of the profits thereof.

G. That the Offeror has received and carefully examined all Addenda issued prior to uploading its response and its response will be in accordance with all Addenda prior to response opening.

H. That by submitting a response, the Offeror certifies that it is not currently debarred from submitting responses for contracts issued by any political subdivision or agency of the State of Florida and that it is not an agent of a person or entity that is currently debarred from submitting responses for contracts issued by any subdivision or agency of the State of Florida.

I. That pursuant to Section 287.087, Florida Statutes, Offerors understands that they may certify in their response that they have implemented a drug free workplace program. If two or more responses are deemed equal, preference will be given in the award process to the Offeror who has furnished such certification with their response.

J. If claiming Local Vendor Preference, the Offeror certifies that they satisfy each of the following criteria at the time of their submission of a response to the solicitation necessary to qualify as a “Local Business”: a) a vendor, supplier, or contractor who does business in Pasco County by providing goods, services, or construction; and b) maintains a physical business address located within the jurisdictional limits of Pasco County in an area zoned for the conduct of such business; and c) which the vendor, supplier or contractor operates or performs business on a daily basis; and d) has for at least twelve (12) months prior to the response opening date; and

e) a copy of their local business tax receipt or qualifies as a business in a neighboring county as listed in the County’s Purchasing Ordinance. Post office boxes shall not be used for the purpose of establishing said physical address.

Please put an “X” in the applicable box or mark N/A

________ Local Business located in Pasco County ________ Business located within Hillsborough, Pinellas, Polk, or Hernando County

This local preference provision is not applicable to those solicitations involving the use of either State or Federal funds as indicated below:

State and/or Federal Funds Involved: __ (Y if applicable, N if not applicable)

Note: If claiming Local Vendor Preference, a valid Local Business Tax Receipt must be provided at the time the response is submitted in order to qualify for such consideration.

K. By signing this Certification, I represent that I am of lawful age and have the authority to bind the Offeror for contract purposes. If someone other than the President of the corporation, or a member of a member-managed limited liability company, or the manager of a manager managed limited liability company, then one of the following must be submitted with this Certification:

1. If Offeror is a corporation (includes incorporated or company, or abbreviations thereof, in its name), and if other than the President of the corporation is signing this Certification, then one of the following must be submitted with this Certification:

a. a current corporate resolution naming the officer or person signing this Certificate as authorized to sign contracts on behalf of the company or,

b. a copy of the Board of Directors’ resolution or meeting minutes designating the officer or person signing this Certificate as authorized to sign contracts for the corporation, certified by the secretary of the corporation.

2. If Offeror is a limited liability company, then the following must be submitted with this Certification: a copy of the Operating Agreement of the limited liability company showing that that person signing this Certificate is authorized to sign contracts for the limited liability company.

L. Attached to this response is a copy of the Certificate of Status from the Florida Secretary of State, Division of Corporations, which can be downloaded from https://dos.myflorida.com/sunbiz/search/.

M. Exceptions to Contract Provisions and Miscellaneous Declarations (attach additional sheets, if necessary):

https://dos.myflorida.com/sunbiz/search/

IN WITNESS WHEREOF, this proposal is hereby signed and sealed as of the date indicated.

OFFEROR:

BY:

(Authorized Signature in Ink)

(Printed name of Signatory)

(Printed Title of Signatory)

(Signature Date)

PASCO COUNTY, FLORIDA

HUMAN TRAFFICKING AFFIDAVIT

This form must be completed by an officer or representative of the company or by the individual entering into, renewing, or extending a contract with Pasco County.

Under penalty of perjury, I hereby attest that based upon my personal knowledge, the below-named company or individual does not use coercion for labor or services, as those terms are defined in section 787.06, Florida Statutes.

Signature

Printed Name

Title

Name of Company if applicable

Date

STATE OF FLORIDA

COUNTY OF_____________________

The foregoing Human Trafficking Affidavit is sworn to (or affirmed) and subscribed before me under penalty of perjury by means of ☐ physical presence or ☐ online notarization, this ______day of________, (month) ________ (year), by _____________________________________________(name of person making statement).

(Signature of Notary Public - State of Florida)

(Print Commissioned Name of Notary Public)

☐ Personally Known OR ☐ Produced Identification

Type of Identification Produced