8-6.0 - Federal Supplement Exhibits.pdf

Federal Requirements Exhibit 1 Page 1 of 1

Exhibit 1

SCHEDULE OF SUBCONTRACTOR PARTICIPATION

Proposers/Bidders/Offerors must include in this Schedule all Subcontractors anticipated to perform a portion of the Work.

Use additional sheets as needed.

Subcontractor Name and

Trade/Discipline

Address

Phone

State Registration/ or License Number

Description Contract Items to be Purchased or

Performed

DBE

Y/N

Estimated Subcontract Value ($)

EXHIBIT 4

PROPOSER’S/BIDDER’S/OFFEROR’S LIST OF SUBCONTRACTORS/SUBCONSULTANTS/SUPPLIERS

NAME OF Proposer/Bidder/Offeror: _____________________________

The Proposer/Bidder/Offeror shall provide information on ALL perspective subcontractors/subconsultants/suppliers who were CONTACTED or SUBMITTED bids/quotation in support of this solicitation. Attach additional copies of the form as necessary.

NAME OF

SUBCONTRACTOR/SUBCONSULTANTS/SUPPLIER(S)

SCOPE OF WORK

TO BE

PERFORMED

CERTIFIED DBE

FIRM?

(Check all that apply)

PREVIOUS YEAR’S

ANNUAL GROSS

RECEIPTS

UTILIZING ON

THIS CONTRACT?

(Please circle answer)

NAME ADDRESS

SCOPE OF WORK: YES: Less than $500K YES or NO

$500K-$2 mil PHONE: NO: $2 mil - $5 mil FAX: more than $5 mil

CONTACT PERSON:

AGE OF FIRM:

SUBCONTRACTOR/SUBCONSULTANTS/SUPPLIER(S)

SCOPE OF WORK

TO BE

PERFORMED

CERTIFIED DBE

FIRM

(Check all that apply)

PREVIOUS YEAR’S

ANNUAL GROSS

RECEIPTS

UTILIZING ON

THIS CONTRACT

(Please circle

PHONE: NO: $2 mil - $5 mil

SUBCONTRACTOR/SUBCONSULTANTS/SUPPLIER(S)

SCOPE OF WORK

TO BE

PERFORMED

CERTIFIED DBE

FIRM

(Check all that apply)

PREVIOUS YEAR’S

ANNUAL GROSS

RECEIPTS

UTILIZING ON

THIS CONTRACT

(Please circle

PHONE: NO: $2 mil - $5 mil

SUBCONTRACTOR/SUBCONSULTANTS/SUPPLIER(S)

SCOPE OF WORK

TO BE

PERFORMED

CERTIFIED DBE

FIRM

(Check all that apply)

PREVIOUS YEAR’S

ANNUAL GROSS

RECEIPTS

UTILIZING ON

THIS CONTRACT

(Please circle

PHONE: NO: $2 mil - $5 mil

Name/Title of person completing this form: ______________________________________________________________________________

Signature: _____________________________________________________________ Date: _____________________________________

Federal Requirements Exhibit 6 Page 1 of 4

EXHIBIT 6

MONTHLY SUBCONTRACTOR UTILIZATION REPORT

INSTRUCTIONS: This form must be filed each month by the Contractor to report actual Subcontractor participation by SFRTA certified subcontractor firms for Work performed during the preceding month.

Contract Contract Reporting Number: Name: __________________________________________________ Period:________________________

Prime Contract Firm _________________________________________________________________ Amount (as Amended) $____________________

Total Invoice Amount this Period: $__________________

Total Invoiced to Date: $__________________

Name of Subcontractor

If DBE Minority

Group*

Gender M/F

Description of Work

Type of Work*

Starting Date

Completion

Date

* Minority Group Enter: B-Black American S – Subcontinent Asian American H-Hispanic American N -Native American P-Asian Pacific American O-Other (specify)

* Type of Work: Professional Consultant/Services, Construction, Supplies, Equipment, Other

• If Contractor is a certified DBE firm, the Contractor’s monthly activity must also be reported.

• This form must be completed monthly and submitted with Contractor’s application for payment.

Federal Requirements Exhibit 6 Page 2 of 4

EXHIBIT 6

Contract Contract Reporting Number: Name: __________________________________________________ Period:___________________________

Prime Contract Firm ___________________________________________________________ Amount (as Amended) $________________________

Total Amount Invoiced for Subcontractors this Period: $

Total Amount Invoiced for DBE Subcontractors this Period: $

Total Amount Invoiced for Subcontractors to Date: $ Total Amount Invoiced for DBE Subcontractors to Date: $

Name of Subcontractor

Sub Contract Amount (as Amended)

Amount Invoiced This Period

Amount Invoiced To Date

Amount Paid This Period

Amount Paid to Date

Percentage Complete

* Minority Group Enter: B-Black American S – Subcontinent Asian American H-Hispanic American N -Native American P-Asian Pacific American O-Other (specify)

* Type of Work: Professional Consultant/Services, Construction, Supplies, Equipment, Other

• If Contractor is a certified DBE firm, the Contractor’s quarterly activity must also be reported.

• This form must be completed monthly and submitted with Contractor’s application for payment.

Federal Requirements Exhibit 6 Page 3 of 4

Circle One

1.) Did any of the DBE subcontractors rent/lease equipment from the prime consultant or an affiliate company during the report period?

Yes No

If yes, explain the arrangement, including a description of the equipment and the cost.

2.) Did any of the DBE subcontractors utilize employees or former employees of the prime consultant or an affiliate company during the reporting period?

3.) Did any of the DBE subcontractors subcontract any portion of its work to a non-DBE during the report period?

If yes, explain fully.

4.) Has the scope of work or the subcontract amount for any of the DBE subcontractors changed since the last report?

If yes, explain fully.

By signing this form, the person individually and on behalf of the Firm represents to the SFRTA that the information contained on both the above forms is complete truthful, and accurate.

AUTHORIZED SIGNATURE: ___________________________ TITLE: ________________________ DATE: ________________

Federal Requirements Exhibit 7 Page 1 of 1

Certificate of Disbursement of Previous Periodic Payment to Subcontractors

Contract No. _____________________ Date ________

Contract Name ___________________

Period of Work Invoiced For: / / to / /____

The Contractor for the above referenced contract, hereby certifies that all subcontractors and vendors having interest in this contract have received their pro rata share of all previous periodic payments made to date by SFRTA for all work, materials and equipment furnished under the contract.

Firm

(Signature of Authorized Representative)

NOTARY STATEMENT

STATE OF FLORIDA COUNTY OF

The foregoing instrument was acknowledged before me the day of , 20 , by who is personally known to me or who has produced as identification and who did/did not take an oath.

Signature of Notary

My Commission Expires

Exhibit 7

Federal Requirements Exhibit 8 Page 1 of 1

EXHIBIT 8

FEDERAL TAX LIABILITY AND RECENT FELONY CONVICTIONS

CERTIFICATION

The undersigned ___________________[insert name of Proposer/Bidder/Offeror] certifies that it:

(a) does not have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability; and

(b) was not convicted of the felony criminal violation under any Federal law within the preceding 24 months.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into.

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

__________________________ Signature of Authorized Representative

__________________________ Name of Authorized Representative

__________________________ Title of Authorized Representative

__________________________ Date

Federal Requirements Exhibit 9 Page 1 of 4

EXHIBIT 9

DEBARMENT & SUSPENSION (NONPROCUREMENT) CERTIFICATION

Debarment, Suspension, Ineligibility and Voluntary Exclusion

Applicable to all Awards of $25,000 or more and to Awards of Federally-Required Auditing Services (regardless of amount)

Instructions for Certification: By signing and submitting this bid or proposal, the Bidder or Proposer1 is providing the signed certification set out below.

(1) The Bidder or Proposer shall comply and facilitate compliance with: (a) U.S. DOT regulations, “Nonprocurement Suspension and Debarment,” 2 C.F.R. Part 1200, which adopts and supplements the U.S. Office of Management and Budget (U.S. OMB) “Guidelines to Agencies on Government wide Debarment and Suspension (Nonprocurement);” (b) 2 C.F.R. Part 180; and (c) Executive Orders 12549 and 12869. In addition to all other requirements of this certification, the Bidder or Proposer shall provide in Exhibit 1 to this certification (attached and made a part hereof) a printout from the System for Award Management (SAM) to show that it and all listed subcontractors in the Bid or Proposal are not debarred or identified as debarred companies in SAM. [see https://www.sam.gov/SAM/]

(2) To the best of its knowledge and belief, that its Principals and Subrecipient’s at the first tier:

a) Are eligible to participate in covered transactions of any Federal department or agency and are not presently:

1. Debarred,

2. Suspended,

3. Proposed for debarment,

4. Declared ineligible,

5. Voluntarily excluded, or

6. Disqualified,

b) Its management has not within a three-year period preceding its latest application or proposal been convicted of or had a civil judgment rendered against any of them for:

1. 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,

2. Violation of any Federal or State antitrust statute, or

3. Commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making any false statement, or receiving stolen property, 1 “Bidder or Proposer” also includes “Offeror” and “Contractor” if single or sole source award or post-award.

https://www.sam.gov/SAM/

Federal Requirements Exhibit 9 Page 2 of 4

c) It is not presently indicted for, or otherwise criminally or civilly charged by a governmental entity (Federal, State, local) with commission of any of the offenses listed in the preceding subsection 2.b of this Certification,

d) It has not had one or more public transactions (Federal, State, local) terminated for cause or default within a three-year period preceding this Certification.

e) If, at a later time, it receives any information that contradicts the statement of subsections 2.a – 2.d above, it will promptly provide that information to FTA, It will treat each lower tier contract or lower tier subcontract under its Project as a covered lower tier contract for purposes of 2 CFR part 1200 and 2 CFR Part 180 if it:

1. Equals or exceeds $25,000,

2. Is for audit services, or

3. Requires the consent of a Federal Official, and

f) It will require that each covered lower tier contractor and subcontractor:

1. Comply and facilitate compliance with the Federal requirements of 2 CFR

Parts 180 and 1200, and

2. Assure that each lower tier participant in its Project is not presently declared by any Federal department or agency to be:

i. Debarred from participation in any federally assisted Award;

ii. Suspended from participation in any federally assisted Award;

iii. Proposed for debarment from participation in any federally assisted

Award;

iv. Declared ineligible to participate in any federally assisted Award;

v. Voluntarily excluded from participation in any federally assisted

Award;

vi. Disqualified from participation in any federally assisted Award.

(3) It will provide a written explanation as indicated on a page attached in FTA’s TEAM-Web or the Signature Page if it or any of its principles including any of its first tier Subrecipient’s or its Third Party Participants at a lower tier, in unable to certify compliance with the preceding statements in this Certification Group.

[REMAINDER OF PAGE LEFT INTENTIONALLY BLANK]

Federal Requirements Exhibit 9 Page 3 of 4

Certification:

Contractor:____________________________________________________________________

Name and Title of Contractor’s Authorized Official____________________________________

Signature:____________________________________________ Date: ____________________

Federal Requirements Exhibit 9 Page 4 of 4

Exhibit 1

SAM Printout(s)

Federal Requirements Exhibit 14 Page 1 of 2

EXHIBIT 14

RESTRICTIONS ON LOBBYING AND NON-COLLUSION AFFIDAVIT/CERTIFICATION

This certification must be executed by the Proposer/Bidder/Offeror and all of the Subcontractors.

I, ___________________________________________(Name of the Firm’s Authorized Representative) hereby certify on behalf of ___________________________________________(Name of the Firm) 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 any agency, a Member of Congress, an office or employee of Congress, or an employee of a Member of Congress in connection with the awarding of a 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. No federal assistance funds shall be used for activities designed to influence Congress or State Legislature on legislation or appropriations, except through proper, official channels.

(2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an office 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.

(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contract 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 is 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 Section 1352, Title 31, U.S. Code. 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.

Executed this _____ day of ________________, ________

By: ____________________________ (signature of Firm’s Authorized Representative)

Name and Title: __________________________________

Federal Requirements Exhibit 14 Page 2 of 2

The Non-Collusion affidavit must be executed by the Proposer/Bidder/Offeror and all Subcontractors.

NON-COLLUSION AFFIDAVIT

STATE OF ________________________

COUNTY OF ______________________

___________________________________(insert name) being first duly sworn, disposes and says that he/she is __________________________________________________________ (Insert “sole owner”, “partner,” “president”, or other title) of _____________________________________________________________________(insert Firm’s name).

The Proposer/Bidder/Offeror submitting this Proposal/Bid/Offer certifies that such Proposal/Bid/Offer was not made in the interest of or in behalf of any undisclosed person, partnership, company, organization or corporation; that such Proposal/Bid/Offer is genuine and not collusive or sham, and that said Proposer/Bidder/Offeror has not been a party to any agreement to propose a fixed amount or to refrain from proposing and has not, directly or indirectly, by agreement, communication or conference with anyone attempted to induce action prejudicial to the interest of the South Florida Regional Transportation Authority, or of any Proposer/Bidder/Offeror or anyone else interested in the proposed Contract.

By: ___________________________________(signature of Firm’s Authorized Representative)

Name: ___________________________________

Title: ____________________________________

The foregoing instrument was acknowledged and sworn before me on this ___ day of _______, 20___, by

_____________________________ (name of person) as ______________________ (type of authority, e.g.

officer) for ____________________________(name of party on behalf of whom instrument was executed):

By: ____________________________ (signature of person swearing and acknowledging)

Name: __________________________

Title: ___________________________

(Seal) Signature of Notary Public

Print, Type/Stamp Name of Notary

Personally known:_________

OR Produced Identification:__________

Type of Identification Produced:________

Federal Requirements Exhibit 17 Page 1 of 1

CONTRACTOR ACKNOWLEDGMENT

By execution of this Federal Funding Supplement, the Contractor acknowledges and agrees that it has: (1) reviewed the provisions of the Federal Funding Supplement, the FTA Master Agreement and the FTA Circular, both as amended (collectively referred to in this Acknowledgement as the “Documents”) prior to execution of the Acknowledgement below and fully understands their meaning and effect; and (2) had the opportunity to have the Documents reviewed by Contractor’s attorney, or has expressly elected to forego such review, and by signing this Acknowledgment, Contractor agrees to be legally bound by all of the terms in the Documents that are applicable to this Agreement.

By: ______________________________________(print name of Contractor’s Authorized Representative)

Date: _________________________