87460_NM_SAM.pdf

CDS Solicitation

PROPOSAL INSTRUCTIONS – CDS SOLICITATION

PLEASE UNDERSTAND THAT ANY APPLICANT WHO DOES NOT FOLLOW THE

PROPOSAL INSTRUCTIONS MAY NOT BE CONSIDERED FOR THE

SOLICITATION.

A. Proposal Submission Instructions

You will be provided with ONE (1) combined PDF file with all the associated documents related to the solicitation.

The ONE (1) file will be named with the 5-digit HCR number, State, and SAM designation (i.e.

40064_CO_SAM). The documents you need to fill-out completely are listed below. These MUST be filled out and returned in the same order as reflected below. Any documents not filled out completely and not in this order may not be considered for review. All documents MUST be submitted in the original PDF format, NO EXCEPTIONS. Proposals can be submitted at any time during the open posting.

All the other documents in the file are for your information and reference ONLY. YOU DO NOT NEED TO RETURN THESE DOCUMENTS WITH YOUR PROPOSAL. The ONLY EXCEPTION is the VETS-4212. This will be required ONLY if you are awarded a contract;

however, it is recommended you start the process to obtain your DUNS number since this can take several days. If you have already applied for VETS-4212 please submit proof with your Proposal Submission Package.

I ENCOURAGE YOU TO READ THE STATEMENT OF WORK AND TERMS AND

CONDITION THOROUGHLY.

Proposal Package (Please return forms in the following order)

PS FORM 7405

PS FORM 7468

Supplier Information

PS FORM 2025

PS FORM 5472

Provision 4-3: Representations and Certifications (November 2012)* Confidentiality and Nondisclosure Agreement Authorization and Release – Background Investigation Response to Provision 4-1 Standard Solicitation Provisions IRS Form W-9 VETS-4212 (if already applied – the email confirmation from the Dept. of Labor is acceptable)

* Section 3. Page 1 of Provision 4-3, with exceptions not related to this solicitation, the US Postal Service DOES NOT enter into contracts with Postal Employees.

THIS IS IMPORTANT:

When submitting your proposal to brian.c.ray@usps.gov, you MUST put this in the Subject Line:

State.xxxxx.Last Name.First Initial (i.e. Colorado.40064.James.C). The xxxxx is the 5-digit HCR number.

NAME ON W-9 SHOULD REFLECT EXACTLY AS SS CARD OR BUSINESS NAME.

Response to Provision 4-1 Standard Solicitation Provisions is your opportunity to “sell yourself” as the best value for the Postal Service.

Electronic submissions within the provided documents will be the only acceptable submission format for this requirement. The electronic submission MUST be in the original PDF format only; ANY OTHER FORMAT WILL NOT BE ACCEPTED. The electronic submission shall not exceed a size limit of 20 megabytes (20MB). It is the responsibility of each offeror to confirm transmission and receipt of their Proposal. Offerors shall allow sufficient time for transmission through the USPS’s Information Technology (IT) firewall. Delays encountered due to the offeror’s IT system DO NOT constitute excusable delays. Proposals must be received by the Contracting Office, no later than the exact time specified below, to be considered for award.

Proposals shall be submitted no later than THURSDAY, MARCH 12, 2020 at 8:00 AM MST.

NOTE: Proposals must be submitted to: brian.c.ray@usps.gov LATE PROPOSALS MAY NOT BE ACCEPTED. Facsimile submissions are not authorized for this solicitation.

Payment of Proposal Costs

This Solicitation does not commit the USPS to pay for any costs incurred in the submission of the offer or in making necessary studies or designs for the preparation thereof, nor to contract for services or supplies.

All Awards are Conditional on Successful Completion of Background Investigation

Supplier Disqualifying Factors

The following factors will disqualify offerors:

The Postal Service does not award a contract to suppliers who are listed as disbarred, suspended or ineligible on (1) SYSTEM FOR AWARD MANAGEMENT (SAM) available at https://www.sam.gov/

The USPS does not award ordering agreements or contracts to current USPS employees or immediate family members of USPS employees.

The USPS does not award contracts where doing so would create a perception of bias or appear to compromise confidentiality.

Notification to Unsuccessful Offerors

The Unsuccessful Offeror Notification Letter will be transmitted electronically by email to the applicants who are not selected.

Follow the Solicitation Instructions:

For efficiency purposes in processing hundreds of proposals we request the files in the instructed format and order, and the Subject Title of your email to read exactly as instructed; otherwise your proposal may not be considered.

800-1258-20

a. SOLICITATION NO.

03/03/2020

b. DATE OF SOLICITATION

87460

c. CONTRACT NO.

04/01/2020

d. BEGIN CONTRACT TERM

09/30/2021

e. END CONTRACT TERM

BLOOMFIELD, NM

CITY & STATE

GOBERNADOR CAMP (87460) (N.O.), NM

CONTRACTING OFFICER

1. PROPOSAL SUBMITTED PURSUANT TO

CITY & STATEf. FOR MAIL SERVICE

IN OR BETWEEN

2. RATE OF COMPENSATION

WRITTEN DOLLAR AMOUNT (Proposal must be submitted on a single annual rate basis unless the solicitation specifically calls for proposals at a per mile, per piece, per trip, or other unit rate.)

AMOUNT (Figures)

3. OFFEROR

a. NAME (Print or Type) b. ADDRESS (Street, City, State, ZIP+4)

c. TELEPHONE NO. d. DOT NO. e. SOCIAL SECURITY NO. OR EMPLOYER IDENTIFICATION NO.

f. LEGAL RESIDENT OF

(Complete if offeror is an individual.)

g. ENGAGED IN BUSINESS IN

(Complete if offeror is a partnership or corporation.)

COUNTY STATE COUNTY STATE

4. CONTRACT

The contract may be terminated by the U.S. Postal Service or by the supplier upon thirty (30) day written notice and without the allowance of any indemnity to the supplier.

5. OFFEROR 6. U.S. POSTAL SERVICE

This proposal is made in good faith and with the intention to enter into a contract to perform service in case the proposal is accepted.

The U.S. Postal Service has caused this contract to be executed.

(Signature of Offeror) (Date) (Signature of Contracting Officer) (Date)

(Name and Title of Offeror) (Title of Contracting Officer)

h. ACKNOWLEDGEMENT OF AMENDMENTS

THE OFFEROR ACKNOWLEDGES RECEIPT

OF AMENDMENTS TO THE SOLICITATION

FOR OFFERS AND RELATED DOCUMENTS

NUMBERED AND DATED AS FOLLOWS:

AMENDMENT NO. DATE AMENDMENT NO. DATE

The offeror submitting the offer or proposal agrees with the U.S. Postal Service that if this offer or proposal is accepted, the offeror will give personal or representative supervision to the performance of the service. The offeror certifies that this proposal is made in the offeror's own interest and not by the offeror as the representative of another person or company and with full knowledge of the required conditions of service.

In compliance with the solicitation of the U.S. Postal Service described above, the above named offeror proposes to provide the service called for in said solicitation and, in the case of a negotiated contract, in the description of service attached hereto and made a part hereof, at the rate of compensation set out above.

The solicitation and all attachments are incorporated by reference as a part of this proposal.

If the offeror is a partnership or corporation, the Contracting Officer may request such offeror to furnish evidence of the authority of the party executing the proposal.

When a partnership offers, the signature of one partner is sufficient.

TRANSPORTATION SERVICES PROPOSAL & CONTRACT

FOR TEMPORARY SERVICE

PS Form 7405B September 2001

EQUAL OPPORTUNITY AFFIRMATIVE ACTION

PROGRAM

b. As used in this certification, segregated facilities means any waiting rooms, work areas, rest rooms or wash rooms, restaurants or other eating areas, time clocks, locker rooms or other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, or housing facilities provided for employees that are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin, because of habit, local custom, or otherwise.

c. The offeror further agrees that (unless it has obtained identical certifications from proposed subcontractors for specific time periods) it will obtain identical certifications from proposed subcontractors before awarding subcontracts exceeding $10,000 that are not exempt from the provisions of the EQUAL OPPORTUNITY clause; that it will retain these certifications in its files; and that it will forward the following notice to these proposed subcontractors (except when they have submitted identical certifications for specific time period(s):

a. A parent company is one that owns or controls the basic business policies of an offeror. To own means to own more than 50 percent of the voting rights in the offeror. To control means to be able to formulate, determine, or veto basic business policy decisions of the offeror. A parent company need not own the offeror to control it; it may exercise control through the use of dominant minority voting rights, proxy voting, contractual arrangements, or otherwise.

b. Enter the offeror's Taxpayer Identification Number (TIN) in the space provided. The TIN is the offeror's Social Security Number or other Employer Identification Number used on the offeror's quarterly Federal Tax Return, U.S.

Treasury Form 941.

Parent Company's Name

Parent Company's Main Office Address

No. and Street

City State ZIP+4

d. If the block above is checked, provide the following information about the parent company:

e. If the offeror is a member of an affiliated group that files its federal income tax return on a consolidated basis (whether or not the offeror is owned or controlled by a parent company, as provided above) provide the name and TIN of the common parent of the affiliated group:

c. Check this block if the offeror is owned or controlled by a parent company: o

The offeror, by checking the applicable block or blocks represents that it (1) o has developed and has on file, o has not developed and does not have on file, at each establishment, affirmative action programs as required by the rules and regulations of the Secretary of Labor (41 CFR 60-1and 60-2) and o has o has not filed the required reports with the Joint Reporting Committee; or (2) o has not previously had contracts subject to the written affirmative action program requirement of the rules and regulations of the Secretary of Labor.

CERTIFICATION OF NONSEGREGATED FACILITIES

a. By submitting this proposal, the offeror certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform services at any location under its control where segregated facilities are maintained.The offeror agrees that a breach of this certification is a violation of the EQUAL OPPORTUNITY clause of this contract.

NOTICE

A certification of no segregated facilities must be submitted before the award of a subcontract exceeding $10,000 that is not exempt from the EQUAL OPPORTUNITY clause. The certification may be submitted whether for each subcontract or for all subcontracts during a period (quarterly, semiannually, or annually).

Offeror's TIN

Name of Common Parent

Common Parent's TIN

Parent Company's TIN

PARENT COMPANY TAXPAYER IDENTIFICATION

NUMBER

PS Form 7405B (Reverse)

PS Form 7468A

800-1258-20

SOLICITATION NO.

03/03/2020

DATE OF SOLICITATION

87460

CONTRACT NO.

04/01/2020

BEGIN CONTRACT TERM

09/30/2021

END CONTRACT TERM

BLOOMFIELD, NM

CITY & STATE

GOBERNADOR CAMP (87460) (N.O.), NM

CITY & STATEFOR MAIL SERVICE

IN OR BETWEEN

OFFEROR: A completed cost worksheet must be submitted with your offer. This worksheet will assist you in determining the cost you expect to incur in performing this service. Please retain a copy of this form for future reference. The instructions for completing this form are listed on the reverse.

OFFEROR'S NAME AND ADDRESS (Include Apt./Suite No./ZIP+4)

NUMBER OF DRIVERS ON ROUTE

FULL-TIME PART-TIME

Remarks:

BASIS FOR DETERMINING COST

Cost Segment COST AS OF

No. of Units Per Year

Unit Cost Annual CostX = (Annual miles) (Rate per mile)

Item

1a. Vehicle Cost

(1) Motor Vehicles

(2) Trailers

1b. Operational Cost (Repairs, repair labor, tires, etc.)

3. Vehicle Registration

4. Miscellaneous

5. General Overhead

6. Fuel (Miles per gallon)

7. Oil (Quarts)

8. Insurance

9. Road Taxes

10. Tolls

11. Total Fixed and Operational Cost (Lines 1-10)

12. Straight Time

13. Overtime

14. Payroll Taxes (Itemized)

a. Social Security

b. Workman's Compensation

c. Federal Unemployment Comp.

d. State Unemployment Comp.

15. Fringe Benefits

a. Health & Welfare

b. Vacation

c. Holiday

d. Pension

16. Total Operation Labor Cost (Lines 12-15)

17. Supplier's Wages (Personal Driving or Supervision)

18. Total Cost (Lines 11, 16 & 17)

19. Return on Investment

20. TOTAL OFFER (Lines 18 & 19)

2. Taxes

Offeror's Signature Date

(Gallons) (Per gallon)

(Quarts) (Per quart)

(Hours) (Per hour)

(Hours) (Per hour)

(No. of employees or hours)

(Rate)

(Hours) (Per hour)

(Trips) (Per trip)

Taxable wages

HIGHWAY TRANSPORTATION CONTRACT — COST WORKSHEET

A

Line 1A, Vehicle Cost Complete annual miles from route schedule, rate per mile and annual cost of vehicle/trailer. Annual cost is derived by adding vehicle purchase price and finance charges and subtracting anticipated trade-in or salvage value. Divide the result by the estimated service life of the vehicle to obtain annual vehicle cost. Divide annual cost by scheduled miles to determine the rate per mile.

Line 1B, Operational Cost Complete annual miles from route schedule, rate per mile and annual cost. This line item includes vehicle repair costs, repair labor, tires and other miscellaneous operational costs not listed on this form.

Line 2, Taxes Gross receipts or personal property tax cost for vehicles used on route, where applicable.

Line 3, Vehicle Registration Annual cost of state and local vehicle registration fees.

Line 4, Miscellaneous Annual cost of miscellaneous items not listed on this form.

Line 5, General Overhead General overhead should include all management expenses not included in other items. It will include the cost for such items as supervision, office expenses, telephone, garage rents, parking fees, bulk fuel handling cost, terminal cost, insurance costs other than for vehicles, etc.

Line 6, Fuel Show consumption rate (miles per gallon), total annual gallons expected to be used on route, average cost per gallon and annual cost.

Line 7, Oil Show expected annual consumption, cost per quart and expected annual cost.

Line 8, Insurance This line is to reflect cost of insurance on vehicles used in the performance of service on the route. (Insurance coverage carried for terminal facilities, key-man insurance coverage, etc. should be included in Line 5, General Overhead.)

Line 9, Road Taxes This line should reflect cost incurred for federal highway use tax, state highway use tax, state mileage tax and state road tax.

Line 10, Tolls Show cost of toll for bridge, turnpike, ferry, tunnel, etc.

Line 11, Total Fixed and Operational Cost Sum of Lines 1 through 10.

Line 12 and 13, Straight Time and Overtime (Hired Drivers) Show expected operational payroll cost of all employees not otherwise included in Lines 1B and 5. Do not include wages for any personal operation of service. All fringe benefits will be shown in Line 15. (Terminal employee's or supervisor's wages are to be included in Line 1B or Line 5, and, therefore, are not to be considered in this line).

Line 14, Payroll Taxes (Itemized) This line should reflect taxes on labor cost for employee hours shown in Lines 12 and 13. It will include cost of social security, workman's compensation, unemployment taxes, etc. Self employment social security tax is a personal tax and not a business cost.

Line 15, Fringe Benefits This line should reflect the cost of employee health and welfare, pension, vacation and holiday benefits, based on the number of employees shown in Line 12. Fringe benefits are computed on the basis of hours paid employees, up to a maximum of eight hours per day or forty hours per week, unless specified otherwise in a collective bargaining agreement. In cases where an employee does not perform forty hours per week, the fringe benefits should be prorated in accordance with the number of hours of work performed.

Line 16, Total Operation Labor Cost Sum of Lines 12 through 15.

Line 17, Supplier's Wages Show wages for your personal operation of route or part of it, including your supervision. (Employee supervision cost should be reflected in Line 5, General Overhead.)

Line 18, Total Cost Sum of Lines 11, 16 and 17.

Line 19, Return on Investment The return expected on funds invested in those portions of facilities and/or capital equipment (e.g., trucks) which are devoted to performing service called for under the contract. This is normally derived by taking fixed percentage of the amount invested.

Line 20, Total Offer Sum of Lines 18 and 19.

PS FORM 7468A INSTRUCTIONS

PS Form 7468-I (Reverse)

5-Digit HCR # Supplier Information

Please print the requested Information in the blank column and return to the Central

Transportation Contracts Office.

Name of Individual or Company (REQUIRED)

Street Address (Physical) Location City, State, ZIP (REQUIRED)

Mailing Address (if different)

Mailing Address (if different) City, State, ZIP Primary Person Who Manages HCR(s)

Title of Person Who Manages HCR(s)

Primary Business Telephone Number (REQUIRED)

Primary Cell Phone Number (REQUIRED)

Primary Contact Residence Telephone

Primary Contact Email Address (REQUIRED)

In Case of Emergency, Person to Notify

Emergency Contact Telephone Number

Emergency Contact Telephone Email

Name of Alternate Person Who Manages HCR(s)

Alternate HCR Driver Phone Alternate HCR Driver Email Alternate HCR Driver Address

Tax Identification Number (Social Security Number or Employer Identification Number):

The United States Postal Service requires correct Tax Identification Number (TIN) Information from all existing and potential suppliers on all contract documents requiring a TIN. The Postal Service will require a copy of the Social Security Card as confirmation If a Social Security Administration Number

(SSN) will be used as the TIN. If an Employer Identification Number will be used as a TIN, the Postal

Service will require a copy of an official Internal Revenue Service (IRS) form as confirmation. Other wise, the Postal Service may be fined by the IRS, and any related fines may be assessed to the supplier.

To confirm your TIN, please provide a copy of your Social Security Administration Card or a preprinted IRS form showing your Employer Identification Number and your name and/or company name on the same form.

Rev. 01/2018

Contract Personnel Questionnaire Prepare in duplicate. Type or print all responses. If answer is No, state so. Attach sheets if more space is needed.

Privacy Act Statement: Your information will be used as a basis for an investigation to determine your fitness and suitability for contractual services to the U.S.

Postal Service® (USPS®). Collection is authorized by 39 U.S.C. 3061. Providing the information is voluntary, but if not provided you may be denied access to Postal Service premises, denied access to the mail, or denied participation under a USPS contract. We may disclose your information as follows: in relevant legal pro-ceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel.

1. Print Your Full Name (Last, First, Middle Name) 2. Print Your Mailing Address (Include Apartment/Suite Number)

4a. Home Telephone Number (Include Area Code)

3. City, State and ZIP+4 Code™

5. List Other Names Used. (i.e., maiden name, names by former marriages, names changed legally or otherwise, aliases, nicknames. Specify which and dates used.)

10. Type of Screening (Check one)

13. Contractor’s Name and Mailing Address

14. Have You Had a Security Screening by USPS or Other Federal Agencies Within the Last Year?

11. Are You Presently a Highway Contract Driver?

(If Yes, include Contract Number and Termini.)

12. Highway Contract Number and Termini (If applicable)

7. Date of Birth (MM/DD/YYYY) 8. Place of Birth (City and State/Country) 9. Sex6. Social Security Number (SSN)

15. Dates and Places of Residence. (If actual places of residence differ from the mailing addresses, furnish and identify both. Begin with present residence and go back for the past five years.)

16. Employment. (List ALL periods of employment for the past five years starting with your present employment. Include dates when unemployed.

Give name under which employed if different from name now used.)

From

(MM/YYYY)

To

(MM/YYYY)

From

(MM/YYYY)

To

(MM/YYYY)

Number and Street City State ZIP+4 Code

Employer’s and Supervisor’s Names

Employer’s Address (City, State, Zip+4Code)

Occupation Reason for Leaving

Male Female

Sub-ContractorContractor’s Employee ADPContractor Yes No

Yes No

18b. Commercial Driver’s License

18a. Do You Have a Valid License? (Driver/Chauffeur) If “Yes”, include License Number, State, and Expiration Date. Yes No Yes No

PS Form 2025, March 2012, (Page 1 of 2) PSN 7530-01-000-9519

4b. Work Telephone Number (Include Area Code)

Other

Agency:

Your Name During Period of Employment

17a. Are You a United States Citizen?

Yes No

17b. Are You a Citizen of American Samoa or Any Other Territory Owing Allegiance to the United States? Yes No

17c. Provide Alien Registration Number if not a United States Citizen

(Continued on Page 2)

Disposition

Action Taken

Action Taken

22. In the Past 5 years, Have You Been Convicted of any Traffic Violations (Other Than Parking) or Currently Have Charges Pending? (If Yes, complete information below.)

19b. Have you registered with the Selective Service System? If “Yes”, provide your registration number. If “No”, show the reason for your legal exemption.

19a. Are you a male born after December 31, 1959? If “No”, go to 20a. If Yes, go to 19b.

20a. Military Service (Past or Present). (If Yes, complete Items 20b, 20c, 20d, 20e, and 20f.)

20c. Branch of Service (Army, Navy, Air Force, Marines, etc.)

20b. Dates of Service (MM/YYYY)

To From

20d. Serial Number (If none, provide Grade or Rating at time of separation)

20e. Were You Discharged from the Military Service Under Honorable Conditions? (If your discharge was changed to “honorable” or “general” by a Discharge Review Board, answer “Yes”. If you received a clemency discharge, answer “No”.) If No, enter the date and type of discharge you received in the blocks below.

Yes

Yes No

No

Yes No

Yes No

Discharge Date (MM/YYYY) Type of Discharge

20f. While in Military Service, Were You Ever Convicted by Court Martial?

Yes No

21a. Have You Ever Been Convicted of, or Forfeited Collateral, for Any Felony/Misdemeanor Violation (Except Traffic Violations)?

(Generally, a felony is defined as any violation of law punishable by imprisonment of one year or longer.) Yes No

Yes No

Yes No

Yes No

21b. During the Last 10 Years Have You Forfeited Collateral, Been Convicted, Been Imprisoned, Been on Probation, or Been on Parole for any Violation of Law? (Do not include violations reported in question 21a.)

21c. Have You Ever Been Convicted of, or Forfeited Collateral for Any Assaults, Firearms or Explosives Violations?

21d. Are You Now Under Charges for Any Violation of Law?

21e. Are You Delinquent on any Federal Debt? (Include delinquencies arising from Federal taxes, overpayment of benefits, or other debts to the U.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgage loans.) Yes No

Date (MM/YYYY) Place (City and State) Court Charge

Date (MM/YYYY) Place (City and State) Court Charge

If necessary, attach additional sheets.

If necessary, attach additional sheets.

Yes No

Warning

Check Here if Your Driver’s Abstract from Department of Motor Vehicles is Attached.

Certification

USPS Official Signature (Sign and print name) Date Signed (MM/DD/YYYY)

For Use of Postal Service Official Responsible for Reviewing for Completeness and Legibility. (See Administrative Support Manual 272.23, Contractor Clearance, for complete instructions.)

Review this form carefully to ensure you have answered all questions fully and correctly. Failure to answer all questions may result in your being denied access to mail and/or Postal Service premises. A fine not to exceed $250,000 or imprisonment of not more than five years or both is provided by law (18 U.S.C. 1001) for making a false statement or concealing any material fact on this Questionnaire.

I certify that the statements made by me on this questionnaire are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

I attest I have advised the Applicant to truthfully complete this Questionnaire, and the Applicant has passed the Drug Screening Test (If applicable, provide documentation).

Applicant’s Signature Date Signed (MM/DD/YYYY)

Date Signed (MM/DD/YYYY)Contractor’s Signature (Sign and print name)

PS Form 2025, March 2012 (Page 2 of 2)

If any answers to 21a - 21d are “Yes”, provide date, place, court location, charge, and disposition on an attached sheet.

Telephone Number (Include area code)

Organization, City, State, and ZIP+4 Code

Telephone Number (Include Area Code)

Court Martial Date (MM/DD/YYYY) Place (City and State/Country) Charge

19. Your Selective Service Record

19c. Registration Number 19d. Legal Exemption Explanation

Pre-Award Questionnaire and Assets and Liabilities Statement

Solicitation No.

1. Nature of Bidder (sole proprietorship, partnership, corporation, etc.)

b. If operating as a Partnership, Attach List of Names, Ages, and Percentage of Ownership of All Partners

c. If operating as a Corporation, Date and State of Incorporation (Attach list of names of corporate officers and majority stockholders, if any, other than officers.)

PS Form 5472, April 2006 (Page 1 of 2) PSN 7530-02-000-9254

2. Describe other business ventures in which the company is, or has been engaged within the past three years. If company has not been engaged full time in business for at least three years, identify the employment and business ventures of the owner, partners, or corporate officers during the period. (Attach additional sheets as necessary to fully explain previous business ventures.)

3. Identify any capacity (e.g., contractor, subcontractor, carrier, driver, etc.) in which the company, its owner, partners, or officers have been engaged in the carrying of the mails within the past five years. If possible, identify routes by number and provide name of contractor and Contracting Officer. If service on any route was terminated by the Postal Service™ for cause, attach explanation.

4. Describe by model, size, and year, the equipment you propose to use on this route. Is the equipment owned or leased? If equipment is not yet acquired, describe the manner proposed for its acquisition.

5. Identify any individual owner, partner, corporate officer, or majority stockholder who is an employee of the U.S. Postal Service®, or who is either the spouse or minor child of an employee of the U.S. Postal Service, or a blood relative of an employee of the U.S. Postal Service residing in the same household with that postal employee. With respect to any affirmative response, identify the postal employee by name and place of work. Postal employees for the purpose of this response include those in full-time, part-time, career and noncareer positions, including specifically persons in positions such as postmaster replacements and rural carrier reliefs.

6. Identify the individuals (owner, partners, officers, employees, etc.) intended to have access to the mails or to postal operations areas during performance of the contract. Indicate which individuals, if any, have previously been screened by the Postal Service for such access.

Name (as shown on bid) Telephone No. (include area code)

Name of Owner Date

a. If Sole Proprietorship

Address (number, street, suite, apt., P.O. Box, etc.) 7. State6. City 8. ZIP+4®

PS Form 5472, April 2006 (Reverse)

Assets and Liabilities Statement Name Date (As of)

Name, Location or Description Amount or Value

Basis for Loan Amount

Assets

Stocks and

Bonds

Notes

Real Estate

Real Estate

Mortgage

Chattel Mortgage

The undersigned authorizes the U.S. Postal Service to make such inquiries as necessary to determine my financial responsibility and capability for performing under the proposed contract based on the pre-award survey information provided.

Signature Title Date

Notes

Cash In Bank

Liabilities

Total LiabilitiesTotal Assets

Other

Taxes

Other

Vehicles

Provision 4-3: Representations and Certifications (November 2012) Page 1 of 4

Provision 4-3: Representations and Certifications (November 2012)

A. Type of Business Organization. The offeror, by checking the applicable blocks, represents that it:

1. Operates as:

__ a corporation incorporated under the laws of the state of ________; or country of________________ if incorporated in a country other than the United States of America.

__ an individual;

__ a partnership;

__ a joint venture;

__ a limited liability company;

__ a nonprofit organization; or __ an educational institution; and

2. Is (check all that apply) __ a small business concern;

__ a minority business (indicate minority below):

__ Black American __ Hispanic American __ Native American __ Asian American:

__ a woman-owned business; or __ none of the above entities.

a. A small business concern for the purposes of Postal Service purchasing means a business, including an affiliate, that is independently owned and operated, is not dominant in producing or performing the supplies or services being purchased, and has no more than 500 employees, unless a different size standard has been established by the Small Business Administration (see 13 CFR 121, particularly for different size standards for airline, railroad, and construction companies). For subcontracts of $50,000 or less, a subcontractor having no more than 500 employees qualifies as a small business without regard to other factors.

b. Minority Business. A minority business is a concern that is at least 51 percent owned by, and whose management and daily business operations are controlled by, one or more members of a socially and economically disadvantaged minority group, namely U.S. citizens who are Black Americans, Hispanic Americans, Native Americans, or Asian Americans. (Native Americans are American Indians, Eskimos, Aleuts, and Native Hawaiians. Asian Americans are U.S. citizens whose origins are Japanese, Chinese, Filipino, Vietnamese, Korean, Samoan, Laotian, Kampuchean (Cambodian), Taiwanese, in the U.S. Trust Territories of the Pacific Islands or in the Indian subcontinent.)

c. Woman-owned Business. A woman-owned business is a concern at least 51 percent of which is owned by a woman (or women) who is a U.S. citizen, controls the firm by exercising the power to make policy decisions, and operates the business by being actively involved in day-to-day management.

d. Educational or Other Nonprofit Organization. Any corporation, foundation, trust, or other institution operated for scientific or educational purposes, not organized for profit, no part of the net earnings of which inures to the profits of any private shareholder or individual.

3. Is (check all that apply) __ a Postal Service employee or a business organization substantially owned or controlled by such an individual __ a spouse of a Postal Service employee or a business organization substantially owned or controlled by such an individual __ another family member of a Postal Service employee or a business organization substantially owned or controlled by such an individual __ an individual residing in the same household as a Postal Service employee or a business organization substantially owned or controlled by such an individual.

http://blue.usps.gov/policy/clauses/provision.htm

Provision 4-3: Representations and Certifications (November 2012) Page 2 of 4

(Note: Offers from any of the sources listed in subparagraph A.3, may not be considered for an award pending review and recommendation by the Postal Service Ethics Office.)

B. Parent Company and Taxpayer Identification Number

1. A parent company is one that owns or controls the basic business polices of an offeror. To own means to own more than 50 percent of the voting rights in the offeror. To control means to be able to formulate, determine, or veto basic business policy decisions of the offeror. A parent company need not own the offeror to control it; it may exercise control through the use of dominant minority voting rights, proxy voting, contractual arrangements, or otherwise.

2. Enter the offeror's U.S. Taxpayer Identification Number (TIN) in the space provided. The TIN is the offeror’s Social Security number or other Employee Identification Number (EIN) used on the offeror’s Quarterly Federal Tax Return, U.S. Treasury Form 941, or as required by Internal Revenue Service (IRS) regulations. Offeror’s TIN: ________________

3. IRS Form W-9, Request for Taxpayer Identification Number and Certification. You must complete a copy of IRS Form W-9 and attach it to this certification.

4. Check this block if the offeror is owned or controlled by a parent company: ______________

5. If the block above is checked, provide the following information about the parent company:

Parent Company’s Name:_______________________________ Parent Company’s Main Office:__________________________ Address:_____________________________________________ No. and Street:________________________________________ City:________________ State:______ ZIP Code:_____________ Parent Company’s TIN:__________________________________

6. If the offeror is a member of an affiliated group that files its federal income tax return on a consolidated basis (whether or not the offeror is owned or controlled by a parent company, as provided above) provide the name and TIN of the common parent of the affiliated group Name of Common Parent: ______________________________ Common Parent’s TIN: _________________________________

C. Certificate of Independent Price Determination

1. By submitting this proposal, the offeror certifies, and in the case of a joint proposal each party to it certifies as to its own organization, that in connection with this solicitation:

a. The prices proposed have been arrived at independently, without consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to the prices with any other offeror or with any competitor;

b. Unless otherwise required by law, the prices proposed have not been and will not be knowingly disclosed by the offeror before award of a contract, directly or indirectly to any other offeror or to any competitor; and

c. No attempt has been made or will be made by the offeror to induce any other person or firm to submit or not submit a proposal for the purpose of restricting competition.

2. Each person signing this proposal certifies that:

a. He or she is the person in the offeror’s organization responsible for the decision as to the prices being offered herein and that he or she has not participated, and will not participate, in any action contrary to paragraph a above; or

b. He or she is not the person in the offeror’s organization responsible for the decision as to the prices being offered but that he or she has been authorized in writing to act as agent for the persons responsible in certifying that they have not participated, and will not participate, in any action contrary to paragraph a above, and as their agent does hereby so certify; and he or she has not participated, and will not participate, in any action contrary to paragraph a above.

Provision 4-3: Representations and Certifications (November 2012) Page 3 of 4

3. Modification or deletion of any provision in this certificate may result in the disregarding of the proposal as unacceptable. Any modification or deletion should be accompanied by a signed statement explaining the reasons and describing in detail any disclosure or communication.

D. Certification of Nonsegregated Facilities

1. By submitting this proposal, the offeror certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform services at any location under its control where segregated facilities are maintained. The offeror agrees that a breach of this certification is a violation of the Equal Opportunity clause in this contract.

2. As used in this certification, segregated facilities means any waiting rooms, work areas, rest rooms or wash rooms, restaurants or other eating areas, time clocks, locker rooms or other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment area, transportation, or housing facilities provided for employees that are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin, because of habit, local custom, or otherwise.

3. The offeror further agrees that (unless it has obtained identical certifications from proposed subcontractors for specific time periods) it will obtain identical certifications from proposed subcontractors before awarding subcontracts exceeding $10,000 that are not exempt from the provisions of the Equal Opportunity clause; that it will retain these certifications in its files; and that it will forward the following notice to these proposed subcontractors (except when they have submitted identical certifications for specific time periods):

Notice: A certification of nonsegregated facilities must be submitted before the award of a subcontract exceeding $10,000 that is not exempt from the Equal Opportunity clause. The certification may be submitted either for each subcontract or for all subcontracts during a period (quarterly, semiannually, or annually).

E. Certification Regarding Debarment, Proposed Debarment, and Other Matters (This certification must be completed with respect to any offer with a value of $100,000 or more.)

1. The offeror certifies, to the best of its knowledge and belief, that it or any of its principals:

a. Are ___ are not ___ presently debarred or proposed for debarment, or declared ineligible for the award of contracts by any Federal, state, or local agency;

b. Have ____ have not ___, within the three-year period preceding this offer, 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) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property;

c. Are ___ are not ___ presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subparagraph (b) above;

d. Have ___ have not ___ within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in conjunction with obtaining, attempting to obtain, or performing a public (Federal, state or local) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion or receiving stolen property; and

e. Are ___ are not ___ presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subparagraph (d) above.

2. The offeror has ___ has not ___, within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal, state, or local agency.

Provision 4-3: Representations and Certifications (November 2012) Page 4 of 4

3. “Principals,” for the purposes of this certification, means officers, directors, owners, partners, and other persons having primary management or supervisory responsibilities within a business entity (e.g., general manager, plant manager, head of a subsidiary, division, or business segment, and similar positions).

4. The offeror must provide immediate written notice to the contracting officer if, at any time prior to contract award, the offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

5. A certification that any of the items in E.1 and E.2 of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered as part of the evaluation of the offeror’s capability (see the Conduct Supplier Capability Analysis topic of the Evaluate Proposals task of Process Step 2: Evaluate Sources, in the Postal Service’s Supplying Practices). The offeror’s failure to furnish a certification or provide additional information requested by the contracting officer will affect the capability evaluation.

6. Nothing contained in the foregoing may be construed to require establishment of a system of records in order to render, in good faith, the certification required by E.1 and E.2 of this provision. The knowledge and information of an offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

7. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under section 1001, Title 18, United States Code.

8. The certification in E.1 and E.2 of this provision is a material representation of fact upon which reliance was placed when making the award. If it is later determined that the offeror knowingly rendered an erroneous certification, in addition to other remedies available to the Postal Service, the contracting officer may terminate the contract resulting from this solicitation for default.

Supplier Name (printed) Supplier Signature Date

Authorization and Release — Background Investigation

(USPS Contractors and Employees of Contractors)

Applicant: Carefully read the following information before you complete and sign this form.

Applicant’s Name (Last, First, Middle)

Date of Birth (Month, Day, Year)

Mailing Address

Email AddressHome Phone Number

Date Signed Signature

PS Form 2181-C, October 2015

Privacy Act Statement: Your information will be used as a basis for an investigation to determine your fitness and suitability for contractual service to the U.S. Postal Service (USPS). Collection is authorized by 39 U.S.C. 401 and 404; and 18 U.S.C.

3061. Providing the information is voluntary, but if not provided, it may have an adverse effect on your opportunities to perform services under contract with the USPS. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS (service providers); to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel. For additional information regarding our privacy policies, visit www.usps.com/privacypolicy.

This constitutes my consent and authorization to the disclosure or furnishing of any relevant and necessary information or records to any duly authorized official of the USPS by any person, corporation, agency, or association concerning my character, personal history, credit standing, educational claims, current or prior employment, military service, and other information which may be relevant and necessary to determine my fitness and suitability to perform services under contract with the USPS.

This authorization is executed with full knowledge and understanding that the USPS will take measures to protect the aforementioned information against unauthorized disclosure to any parties not having a legitimate need for it in the discharge of official business of the United States, or its agencies and instrumentalities.

I hereby RELEASE the aforementioned persons, corporators, agencies, associations and their employees, agents and representatives from any and all liability for damages resulting from a decision by the USPS not to contract for my services on account of compliance with this authorization, except for any damages resulting from knowingly providing false or misleading information or records about me.

A copy of this authorization shall be as effective and valid as the original. This authorization shall be valid from the date it is signed until any contract employment with the USPS is completed or terminated.

Attach additional pages if needed and label the page by the appropriate section (i.e. Section 4:Operating Plan)

Response to Provision 4-1 Standard Solicitation Provisions Refer to the Terms and Conditions Document for Full Descriptions of the Provisions

Section 1: Supplier Eligibility

Yes No Provision Explain any “Yes” responses I am at least 21 years of age.

I am an employee of the US Postal Service*

I am a member of a USPS employees immediate family or household

I have been, or am currently proposed to be suspended, debarred or ineligible to conduct business with the USPS.

Section 3: Supplier Capability

The extent to which the offeror has the resources (e.g., financial, technical, equipment, etc.) adequate to perform the work will be evaluated. Provide a statement to demonstrate you can meet the start date of the contract and provide the necessary equipment.

Also include information to support financial capability.

Section 4: Operating Plan

Submit a detailed operating plan to include conducting normal operations (sole proprietor or hired driver model, DOL compliance if applicable, monitor service performance, secure the mail) and contingency operations (extra trips, schedule changes, equipment breakdowns, inclement weather, supplier or hired driver absence [substitute driver plan]). The plan should also include a statement addressing the vehicle requirements of the contract (age/size requirement).

HCR#;_____________ Offeror Name:____________________________

* Page 1, section 3 of Provision 4-3, with exceptions not related to this solicitation, the US Postal Service DOES NOT enter into contracts with Postal Employees.

Section 2: Past Performance

List all current or recent Postal contracts, as well as any non-postal employment or contracts that are comparable to Contract Delivery Service. For each contract listed, the offeror should provide a record of adherence to contract requirements, and in the case of non-postal employment or contracts, an additional record of on-time performance (a history of being reasonable and cooperative with customers, commitment to customer satisfaction, integrity, and ethics).

Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

P ri n t o r ty p e

S ee

S p e c if ic

I n s tr u c ti o n s o n p ag e

2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number or Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S.