ALL REQUIRED COMM OF MA FORMS.pdf

Bid Spreadsheet

Complete Bid Spreadsheet as instructed in spreadsheet.

INSTRUCTIONS: Indicate if you are bidding on specific District by marking "X" below next to each District being bid. If bidding on multiple Districts with different bids per District, copy this sheet to provide a sheet for each District being bid. For example, if bidding three (3) Districts with different pricing, 3 sheets will be required (one per District). If bidding on all Districts with single bid, select "All Districts" and submit the single sheet.

District 1 □ District 4 □

District 2 □ District 5 □

District 3 □ District 6 □

All Districts □

Bid Items – See Section 3.12

Item# Description Unit Price (or % above Manufacturer's Price)

1 FURNISH & INSTALL 5,000 GALLON TANK (ON A BASE) WITH ALL

OPERATIONAL HARDWARE FOR A FUNCTIONING UNIT EACH $

FURNISH & INSTALL 10,000 GALLON TANK (ON A BASE) WITH ALL

OPERATIONAL HARDWARE FOR A FUNCTIONING UNIT EACH $

FURNISH & INSTALL 5,000 GALLON TANK (ON AN EXISTING BASE)

WITH ALL OPERATIONAL HARDWARE FOR A FUNCTIONING UNIT EACH $

FURNISH & INSTALL 10,000 GALLON TANK (ON AN EXISTING BASE)

WITH ALL OPERATIONAL HARDWARE FOR A FUNCTIONING UNIT EACH $

5 FURNISH & INSTALL TANK BASE EACH $

6 FURNISH & INSTALL 1-INCH HOSE WITH FITTINGS – 25-FT IN LENGTH EACH $

7 FURNISH & INSTALL 1-INCH HOSE WITH FITTINGS – 50-FT IN LENGTH EACH $

8 FURNISH & INSTALL 2-INCH HOSE WITH FITTINGS – 25-FT IN LENGTH EACH $

9 FURNISH & INSTALL 2-INCH HOSE WITH FITTINGS – 50-FT IN LENGTH EACH $

FURNISH & INSTALL 2-INCH LINE SCREEN

(INCL. HOUSING PLUS 2 SCREENS) EACH $

11 FURNISH & INSTALL SYSTEM PUMP EACH $

12 FURNISH PUMP REBUILD KIT EACH $

13 FURNISH & INSTALL COMPLETE MODULAR DISPENSING SYSTEM EACH $

14 TANK REPAIR – REPLACEMENT STARTER KIT EACH $

15 DISPENSING SYSTEM REPAIR – REPLACEMENT STARTER KIT EACH $

16 MISCELLANEOUS PARTS (% MARK-UP) PERCENTAGE %

17 SERVICE CALLS HOURLY

RATE $

Sensitivity Level: Low

Business Reference Form

Reference Guidelines

1. The bidder must provide Insert number here business references.

2. References will be contacted to confirm the bidder’s abilities and qualifications as stated in the bidder’s response. The department may deem the bidder’s response unresponsive if a reference is not obtainable from a listed reference after reasonable attempts.

Request for Response (RFR) Information

Bidder: Click here to enter text.

RFR Name/Title: Click here to enter text.

RFR Number: Click here to enter text.

Reference Information

Reference Name: Click here to enter text. Contact: Click here to enter text.

Address: Click here to enter text. Email Address: Click here to enter text.

Phone Number: Click here to enter text. Fax/Other Number: Click here to enter text.

Description and dates(s) of commodities/services provided: Click here to enter text.

COMMONWEALTH OF MASSACHUSETTS

CONTRACTOR AUTHORIZED SIGNATORY LISTING

CONTRACTOR LEGAL NAME :

CONTRACTOR VENDOR/CUSTOMER CODE:

Issued May

INSTRUCTIONS: Any Contractor (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who are authorized as legal representatives of the Contractor who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf. In addition to this listing, any state department may require additional proof of authority to sign contracts on behalf of the Contractor, or proof of authenticity of signature (a notarized signature that the Department can use to verify that the signature and date that appear on the Contract or other legal document was actually made by the Contractor’s authorized signatory, and not by a representative, designee or other individual.)

NOTICE: Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the Contractor challenging the existence of a valid Contract due to an alleged lack of actual authority to execute the document by the signatory.

For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.

AUTHORIZED SIGNATORY NAME TITLE

I certify that I am the President, Chief Executive Officer, Chief Fiscal Officer, Corporate Clerk or Legal Counsel for the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals identified on this listing are current as of the date of execution below and that these individuals are authorized to sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated to any state department with which the Contractor does business whenever the authorized signatories above retire, are otherwise terminated from the Contractor’s employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with the Commonwealth or whenever new signatories are designated.

_____________________________________________ Date:

Signature

Title: Telephone:

Fax: Email:

[Listing can not be accepted without all of this information completed.] A copy of this listing must be attached to the “record copy” of a contract filed with the department.

PROOF OF AUTHENTICATION OF SIGNATURE

This page is optional and is available for a department to authenticate contract signatures.

It is recommended that Departments obtain authentication of signature for the signatory who submits the Contractor Authorized Listing.

This Section MUST be completed by the Contractor Authorized Signatory in presence of notary.

Signatory's full legal name (print or type):

Title:

X_____________________________________________________________ Signature as it will appear on contract or other document (Complete only in presence of notary):

AUTHENTICATED BY NOTARY OR CORPORATE CLERK (PICK ONLY ONE) AS FOLLOWS:

I, _____________________________________________________ (NOTARY) as a notary public certify that I witnessed the signature of the aforementioned signatory above and I verified the individual's identity on this date:

__________________________, 20 _______.

My commission expires on:

AFFIX NOTARY SEAL

I, _____________________________________________________ (CORPORATE CLERK) certify that I witnessed the signature of the aforementioned signatory above, that I verified the individual’s identity and confirm the individual’s authority as an authorized signatory for the Contractor on this date:

__________________________, 20 _______.

AFFIX CORPORATE SEAL

PART I: REASON FOR SUBMISSION – See Instructions on Page 2

New Enrollment Change Enrollment Cancel Enrollment Document Included: Voided Check Bank Letter

PART II: ACCOUNT HOLDER INFORMATION- See Instructions on Page 2 Account Holder Legal Name: DBA Name:

Street Address: City: State: Zip Code:

Account Holder Tax Identification Number (9 digits EIN or SSN) EIN: SSN:

PART III: FINANCIAL INSTITUTION INFORMATION- See Instructions on Page 2 Financial Institution Name:

Routing Number (only nine digits): Account Number: Account Type (Checking or Saving):

IF YOU ARE MODIFYING BANKING INFORMATION, YOU MUST INCLUDE YOUR OLD BANK INFORMATION OR YOUR

REQUEST WILL BE RETURNED

Old Financial Institution Name:

Old Routing Number (only 9 digits): Old Account Number: Old Account Type(Checking or Saving):

PART IV: VENDOR/CUSTOMER CONTACT INFORMATION: This is the person we will contact for any questions regarding this EFT – See Instructions on Page 2 Contact Person’s Name: Contact Person’s Title:

Contact Person’s Phone: Contact Person’s Email Address:

PART V: AUTHORIZATION- See Instructions on Page 2

By signing below, I hereby certify that the account(s) indicated on this form is under my direct control and access; therefore, I authorize the State Treasurer as fiscal agent for the Commonwealth of Massachusetts to initiate, change, or cancel credit entries to the account(s) as indicated on this form. For ACH debits consistent with the International ACH Transaction (IAT) rules check one:

� I affirm that payments authorized b y t h i s a g r e e m e n t are not to an account that is subject to being transferred to a foreign bank account.

� I affirm that payments authorized b y t h i s a g r e e m e n t are to an account that is subject to being transferred to a foreign bank account.

This authority is to remain in full force and effect until the Office of Comptroller (CTR) has received written notification from either me or an authorized officer of the organization of the account's termination in such time and in such a manner as to afford CTR a reasonable opportunity to act upon it.

Account Holder must sign and mail this EFT form and include a confirmation of account information on bank letterhead or a void check and mail to the Commonwealth Department you are doing business with.

Account Holder Authorized Signature: Print Name:

Title

Date:

COMMONWEALTH OF MASSACHUSETTS

OFFICE OF THE COMPTROLLER

Electronic Funds Transfer (EFT) Authorization Agreement Complete this form to enroll, modify, or terminate an existing in electronic funds transfer (EFT) agreement with the Commonwealth of Massachusetts Departments.

Effective 8/6/2020

PART VI: VERIFICATION FROM THE COMMONWEALTH DEPARTMENT – See Instructions on Page 2

I hereby certify the Vendor/Customer is an authorized signatory and verified by internal records and verbal confirmation initiated by our department.

VCC/VCM Document ID: Three letter Department Code:

Signature:________________________________________________

Print Name:____________________________________________

Title:__________________________________

Phone #_______________________________ Date:______________________

INSTRUCTIONS FOR COMPLETING THE EFT AUTHORIZATION AGREEMENT

All EFT requests are subject to a 5 (five) day pre-certification period in which all accounts are verified by the qualifying financial institution before any direct deposits are made.

PART I: REASON FOR SUBMISSION

Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment, a change to your EFT enrollment account information, or cancellation of your EFT enrollment.

PART II: ACCOUNT HOLDER INFORMATION

• Account Holder Name: Enter the accounts holder legal name (individual or business name), as reported

• to the Internal Revenue Service (IRS).

• DBA Name: Enter the DBA name if applicable.

• Street Address: Enter the account holder’s street address.

• Enter the account holder’s city, state, and zip code.

• Account Holder Tax Identification Number: Enter the tax identification number as reported to the IRS. If the business is a group, organization or corporation, provide the Federal employer identification number (EIN). If enrolling as an individual provide your Social Security Number.

PART III: FINANCIAL INSTITUTION INFORMATION

• Financial Institution Name: Enter your Financial Institution’s name (this is the name of the bank or qualifying depository

• that will receive the funds).

o NOTE: The account name to which EFT payments will be paid is to the name submitted on Part II of this form.

• Routing Number: Enter the bank or financial institutional nine-digit routing number, including applicable leading zeros.

• Account Number: Enter the account holder’s account number with the financial institution, including applicable leading zeros.

• Account Type: Enter the account type (Checking or Saving).

• If account holder is changing the banking information, you must provide OLD banking information.

• Old Financial Institution Name: Enter your Financial Institution’s name (this is the name of the bank or qualifying depository that will receive the funds).

• Old Routing Number: Enter the Old bank or financial institutional nine-digit routing number, including applicable leading zeros.

• Old Account Number: Enter the Old account holder’s account number with the financial institution, including applicable leading zeros.

• Account Type: Enter the Old account type (Checking or Saving).

o NOTE: Supporting bank documents must be in the account holder legal name only.

• If you do not submit this information, your EFT authorization agreement will be returned without further processing.

PART IV: CONTACT INFORMATION

• Enter the name and title of a contact person who can answer questions about the information submitted on this EFT form.

• Enter the contact person’s telephone number. Enter the contact person’s e-mail address.

PART V: AUTHORIZATION

• By your signature on this form, you are certifying that the account is drawn in the Name of an Individual, or the Legal Business Name of the person or entity who has sole control of the account to which EFT deposits are made.

• The EFT authorization form must be signed and dated by the same account holder name in Part II and include a title and telephone number.

• Mail this form with the original signature in black or blue ink (no facsimile signatures can be accepted) to the Commonwealth

Department that you doing business with.

PART VI: VERIFICATION FROM THE COMMONWEALTH DEPARTMENT

By your signature on this form, you are certifying that authentication of the vendor/customer’s authorized signatory was conducted by review of the Contractor Signatory Authorization Form (CASL) or by another internal verification process, and additional verification was conducted to confirm banking or address change request. Departments should have multiple known vendor contacts to confirm any registration change.

Bidder Current Environmentally Preferable Products and Practices Form

[NOTE TO RFR OR RFQ DEVELOPERS: The following form requires editing prior to including in an RFR or RFQ. This form is to be used for evaluation purposes only. Depending on the products/service bid, some of the entries below may not be applicable. Bid developers should keep those entries that make sense for the product/service bid (e.g., packaging may not apply to some bids).

In addition, bid developers may add entries that are applicable (e.g., if there is a specific certification for the industry or a particular environmental practice to add)]

BIDDER CURRENT ENVIRONMENTALLY PREFERABLE PRODUCTS / PRACTICES FORM

Bidder Company Name: _________________________________________ Date: _______________

This form is a standard evaluation tool. Questions 1- 6 apply to the operations of the Bidder (not the operations of a manufacturer or other company the bidder works with). Question 7 requests additional information about environmentally preferable product offerings.

The primary purpose of this form is to encourage potential Bidders to communicate existing business practices that foster a sustainable approach to conducting their operations. This may include one that has a reduced impact on the environment or public health, such as, but not limited to, creating less waste by using less packaging; eliminating the use substances and/or materials that are considered toxic; or using alternative fuel vehicles in the delivery fleet for the purpose of reducing air pollution and greenhouse gas emissions.

The Commonwealth considers such initiatives part of the “best value” of procurement. Bidders have an opportunity to receive additional points in the evaluation phase of the RFR for the environmental initiatives they have identified. However, bidders must substantiate all answers in the space provided below or in an attachment in order to receive any additional points. If reference is made to an attached document, or a website, list the specific page and line to which information is referenced.

1. Sustainability Program/Environmental Business Practices

a) Does your firm have a corporate-wide sustainability policy? If yes, attach or provide a link to your sustainability policy AND summarize what your corporate sustainability policy directs your company to do: Click here to enter text.

b) Indicate any other types of corporate sustainability policies AND attach policy in order to receive credit.

☐Climate Action Plan ☐Zero Waste Policy ☐Toxics Reduction Strategy ☐Green Fleet Policy ☐Sustainable Procurement Policy or Environmentally Preferable Purchasing Policy ☐Waste Prevention and/or recycling policy/program (describe and list types of materials you recycle)

Briefly describe and list sustainable procurement practices and achievements as a result of the policies checked above: Click here to enter text.

c) Does your company publish an annual Sustainability Report listing accomplishments and future goals?

If yes, please attach (or provide a link to) your latest Sustainability Report. Please describe key elements and accomplishments (such as receiving sustainability awards). Click here to enter text.

d) Please list individual steps not indicated above that your firm has taken to improve the sustainability at your own operations:

☐ Uses at least 50% remanufactured toner cartridges in printers (attach total annual spend on remanufactured and Original Equipment Manufacturer cartridges) Click here to enter text.

☐ Uses Green Cleaning products (certified by UL Ecologo, GreenSeal or SaferChoice) in all cleaning or janitorial services (attach copy of scope of work with cleaning services provider and types of green products used) Click here to enter text.

☐ Purchase appliances and equipment (printers, copiers, microwaves, etc.), that are Energy Star or EPEAT certified models. (list certified products) Click here to enter text.

☐ Incorporates green building design elements into all construction and renovation projects (list green design elements and provide documentation). Click here to enter text.

☐ Owns or leases buildings certified to LEED or another green building standard? (describe) Click here to enter text.

☐ Purchases or creates renewable electricity onsite (through solar or wind systems, for example)? Describe and indicate the % of energy that is derived from renewable sources: Click here to enter text.

☐ Has received a third party energy audit (usually through the utility) and implemented recommendations (attach audit recommendations and identify what has been completed). Click here to enter text.

☐ Has received a third party waste audit and implemented recommendations (attach audit recommendations and identify what has been completed). Click here to enter text.

☐ Please list other sustainable initiatives (e.g., waste reduction programs, green building management programs, other energy efficiency programs, etc.) and provide any measurable data: Click here to enter text.

2. Packaging:

Has your company implemented any of the following environmental packaging initiatives?

☐ All packaging contains post-consumer recycled materials. List post-consumer recycled content: Click here to enter text.

☐ Eliminates the use (or reduces the size) of disposable containers (e.g., uses reusable shipping containers). Please describe: Click here to enter text.

☐ Packaging materials do not contain chemicals or materials of concern such as PVC (vinyl), BPA, etc.). Please describe: Click here to enter text.

3. Shipping/Transportation:

Describe in detail how your company has implemented environmentally sound shipping and transportation practices.

☐ Your firm uses electric, hybrid-electric, bicycles or other alternative fuel vehicles to transport products to your retail stores or other locations. (Describe program) Click here to enter text.

☐ Your firm is a US EPA SmartWay Partner. Attach partnership agreement. Click here to enter text.

☐ Has an anti-idling policy. Attach policy.

☐ Diesel vehicles are equipped with emission control devices. List device(s) here: Click here to enter text.

☐ Uses biodiesel in your vehicles. List estimated amount used in the last year: Click here to enter text.

☐ Use environmentally preferable products in its fleet program (e.g., retread tires, re-refined motor oil, low-VOC solvents, etc.). List products here: Click here to enter text.

☐ Encourages the use of public/green transit. Provide name and description of program(s): Click here to enter text.

☐ Minimizes shipping energy and environmental impacts in other ways? Please describe: Click here to enter text.

4. Training and Education Describe how your company trains staff and educates customers on the products or service that involves an environmentally preferable component. Click here to enter text.

5. Certifications http://www.epeat.net/

Bidders should familiarize themselves with the various certifications for products and processes that are available within the industry in which they operate, with particular attention to those concerning environmental issues. Has your company or any of its manufacturers and/or subcontractors obtained any of the following product / industry certifications? In order to receive credit, please attach a copy certifications listed below:

☐ Is a reporting member of the WasteWise Program (EPA and Massachusetts) (attach most recent reporting).

☐ Has adopted an environmental management system that is geared to continuous improvement (e.g., ISO 14000)

(attach copy of summary EMS audit).

☐ Certified as a Massachusetts Sustainable Business Leader through the Sustainable Business Leader Program

(attach certification). Click here to enter text.

☐ Other industry environmental standards (where applicable), such as the CERES principles, LEED Certification, C2C

Protocol, Responsible Care Codes of Practice or other similar standards (list standard) Click here to enter text.

☐ Other. Please describe: Click here to enter text.

6. Other Environmental Criteria

Bidders may provide additional information about environmentally preferable practices that are not indicated and explained above (attach any appropriate documentation to substantiate claim) Click here to enter text.

7. Environmental Product Offering:

Bidders providing environmentally preferable options in the price sheet should also provide additional information about those options here. Please include a description of the product, how the product is environmentally preferable, how pricing compares to the conventional product counterpart, links to additional information, or if attaching product information, please reference names of files, and any additional information that would be helpful for reviewer:

Click here to enter text.

http://www.recyclingworksma.com/wastewise/ http://sustainablebusinessleader.org/

Form W-9 (Massachusetts Substitute W-9 Form) Rev.

March 2020

Request for Taxpayer Identification Number and Certification

Completed form should be given to the requesting department or the department you are currently doing business with.

Company/Taxpayer Name (as shown on your income tax return). Name is required on this line, do not leave this line blank.

DBA Name if different from above:

Check the appropriate box: Individual/Sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/ Estate Other

Legal Address: number, street, and apt. or suite no.

City:

State:

Zip code:

Remittance Address: if different from legal address number, street, apt. or suite no.

City:

State:

Zip code:

Phone:

Fax: Email address:

Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. 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 2. Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter.

Company/Taxpayer Tax Identification Number (9 digits EIN or SSN) Vendors:

Dunn and Bradstreet Universal Numbering System (DUNS) All vendors that receive federal grant funds must submit their DUNS number. Please confirm with the state agency if this is required.

EIN:

SSN:

DUNS:

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 Services (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 an U.S. person (including an U.S. resident alien).

4. I am currently a Commonwealth of Massachusetts’s state employee: (check one): No Yes If yes, in compliance with the State Ethics Commission requirements. Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.

Sign Authorized Signature ► Here

Printed Name ► Date ►

Purpose of Form A person who is required to file an information return with the IRS must get your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to give your correct TIN to the person requesting it (the requester) and , when applicable, to:

1. Certify the TIN you are giving is correct (or you are waiting for a number to be issued).

2. Certify you are not subject to backup withholding

If you are a foreign person, use the appropriate Form W-8. See Pub 515, Withholding of Tax on Nonresident Aliens and Foreign Corporations.

What is backup withholding? Persons making certain payments to you must withhold a designated percentage, currently 28% and pay to the IRS of such payments under certain conditions. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. If you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return, payments you receive will not be subject to backup withholding. Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester, or

2. You do not certify your TIN when required (see the Part II instructions on page 2 for details), or

3. The IRS tells the requester that you furnished an incorrect TIN, or

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the Part II instructions on page

Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Name. If you are an individual, you must generally enter the name shown on your social security card.

However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first and then circle the name of the person or entity whose number you enter in Part I of the form.

Sole proprietor. Enter your individual name as shown on your social security card on the

“Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name” line.

Limited liability company (LLC). If you are a single-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301.7701-3, enter the owner’s name on the “Name” line. Enter the LLC’s name on the “Business name” line.

Caution: A disregarded domestic entity that has a foreign owner must use the appropriate

Form W-8.

Other entities. Enter your business name as shown on required Federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity.

You may enter any business, trade, or DBA name on the “Business name” line.

Part I - Taxpayer Identification

Number (TIN)

Enter your TIN in the appropriate box.

If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are an LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) above), and are owned by an individual, enter your SSN (or “pre-LLC” EIN, if desired). If the owner of a disregarded LLC is a corporation, partnership, etc., enter the owner’s EIN.

Note: See the chart on this page for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office. Get Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN or Form SS-4, Application for Employer Identification Number, to apply for an EIN.

You can get Forms W-7 and SS-4 from the IRS by calling

1-800-TAX-FORM (1-800-829-

3676) or from the IRS’s Internet Web Site www.irs.gov.

If you do not have a TIN, write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments.

The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note: Writing “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Part II - Certification

To establish to the paying agent that your TIN is correct or you are a U.S. person, or resident alien, sign Form W-9.

For a joint account, only the person whole TIN is shown in Part I should sign (when required).

Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to give your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or MSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold a designated percentage, currently 28% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

What Name and Number to Give the Requester

For this type of account: Give name and SSN of:

1. Individual

2. Two or more individuals (joint account)

3. Custodian account of a minor (Uniform Gift to Minors Act)

4. a. The usual revocable savings trust (grantor is also trustee)

b. So-called trust account that is not a legal or valid trust under state law

5. Sole proprietorship

The individual The actual owner of the account or, if combined funds, the first individual on the account 1 The minor2

The grantor-trustee 1

The actual owner 1

The owner 3

For this type of account: Give name and EIN of:

6. Sole proprietorship

7. A valid trust, estate, or pension trust

8. Corporate

9. Association, club, religious, charitable, educational, or other tax-exempt organization

10. Partnership

11. A broker or registered nominee

12. Account with the

Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The owner 3 Legal entity 4

The corporation The organization

The partnership The broker or nominee

The public entity

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name, but you may also enter your business or “DBA” name. You may use either your SSN or EIN (if you have one).

. List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.)

Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

If you have questions on completing this form, please contact the Office of the State Comptroller. (617) 973-2468.

Upon completion of this form, please send it to the Commonwealth of Massachusetts Department you are doing business with.

Commonwealth Department Use Only: Doc Code – Department Code – Doc ID http://www.irs.gov/

Prompt Pay Discount Form

(Invoice discounts for receiving fast payments)

Revised 3/9/07 Bidder Name: .

Vendor Code (VCUST): .

Contract/RFR Number(s): .

Prompt Payment Discounts (PPD). All contractors/vendors doing business with the Commonwealth must provide a Prompt Payment Discount (PPD) for receiving early payments unless the Contractor/vendor can provide compelling proof that providing a prompt pay discount would be unduly burdensome. Contractors benefit from PPD by increased, usable cash flow as a result of fast and efficient payments for commodities or services rendered. Contractors who agree to accept Electronic Funds Transfer (EFT) increase the prompt pay benefit by ensuring that funds are paid directly to their designated bank accounts, thus eliminating the delay of check clearance policies and traditional mail lead time. Payments processed through the state accounting system (MMARS) can be tracked and verified through the Comptroller’s Vendor Web system using the Vendor/Customer Code assigned to you by a Commonwealth department.

The Commonwealth benefits because contractors reduce the cost of products and services through the applied discount. While Bidders/Contractors have flexibility in determining the actual % discount(s) offered to the Commonwealth, the discount(s) must be identified for 10, 15, 20 and/or 30 days for payment issuance in the column entitled “% Discount Off Proposed Price” below. The Commonwealth may use the prompt pay discounts submitted as a basis for selection and may negotiate discounts as deemed in the best interest of the Commonwealth. The requirement to offer PPD discounts may be waived by the Commonwealth on a case-by-case basis if participation in the program would be unduly burdensome, provided the specific reason for the hardship is outlined below.

All discounts offered will be taken in cases where the payment issue date is within the specified number of days listed below and in accordance with the Commonwealth’s Bill Paying Policy. Payment days will be measured from the date goods are received and accepted / performance was completed OR the date an invoice is received by the Commonwealth, whichever is later to the date the payment is issued as an EFT (preferred method) or mailed by the State Treasurer. The date of payment “issue” is the date a payment is considered “paid” not the date a payment is “received” by a Contractor.

If internal Bidder/Contractor systems require an alternate method of measuring payment issue dates, the Bidder/Contractor must note the issues below or on an attached page if necessary to be considered by the PMT. In cases where the Bidder/Contractor considers that offering a Prompt Payment Discount would be a hardship, the Bidder must clearly define the issues and reasons for said hardship. Providing volume discounts or other discounts on prices is not considered a hardship, since the PPD provides the additional benefit of early cash flow for the Contractor.

Enter the Prompt Payment Discount percentage (%) off the invoice payment, for each of the payment issue dates listed, if the payment is issued within the specified Payment Issue days. For example:

5% - 10 Days 4% - 15 Days 3% - 20 Days 2% - 30 Days

If no discount is offered enter 0% Prompt Payment Discount % Payment Issue Date w/in

% 10 Days % 15 Days % 20 Days % 30 Days

The Contractor is unable to provide a prompt payment discount due to the following hardship:

Contractor/Bidder Authorized Signature _________________________________ Date: ____________

Contractor/ Bidder Authorized Signatory Print Name and Title: __________________________________ https://massfinance.state.ma.us/VendorWeb/vendor.asp

Revised: August 28, 2019

Supplier Diversity Program (SDP) Plan Commitment SDP Plan Form #1

Contract/RFR Document Number: Click here to enter text.

Instructions: Completing all parts of this form is mandatory. Please read all sections of the Bid related to the SDP. Complete one form and submit with your Quote.

Important: Prime bidders that are certified as an M/WBE, M/WNPO, VBE, SDVOBE, DOBE and LGBTBE must also submit an SDP Plan Form and may not list themselves or their affiliates as SDP Partners.

Supplier Diversity Program (SDP) Resources:

• Lists of M/WBEs, M/WNPOs, VBEs, SDVOBEs, DOBEs and LGBTBEs certified or verified by the Supplier

Diversity Office (SDO) are located at www.mass.gov/sdo.

• Resources to assist Prime Bidders in finding potential Certified Partners can be found at www.mass.gov/sdp.

Part I Bidder/Contractor Information (Required)

Business Name: Click here to enter text.

Contact Name: Click here to enter text.

Phone #: Click here to enter phone number.

Email address: Click here to enter email address.

Part II Annual Financial Commitment (Required)

Provide a specific percentage of Bidder/Contractor sales derived from this contract to be spent with all certified SDP Partners on a Massachusetts fiscal year (July 1-June 30) basis.

Annual SDP Percentage Committed in Bid Response for Life of Contract:

Click here to enter percentage.% http://www.mass.gov/sdo http://www.mass.gov/sdp