Andrews Park Restrooms ITB 2_2_26.pdf

City of Madison ITB #2026-6200-01

Invitation to Bid (ITB) City of Madison, Georgia

Issued on: 02/06/2026

Table of Contents Page

Contact Info 2 A. Section I - Project Overview & Schedule 3 B. Section II – Scope of Work 3 – 7 C. Section III – Required Documents 7 D. Section IV – Instructions to Bidders 7 – 8 E. Section V – Basis for Award 9 F. Section VI – Terms & Conditions 9 - 10 G. Checklist, Appendices and Exhibits 11...

Laurinda Mason Cross-Out

ITB No. 2026-6200-01

Project Location: City of Madison

Description of Project: Andrews Park Restroom Facility Project

Primary Contact: Laurinda Mason, Procurement Agent

Phone: 706-752-5596

Address: 132 N Main St Madison, GA 30650

Email: lmason@madisonga.com

Project Documents: This ITB will published in the local newspaper and posted on the State of Georgia Procurement Registry and the City of Madison’s procurement website:

https://www.madisonga.com/Bids.aspx

The City of Madison gives public notice that it is the policy of the City to ensure full compliance with Title VI of the Civil Rights Act of 1964, the Civil Rights Restoration Act of 1987, and related statutes and regulations in all programs and activities. It is our policy that no person in the United States of America shall, on the grounds of race, color, national origin, sex, age or disability be excluded from the participation in, be denied the benefits of, or be otherwise subjected to discrimination under any of our programs or activities.

mailto:lmason@madisonga.com https://www.madisonga.com/Bids.aspx

Section I - Introduction and Project Overview The City of Madison is accepting Bids for the construction of a new restroom facility at Andrews Park, located at 501 Wellington St, Madison, Georgia 30650.

Bid Activity Schedule

Invitation to Bid Issued February 6th, 2026

Deadline for Questions February 18th, 2026 4:00 PM

All Addendums Posted February 23rd, 2026 4:00 PM

Bid Deadline March 13th, 2026 2:00 PM

Bid Opening March 13th, 2026 2:15 PM

Section II - Scope of Work

1. Purpose, Intent, and Project Description

The City of Madison (“City”) is inviting qualified contractors to bid on the construction of a new permanent restroom facility at Andrews Park, located at 501 Wellington St, Madison, Georgia 30650. The work under this contract includes the complete construction of a new facility, including all building components, site work, finishes, and all related elements required for a fully functional restroom building.

The contractor shall provide all materials, labor, equipment, tools, transportation, delivery, installation, and incidentals necessary to complete the project in its entirety.

While the City has established baseline requirements through the construction documents Bidders may propose alternative means and methods, materials, or sequencing approaches that meet or exceed the intent of the design and applicable codes, provided such alternatives are clearly identified and explained, and do not reduce quality, durability, or functionality. All work shall be coordinated with the Director of Public Works, Shawn Wood.

2. Background

Andrews Park is a public recreation area serving residents and visitors in the City of Madison. The new restroom construction is intended to enhance user experience, support recreational activities, and ensure that the park continues to meet accessibility and public health standards.

This project reflects the City’s ongoing commitment to providing well-maintained and high-quality public spaces, improving facilities, and supporting the overall recreational environment for the community.

3. General Conditions

The contractor will be responsible for providing all labor, materials, equipment, and incidentals necessary to complete the work described in the project documents. The project will be delivered under a lump sum contract; however, the City reserves the right to consider if bids demonstrate enhanced value, constructability, or lifecycle benefits, provided the base scope requirements are met.

Bidders are responsible for conducting their own site inspection prior to submitting a Bid.

Change orders must be reviewed and approved by the City Manager prior to any work being performed from change order.

Unless otherwise specified by written addendum, the project shall be completed in compliance with the Construction Documents, applicable specifications, and the Bid Documents, including all appendices and addenda. The Lump Sum Bid shall be all-inclusive and shall cover all labor, materials, equipment, tools, transportation, permits, supplies, and incidentals required to construct the restroom facility and associated site improvements. The Bid shall include on-site utility connections but shall exclude fees related to the installation of the water meter and lift station.

The successful Bidder must include a minimum of three (3) completed projects (include projects of similar size and complexity if possible). Bidders shall provide a minimum of three (3) references including project name, organization, contact person, their direct phone number, and email address demonstrating successful completion of similar work.

A 10% retainage shall be withheld in accordance with applicable Georgia law. The City will inspect work as it progresses.

4. Prosecution and Progress

Bidders shall submit a proposed construction schedule demonstrating the ability to achieve substantial completion within 180 calendar days from issuance of the Notice to Proceed.

Proposed phasing, sequencing, or accelerated approaches that improve efficiency, reduce disruption to park users, or enhance constructability may be considered as part of the evaluation process.

Once construction begins, the contractor shall work diligently and continuously to minimize disruptions to park users and nearby residential areas. Delay in project completion affects public access, safety, and the City's operational planning; therefore, time is of the essence.

The contractor shall perform cleanup and restoration activities daily. If the contractor fails to maintain the site in a clean and orderly condition, the City may direct work to stop until acceptable cleanup is completed. Continued failure to perform cleanup may result in suspension of work.

5. Compliance and Safety

From mobilization through final acceptance, the contractor is responsible for always maintaining a safe work environment. All work shall comply with applicable OSHA safety regulations and any other safety requirements relevant to this project.

All work shall comply with the Americans with Disabilities Act (ADA), as amended, and all applicable federal and state accessibility requirements, including the 2010 ADA Standards for Accessible Design. The Contractor shall be responsible for ensuring that all constructed elements meet required accessibility standards.

6. Bonding and Insurance Requirements

All Bids must be accompanied by a Bid Bond issued by a reputable bonding company authorized to conduct business in the State of Georgia, in an amount equal to at least five percent (5%) of the total Bid amount.

Upon issuance of the Notice of Award, the successful contractor shall provide a Performance Bond payable to the City of Madison in the amount of one hundred percent (100%) of the total contract price. The successful contractor shall also provide a Payment Bond in the amount of one hundred percent (100%) in accordance with O.C.G.A. §§ 36-91- 70 and 36-91-90.

The contractor shall procure and maintain the following insurance coverage:

• Commercial General Liability Insurance with limits of not less than $1,000,000 combined single limits per occurrence for bodily injury and/or property damage. The policy shall name the City of Madison as an additional insured.

• Statutory Workers’ Compensation and Employers’ Liability Insurance with limits of not less than $1,000,000, including a waiver of subrogation in favor of the City of Madison and its affiliates.

• Commercial Automobile Liability Insurance with limits of not less than $1,000,000 combined single limits per occurrence for bodily injury and/or property damage. The policy shall name the City of Madison as an additional insured.

7. Subcontracting

The contractor shall not subcontract the entire scope of work or substitute key subcontractors identified in Bid without prior written approval from the City. Any contractor proposing to use subcontractors must submit a list of all intended subcontractors (form provided). Upon award of the contract, the contractor shall provide a Notarized Subcontractor Affidavit (form provided) for each approved subcontractor.

8. Definition of Substantial Completion

The work shall be considered substantially complete when the restroom facility is fully constructed and functional for public use, with only minor punch list items remaining.

Punch list items must be capable of being completed within 30 calendar days, weather permitting.

9. Contractor Work Hours

Normal work hours for this project are:

8:00 a.m. to 7:00 p.m., Monday through Friday Extended hours may be approved in advance by written request.

10. Final Inspection

The City will perform a Final Inspection upon Substantial Completion. The contractor may be present during this inspection. All required corrections shall be completed at the contractor’s expense prior to Final Acceptance.

11. Liquidated Damages

To ensure timely completion, liquidated damages will be assessed as follows:

• $300.00 per calendar day for failure to achieve substantial completion by the contract completion date (excluding punch list work).

• $150.00 per calendar day for failure to complete punch list items within 30 calendar days after the issuance of the punch list.

Liquidated damages will be deducted from retainage held by the City.

12. Schedule Submittals

The contractor shall submit a Progress Schedule upon Notice of Award.

Additionally, the contractor shall submit a two-week advance schedule every Friday by 2:00 p.m., outlining planned activities for the upcoming week to the Director of Public Works, Shawn Wood (swood@madisonga.com).

mailto:(swood@madisonga.com

13. Budget Details

The City of Madison intends to fund this project using Special Purpose Local Option Sales Tax (SPLOST) funds. No grant funding is anticipated for this project. Bidders may include recommendations for cost efficiencies, if applicable.

Section III – Required Documents The City reserves the right to determine that no bids meet the minimum requirements and to reject any or all submissions if deemed in the City’s best interest.

ITB package must include the following:

1. Narrative describing their proposed construction approach, including:

• Staffing

• Sequencing

• Coordination strategies

• Materials

• Maintenance requirements

• Any proposed alternatives to the plans must be clearly described and may be accepted or rejected at the City’s discretion.

2. Cost Bid Form (Provided)

3. Required for Contractors and Sub-Contractors with employees:

• W-9 Form (Provided)

• E-Verify & Save Affidavits

• Certificate of Insurance (COI)

4. Notarized Contractor Affidavit (Provided)

5. Notarized Bid Bond Form (Provided)

6. Proposed List of Subcontractors Form (Provided)

7. Project manager and superintendent qualifications (one page per person)

8. References Form (3 minimum) (Provided)

9. Related Experience (3 minimum)

• Each experience listed must include duration to complete project, proposed budget and actual cost of completed project, list of change orders with reasons, type of project and square footage, picture of completed project, and proposed cost as well as actual cost.

10. Contractor License

11. Acknowledgment of any Addendum issued with each Addendum

12. Notarized Oath of Non-Collusion (Provided)

13. Contact Form (Provided)

14. Signed Independent Contractor Agreement with Exhibit A & B (Provided as Separate Attachment)

15. Exhibit C - Architect's Bid Set (Provided as Separate Attachment)

Section IV – Instructions to Bidders From the date this ITB is issued until a contract is awarded, Bidders are prohibited from contacting any City of Madison staff or elected officials regarding this solicitation, except through the authorized point of contact identified below.

Any unauthorized communication may result in disqualification from further consideration.

Submission Deadline: All Bids received after this deadline will not be considered. Late or misdirected bids (including those delayed by mailing/ shipping services) will be rejected and unopened.

Envelopes must be marked “Andrews Park Bathroom ITB”. Bids must be physically delivered to the following address, no email bids accepted. Submit three (3) printed copies and one (1) digital PDF copy on USB Drive of each bid no later than March 13th, 2026 at 2:00PM EST to:

City of Madison Attn: Laurinda Mason 132 N. Main St. Madison, GA. 30650 lmason@madisonga.com 706-752-5596

A. Inquiries

Bidders with questions, requests for clarification, or interpretation of any portion of this ITB must submit questions to Laurinda Mason by email to lmason@madisonga.com.

Questions must be received no later than February 18th, 2026. Questions received after the deadline may not be considered.

B. Answers

Responses to inquiries and requests for clarification will be issued by the City in the form of a written addendum by February 23rd, 2026.

It is the responsibility of each Bidder to check regularly for any updates or additional information related to this ITB.

C. Addenda

The City may revise this ITB by issuing an addendum prior to the submission deadline. All addenda will be posted on the state and City’s procurement websites no later than February 23rd, 2026 and shall become part of the official ITB documents.

Bidders must acknowledge receipt of each addendum with their submission. Failure to comply with any issued addendum may result in rejection of the Bid.

In the event of significant revision, the City may extend the submission deadline to allow

Bidders adequate time to adjust their Bids.

mailto:lmason@madisonga.com

Bid Opening will take place on March 13th, 2026 at 2:15pm EST, at 160 N Main St, Madison, GA 30650.

Section V – Basis for Award The City of Madison anticipates that contract will be awarded to the responsive and responsible bidder who provides lowest bid within the budget. The City reserves the right to reject any or all bids, to waive technicalities or informalities, and to re-advertise the project if deemed in the City’s best interest. The City is not obligated to award the contract to the Bidder submitting the lowest price if contractor fails to meet all requirements included in this ITB or if City has any reason they deem appropriate for not awarding contract.

The City may request clarification of scope refinements, pricing, or schedule adjustments prior to awarding a contract.

Notice of Award will be sent to the selected contractor contingent on Mayor and Council approval of the construction agreement/contract.

Section VI - Terms and Conditions All bids, supporting materials, and correspondence submitted in connection with this ITB become the property of the City of Madison upon receipt.

If a Bid contains proprietary information, it must be clearly identified; however, blanket designations marking the entire submission as proprietary will not be accepted.

1. Compliance with Laws All applicable federal, state, and local laws, ordinances, regulations, and licensing requirements shall apply.

Firms or individuals requiring special licenses must be properly licensed in the State of Georgia.

2. Disqualification Criteria No bids will be accepted from any firm or individual who is in default or indebted to the City or otherwise deemed irresponsible or unreliable.

3. Financial Capacity The City reserves the right to request evidence of Bidder’s financial stability and ability to perform the required services.

4. Communication Restriction From the issuance of this ITB until award, Bidders shall not contact City staff or elected officials regarding this solicitation except through the authorized Procurement Agent.

Unauthorized contact may result in disqualification.

Contact Information:

Procurement Agent – Laurinda Mason Phone: 706-752-5596 Address: 132 N Main St. Madison, GA 30650

5. Cost of Submittal All costs associated with preparing and submitting a Bid are the sole responsibility of the Bidder. The City shall not reimburse any such expenses.

6. City Rights and Reservations Issuance of this ITB does not obligate the City to make an award. The City reserves the right to:

1. Cancel or withdraw this ITB at any time;

2. Reject any or all Bids;

3. Waive informalities or irregularities;

4. Request additional information or clarification;

5. Make partial or multiple awards if in the City’s best interest; and

6. Terminate any resulting contract if funding is not available.

7. Contract Requirements The selected bidder will serve as the prime contractor and be fully responsible for the performance of all subcontractors.

All subcontractors must be identified in the bid and approved by the City. Nothing in this ITB or any resulting contract shall create a contractual relationship between the City and any subcontractor.

8. Contract Term The contract term and renewal options shall be as stated in the final agreement executed by the City of Madison.

BIDDER’S CHECKLIST

1. Read the entire document. Note critical items such as supplies/services required; submittal dates; number of copies required;

contract requirements, if any (e.g. bonding and insurance requirements).

2. Note the Procurement Agent’s name, address, phone numbers, and e-mail address. This is the only person you are allowed to communicate with regarding the ITB and is an excellent source of information.

3. Take advantage of the “question and answer” period. Submit your questions to the Procurement Agent by the due date listed in the ITB and view the answers given in any formal “addenda” issued for the ITB.

4. Follow the format required in the ITB when preparing your Bid. Provide point-by-point responses to all sections in a clear and concise manner

5. Provide complete answers/descriptions. Read and answer all questions and requirements. Don’t assume the City will know what your company’s capabilities are or what items/services you can provide, even if you have previously contracted with the City. Bids are evaluated based solely on the information and materials provided in the ITB

6. Use the forms provided, e.g. cover page, reference questionnaire, etc.

7. Review the ITB document again to make sure that you have addressed all requirements. Your original Bid and the requested copies must be identical and complete.

8. Submit your Bid on time. Note all the dates and times listed in this ITB and be sure to submit all required items on time. Late Bids will not be accepted.

ITB #2026-Andrew’s Andrews Park Restroom Facility Project

Cost Bid

LUMP SUM COST BID:

Furnish all labor, materials, equipment, and incidentals necessary for the construction of the referenced project in accordance with the specifications as specified in the Scope of Work.

Lump Sum: $ (Figures)

Please print or type

Bid Price Certification

In compliance with the attached specification, the undersigned understands the minimum scope requirements of the City of Madison for this project.

The undersigned offers and agrees that if this Bid is accepted by the Mayor and City Council within one hundred eighty (180) days of the date of Bid opening, that the undersigned will furnish any or all deliverables and additional services offered, at the quoted price, to the designated point(s) within the time specified.

DATE

COMPANY

ADDRESS

AUTHORIZED SIGNATURE

PRINT / TYPE NAME

PHONE NUMBER

EMAIL ADDRESS

GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT AFFIDAVIT

GEORGIA E-Verify and Public Contracts: The Georgia E-Verify law requires contractors and all sub-contractors on Georgia public contract (contracts with a government agency) for the physical performance of services over $2,499 in value to enroll in E-Verify, regardless of the number of employees.

Contractor Name:

Solicitation/Bid number or Project Description:

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, entity or corporation which is engaged in the physical performance of services under a contract on behalf of the City of Madison, Georgia has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91.

Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period as required by O.C.G.A. § 13-10-91(b) and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number Date of Authorization (EEV/E-Verify Company Identification Number)

Name of Contractor

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

Printed Name (of Authorized Officer or Agent of Contractor) Title (of Authorized Officer or Agent of Contractor)

Signature (of Authorized Officer or Agent) Date Signed

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE

DAY OF , 20

[NOTARY SEAL]

Notary Public

My Commission Expires:

BID BOND

KNOW ALL MEN BY THESE PRESENTS, THAT

(Name of Contractor) at

(Address of Contractor)

(Corporation, Partnership and / or Individual) hereinafter called Principal, and

(Name of Surety)

(Address of Surety)

A corporation of the State of , and a surety authorized by law to do business in the State of Georgia, hereinafter called Surety, are held, and firmly bound unto

(Name of Obligee) City of Madison Georgia

(Address of Obligee) 132 N Main St, Madison, GA 30650

Hereinafter referred to as Obligee, in the penal sum of Dollars ($ ) in lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators and successors, jointly and severally, firmly by these presents.

WHEREAS, the Principal is about to submit, or has submitted, to the City of Madison, Georgia, a Bid for furnishing materials, labor, and equipment for:

ITB # 2026-Andrew’s Andrews Park Restroom Facility Project

WHEREAS, the Principal desires to file this Bond in accordance with law in lieu of a certified Bidder’s check otherwise required to accompany this Bid.

NOW, THEREFORE, the conditions of this obligation are such that if the Bid is accepted, the

Principal shall within ten days after receipt of notification of the acceptance execute a Contract in accordance with the Bid and upon the terms, conditions, and prices set forth in the form and manner required by the City of Madison Georgia, and execute a sufficient and satisfactory

Performance Bond and Payment Bond payable to the City of Madison, Georgia, each in an amount of 100% of the total Contract Price, in form and with security satisfactory to said the

City of Madison, Georgia, and otherwise, to be and remain in full force and virtue in law; and the

Surety shall, upon failure of the Principal to comply with any or all of the foregoing requirements within the time specified above, immediately pay to the City of Madison, Georgia, upon demand, the amount hereof in good and lawful money of the United States of America, not as a penalty, but as liquidated damages.

PROVIDED, FURTHER, that Principal and Surety agree and represent that this bond is executed pursuant, to and in accordance with the applicable provisions of the Official Code of Georgia Annotated, as Amended, including, but not limited to, O.C.G.A. § 13-10-20, et. Seq. And § 36- 91-50, et.

Seq. and is intended to be and shall be constructed as a bond in compliance with the requirements thereof.

Signed, sealed, and dated this day of A.D., 20 .

ATTEST:

(Principal Secretary) (Principal)

(SEAL) BY:

(Witness to Principal) (Address)

(Address) (Surety)

ATTEST:

BY:

(Attorney-in-Fact) and Resident Agent

(Attorney-in-Fact)

(Address)

(SEAL)

(Witness as to Surety)

PROPOSED SUBCONTRACTOR FORM: ITB 2026-Andrews Please complete this form and return it as part of the submitted Bid package. Name of Bidder

1. Subcontractor Name:

% of Bid Amount:

Description of Work provided:

2. Subcontractor Name:

% of Bid Amount:

Description of Work provided:

3. Subcontractor Name:

% of Bid Amount:

Description of Work provided:

4. Subcontractor Name:

% of Bid Amount:

Description of Work provided:

REFERENCES FORM: ITB 2026-Andrew’s

Please complete this form and return it as part of the submitted Bid package.

Name of Bidder

REFERENCE #1

Contact Name:

Contact Number/Email

Brief Description of work provided:

REFERENCE #2

Contact Number/Email:

REFERENCE #3

Contact Number/Email:

Please complete and submit in Bid package

OATH OF NON-COLLUSION

COMES NOW, (“Contractor”), [name of Contractor] appearing by and through , [name of individual with authority to bind Contractor] its (“Individual And Representative Affiant”), and [title]

[insert the names of all those required to give the oath]

(collectively, “Individual Affiants”), and each of the Individual And Representative Affiant and

Individual Affiants, after first being duly sworn, deposes and says that:

1. Affiant is the ______________________________ of the Contractor and is duly authorized to make this affidavit on behalf of the Contractor.

2. Contractor has not directly or indirectly violated subsection (d) of the Official Code of Georgia Annotated § 36-91-21, which provides in part that:

Whenever a public works construction contract for any governmental entity subject to the requirements of this chapter is to be let out by competitive sealed bid or competitive sealed Bid, no person, by himself or herself or otherwise, shall prevent or attempt to prevent competition in such bidding or Bids by any means whatever. No person who desires to procure such work for himself or herself or for another shall prevent or endeavor to prevent anyone from making a bid or Bid therefor by any means whatever, nor shall such person so desiring the work cause or induce another to withdraw a bid or Bid for the work.

3. Contractor has not colluded, conspired, agreed, or arranged with any other Bidder, bidder, firm, or person to submit a collusive or sham Bid, to refrain from submitting a Bid, or to submit a Bid at a predetermined price or condition.

4. Contractor has not communicated with any other Bidder regarding pricing, scope, intent to submit a Bid, or any other matter that would restrict or prevent fair and open competition.

5. Contractor has not offered, given, solicited, or accepted any inducement, gratuity, or thing of value in connection with this Invitation to Bid.

6. This affidavit is made in connection with the submission of a Bid for:

ITB No.:2026-6200-01 Project Name: Andrews Park Restroom Facility Project Owner: City of Madison, Georgia

Further affiants sayeth not.

This day of , 20 .

By: , individually and on behalf of Contractor

[signature of Individual and Representative Affiant]

Name: Title:

Individual Affiants’ signatures and names:

Name: Name:

Subscribed and Sworn before me on this day of , 20 .

NOTARY PUBLIC

Contact Information Form

Please fill out this form with the appropriate contact information for your company.

Full Legal Name of Company:

Date:

Contractor Information:

Primary Contact Person:

Title: Telephone Number:

E-mail Address:

Secondary Contact Person:

Title: Telephone Number:

E-mail Address:

Preferred Contact for Administration: (i.e. Document Processing) (Choose one)

☐ Primary Contact ☐ Secondary Contact

Address:

City / State / Zip:

Mailing Address (If different than above):

City / State / Zip:

Federal Employee ID Number (FEIN):

D New Vendor □Changes to Vendor

MADISON

D Updated-Year _____ _

VENDOR REQUEST FORM

l 'cndor T) pc

D One time vendor

D Customer Deposit Refund

D Employee

D Regular

D Contract Labor

Vendor lnfinnwtion

Name (Last, First) or Company

Address# 1

Address# 2

City

State

Federal ID#

Contact Person

E-Mail Address Phone#

1099 Vendor DYES ONO

City of Madison 132 N. Main Street P.O. Box 32

Accounts Payable Use Only:

Date:

Requested By:

Approved:

Vendor#

W - 9 Attached DYES ONO

Zip Code or Social Security #

Brief description of type of work/product being provided

CONFIDENTIALITY NOTICE

[IIIIRil Madison, Georgia 30650

(706) 342-1251

This document and the information contained herein is provided for the City of Madison and is considered confidential and privileged. The information is only for the use of the City of Madison. Review, disclosure, copying, distribution or any action in reliance upon the contents of the information by person or persons other than the City of Madison is strictly prohibited

CITY OF MADISON

P O Box 32

Madison, GA 30650

(706) 342-1251

Contractor (E-Verify) Affidavit under O.C.G.A. §13-10-91(b)(1)

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of the City of Madison has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Exempt/No Employees (Driver’s License Presented with Affidavit)

E-Verify/Federal Work Authorization User Identification Number

Date of Authorization

Name of Contractor

Name of Project

Name of Public Employer

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

Executed on _____, _____, 20__ in ________________(city), ________ (state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE _____ DAY OF ________________, 20___.

NOTARY PUBLIC

SAVE AFFIDAVIT

By executing this affidavit under oath, as an applicant for an occupational tax certificate, as referenced in

O.C.G.A. §50-36-1, from the City of Madison, the undersigned applicant verifies one of the following with respect to my application for a public benefit:

1) _________ I am a United States citizen.

2) _________ I am a legal permanent resident of the United States.

3) _________ I am a qualified alien or non-immigrant under the Federal Immigration and

Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency.

My alien number issued by the Department of Homeland Security or other federal immigration agency is: ____________________________.

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A. §50-36-1(e)(1), with this affidavit.

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. §16-10-20, and face criminal penalties as allowed by such criminal statute.

Executed in ________________________ (city), _______________________ (state).

Signature of Applicant

Printed Name of Applicant

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

____ day of __________, 20___.

Notary Public My commission expires: ___________

Official Use Only The secure and verifiable document provided with this affidavit can best be classified as:

__U.S. Passport __U.S. Driver’s License __Alien Registration Card __Merchant Mariner Card __SENTRI Card __Certificate of Naturalization

__U.S. Passport Card __Tribal ID Card __Foreign Gov. Passport __Free & Secure Trade Card __Canadian Driver’s License __Matricula Consular ID

__U.S. Military ID __U.S. Permanent Resident Card __Employment Authorization Card __Nexus Card __Certificate of Citizenship

____Copy of Document Attached

Verified By:________________________________ Date____________________

MWatkins Typewritten Text Form must included a copy of one of the documents listed below.

Notary public is available at the City of Madison.

mwatkins Highlight

Form W-9 (Rev. December 2014)

Internal Revenue Service

Request for Taxpayer Identification Number and Certification

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

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

Business name/disregarded entity name, if different from above

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

Requester’s name and address (optional)

7 List account number(s) here (optional)

6 City, state, and ZIP code

Trust/estate

Part I

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.)

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)

Social security number

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. or

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.

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. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

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. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

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

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

Sign Here

Signature of

U.S. person

Employer identification number

P ri n t o r ty p e

S e e S p e c if ic I n s tr u c ti o n s o n p a g e http://www.irs.gov/fw9

Page 2 Form W-9 (Rev. 12-2014)

Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S.

person if you are:

• An individual who is a U.S. citizen or U.S. resident alien;

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;

• An estate (other than a foreign estate); or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States:

• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4. The type and amount of income that qualifies for the exemption from tax.

5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years.

However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup Withholding

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive 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 be subject to backup withholding if:

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

2. You do not certify your TIN when required (see the Part II instructions on page 3 for details),

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

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable 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 Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

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

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note. ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c. Partnership, LLC that is not a single-member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. 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 line 2.

e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Page 3 Form W-9 (Rev. 12-2014)

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3.

Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the “Limited Liability Company” box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the “Limited Liability Company” box and in the space provided enter “C” for C corporation or “S” for S corporation. If it is a single-member LLC that is a disregarded entity, do not check the “Limited Liability Company” box; instead check the first box in line 3 “Individual/sole proprietor or single-member LLC.”

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code.

• Generally, individuals (including sole proprietors) are not exempt from backup withholding.

• Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

• Corporations are not exempt from backup…