Appendix C _ Required Forms.pdf

ITB #2025005 Various LED Monument Sign Replacement for Clayton County Public Schools

APPENDIX C

REQUIRED FORMS

RESPONSE SUBMISSION FORM

This form must be completed in its entirety and signed by the authorized representative or official submitting the response. This completed and signed form must be returned with each response. Failure to do so may render a bid non-responsive.

Company Name:

Mailing Address:

(Street, City, State, Zip Code)

Email Address:

Phone Number:

Fax Number:

Social Security or Tax ID#:

Name of Authorized Representative: (printed or typed only)

Title of Authorized Representative:

Signature of Authorized Representative:

Date of Signature:

CONTRACTOR AFFIDAVIT AND

AGREEMENT

CCPS, Req. Form 1, 08/2016

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 for services on behalf of Clayton County Board of Education. (name of public employer), 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 sub-Contractors 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

Name of Contractor

Name of Project

Clayton County Board of Education 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 MEONTHIS THE DAY OF .

20 .

NOTARYPUBLIC

My Commission Expires:

SUB-CONTRACTOR AFFIDAVITAND AGREEMENT CCPS, Req. Form 2,08/2016

By executing this affidavit, the undersigned Sub-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 under a contract with (name of Contractor) on behalf of the Clayton County Board of Education 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 Sub-contractor will continue to use the federal work authorization program throughout the contract period and the undersigned Sub-contractor will contract for the physical performance of services in satisfaction of such contract only with Sub-Sub-Contractors who present an affidavit to the Sub-contractor with the information required by O.C.G.A. § 13-10-91(b). Additionally, the undersigned Sub-contractor will forward notice of the receipt of an affidavit from a Sub- Sub-contractor to the Contractor within five business days of receipt. If the undersigned Sub-contractor receives notice of receipt of an affidavit from any Sub-Sub-contractor that has contracted with a Sub- Sub-contractor to forward, within five business days of receipt, a copy of such notice to the Contractor. Sub-contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

ITB #2025005 Various LED Monument Sign Replacement for Clayton County Public Schools Name of Project

SUBSCRIBED AND SWORN BEFOREME ON THIS THE DAY OF 20 .

NOTARY PUBLIC

SUB-SUBCONTRACTOR AFFIDAVITANDAGREEMENT CCPS, Req. Form 3,08/2016

By executing this affidavit, the undersigned Sub-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 under a contract with (name of Contractor) on behalf of the Clayton County Board of Education 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 Sub-contractor will continue to use the federal work authorization program throughout the contract period and the undersigned Sub-contractor will contract for the physical performance of services in satisfaction of such contract only with Sub-Sub-Contractors who present an affidavit to the Sub-contractor with the information required by O.C.G.A. § 13-10-91(b). Additionally, the undersigned Sub-contractor will forward notice of the receipt of an affidavit from a Sub- Sub- contractor to the Contractor within five business days of receipt. If the undersigned Sub- contractor receives notice of receipt of an affidavit from any Sub-Sub-contractor that has contracted with a Sub- Sub-contractor to forward, within five business days of receipt, a copy of such notice to the Contractor. Sub-contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

ITB #2025005 Various LED Monument Sign Replacement for Clayton County Public Schools Name of Project

SUBSCRIBED AND SWORN BEFOREMEONTHIS THE DAY OF 20 .

NOTARY PUBLIC

CCPS, Req. Form 4, 8/2016

CCPS, Req. Form 5, 08/2016

ITB #2025005

VARIOUS LED MONUMENT SIGN REPLACEMENT

FOR CLAYTON COUNTY PUBLIC SCHOOLS

BIDDER REPRESENTATIONS AND DECLARATIONS

This Acknowledgement of Representations and Declarations and Agreement must be properly signed and notarized, and returned with Bidders response to this ITB.

1. Anti-Lobbying Provision. All respondents, including agents, personnel, representatives, lobbyists, attorneys and proposed partner(s), subcontractor(s) or joint venturer(s), will refrain, under penalty of the respondent’s disqualification, from direct or indirect contact for the purpose of influencing the selection or creating bias in the selection process with any person who may play a part in the selection process.

2. Certification of Independent Price Determination/Non-Collusion. Collusion and other anticompetitive practices among offerors are prohibited by city, state and federal laws. All Respondents shall identify a person having authority to sign for the Respondent who shall certify, in writing, as follows:

“I certify that this bid/bid is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a bid or offer for the same supplies, labor, services, construction, materials or equipment to be furnished or professional or consultant services, and is in all respects fair and without collusion or fraud. I understand collusive bidding is a violation of city, state and federal law and can result in fines, prison sentences, and civil damages awards. By signing this document, I agree to abide by all conditions of this solicitation and offer and certify that I am authorized to sign for this Respondent/Offeror.”

3. Prohibition on Kickbacks or Gratuities/Non-Gratuity. The undersigned acknowledges the following prohibitions on kickbacks and gratuities:

a. It is unethical for any person to offer, give or agree to give any employee or former employee a gratuity or an offer of employment in connection with any decision, approval, disapproval, recommendation, preparation or any part of a program requirement or a purchase request, influencing the content of any specification or procurement standard, rendering of advice, investigation, auditing or in any other advisory capacity in any proceeding or application, request for ruling, determination, claim or other particular matter pertaining to any program requirement or a contract or subcontract or to any solicitation or bitterer.

b. It is unethical for any employee or former employee to solicit, demand, accept or agree to accept from another person a gratuity or an offer of employment in connection with any decision, approval, disapproval, recommendation, preparation or any part of a program requirement or a purchase request, influencing the content of any specification or procurement standard, rendering of advice, content of any specification or procurement standard, rendering of advice, investigation, auditing or

(Page 1 of 4) in any other advisory capacity in any proceeding or application, request for ruling, determination, claim or controversy or other particular matter pertaining to any program requirement or a contract or subcontract or to any solicitation or bid therefor.

c. It is also unethical for any payment, gratuity or offer of employment to be made by or on behalf of a subcontractor under a contract to the prime Contractor or higher tier subcontractor or any person associated therewith as an inducement for the award of a subcontract or order.

4. Debarment. The undersigned Service Provider/Contractor provides this assurance and certification that they are not currently debarred from submitting bids or bids on contracts by any agency in the State of Georgia and the federal government, nor are they an agent of any person or entity that is currently debarred from submitting bids on contracts by any agency of the State of Georgia or the federal government.

5. Covenant of Non-Discrimination. The undersigned understands that it is the policy of CCPS to promote full and equal business opportunity for all persons doing business with the CCPS. The undersigned covenants that we have not discriminated, on the basis of race, color, religion, sex, gender, national origin or ethnicity, with regard to prime contracting, subcontracting or partnering opportunities.

6. Small Local Business Enterprise (SLBE) Program. The undersigned bidder/Bidder hereby state that they have read and understand the requirements and conditions as set forth in the CCPS Inclusivity in Purchasing, Small Local Business Enterprise Program, and that reasonable effort were made to support the CCPS in providing the maximum practicable opportunity for the utilization of SLBEs consistent with the efficient and economical performance of this contract. The Bidder/Bidder and any subcontractors shall file compliance reports at reasonable times and intervals with CCPS in the form and to the extent prescribed by. Compliance reports filed at such times as directed shall contain information as to the employment practices, policies, programs and statistics of Bidders/Bidders and their subcontractors/suppliers. The undersigned understands and agrees that if any of the statements and representations are made by the Bidder/Bidder knowing them to be false, or if there is a failure of the successful Bidder/Bidder to implement any of the stated agreements, intentions, objectives, goals and commitments set forth herein without prior approval of CCPS, then in any such events the Bidder/Bidder’s act or failure to act shall constitute a material breach of contract, entitling CCPS to terminate the Contract for default. The right to so terminate shall be in addition to, and not in lieu of, any other rights and remedies CCPS may have for other defaults under the Contract. Additionally, Bidder/Bidder will be subject to the loss of any future contract awards by the CCPS for a period of one (1) year.

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7. Certify Satisfaction of all Underlying Obligations. (If Applicable). If a Contract is awarded through this solicitation, then such Contractor should know that before final payment is made to a Contractor by CCPS, the Contractor shall certify to CCPS in writing, in a form satisfactory to CCPS, that all subcontractors, materialmen suppliers and similar firms or persons involved in the CCPS contract have been paid in full at the time of final payment to the Contractor by CCPS or will be paid in full utilizing the monies constituting final payment to the Contractor.

8. Bidder Declarations:

a. I, the undersigned, have carefully examined and fully understand the CCPS General Terms and Conditions and this solicitation in its entirety, including all required forms and Bidder Representations, and agree to conform with every requirement. I certify that I am legally authorized to make the statements and representations herein and sign this quote for the Bidder. Signing this form affirms that the Original Request for Bid Document has not been altered in anyway.

b. I certify that this offer is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting an offer for the same supplies, services, construction, or professional or consultant services, and is in all respects fair and without collusion or fraud. I understand collusive bidding is a violation of city, state and federal law and can result in fines, prison sentences, and civil damages awards. I agree to abide by all conditions of this solicitation and offer and certify that I am authorized to sign for this Bidder.

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Sign here if you are an individual:

Printed Name:

Signature: Date:

Subscribed and sworn to or affirmed by (name)this day of , 20 .

Notary Public of (state)

My commission expires:

Sign here if you are an authorized representative of a responding entity or partnership:

Printed Name of Entity or Partnership:

Signature of authorized representative:

Title:

Date: , 20

Subscribed and sworn to or affirmed by

(name), as the

(title) of

(entity or partnership name) this day of , 20 .

Notary Public of (state)

My commission expires:

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REFERENCE ANDRELEASE FORM CCPS, Req. Form 6, 08/2016

Please provide the information and contact person who will verify Contractor’s experience and ability to perform the services listed in the ITB. Submission of this form grants CCPS the authority to contact each reference listed. Please print legible or you may type the information.

Bidder Name:

Project Name:

Project Number:

Contract Period:

Contact Person: (Name and Title)

Email Address: Address

Telephone Number:

City State Zip Code

Project Name:

Project Number:

Authorized Signature: Date:

CCPS, Req. Form 7, 05/2024

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER

RESPONSIBILITY MATTERS; PRIMARY COVERED TRANSACTIONS

This Form Must Be Completed, Signed and Returned with Bid or Bid may be deemed Non-Responsive.

The Bidder , certifies to the best of its knowledge and that it and its principals: belief,

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal, State, or local department or agency.

2. Have not within a three-year period preceding this Bid 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) transaction or Contract under a public transaction; violation of Federal or State antitrust statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with the commission of any of the offenses enumerated in paragraph (2) of this certification; and

4. Have not within a three-year period preceding this application/Bid had one or more public transactions (Federal, State, or local) terminated for cause or default.

Where the Contractor is unable to certify to any of the statements in this certification, such participant shall attach an explanation to this Bid.

The Contractor, , certifies or affirms the truthfulness and accuracy of the contents of the statements submitted on or with this Certification and understands that the provisions of 31 U.S.C. Sections 3801 Et Seq., are applicable thereto.

Signature of Authorized Agent

Name/Title of Authorized Agent

Date

Witness

CCPS, Req. Form 8, 05/2024

NON-COLLUSION BIDDING CERTIFICATE

This Form must be Signed and Returned with the Bid or Bid may be deemed Non-Responsive.

By submission of this certificate, each Bidder and each person signing on behalf of any Vendor certifies under penalty of perjury, that to the best of its knowledge and belief:

1. The cost or prices to be negotiated shall have been arrived at independently without collusion, consultation, communication or agreement, for any purpose of restricting competition as to any matter relating to such costs or prices with any other Bidder or with any competitor.

2. Unless otherwise required by law, the cost or prices to be negotiated have not been knowingly disclosed by the firm prior to the opening of price negotiations, directly or indirectly to any other Bidder or to any competitor; and,

3. No attempt has been made or will be made by the Bidder to induce any person, partnership or corporation to submit or not submit a Statement of Qualifications for the purpose of restricting competition.

Signature of Authorized Agent:

Name/Title of Authorized Agent:

Date:

CCPS, Req. Form 9, 05/2024

CLAYTON COUNTY PUBLIC SCHOOLS CONFLICT OF INTEREST

This Form Must Be Signed and Return with Bid or Bid may be Deemed Non-Responsive.

I hereby certify that I am a principal and duly authorized agent of , and, it is also, whose address is , certifies that to the best of its knowledge there are no circumstances which shall cause a Conflict of Interest in performing services for Clayton County Public Schools.

Signature of Authorized Agent:

Name/Title of Authorized Agent:

Date: