Att G - Affidavit of Eligibility.docx
DOCX document 215 KB Posted
- Attached to
- DNR Fish FeedBid Documents State and local contract opportunity
- Solicitation number
- NB 26-88274
- Issued by
- Elkhart County, Indiana
About this file
This is an Affidavit of Eligibility document for a state and local contract opportunity. The affidavit serves as a certification form that bidders must complete to verify their eligibility to participate in the contracting process. The document is designed to be executed by authorized representatives of bidding entities and requires attestation of specific eligibility criteria established by the procuring agency. While the specific products, services, project scope, quantities, response dates, and contract terms are not detailed within this eligibility affidavit itself, this document functions as a mandatory prerequisite submission that bidders must provide alongside their formal proposals.
The affidavit requires bidders to make sworn statements regarding their legal status, business registration, and compliance with applicable regulations and statutes. Bidders must certify that they meet all requirements set forth by the procuring jurisdiction and that the information provided is accurate and truthful. This document typically includes provisions regarding penalties for false statements and requires notarization or official verification of the signatory's authority. The specific eligibility criteria, pricing terms, set-asides, incumbent preferences, and funding mechanisms would be outlined in accompanying solicitation documents rather than in this certification form. Submission of a completed and properly executed affidavit is generally a condition of proposal acceptance and bid evaluation.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Att C Cost Proposal.xlsx | XLSX spreadsheet | |
| Att D- Q&A Template.xlsx | XLSX spreadsheet | |
| Att A1 - IVOSB.docx | DOCX document | |
| Att F - Preferences.docx | DOCX document | |
| Att B - Sample Contract.docx | DOCX document | |
| Att H Fish Feed Specs.docx | DOCX document | |
| Negotiated Bid Main Document 26-88274 (1).pdf | ||
| Att E - Attestation Form.docx | DOCX document |
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Text version
STATE OF INDIANA
DEPARTMENT OF ADMINISTRATION
Commissioner’s Office
Indiana Government Center South 402 West Washington Street, Room W462 Indianapolis, IN 46204
Mike Braun, Governor
Attachment G
Affidavit of Eligibility (Affidavit) Per IC 5-22-15-26 Businesses providing specialized employee services
By submitting this document with the solicitation event attachments, the Business indicates eligibility for the 15% preference per IC 5-22-15-26.
Legal Name of Business:
Printed Name of Authorized Representative:
Email Address:
Phone Number:
Mailing Address:
Federal Tax Identification Number:
Bidder ID:
Mail the completed document to:
Indiana Department of Administration Procurement Division Attn: IDOA Procurement CPO 402 W Washington St – W468 Indianapolis, IN 46204
After IDOA review, the original signed form will be returned via US Mail to the above address provided. Therefore, please allow sufficient time for processing and return of signed affidavit.
By signing below, you as the authorize representative for the business, attest the business meets all the requirements of Indiana Code 5-22-15-26 as set forth below:
As used in this section, "business providing specialized employee services" refers to a business that satisfies all of the following:
(a) This section applies only to a contract awarded by a state agency
(b) As used in this section, “business providing specialized employee services” refers to a business that satisfies all of the following:
(1) Not less than seventy-five percent (75%) of the employees of the business are Indiana residents who meet at least one (1) of the following criteria:
(A) The employee is incarcerated or was formerly incarcerated.
(B) The employee is on probationary status.
(C) The employee is receiving government funded public assistance.
(D) The employee is a military veteran.
(2) The business pays a minimum wage of not less than thirteen dollars and fifty cents ($13.50) per hour.
(3) The business maintains a company representative to assist employees with at least one (1) of the following:
(A) Transitional services out of incarceration or probation.
(B) Job skills based training programs.
(C) Social skills training and assistance relating to personal finance and basic legal assistance.
(4) The business provides employees with health insurance, vision insurance, dental insurance, and access to retirement savings options.
(c) The Indiana department of administration shall determine whether a particular business meets the requirements of this section.
(d) There is a price preference of fifteen percent (15%) for supplies or services purchased from a business providing specialized employee services.
(e) A business that wants to claim a preference provided under this section must do all of the following:
(1) State in the business’s offer that the business claims the preference provided by this section.
(2) Provide information to the Indiana department of administration necessary to demonstrate that the business is a business providing specialized employee services.
Signature
Title
Printed Name
Date
IDOA signature below acknowledges the required representations have been made per IC 5-22-15-26.
Signature
IDOA Procurement CPO
Printed Name
Date
Please note IDOA does not maintain a copy of this affidavit; this is the Business’s responsibility to submit a copy of the signed form with each solicitation.
The signed Affidavit is valid for one (1) year from the date of IDOA signature.
The Supplier is required to cease use of the signed Affidavit in the event the business no longer is eligible under IC 5-22-15-26.
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File details come from the government source that posted it. Updated .