Att H - Affidavit of Eligibility.docx
DOCX document 221 KB Posted
- Attached to
- DNR AmmunitionBid Documents
- Solicitation number
- 27-87904
- Issued by
- Indiana
About this file
This is an Affidavit of Eligibility form issued by the Indiana Department of Administration's Procurement Division to establish eligibility for a 15% price preference under Indiana Code 5-22-15-26 for businesses providing specialized employee services on state contracts. The form requires authorized representatives to attest that their business meets all statutory requirements and must be submitted with solicitation event attachments to claim the preference. The completed affidavit should be mailed to the Indiana Department of Administration Procurement Division at 402 W Washington Street, W468, Indianapolis, Indiana 46204, where IDOA will review the submission and return the original signed form via U.S. Mail. Businesses should allow sufficient processing time for return of the signed affidavit.
To qualify for the 15% price preference, a business must satisfy four key requirements: at least 75% of employees must be Indiana residents meeting one of four criteria (formerly or currently incarcerated, on probationary status, receiving government-funded public assistance, or military veterans); the business must pay a minimum wage of $13.50 per hour; the business must maintain a company representative to assist employees with transitional services, job skills training, or social skills training; and the business must provide health insurance, vision insurance, dental insurance, and retirement savings options to employees. The signed affidavit remains valid for one year from the date of IDOA signature, and businesses are responsible for submitting a copy of the signed form with each solicitation and must cease use immediately if they no longer meet eligibility requirements.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Negotiated Bid Main Document (PURCHASE ORDER).docx | DOCX document | |
| Att I - Requirements.docx | DOCX document | |
| Att B - Sample Purchase Order T&C.docx | DOCX document | |
| Att A1 - IVOSB.docx | DOCX document | |
| Att E - Q&A Template.xlsx | XLSX spreadsheet | |
| Att C - Indiana Economic Impact Form.xlsx | XLSX spreadsheet | |
| Att G - Purchasing Preference Form.docx | DOCX document | |
| Att F - Attestation Form.docx | DOCX document | |
| Att D - Cost Proposal Template.xlsx | XLSX spreadsheet |
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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 H
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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