Att H - Affidavit of Eligibility.docx

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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