Att H - Affidavit of Eligibility.docx
DOCX document 221 KB Posted
- Attached to
- Negotiated Bid 26-87559 DNR AmmunitionBid Documents State and local contract opportunity
- Solicitation number
- 26-87559
- Issued by
- Johnson County, Indiana
About this file
This is an Affidavit of Eligibility form issued by the Indiana Department of Administration, Procurement Division, establishing criteria for businesses seeking a 15% price preference under Indiana Code 5-22-15-26 for specialized employee services contracts awarded by state agencies. The affidavit documents that a business meets all statutory requirements to claim the preference, requiring submission with solicitation event attachments. No specific products, services, quantities, response dates, due dates, site visits, bidder meetings, award dates, or contract terms are outlined in this form, as it serves as a qualification and eligibility verification document rather than a procurement solicitation.
The affidavit establishes four core eligibility requirements for businesses providing specialized employee services: at least 75% of employees must be Indiana residents meeting specific 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 providing transitional services, job skills training, or social skills assistance; and the business must provide employees with health, vision, dental insurance and retirement savings access. The signed affidavit remains valid for one year from the IDOA Procurement CPO signature date and becomes invalid if the business no longer meets eligibility requirements. Businesses are responsible for maintaining and submitting copies of the signed affidavit with each solicitation event.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Att A - MWBE_Neg Bid.docx | DOCX document | |
| Att B - PO Terms.docx | DOCX document | |
| Negotiated Bid Main Document 26-87559.docx.pdf | ||
| Att D - Cost Proposal Template.xlsx | XLSX spreadsheet | |
| Att A1 - IVOSB_Neg Bid.docx | DOCX document | |
| Att F - Attestation Form.docx | DOCX document | |
| Att G - Preferences.docx | DOCX document | |
| Att C - Indiana Economic Impact Form.xls | XLS spreadsheet | |
| Att E - Q&A 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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File details come from the government source that posted it. Updated .