Attachment_1_Forms_Packet.pdf

Form #1 – Acknowledgement Form Page 1 of 1

City of Sarasota Submittal Acknowledgement

Solicitation Number: _____________

Solicitation Title: _____________________________________________________________

Company Name: ______________________________________________________________

Company Address: ____________________________________________________________

Company City: ___________________________ Company State: ______ Company ZIP: _________

Contact Name: ______________________________________________________________________

Contact Phone Number (include area code): ______________________________________________

Contact Email (Required): ____________________________________________________________

Are you claiming local preference: YES NO If yes, you must include Form #6 Local Vendor Certification.

(1) Employer Identification Number -or- (2) Social Security Number: ** The City of Sarasota collects your social security number for tax reporting purposes: ______________________________________

In submitting this Solicitation, the respondent makes all representations required by the Instructions to respondent and further warrants and represents that: Respondent has examined copies of all the Solicitation Documents and acknowledges that all addenda have been reviewed.

Addendum No.________ through Addendum No.__________

City of Sarasota, Sarasota, Florida In the event of an emergency, Respondent will provide priority service for the City of Sarasota.

CONTINUITY OF OPERATION DURING EMERGENCY? YES NO

The undersigned, as Respondent, hereby declares that no person or other persons other than the undersigned are interested in this Solicitation as Principal, and that this Solicitation is made without collusion with others;

and that we have carefully read and examined the specifications, and with full knowledge of all conditions under which the services herein is contemplated must be furnished, hereby propose and agree to furnish this service according to the requirements set out in the specifications for said service for the prices as listed on the previous pages.

THIS FORM MUSE BE SIGNED BY A PERSON AUTHORIZED TO ENTER INTO CONTRACTS FOR THE COMPANY.

Name of Respondent (Print or Type)

Title of Respondent

Signature of Respondent

Your firm must be authorized to conduct business in the State of Florida, as provided by the Florida Department of State, Division of Corporations.

https://dos.myflorida.com/sunbiz/ https://dos.myflorida.com/sunbiz/

Form# 2 – Interest in Competitive Bid Page 1 of 1

FORM 3A INTEREST IN COMPETITIVE BID FOR PUBLIC BUSINESS

LAST NAME, FIRST NAME, MIDDLE NAME

OFFICE POSITION HELD

MAILING ADDRESS

AGENCY

CITY, STATE, ZIP, COUNTY ADDRESS OF AGENCY

WHO MUST FILE THIS STATEMENT

Sections 112.313(3) and 112.313(7), Florida Statutes, prohibit certain business relationships on the part of public officers and employees, their spouses, and their children. See Part III, Chapter 112, Florida Statutes and/or the brochure entitled "A Guide to the Sunshine Amendment and Code of Ethics for Public Officers, Candidates and Employees" for more details on these prohibitions.

However, Section 112.313(12), Florida Statutes (1983), provides certain limited exemptions to the above-referenced prohibitions, including one where the business is awarded under a system of sealed, competitive bidding; the public official has exerted no influence on bid negotiations or specifications; and where disclosure is made, prior to or at the time of the submission of the bid, of the official's or his spouse's or child's interest and the nature of the intended business. The Commission on Ethics has promulgated this form for such disclosure, if and when applicable to a public officer or employee.

INTEREST IN COMPETITIVE BID FOR PUBLIC BUSINESS (Required by 112.313(12)(b), Florida Statute (1983))

1. The competitive bid to which this statement applies has been/will be (strike one) submitted to the following government agency:

2. The person submitting the bid is: Name Position

3. The business entity with which the person submitting the bid is associated is:

4. My relationship to the person or business entity submitting the bid is as follows:

5. The nature of the business intended to the transacted in the event that this bid is awarded is as follows:

a. The realty, goods and/or services to be supplied specifically include:

b. The realty, goods and/or services will be supplied for the following period of time: _______________________________________

c. Will the contract be subject to renewal without further competitive bidding? Yes ☐ No ☐ if so, how often? ___________________

6. Additional comments:

7. Signature

Date Signed

Date Filed

FILING INSTRUCTIONS

If you are a state officer or employee required disclosing the information above, please filing this form with the Secretary of State at the Capitol, Tallahassee, Florida 32301. If you are an officer or employee of a political subdivision of this state and are subject to this disclosure, please file the statement with the Supervisor of Elections of the county in which the agency in which you are serving has its principal office.

NOTICE: UNDER THE PROVISIONS OF FLORIDA STATUTES #112.317 (1983), A FAILURE TO MAKE ANY REQUIRED DISCLOSURE CONSTITUTES GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE FOLLOWING:

IMPEACHMENT, REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT, DEMOTION, REDUCTION IN

SALARY, REPRIMAND, OR A CIVIL PENALTY NOT TO EXCEED $5,000.00.

Form# 3 – Non-collusive Affidavit Page 1 of 1

NON-COLLUSIVE AFFIDAVIT

(Prime Contractor/Vendor)

State of ______________________

County of _____________________

___________________________________, being first duly sworn, deposes and says that they are (Name of corporate officer)

______________________________________, the party making the fore-going solicitation (Partner or officer of the firm, etc.)

is genuine and not collusive or sham; that said contractor/vendor has not colluded, conspired, connived or agreed, directly or indirectly, with any contractor/vendor or person, to put in a sham solicitation or to refrain from bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference, with any person, to fix the solicitation price of affiant or of any other contractor/vendor, or to fix overhead, profit or cost element of said solicitation price, or of that of any other contractor/vendor, or to secure any advantage against the City of Sarasota of any person interested in the proposed contract; and that all statements in said solicitation are true.

(Contractor/Vendor, if the Contractor/vendor is an individual, Partner, if the Contractor/vendor is a partnership, Officer, if the Contractor/vendor is a corporation)

(Company Name)

STATE OF ________________________

COUNTY OF _______________________

The foregoing instrument was acknowledged before me this ____ day of _______________ by

______________________________ (name and title of corporate officer) of ______________________________

(name of corporation), a ____________________ (state or place of incorporation) corporation, on behalf of the corporation. He/she is personally known to me or has produced ___________________ (type of identification) as identification.

(Signature line for notary public)

(Name of notary typed, printed or stamped)

(Title or rank)

My commission expires:

(Serial number, if any)

Form# 4 – Public Entity Crimes Page 1 of 2 SWORN STATEMENT UNDER SECTION 287.133(3)(a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES

This form must be signed and sworn to in the presence of a notary public or other officer authorized to administer oaths.

1. This sworn statement is submitted to_________________________________________________ (Print name of the public entity) by_____________________________________________________________________________ (Print individual’s name and title) for____________________________________________________________________________ (Print name of entity submitting sworn statement) whose business address is__________________________________________________________

(If applicable) its Federal Employer Identification Number (FEIN) is _______________________

(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement on the attached sheet.) Required as per IRS Form W-9.

2. I understand that a “public entity crime” as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including but not limited to, and bid or contract for goods or services to be provided to any public entity or agency or political subdivision or any other state or of the Unites States, and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

3. I understate that “convicted” or “conviction” as defined in Paragraph 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.

4. I understand that “affiliate” as defined in Paragraph 287.133(1)(a), Florida Statutes, means:

1. A predecessor or successor of a person convicted of a public entity crime.

or

2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term “affiliate” includes those offices, directors, executives, partners, shareholders, employees, members and agents who are active in the management of the affiliate.

The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not fair market value under an arm’s length agreement, shall be a facie case that one person controls another person. A person who knowingly enters into a join venture with a person who has been convicted of a public entity crime in Florida during the proceeding 36 months shall be considered an affiliate.

5. I understand that a “person” as defined in Paragraph 287.133(1)(c), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term “person” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of the entity.

6. Based on information and belief, the statement, which I have marked below, is true in relation to the entity submitting those sworn statements. (Please indicate which statement applies.)

Form# 4 – Public Entity Crimes Page 2 of 2

______ Neither the entity submitted this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity nor affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989.

______ The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, member, or agents who are active in management of the entity, or an affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989.

______ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, member, or agents who are active in management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearing and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order)

I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OR ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.

(Signature)

(Date)

STATE OF_________________________________

COUNTY OF_______________________________

PERSONALLY APPEARED BEFORE ME, the undersigned authority, _____________________________ (Name of individual signing) who, after first being sworn by me, affixed his/her signature in the space provided above on this_________ day of___________________, 2____.

(NOTARY PUBLIC)

My Commission Expires: _____________________________

Form# 5 – Drug-Free Workplace Page 1 of 1

DRUG-FREE WORKPLACE CERTIFICATION

Preference shall be given to businesses with drug-free workplace programs. Pursuant to Section 287.087, Florida Statutes, whenever two or more competitive solicitations that are equal with respect to price, quality, and service are received by the State or by any political subdivision for the procurement of commodities or contractual services, a response received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. Established procedures for processing tie responses will be followed if none of the tied providers has a drug free workplace program. In order to have a drug-free workplace program, a business shall:

1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

3. Give each employee engaged in providing the commodities or contractual services that are under proposal a copy of the statement specified in Subsection (1).

4. In the statement specified in Subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under proposal, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 894, Florida Statutes, or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction.

5. Impose a sanction on any employee who is so convicted or require the satisfactory participation in a drug abuse assistance or rehabilitation program as such is available in the employee's community.

6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of applicable laws, rules and regulations.

As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements.

RESPONDENT NAME AUTHORIZED SIGNATURE

Form #5A – Scrutinized Companies Certification Page 1 of 1

CERTIFICATION REGARDING SCRUTINZED COMPANIES LISTS

Respondent Name: __________________________________________________________________

Respondent’s Authorized Representative Name and Title:____________________________________

Address: __________________________________________________________________________

City: _________________________ State: _____________________________ Zip: ______________

Phone Number: _______________________________ Respondent FEIN: _____________________

Email Address:______________________________________________________________________

Section 287.135, Florida Statutes prohibits a company from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services of any amount if, at the time of contracting or renewal, the company is on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, or is engaged in a boycott of Israel. Section 287.135, Florida Statutes, also prohibits a company from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services of $1,000,000 or more, that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector Lists which were created pursuant to s. 215.473, Florida Statutes.

Certification:

As the person authorized to sign on behalf of Respondent, I hereby certify that the company identified above in the section entitled “Respondent Vendor Name” is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or the Scrutinized Companies that Boycott Israel List. I further certify that the company is not engaged in a boycott of Israel. I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject company to civil penalties, attorney’s fees, and/or costs.

Certified By: _______________________________________________________________________, who is authorized to sign on behalf of the above referenced company.

Authorized Signature:_______________________________________________________________

Print Name and Title:_______________________________________________________________

Form# 6b – Local Employee Certification Page 1 of 1

Employees:

City Residents: the employee’s residence is located within the City of Sarasota City limits

County Residents: the employee’s residence is located within Sarasota County, but outside the City of Sarasota City limits.

Non-Local Residents: the employee’s residence is located outside Sarasota County

Full-time Employees: The employee works greater than 30 hours per week or greater than 1560 hours per year.

Part-time Employees: The employee works less than 30 hours per week or less than 1560 hours per year.

Expected New Hire Employees: Employees expected to be hired to complete the work specified in this proposal.

Employee Residence Statistics: List number of employees in each category

City Residents County Residents Non-Local Residents TOTAL

Current Full-time Employees

Current Part-time Employees

Expected New Hire Full-time Employees

Expected New Hire Part-time Employees

Sub-Contractor’s Full-time Employees

Sub-Contractor’s Part-time Employees

Form# 7 – Subcontractor/subconsultant List Page 1 of 1

SUBCONTRACTORS LIST

Subcontractor/Subconsultant Name Area Of Work Point Of Contact Or

Project Supervisor Phone Number and Email

Qualifed

MBE

Yes/No

Amount or Percentage of

Total Bid

Please include subcontractors/subconsultants name, area of work (i.e. mechanical, electrical, etc..) and a valid phone number and email. Also include the dollar value or percentage that the subcontractor will be performing. If subcontractors qualify as MBE contractors, provide a copy of the State of Florida certification for each subcontractor/subconsultant listed certified in accordance with Section 287.0943 or 287.0943(1), Florida Statutes.

Form# 8 – Contractor Vendor Reference List Page 1 of 1

Contractor/Vendor References

Name of Company Submitting bid: __________________________________________________

References

Contact Person & Title:

Email Address Phone No.

Company Name:

Mailing Address:

City: State: Zip:

Type of commercial work contracted:

Contact Person & Title:

Email Address Phone No.

Company Name:

Mailing Address:

City: State: Zip:

Type of commercial work contracted:

Contact Person & Title:

Email Address Phone No.

Company Name:

Mailing Address:

City: State: Zip:

Type of commercial work contracted:

Contact Person & Title:

Email Addresss Phone No.

Company Name:

Mailing Address:

City: State: Zip:

Type of commercial work contracted:

Three of the references above will receive electronic surveys from the Purchasing Division. Email addresses are required. Please ensure that your references are willing to complete the electronic survey. Failure to received survey results may result in your company being declared nonresponsive.