ATTACHMENT A

SON # 98000-5619, Department of Community Affairs Security Assessment

RFQC # 98000-3088, Information Technology Security Services

ATTACHMENT A

CONTRACTOR INFORMATION FORM

All information on this page must be provided:

Offeror Name: ________________________________________

Contact Name/Title: ________________________________________

Address: ________________________________________

Telephone: ________________________________________

Contact Email: ________________________________________

STATEMENT OF RESPONSIBILITY

THIS FORM MUST BE COMPLETED, SIGNED, NOTARIZED AND SUBMITTED WITH YOUR

RESPONSE/PROPOSAL.

Please complete this form, answering every question. A “Yes” answer to any of the subparts of QUESTION NO. 3 requires a written explanation attached to the completed form, submitted on your company letterhead and signed by an authorized representative of the company. A “Yes” answer to any of the subparts of Question No. 3 will not necessarily result in denial of award but will be considered in determining Respondent responsibility in the event GTA undertakes an investigation into Respondent’s responsibility status. For any explanation, indicate to whom it applies; identify the initiating agency and the dates of action.

Respondents are responsible for updating any information submitted in their Statement of Responsibility Certification Form if a change occurs prior to the award of the contract.

QUESTIONS:

1. Does Respondent certify that it has, or has the ability to obtain, adequate financial resources to perform the Services and Deliverables identified in the Agreement? This includes, but is not limited to, the ability to obtain required bonds and insurance from sureties and insurance companies authorized to do business in Georgia.

YES NO

2. Does Respondent certify that it is their intent to comply with all contractual requirements and fulfill all of its contractual obligations if awarded the contract, considering Respondent’s other business obligations?

3. Within the past three (3) years, has Respondent’s company or any principal (e.g., any owner, partner, officer, or major stockholder with 10% or more shares) been the subject of any of the following:

a. judgment or conviction for any conduct constituting a felony under local, state or federal law, including, but not limited to, fraud, extortion, bribery, racketeering, labor, antitrust, price-fixing, or bid collusion?

b. a criminal investigation or indictment for any conduct constituting a felony under local, state or federal law, including, but not limited to, fraud, extortion, bribery, racketeering, price-fixing, or bid collusion (to the best of Respondent’s knowledge*)?

c. an unsatisfied judgment, injunction or lien obtained by a Georgia state government agency including, but not limited to, judgments based on taxes owed and fines and penalties assessed by any Georgia state government agency?

d. an investigation for a civil violation by any local, state or federal agency (to the best of Respondent’s knowledge*)?

e. a suspension, debarment or termination for cause from any local, state or federal government procurement process?

f. a suspension or termination for cause prior to the completion of the term of any local, state or federal government contract?

g. a denial of award for non-responsibility determination made by any local, state or federal government?

h. an agreement to a voluntary exclusion from bidding/contracting on any local, state or federal procurement?

i. an administrative proceeding or civil action seeking specific performance or restitution in connection with any local, state or federal procurement (to the best of Respondent’s knowledge*)?

j. any bankruptcy proceeding?

CERTIFICATION:

The undersigned: (i) recognizes that this questionnaire is submitted for the express purpose of assisting the Georgia Technology Authority (GTA) to make a determination regarding the eligibility for award of a contract, or to approve a subcontract; (ii) acknowledges that the GTA, the State of Georgia, its agencies and political subdivisions may, in their sole discretion, by means which they may choose, verify the truth and accuracy of all statements made herein;

(iii) acknowledges that submissions of false or misleading information may constitute fraud, may result in ineligibility for contract award, may be used as grounds for termination for default of any contract awarded in relation to this certification, may be considered by the GTA, the State of Georgia, its agencies and political subdivisions in making responsibility determinations in other procurements, and may subject the Respondent or its representatives to criminal liability;

(iv) as the authorized representative of the Respondent, states that the information submitted on this certification form and any attached pages is true, accurate and complete.

The undersigned hereby attests that he/she is duly authorized by the Respondent to make the statements and representations contained herein and/or attached hereto, on behalf of such Respondent.

Legal Name of Respondent’s Company

Signature of Respondent’s Authorized Representative

Printed Name of Respondent’s Authorized Representative/Title

Company Address

City, State, Zip

State of

County of

. Sworn to and subscribed before me on this day of

Notary Public:

My Commission Expires:

Note: *As used herein, the term “to the best of Respondent’s knowledge” shall refer to the current actual knowledge of Respondent and shall be construed, by imputation or otherwise, to refer to the knowledge of any agent, manager, representative or employee of Respondent but does not impose upon Respondent any duty of inquiry or investigation of the matter to which such actual knowledge, or the absence thereof, pertains. The fact that Respondent (or their principals) are under investigation will not necessarily result in a determination of non- responsibility; rather, GTA will determine if the information and circumstances regarding such investigation are of such a nature or magnitude as to cause the GTA to deem the respondent non-responsible in order to protect the interests of the GTA and/or the State.

STATEMENT OF WORK CERTIFICATION FORM

(Offeror must sign and return with bid in the Administrative Package)

1. I certify that, if awarded a contract, I, the Offeror will deliver goods and services as provided in its SON response, which will meet or exceed the specifications set forth in this SON and the terms of the fully executed contract 98000- 3088, RFQC for Information Technology Security Services.

2. I certify on behalf of the Offeror that this Bid is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a bid for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud. I understand that collusive bidding is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards. I agree to abide by all conditions of the Bid and certify that I am authorized to sign this Bid for the Offeror.

3. I certify that the Offeror has not violated and will not violate the provisions of the Official Code of Georgia Annotated, Section 45-10-20 ET. seq.

4. OFFEROR MUST CHECK ONE OF THE CERTIFICATIONS BELOW:

4a. I certify on behalf of the Offeror that no lobbyists have been employed or retained by Offeror in regards to this procurement or its underlying contract in a manner that would invoke the Executive Order dated October 1, 2003 (“Providing for the Registration and Disclosure of Lobbyists Employed or Retained by Vendors to State Agencies”).

OR

4b. I certify that the Offeror and all lobbyists that have been employed or retained by Offeror in regards to this procurement or its underlying contract have complied with all of the requirements of the Executive Order dated October 1, 2003 (“Providing For The Registration And Disclosure Of Lobbyists Employed Or Retained By Vendors To State Agencies”) and GTA’s Vendor Lobbyist Policy. I further certify that Offeror and its lobbyists will continue to comply with such Executive Order until this procurement process concludes. I understand and acknowledge that such requirements include, without limitation, the requirement to register with the Georgia State Ethics Commission and to file the disclosures required by Article 4 of Chapter 5 of Title 21 of the Official Code of Georgia Annotated.

[Offeror shall submit a list of all lobbyists employed or retained for this procurement along with their Bid]

Authorized Signature: __________________________________Date: _____________ Print/Type Name: _____________________________ Print/Type Company Name: _______________________________