Attachment A

Proposal Certification Form

We propose the qualifications to furnish and deliver any and all of the goods and/or services named in the attached Request for Qualified Contractors (RFQC).

We further agree to strictly abide by all the terms and conditions contained in the Georgia Supplier Manual, located at: https://gta.georgia.gov/sites/gta.georgia.gov/files/GTAProcurementManual.pdf , and any modifications or attached special terms and conditions, all of which are made a part hereof.

Any exceptions are noted in writing and included with this bid.

It is understood and agreed that this proposal constitutes an offer, which when accepted in writing by the Agency, and subject to the terms and conditions of such acceptance, will constitute a valid and binding contract between the undersigned and the Agency.

It is understood and agreed that we have read the specifications shown or referenced in the RFQC and that this proposal is made in accordance with the provisions of such specifications. By our original signature, entered below, we guarantee and certify that all items included in this proposal meet or exceed any and all such stated specifications.

We further agree, if awarded a contract, to deliver goods and/or services that meet or exceed the specifications in any subsequent Statement of Need (SON) solicitation issued by the Georgia Technology Authority (GTA) as a result of this RFQC.

It is understood and agreed that this proposal shall be valid and held open for a period of one hundred twenty days from proposal opening date.

PROPOSAL SIGNATURE AND CERTIFICATION

(Bidder to sign and return with proposal)

I certify that this proposal is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a proposal for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud. I understand 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 proposal and certify that I am authorized to sign this proposal for the Supplier. I further certify that the provisions of the Official Code of Georgia Annotated, Sections 45-10-20 et. seq. has not been violated and will not be violated in any respect.

The Supplier also certifies that the Supplier and its Lobbyists have complied with the Lobbyist Registration Requirements in accordance with the Georgia Supplier Manual.

Authorized Signature Date

Print/Type Name

Company Name

Address:

Phone Number: E-Mail:

https://gta.georgia.gov/sites/gta.georgia.gov/files/GTAProcurementManual.pdf

Tax Compliance

TAX COMPLIANCE

INSTRUCTIONS TO SUPPLIERS

Please complete the following information:

• Supplier’s Name: _________________________________

• Physical Location Address:__________________________

• Federal Identification Number (FEI):______________________________

• Have you ever been registered in the State of Georgia? N/A

• If so, please provide the following information, if applicable:

o State Taxpayer Identification Number (STI):_______________________ o Sales and Use Tax Number:____________________________________ o Withholding Tax Number:_____________________________________

• What type of service will you perform?_________________________________

• Will you sell any tangible personal property or goods?_____________________

• Supplier’s Affiliate’s Name:

o FEI:_______________________ o STI:_______________________ o Sales and Use Tax Number:_____________________________ o Withholding Tax Number:______________________________

If there is more than one affiliate, please attach a separate sheet listing the information above.

• Person responsible for handling supplier’s tax issues (such as the CFO, the company tax officer, etc.):

o Name:_______________________________ o Telephone Number:____________________ o E-mail Address:________________________

NOTICE TO SUPPLIER:

In the event the supplier is considered for contract award, the information provided in the form will be submitted by the State Entity to the Georgia Department of Revenue (“DOR”) for a determination as to whether the supplier is a “prohibited source” (as defined by O.C.G.A. §50-5-82) or whether there are any other outstanding tax issues. MISSING, INCOMPLETE, OR ERRONEOUS DATA MAY DELAY OR PROHIBIT VERIFICATION OF YOUR ELIGIBILITY FOR CONTRACT AWARD. NO PROHIBITED SOURCE MAY RECEIVE CONTRACT AWARD; THEREFORE, YOU ARE STRONGLY ENCOURAGED TO CHECK YOUR TAX STATUS NOW

AND RESOLVE ANY OUTSTANDING TAX LIABILITIES AND/OR MISSING TAX RETURNS.

STATE ENTITY: Please submit this form via email to DOR at https://gtc.dor.ga.gov/_/#1 for processing in accordance with the Georgia Procurement Manual.

https://gtc.dor.ga.gov/_/#1

CONTACT INFORMATION

Name / Title of primary company contact relative to this submission:

Telephone Number / Fax Number:

E-Mail Address:

Complete Company Mailing Address:

Provide Name / Title of company officer empowered to obligate company:

Contractor Affidavit under O.C.G.A. § 13-10-91(b)(1)

Contractor Name:

Contractor Address:

Contract Number: _

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of Georgia Technology Authority has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number Date of Contract Enter the E-Verify Number. This is NOT your FEIN number (XX-XXXXXXXX). For information see -https://www.e-verify.gov/

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , , 20 in (city), (state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF , 20 .

NOTARY PUBLIC

My Commission Expires:

404-463-6500 – Procurement@gta.ga.gov https://www.e-verify.gov/ mailto:Nanci.glazer-gay@gta.ga.gov

Supplier Affirmations Scrutinized Companies – O.C.G.A. § 50-5-84

Any Supplier that currently and/or previously, within the last three years, has had business activities or other operations outside of the United States, must certify that it is not a “scrutinized company.”

A scrutinized company is a company conducting business operations in Sudan that is involved in power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, but excludes a company which can demonstrate any of the following exceptions noted in O.C.G.A. § 50-5-84. False certification hereunder may result in civil penalties, contract termination, ineligibility to bid on a state contract for three or more years, and/or any other available remedy.

If the Supplier is a scrutinized company, the Supplier shall not be eligible to bid on or submit a proposal for a contract with a State Entity unless the Department of Administrative Services (DOAS) makes a determination that it is in the best interest of the State to permit the scrutinized company to submit a bid or proposal. Any scrutinized company desiring DOAS to make such a determination should contact DOAS and GTA Procurement immediately.

Please initial below which statement applies to your company:

I certify that my company is NOT a “scrutinized company.”

I certify that my company IS a “scrutinized company.”

I certify that my company has requested and received written permission from DOAS to submit a response to an RFP/RFQC in accordance with O.C.G.A. § 50-5-84.

Vendor Name:

Contract Number:

Signed by:

SUPPLIER AFFIRMATIONS

Boycott of Israel - O.C.G.A. § 50-5-85

Any Supplier that currently and/or previously, within the last three years, has had business activities or other operations outside of the United States, must certify that it has not nor will engage in a "Boycott of Israel." The State of Georgia passed a law that requires our current and future supplier certify that they will not boycott Israel in accordance with O.C.G.A. § 50-5-85.

"Supplier certifies that the Supplier is not currently engaged in and agrees for the duration of this Agreement not to engage in, a boycott of Israel, as defined in O.C.G.A. § 50-5-85."

False certification hereunder may result in civil penalties, contract termination, ineligibility to bid on a state contract for three or more years, and/or any other available remedy.

If the Supplier is engaged in or has previously participated in a boycott of Israel, the Supplier shall not be eligible to bid on or submit a proposal for a contract with a State Entity unless the Department of Administrative Services (DOAS) makes a determination that it is in the best interest of the State to permit that company to submit a bid or proposal. Any company that has engaged in a boycott of Israel desiring DOAS to make such a determination should contact DOAS and GTA Procurement immediately.

Please initial below which statement applies to your company:

I certify that my company is NOT engaged in a boycott of Israel.

I certify that my company IS engaged in a boycott of Israel.

I certify that my company has requested and received written permission from DOAS to submit a response to an RFP/RFQC in accordance with O.C.G.A. § 50-5-85.

Vendor Name:

Contract Number:

Signed by:

CERTIFICATE OF NON-COLLUSION

By responding to this solicitation, the supplier understands and agrees to the following:

1. That the submitted response constitutes an offer, which when accepted in writing by the State Entity, and subject to the terms and conditions of such acceptance, will constitute a valid and binding contract between the undersigned and the State Entity; and

2. That the supplier has read the specifications and requirements shown or referenced in the solicitation and that the supplier’s response is made in accordance with the provisions of such specifications and requirements except as expressly stated otherwise in the supplier’s response; and

3. That the supplier guarantees and certifies that all items included in the supplier’s response meet or exceed any and all such stated specifications and requirements of the solicitation except as expressly stated otherwise in the supplier’s response; and

4. That, if awarded a contract, the supplier will deliver goods and/or services that meet or exceed the specifications and requirements of the solicitation except as expressly stated otherwise in the supplier’s response; and

5. That the response submitted by the supplier shall be valid and held open for a period of one hundred and twenty (120) days (or such other time period as identified in the solicitation) from the final solicitation closing date and that the response may be held open for an additional period of time subject to the supplier’s consent; and

6. That the supplier’s response is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a response for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud. The supplier understands and agrees that collusive bidding is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards; and

7. That the provisions of the Official Code of Georgia Annotated, Sections 45-10-20 et seq. have not been violated and will not be violated in any respect.

DO NOT MODIFY THE BID/PROPOSAL CERTIFICATION TERMS IN ANY WAY. THIS FORM MUST BE

COMPLETED, SIGNED AND SUBMITTED WITH YOUR RESPONSE.

Contractor’s Full Legal Name:

(PLEASE TYPE OR PRINT)

Authorized Signature:

Printed Name and Title of Person Signing:

Date:

Company Address:

FAX Number:

Email Address:

*This table must be completed in its entirety by the supplier.

Statewide Sexual Harassment Prevention Policy (effective March 1, 2019)

CONTRACT LANGUAGE FOR TECHNOLOGY SERVICES

I. PERFORMANCE

In performance of this contract, the contractor agrees to comply with and assume responsibility for compliance by his or her employees with the following requirements:

*Policy on next page

POLICY MEMORANDUM

SUBJECT: Statewide Sexual Harassment Prevention Policy

EFFECTIVE: March 1, 2019

ISSUED BY: DEPARTMENT OF ADMINISTRATIVE SERVICES

OFFICE OF THE STATE INSPECTOR GENERAL

I. Introduction

While there are multiple types of workplace harassment, as Executive Order 01.14.19.02 recognizes, incidents of sexual harassment present unique challenges which warrant special emphasis and the implementation of a particularized approach to the prevention, detection and elimination of sexual harassment from the State workplace.

II. Purpose

The State of Georgia promotes respect and dignity and does not tolerate sexual harassment in the workplace. The State is committed to providing a workplace and environment free from sexual harassment for its employees and for all persons who interact with state government. All State of Georgia employees are expected and required to interact with all persons including other employees, contractors, and customers in a professional manner that contributes to a respectful work environment free from sexual harassment.

This Policy is intended to set standards for Executive Branch agencies and employees in furtherance of this commitment and to protect individuals from sexual harassment and retaliation.

III. Authority

Executive Order 01.14.19.02 directs the Georgia Department of Administrative Services Human Resources Administration Division (HRA), in consultation with the Executive Counsel to the Governor, to promulgate a uniform sexual harassment prevention policy that shall apply to all Executive Branch agencies.

In addition, pursuant to O.C.G.A § 45-20-4, the Georgia Department of Administrative Services is responsible for ensuring compliance with all applicable federal and state statutes and regulations concerning personnel administration and related matters. This includes, but is not limited to, the Equal Protection Clause of the Fourteenth Amendment of the United States Constitution, U.S. Const. amend.

XIV., the Equal Protection Clause of the Georgia Constitution, Ga. Const. Art. 1, Sec. I, Para. II., Title VII of the Civil Rights Act of 1964, 42 U.S.C. §§ 2000e, et seq., and the Fair Employment Practices Act of 1978, O.C.G.A §§ 45-19-20, et seq., which prohibit employment discrimination and harassment on the basis of sex.

IV. Applicability

The provisions of this Policy apply to all Executive Branch agencies. This Policy does not apply to the Board of Regents of the University System of Georgia, the Legislative Branch, or the Judicial Branch.

V. Definitions

For purposes of this Policy, the following definitions apply:

(a) “Agency” or “Agencies” means any Executive Branch agency, authority, board, bureau, commission, council, department, office, unit, entity, or instrumentality of any kind, and others as may be designated by the Governor, or to the extent that such designation does not conflict with state law.

(b) “Employee” is a person who is hired to provide services to the State on a regular basis in exchange for compensation and who does not provide these services as part of an independent business. “Covered Employee” is a person who is hired to provide services to an Agency on a regular basis in exchange for compensation and who does not provide these services as part of an independent business.

(c) “Investigator” is a person designated by his or her Agency head to conduct investigations related to sexual harassment complaints or reports.

(d) “Retaliation” is an act or omission intended to, or having the reasonably foreseeable effect of, punishing or otherwise negatively impacting an individual for submitting (or assisting with submitting) a complaint of or reporting sexual harassment, for participating in a sexual harassment investigation or proceeding, or for otherwise opposing sexual harassment.

(e) “Sexual harassment” is physical, verbal, or non-verbal/visual conduct that is either (i) directed toward an individual or (ii) reasonably offensive to an individual because of his or

(f) her sex. Therefore, for purpose of this Policy, “Sexual harassment” includes physical, verbal, or non-verbal/visual conduct constituting:

1. Unwanted sexual attention, sexual advances, requests for sexual favors, sexually explicit comments, and other conduct of an expressed or obviously implied sexual nature, by an individual who knows, or reasonably should know, that such conduct is unwanted and offensive; and

2. Conduct that is hostile, threatening, derogatory, demeaning, or abusive or intended to insult, embarrass, belittle, or humiliate an individual because of his or her sex – regardless of whether the underlying reason for the conduct is apparent.

This Policy purposefully prohibits all sexual harassment and is not limited to conduct that would rise to the level of unlawful conduct under state or federal anti- harassment laws.

(g) “Supervisor” or “Manager” is a Covered Employee who has the authority to oversee, hire, fire, demote, or to effectively recommend hiring, firing, or demotion, or to make or effectively recommend other material changes to the working conditions of at least one employee.

VI. Prohibited Conduct

(a) All Covered Employees are strictly prohibited from engaging in sexual harassment as defined herein. This prohibition applies to conduct occurring in or otherwise affecting the workplace. As such, it includes conduct occurring both on and off the work premises and during or outside of work hours. While sexual harassment encompasses a wide range of conduct, some examples of conduct specifically prohibited by this Policy include, but are not limited to:

1. Denying (directly or indirectly) an employment benefit or employment-related opportunity to an employee for refusing to comply with a sexually-oriented request;

2. Threatening (directly or indirectly) to deny an employment benefit or an employment-related opportunity to an employee for refusing to comply with a sexually-oriented request;

3. Providing or promising (directly or indirectly) to provide an employment benefit or employment-related opportunity to an employee in exchange for complying with a sexually-oriented request;

4. Engaging in sexually-explicit or suggestive physical contact, including touching another employee in a way that is unwelcome or restricting an employee’s movement;

5. Displaying or transmitting pornographic or sexually-oriented materials (such as photographs, posters, cartoons, drawings, or other images) or storing or accessing such materials on State-owned equipment for personal use or consumption;

6. Engaging in indecent exposure;

7. Making obscene gestures (i.e., hand or bodily gestures);

8. Making romantic advances and persisting despite rejection of the advances;

9. Using sexually-oriented language or making sexually-related propositions, jokes, or remarks, including graphic verbal commentary about an individual’s body or clothing;

and,

10. Sending sexually suggestive or obscene messages by mail, in person, by telephone, or by electronic communication.

(b) Agencies and Covered Employees are further prohibited from engaging in retaliation against an employee for submitting (or assisting with submitting) a complaint of or reporting sexual harassment, for participating in a sexual harassment investigation or proceeding, or for otherwise opposing sexual harassment.

(c) A Covered Employee found to have engaged in sexual harassment and/or retaliation in violation of this Policy will be subject to corrective and/or disciplinary action, up to and including termination of employment.

(d) A third party found to have engaged in sexual harassment and/or retaliation may be subject to appropriate corrective action. Such action may include, but is not limited to, termination of contract, removal from Agency premises, restricted access to Agency premises and/or personnel, or notification to the third party’s employer.

(e) Agencies shall immediately refer any reported criminal conduct the appropriate law enforcement agency. Such referral shall not prohibit an Agency from pursing its own investigation of the complaint or report. If criminal activity is suspected the Agency shall confer with the Office of the State Inspector General (OIG) regarding how to proceed with the Agency investigation.

VII. Training

(a) Agencies shall require all Covered Employees, including part-time, temporary, seasonal employees, and independent contractors who are regularly on Agency premises and/or regularly interact with Agency personnel to complete employee sexual harassment prevention training on an annual basis. An independent contractor may waive state-mandated training upon acknowledgement of this Policy and documentation that he/she has completed sexual harassment prevention training offered by his/her employer within the last year.

(b) Agencies shall provide sexual harassment prevention training to all new or transferred

Covered Employees within thirty (30) calendar days of hire.

(c) Agencies shall require sexual harassment prevention training for supervisors and managers on an annual basis. New supervisors and managers must complete this training within thirty

(30) calendar days of employment or promotion to a supervisory or Managerial position.

(d) Agencies shall utilize the standardized training provided by HRA to fulfill the obligations under this Policy for employee and manager training.

(e) Agencies shall track and maintain records pursuant to the statewide record retention schedule documenting attendance of employee and manager training. Such records are subject to audit by the OIG.

(f) Agencies shall require designated investigators (see Section IX. Investigations) to complete statewide investigator training provided by the OIG to ensure consistency in sexual harassment investigations across the State. Agencies shall require designated investigators to complete the statewide training within thirty (30) calendar days of the effective date of this Policy. Designated investigators appointed subsequent to the effective date of this Policy shall complete such training as soon as practicable.

VIII. Complaint Procedure

(a) Covered Employees who believe they have been subjected to sexual harassment or retaliation in violation of this Policy are strongly encouraged to promptly submit a complaint regarding the incident(s) to one of the following officials:

1. The Covered Employee’s supervisor or manager;

2. The Covered Employee’s division director;

3. The Agency's Human Resources Director; or,

4. Other Agency designee.

(b) Covered Employees who have witnessed or otherwise have reason to believe that another employee is being or has been subjected to sexual harassment or retaliation shall promptly report the same to one of the Agency officials listed above.

(c) To the extent that any of the above officials are the alleged harasser or retaliator, or if a

Covered Employee has a reasonable fear of retaliation by one of the above officials, a Covered Employee may submit a complaint or report of sexual harassment or retaliation directly to the OIG.

(d) While written complaints and reports of sexual harassment or retaliation are preferred, Agencies shall accept all complaints and reports, whether written, verbal, or anonymous, and will ensure that each complaint or report is promptly and appropriately investigated and resolved.

(e) Agencies shall review all complaints and reports of sexual harassment and retaliation they receive and shall notify the OIG of the same within two (2) business days of receipt.

IX. Investigations

(a) Each Agency shall designate at least two of its employees, not of the same gender, to conduct investigations under this Policy. Agencies must ensure that employees directly supervised by designated investigators have the ability to submit complaints or reports of sexual harassment to an individual other than their direct supervisor or manager.

(b) Agencies shall report to the OIG the names and contact information for the designated investigators and a HR contact via the OIG’s online portal within seven (7) business days of the effective date of this Policy. Should a vacancy in an investigator or HR contact role occur, a replacement shall be designated and reported to the OIG within seven (7) business days of the vacancy via the OIG online portal.

(c) Agencies shall cooperate with any determination by the OIG that a complaint or report cannot be handled internally at the Agency from which it originated. Agencies shall cooperate fully with the impartial investigator assigned by the OIG to handle the complaint or report.

(d) The assigned investigator shall complete the investigation and issue a report of findings as promptly as possible but at least within forty-five (45) calendar days of assignment. An Agency Head may consider an extension of time due to extenuating circumstances.

X. Resolution

(a) Agencies shall make a final determination, and if necessary, implement appropriate corrective or disciplinary action and remedial measures depending upon the nature of the policy violation, as soon as possible but in no event more than twenty-one (21) calendar days of receipt of the investigative report.

(b) Agencies shall consult with and provide updates to the OIG as requested and promptly produce any information related to a sexual harassment or retaliation complaint or report or the investigation upon the OIG’s request.

(c) Agencies shall, to the extent consistent with thorough investigation and with procedures outlined in this Policy, maintain confidentiality of information reported to the Agency.

Complaints and reports of sexual harassment or retaliation, investigative reports, final determinations, and other related documents will be subject to disclosure under the Open Records Act upon completion of the investigation.

XI. Acknowledgement and Recordkeeping

(a) Agencies shall make this Policy available to all Covered Employees and retain

(b) documentation of each Covered Employee’s acknowledgment of receipt of the Policy in his or her personnel file.

(c) All complaints and reports, investigative documents, policy acknowledgements, and records of training attendance shall be retained pursuant to the statewide record retention schedule and as otherwise required by law pursuant to specific requests for preservation.

Effective Date This Policy becomes effective March 1, 2019 and may be revised as necessary.

Revision History

Acknowledgement of the State of Georgia Statewide Sexual Harassment Prevention Policy and Employee Training

I acknowledge that _________________ {company name} has received the Statewide Sexual Harassment Prevention Policy as a result of the Governor’s executive order; 01.14.19.02 for sexual harassment prevention. This attestation confirms that all personnel who are regularly on GTA or State of Georgia premises or that regularly interact with state employees on the account have completed the Sexual Harassment Prevention Training.

________________ {company name} attests that we have collected the signed employee attestations from our staff and will provide to GTA such documents as proof of training completion upon request.

I understand that failure to comply with the Policy could result in corrective action up to and including termination of the contract, removal from Agency premises, restricted access to Agency premises and/or personnel.

Version Date

1.0 March 1, 2019

Company Name Authorized Signature

Date Authorized Signee Name

SUPPLIER’S CODE OF ETHICS

PURPOSE

The Georgia Technology Authority (GTA) subscribes to the State's Code of Ethics for Governmental Service.

It is expected that Suppliers used by GTA will conduct themselves in such a manner as to foster public confidence in the integrity of the organization and the public procurement process.

SCOPE

The general scope of this policy is to protect governmental integrity. Suppliers of the Georgia Technology Authority must ensure fairness and transparency in procurements and governance. This will be the central focus in moving to best valued procurements. GTA will assure fair and competitive access to governmental procurement by responsible vendors.

POLICY

The Georgia Technology Authority subscribes to the following ethical principles that govern the code of conduct for every Supplier doing business with GTA. GTA expects that Suppliers:

• Believe in the dignity and worth of the service rendered by the organization, and the societal responsibilities assumed as part of the trusted public servant.

• Are governed by the highest ideals of honor and integrity in all public and personal relationships in order to merit the respect and inspire the confidence of the organization and the public being served.

• Believe that personal aggrandizement or personal profit obtained through misuse of public or personal relationships is dishonest and not tolerable.

• Identifies and eliminates participation of any individual in operational situations where a conflict of interest may be involved.

• Believe that members and staff should at no time, or under any circumstances, accept directly or indirectly, gifts, gratuities, or other things of value from suppliers, which might influence or appear to influence purchasing decisions.

• Resist encroachment on control of personnel in order to preserve integrity as a professional manager.

• Handle all personnel matters on a merit basis, and in compliance with applicable laws prohibiting discrimination in employment on the basis of politics, religion, color, national origin, disability, gender, age, pregnancy and other protected characteristics.

• Seek or dispense no personal favors. Handle each administrative problem objectively and empathetically, without discrimination.

COMPANY NAME: ______________________________________________

SUPPLIER SIGNATURE:___________________________________________

Client References Information

Service Provider Guidelines

Using the table format on the following page, Service Provider is required to complete at least three (3) client references that support the Service Provider’s RFP response. Limit to 1 page per Client Reference.

The table format is being provided to provide assistance with responses and how the evaluators may read the information. The Service provider should ensure the content is clear and easily readable. The Service Provider should insert additional form pages to provide additional references beyond three.

The fields of the form should contain the following:

Company Name: Service Provider organization name

Client Reference # : a count or identifier for this reference

Client Reference: in box to right, provide name and address of client reference

Size of Engagement: in box to right, provide meaningful measures of the engagement with this client reference, including at least:

• Term of contract

• Dollars per year

• Services under management

Client Reference Narrative: description of significant client activity, including at least:

• Engagement dates

• Major activities or milestones

• Description of services provided

• Staffing model and number of staff required to provide services

• Average industry experience of staff working on the engagement

• Applicability to a State outsourced IT environment

PSP Company Name:

Client Reference #:

Name and address of Client Reference

Size of Engagement:

• Term of contract

• Dollars per year

• Complete list of Services under management

• Dollars per year

• Dollars per year

Service Provider Guidelines

This document is for the Service Provider’s use when responding to the RFP.

THIS FORM MUST BE COMPLETED, SIGNED, NOTARIZED AND SUBMITTED WITH PROSPECTIVE SERVICE

PROVIDER RESPONSE/PROPOSAL.

Service Provider Instructions

1. The Service Provider must provide this file as the original filename prefixed with a Service Provider name identifier

2. Service Provider will complete this form, answering every question.

2.1. 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.

2.2. 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 Offeror responsibility in the event GTA undertakes an investigation into Offeror’s responsibility status.

2.3. For any explanation, indicate to whom it applies; identify the initiating agency and the dates of action.

3. Offerors are responsible for updating any information submitted in their Administrative C (Offeror Statement of Responsibility Certification) if a change occurs prior to the award of the contract.

4. Except for completing the questions and completing the certification, Service Provider should not change this document in any other way.

Statement of Responsibility Certification Form

QUESTIONS Answer

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

3. Within the past three (3) years, has Offeror’s company or any principal of Offeror (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, anti-trust, 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 Offeror’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) a suspension, debarment or termination for cause from any local, state or federal government procurement process?

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

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

QUESTIONS Answer

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

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

i) any bankruptcy proceeding within the last seven years?

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 Offeror or its representatives to criminal liability; (iv) as the authorized representative of the Offeror, 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 Offeror to make the statements and representations contained herein and/or attached hereto, on behalf of such Offeror.

Legal Name of Offeror’s Company Signature of Offeror’s Authorized Representative

Address Printed Name of Offeror’s Authorized Representative

City, State, Zip Title

State of County of

Sworn to and subscribed before me on this day of 20 .

Notary Public My Commission Expires:

Note: *As used herein, the term “to the best of Offeror’s knowledge” will refer to the current actual knowledge of Offeror and will be construed, by imputation or otherwise, to refer to the knowledge of any agent, manager, representative or employee of Offeror but does not impose upon Offeror any duty of inquiry or investigation of the matter to which such actual knowledge, or the absence thereof, pertains. The fact that Offerors (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 bidder non-responsible in order to protect the interests of the GTA and/or the State.