Attachment A Forms - Proposer Required Forms v2_2025.pdf

ATTACHMENT “A”

OFFEROR’S REQUIRED FORMS

Offeror must read, complete and return required forms. Any misinterpretation or failure to comply WILL result in a non-responsive determination of the bid proposal.

All responses MUST be submitted electronically, and it is essential for the responder to confirm their submission in BIDNET to ensure the City receives a valid response.

OFFEROR’S CHECKLIST

Offerors must thoroughly examine this solicitation, including the specifications (if applicable), and all provided instructions. Any failure to do so will be at the Offeror’s own risk.

• All notations must be made in ink or typewritten. No erasures are permitted. Mistakes may be crossed out, but corrections must be typed next to the error. The individual signing must initial and date these corrections in ink.

• All Solicitations must be signed with the firm’s name and by a responsible officer or employee. The obligations assumed by the signature must be fully honored.

• Each Offeror must provide all information as requested in the solicitation and Attachment “A” (Offeror’s Required Forms).

• Offerors must complete, sign, and submit all required forms included in the solicitation. Failure to submit the required forms will result in the solicitation response being deemed non-responsive.

• Offerors should carefully review their submissions using the checklist provided before finalizing and submitting their responses.

• All required forms must be uploaded and submitted in BidNet.

SOLICITATION CHECKLIST (THIS LIST MAY NOT BE INCLUSIVE)

Offerors are cautioned to check their submittals very carefully, using the following checklist:

Addendum Acknowledgment Authorized Signatories – REQUIRED Certificate of Insurance Acknowledgment Form - REQUIRED Cone of Silence Acknowledgement Form – REQUIRED Conflict of Interest Disclosure Form – REQUIRED Drug Free Workplace Form – REQUIRED E-Verify Affirmation Statement -REQUIRED Human Trafficking Affidavit – REQUIRED Litigation Statement – REQUIRED Non-Discrimination Affidavit – REQUIRED Non-Collusion Affidavit – REQUIRED Proposal Certification - REQUIRED Public Access Form – REQUIRED Public Entity Crimes Affidavit – REQUIRED Required References – REQUIRED Scrutinized Companies Certification REQUIRED

It is the Offeror’s responsibility to review BidNet prior to submitting to ascertain if any addenda have been issued and return executed addenda with their submission.

ADDENDA ACKNOWLEDGMENT

If an addendum has been issued, the Offeror must complete, sign, and submit this form with each bid or proposal.

SOLICITATION NUMBER:

PROJECT NAME:

Addenda Numbers Received:

The undersigned hereby acknowledges receipt of the addenda listed above and confirms that the information contained therein has been fully considered in the formulation of this bid or proposal. Acknowledgment of all addenda is required; failure to do so may disqualify your proposal.

NAME OF BUSINESS:

SIGNATURE OF AUTHORIZED

OFFICER:

PRINTED NAME AND TITLE:

DATE:

AUTHORIZED SIGNATORIES

The Offeror represents that the following principals are authorized to sign bids, proposals, negotiate, and/ or sign contracts and related documents to which the offeror will be duly bound. A principal is defined as an employee, officer, or other technical or professional in a position capable of substantially influencing the development or outcome of an activity required to perform the covered transaction.

SIGNATURE OF AUTHORIZED OFFICER:

PRIMARY OFFICE ADDRESS:

TELEPHONE NUMBER:

EMAIL ADDRESS:

DUNS NUMBER (if applicable)

FEIN number:

Name (printed): Signature: Title:

Name (printed):

Signature:

Title:

CERTIFICATE OF INSURANCE ACKNOWLEDGEMENT FORM

Solicitation Number:

Vendor Name:

Authorized Representative:

Title:

Email Address:

Phone Number:

As a condition of contract award, the undersigned vendor acknowledges and agrees that, if selected for award, they will be required to provide a valid Certificate of Insurance (COI) within four (4) business days of notification meeting the minimum insurance requirements specified by the solicitation.

These requirements may include, but are not limited to:

General Liability Insurance Workers’ Compensation Insurance (as applicable) Automobile Liability Insurance Professional Liability or Errors & Omissions Insurance (if applicable) Additional Insured endorsements, where required

The Certificate of Insurance must:

• Be issued by an insurance carrier licensed to do business in the State of Florida

• Name the City of Riviera Beach as certificate holder (Or City of Riviera Beach Community

Redevelopment Agency if applicable)

• Include evidence of all required coverage and limits

• Be submitted prior to contract execution or commencement of work

Failure to provide the required Certificate of Insurance within the specified timeframe may result in revocation of the award and disqualification from the procurement process.

By signing below, the vendor confirms their understanding and acceptance of this requirement.

Signature of Authorized Representative:

Print Name:

Date:

CONE OF SILENCE ACKNOWLEDGMENT FORM

The Cone of Silence (Sec. 2-166) is an important rule within the City of Riviera Beach’s ordinances aimed at ensuring fairness, transparency, and the integrity of the procurement process. The Cone of Silence is applicable to all competitive solicitations. Here’s a summary and breakdown of its key components:

1. Prohibition on Communication:

o Once a formal solicitation closes, oral communication about the solicitation is strictly prohibited.

o Exceptions include:

Oral presentations before selection committees, Contract negotiations, and Protest hearings.

2. Timing:

o The cone of silence starts immediately after the solicitation deadline has passed.

o It remains in effect until one of the following occurs:

The City awards the contract, The City rejects all bids or responses; or The City otherwise ends the solicitation process.

3. Consequences of Violation:

o Any contract entered into in violation of the Cone of Silence provision is automatically invalid. This ensures that the integrity of the process is maintained

4. Contact for Inquiries:

o For questions or communications regarding the solicitation, offerors should direct their inquiries only to the designated Procurement Contact or the Director/Assistant Director of Procurement.

The purpose of the Cone of Silence is to reduce the potential for undue influence during the procurement process, fostering a fair and transparent environment in which decisions are made without external pressure or manipulation.

I hereby acknowledge and agree to abide by the City of Riviera Beach’s Cone of Silence policy. I understand that I am prohibited from discussing, copying, or otherwise disclosing any information I have received or accessed in connection with this matter, except in the prescribed settings designated for its evaluation.

Furthermore, I confirm that I have read, understood, and accept my responsibilities in upholding the Cone of Silence for this project.

CONFLICT OF INTEREST DISCLOSURE FORM

The award of this contract is subject to the provisions of Chapter 112, Florida Statutes. All Offeror’s must disclose within their Bids: the name of any officer, director, or agent who is also an employee of the City of Riviera Beach.

Furthermore, all Offeror’s must disclose the name of any City employee who owns, directly, or indirectly, an interest of more than five percent (5%) in the Offeror’s firm or any of its branches.

The purpose of this disclosure form is to give the City the information needed to identify potential conflicts of interest for evaluation team members and other key personnel involved in the award of this contract.

The term “conflict of interest” refers to situations in which financial or other personal considerations may adversely affect, or have the appearance of adversely affecting, an employee’s professional judgment in exercising any City duty or responsibility in administration, management, instruction, research, or other professional activities.

Please check one of the following statements and attach additional documentation if necessary:

To the best of our knowledge, the undersigned firm has no potential conflict of interest.

The undersigned firm, by attachment to this form, submits information which may be a potential conflict of interest.

Conflict of Interest Disclosure form Acknowledged by:

SIGNATURE OF AUTHORIZED

OFFICER:

DRUG-FREE WORKPLACE FORM

Preference shall be given to businesses with drug-free workplace programs. Whenever two or more proposal’s, which are equal with respect to price, quality, and service, are received by the City or by any political subdivision for the procurement of commodities or contractual services, a proposal 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 proposal’s will be followed if none of the tied vendors 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 violating 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 under this 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 this 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 contender to, any violation of Chapter 893, 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 suchconviction.

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

6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.

As the person authorized to sign the statement, I certify that this form complies fully with the above requirements (Section 287.087, Florida Statutes).

E-VERIFY AFFIRMATION STATEMENT

Offeror acknowledges and agrees to utilize the U.S. Department of Homeland Security’s E- Verify System to verify the employment eligibility of;

(a) all persons employed by Offeror to perform employment duties within Florida during the term of the Contract, and,

(b) all persons (including subcontractors/vendors) assigned by Offeror to perform work pursuant to the Contract.

The offeror acknowledges and agrees that use of the U.S. Department of Homeland Security’s E-Verify System during the term of the Contract is a condition of the Contract.

Contractor/Offeror/ Offeror Company Name:

Authorized Company Person’s Printed Name:

Authorized Company Person’s Title:

Authorized Company Person’s Signature:

Date:

(Per Florida Statue 448.095)

HUMAN TRAFFICKING AFFIDAVIT

Pursuant to Florida Statute Section 787.06(13), this affidavit MUST be signed and notarized.

I, the undersigned, am an officer or representative of (Offeror) and attest that Offeror does not use coercion for labor or services as defined in section 787.06, Florida Statutes.

Under penalty of perjury, I hereby declare and affirm that the above-stated facts are true and correct.

Authorized Officer or Representative Name

Authorized Officer or Representative Title

Authorized Officer or Representative Signature

State of

County of

The foregoing instrument was acknowledged before me this day of 20 , by, who is (who are) personally known to me or who has produced as identification and who did (did not) take an oath.

Notary Public Signature

Notary Name, Printed, Typed or Stamped

Commission Number:

Commission Expires:

LITIGATION STATEMENT

The CITY will consider an Offeror’s litigation history information in its review and determination of responsibility. All Offerors are required to disclose to the CITY all "material" cases filed or resolved in the three (3) year period ending with the solicitation response due date, whether such cases were brought by or against the Offeror, any parent or subsidiary of the Offeror, or any predecessor organization. If the Offeror is a joint venture, the information provided should encompass the joint venture (if it is not newly formed for purposes of responding to the solicitation) and each of the entities forming the joint venture.

A. Case Information For each case, the Offeror must provide the following details:

1. The name of the claim, arbitration, litigation, or action.

2. The amount at issue or the criminal charges alleged.

3. The status or final disposition of the case.

Additionally, the Offeror must provide details of any current or threatened legal actions against the Offeror, its parent company, subsidiaries, partners, principals, or joint venture company(ies) by a governmental entity contracting with the Offeror or its parent. The Offeror must also disclose any legal actions against such a government entity by the Offeror, its parent company, or joint venture company(ies). For each action, the Offeror must provide the following:

• The name of the action.

• The court in which the action is pending.

• The action number.

• The amount at issue.

B. Enforcement Actions

The Offeror shall provide a list of all enforcement actions taken against it during the last three (3) years by any regulatory agency, including but not limited to the Internal Revenue Service, Securities and Exchange Commission, or any other enforcement agency. The list shall include the regulatory agency’s name and the date of the enforcement action.

C. Definition of “Case”

For the purposes of this disclosure requirement, a “case” includes lawsuits, administrative hearings, and arbitrations. A case is considered "material" if it relates, in whole or in part, to any of the following:

1. A similar type of work that the Offeror is seeking to perform for the City under the current solicitation.

2. An allegation of negligence, error, omission, or malpractice against the Offeror or any of its principals or agents who would be performing work under the current solicitation.

3. A Offeror's default, termination, suspension, failure to perform, or improper performance in connection with any contract.

4. The financial condition of the Offeror, including any bankruptcy petition (voluntary or involuntary).

5. A criminal proceeding or hearing concerning business-related offenses in which the Offeror or its principals (including officers) were or are defendants.

Notwithstanding the descriptions listed in 1-5 above, a case is not considered "material" if the claims raised in the case involve only garnishment, auto negligence, personal injury, or a proof of claim filed by the Offeror.

D. Subcontractor Disclosure The Offeror is also required to disclose to the City any and all cases involving the City and any of the Offeror’s subcontractors or subconsultants proposed to work on this project.

E. Non-Disclosure Consequences Failure to disclose any material case or to provide all requested information regarding each such case will result in the Offeror being deemed non-responsive.

F. License Revocation or Suspension The Offeror shall inform the City if it has had any permit, franchise, license, entitlement, or business license revoked or suspended in the last three (3) years.

G. Bid or Performance Bond Claims The Offeror must list any claims against a Bid or Performance Bond and the results, or any contractual defaults or terminations, in the last three (3) years.

CHECK ONE:

Neither the undersigned firm nor any of its officers or principals has been a party to any litigation and/or judgments entered against it or them by any local, state, or federal governmental entity and has had no litigation and/or judgments entered against any such entity on its or their behalf during the past three (3) years.

OR

The undersigned firm, BY ATTACHMENT TO THIS FORM, submits a summary and disposition of individual cases of litigation and/or judgments entered by or against it or one or more of its officers or principals by any local, state or federal governmental entity, by any state or federal court, during the past three (3) years.

Failure to check the appropriate block above shall result in disqualification of your response. Likewise, failure to provide documentation of a possible conflict of interest or a summary of past litigation and/or judgments shall result in disqualification of your response.

NAME OF BUSINESS:

SIGNATURE OF AUTHORIZED OFFICER:

NON-COLLUSION AFFIDAVIT OF PRIME OFFEROR

State of ) County of )

, being first duly sworn, deposes and says that:

That he/she is (a partner or officer of the firm, etc.)

the party making the foregoing proposal or bid and that such proposal or bid is genuine and not collusive or sham; that said Offeror has not colluded, conspired, connived or agreed directly or indirectly with any Offeror or person to put in a sham bid 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 bid price of the affiant or of any other Offeror, or to fix any overhead, profit or cost element of said bid price, or of that of any other Offeror, or to secure any advantage against the City of Riviera Beach, or any person interested in the proposed contract; and that all statements in said proposal or bid are true.

(Firm Name)

By:

The foregoing instrument was acknowledged before me this day of 20 , by, who is (who are) personally known to me or who has produced

Commission Number:

Commission Expires:

NON-DISCRIMINATION AFFIDAVIT

The undersigned bidder, offeror, or proposer hereby certifies and agrees that the following information is correct:

a) In preparing its enclosed bid, offer, or proposal, the bidder, offeror, or proposer has considered all bids, offers, and proposals submitted from qualified, potential subcontractors and suppliers, and has not engaged in discrimination as defined below.

b) For purposes of this section, discrimination shall mean any disadvantage, difference, distinction, or preference in the solicitation, selection, hiring, or commercial treatment of a contractor, vendor, supplier, subcontractor, or commercial customer on the basis of race, color, national origin, religion, ancestry, sex, age, marital status, familial status, sexual orientation, gender identity or expression, disability, or genetic information, or on the basis of any otherwise unlawful use of characteristics regarding the vendor's, supplier's, or commercial customer's employees or owners. Without limiting the foregoing, discrimination also includes retaliating against any person or other entity for reporting any incident of discrimination.

c) Without limiting any other remedies that the city may have for a false certification, it is understood and agreed that, if this certification is false, such false certification will constitute grounds for the city to reject the bid or proposal submitted with this certification, and terminate any contract awarded based on such bid or proposal. It shall also constitute a violation of the city's commercial non-discrimination ordinance and shall subject the bidder, offeror, or proposer to any remedies allowed thereunder, including possible disqualification from participating in city contracts or bid processes for up to two years.

d) As a condition of contracting with the city, the bidder, offeror or proposer agrees to promptly provide to the city all information and documentation that may be requested by the city from time to time regarding the solicitation and selection of suppliers and subcontractors in connection with this solicitation process. Failure to maintain or failure to provide such information shall constitute grounds for the city to reject the bid or proposal and to any contract awarded on such bid or proposal. It shall also constitute a violation of the city's commercial non-discrimination ordinance, and shall subject the bidder, offeror or proposer to any remedies that are allowed thereunder.

e) As part of its bid, offer or proposal, the bidder, offeror or proposer shall provide to the city a list of all instances within the past four years where a complaint was filed or pending against bidder, offeror or proposer in a legal or administrative proceeding alleging that bidder, offeror or proposer discriminated against its subcontractors, vendors, suppliers, or commercial customers, and a description of the status or resolution of that complaint, including any remedial action taken.

f) As a condition of submitting a bid, offer or proposal to the city the bidder or proposer agrees to comply with the city's commercial non-discrimination policy as described herein.

Non-Discrimination Form Acknowledged By:

(per Sec. 16.5-40. - Commercial nondiscrimination)

SIGNATURE OF AUTHORIZED

OFFICER:

https://library.municode.com/fl/riviera_beach/codes/code_of_ordinances?nodeId=PTIICOOR_CH16.5PRCO_ARTIINGE_DIV4CONOPO_S16.5-40CONO

PROPOSAL CERTIFICATION

I have carefully examined the instructions to Offerors, the General and/or Special Conditions, the Specifications, and any other documents accompanying or making part of this solicitation.

I hereby propose to provide the goods or services specified in the solicitation. Furthermore, I agree to abide by all conditions outlined in the solicitation.

I certify that all information submitted is true and accurate to the best of my knowledge and belief. I certify that I am duly authorized to submit on behalf of the Offeror/Contractor as its authorized representative and that the Offeror/Contractor is fully prepared, willing, and able to perform the work if awarded.

I also certify that this submission is without prior understanding, agreement, connection, discussion, or collusion with any person, firm, or corporation submitting for the same product or service, nor with any officer, employee, or agent of the City. The undersigned has executed this Offeror’s Certification with full knowledge and understanding of the contents and is duly authorized to do so.

The foregoing instrument was acknowledged before me this day of 20 , by, who is (who are) personally known to me or who has produced

Commission Number: Commission Expires:

NAME OF BUSINESS:

SIGNATURE OF AUTHORIZED OFFICER:

PRINTED NAME AND TITLE:

MAILING ADDRESS:

CITY, STATE, ZIP CODE:

TELEPHONE NUMBER:

FAX NUMBER:

EMAIL ADDRESS:

PUBLIC ACCESS FORM

The entity responding to a solicitation from the City acknowledges that as an offeror, they shall comply with the requirements of Florida’s Public Records law. In accordance with Section 119.0701, Florida Statutes, Contractor shall:

A. Keep and maintain public records required by the public agency in order to perform the service.

B. Upon request from the public agency’s custodian of public records, provide the public agency with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided under Florida’s Public Records Law or as otherwise provided by law.

C. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of this contract if Contractor does not transfer the records to the public agency: and

D. Upon completion of the contract, transfer, at no cost, to the public agency all public records in possession of Contractor or keep and maintain public records required by the public agency to perform the service. If Contractor transfers all public records to the public agency upon completion of the contract, Contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If Contractor keeps and maintains public records upon completion of this contract, the Contractor shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the public agency, upon request from the public agency’s custodian of public records, in a format that is compatible with the information technology systems of the public agency.

E. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA

STATUTES, TO THE CONTRACTOR’S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS

AGREEMENT, CONTACT THE CITY’S CUSTODIAN OF PUBLIC RECORDS, City Clerk’s Office, City Of Riviera Beach, 600 W Blue Heron Blvd, Riviera Beach, FL 33404, CityClerk@rivierabeach.org.

F. In the event the public agency must initiate litigation against Contractor to enforce compliance with Chapter 119, Florida Statutes, or in the event of litigation filed against the public agency because Contractor failed to provide access to public records responsive to a public record request, the public agency shall be entitled to recover all costs, including but not limited to reasonable attorneys’ fees, costs of suit, witness, fees, and expert witness fees extended as part of said litigation and any subsequent appeals.

Public Access Form Acknowledged By:

mailto:CityClerk@rivierabeach.org

PUBLIC ENTITY CRIMES CITY OF RIVIERA BEACH, FLORIDA

SWORN STATEMENT UNDER SECTION 287.133 (3) (A) FLORIDA STATUTES ON PUBLIC ENTITY

CRIMES. THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER

AUTHORIZED TO ADMINISTER OATHS.

1. This sworn statement is submitted with Bid, Proposal or Contract

[number/title]

2. This sworn statement is submitted by [name of company/firm] whose business address is and (if applicable) Federal Employer Identification Number (FEIN) is (if the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement:

3. My name is and my relationship to the entity named above is

4. I understand that a "public entity crime" as defined in Paragraph 287.133(a)(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, any bid proposal or contract for goods or services to be provided to any public entity or any agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

5. I understand that "convicted" or "conviction" as defined in paragraph 287.133(a)(b), Florida Statutes, means 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 records relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere.

6. I understand that an "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.

3. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one of shares constituting a controlling income among persons when not for fair interest in another person, or a pooling of equipment or income among persons when not for fair market value under a length agreement, shall be a prima facie case that one person controls another person. A person who was knowingly convicted of a public entity crime, in Florida during the preceding 36 months shall be considered an affiliate.

7. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of the state or of the United States with the legal power to enter into a binding contract for the provision of goods or services 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 an entity.

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

Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the 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, members, 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. (Please attach a copy of the final order)

The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer determined that it was in the public interest to remove the person or affiliate from the convicted vendor list. (Please attach a copy of the final order)

The person or affiliate has not been placed on the convicted vendor list. (Please describe any action taken by, or pending with, the Department of General Services.

The foregoing instrument was acknowledged before me this day of 20 , by, who is (who are) personally known to me or who has produced

Commission Number: Commission Expires:

REQUIRED REFERENCES

Provide ALL information requested below for three (3) references. If available, such references should be from public agencies. It is the sole responsibility of each Offeror to provide accurate information regarding these references. In the event that the City is unable to verify the project information submitted or if the information provided is incorrect, the Offeror may be deemed NON-RESPONSIVE. Attach additional pages as necessary.

Note: Do not include the City of Riviera Beach, proposed team members or parent/subsidiary/affiliated companies as references in your submittals.

Client Name:

Contact Person (Name & Title)

Email:

Address:

City:

State:

Zip Code:

Contract # (if applicable)

Date Services Were Provided:

Description of Services Provided and Cost:

REQUIRED REFERENCES

SCRUTINIZED COMPANIES CERTIFICATION

“Company” means Contractor throughout this exhibit. Section 287.135, Florida Statutes, prohibits companies from bidding, submitting proposals, entering into, or renewing contracts with a local government for goods or services over one million dollars if that company is on the Scrutinized Companies with Activities in Sudan List, on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List or that is engaged in business operations in Syria. Both lists are created pursuant to Section 215.473, Florida Statutes.

In addition, regardless of contract value, the companies may not be listed on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, or be engaged in a boycott of Israel, if bidding, submitting proposals, entering into, or renewing contacts with a local government for goods and services.

As the person authorized to sign on behalf of the company, I hereby certify that the company identified below is not listed on the Scrutinized Companies with Activities in Sudan List, is not listed on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List and is not engaged in business operations in Syria. In addition, the company is not listed on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, and is not participating in a boycott of Israel.

I further understand that pursuant to the Florida Statutes, any contract with the City for goods or services of any amount may be terminated at the option of the City if the company (i) is found to have submitted a false certification, (ii) has been placed on the Scrutinized Companies that Boycott Israel List, or (iii) is engaged in a boycott of Israel. And, in addition to the foregoing, if the amount of the contract is one million dollars ($1,000,000) or more, the contract may be terminated at the option of the City if the company is found to have submitted a false certification, has been placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or has been engaged in business operations in Syria.

This Certification is deemed amended by any amendments to Fla. Stat. 287.135 binding on the City.

By the signature(s) below, I/we, the undersigned, as an authorized signatory to commit the company, certify that the information as provided in this Contractor Certification Regarding Scrutinized Companies is truthful and correct at the time of submission.