Attachment A _ Proposer_s Required Forms.pdf

ATTACHMENT “A”

PROPOSER’S REQUIRED FORMS

Proposers are instructed to read and follow the instructions carefully, as any misinterpretation or failure to comply with instructions may lead to a Proposer’s submittal being deemed non-responsive, non-responsible and may be rejected.

Proposer MUST submit its bid response electronically and MUST confirm its submittal in order for the City to receive a valid response through Bidnet.

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Sidewalk Design Services

PROPOSERS CHECKLIST

Proposer’s are expected to examine this RFP form, attached drawings, specifications, if any, and all instructions.

Failure to do so will be at the Proposer’s risk.

All notations must be in ink or typewritten. No erasure permitted. Mistakes may be crossed out and corrections typed adjacent and must be initialed and dated in ink by the person signing the RFP. All Proposals must be signed with the firm name and by a responsible officer or employee. Obligations assumed by such signature must be fulfilled.

Each Proposer shall furnish the information required in accordance with the RFP solicitation and Attachment “A” Proposer’s Required Forms.

Proposer’s must complete, sign and submit with their Proposals, all forms herein. Failure to submit these forms will render such proposal’s responses non-responsive.

PROPOSAL CHECK LIST:

Proposers are cautioned to check their proposal very carefully, using the following checklist:

__________ Proposer’s Certification Page signed and notarized

__________ All required forms completed, signed and notarized (as applicable)

__________ Price Proposal Form, including Hourly Rate.

__________ Proposal Electronically submitted as specified

It is the Proposer’s responsibility to check Bidnet prior to submitting a bid response to ascertain if any addenda have been issued, to obtain such addenda and return signed addenda with the bid.

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PROPOSER’S CERTIFICATION

I have carefully examined the Request for Proposal (RFP), Instructions to Proposers, General Terms and Conditions, Scope of Services, Proposal Submittal Instructions and any other documents accompanying or made a part of this RFP.

I hereby propose to furnish the goods or services specified in the Request for Proposal (RFP) at the prices or rates quoted in my proposal. I agree that my price proposal will remain firm for a period of up to One Hundred and Twenty (120) days in order to allow the City adequate time to evaluate the responses. Furthermore, I agree to abide by all conditions of the RFP.

I certify that all information contained in this proposal is truthful to the best of my knowledge and belief. I further certify that I am duly authorized to submit this proposal on behalf of the Proposer as its act and deed and that the Firm is ready, willing and able to perform if awarded the bid.

I further certify that this bid is made without prior understanding, agreement, connection, discussion, or collusion with any person, firm or corporation submitting a proposal for the same product or service; no officer, employee or agent of the City of Stonecrest or of any other Proposer interested in said RFP; and that the undersigned executed this Proposer’s Certification with full knowledge and understanding of the matters therein contained and was duly authorized to do so.

NAME OF BUSINESS E-MAIL ADDRESS

BY: ______________________________________________

SIGNATURE OF AUTHORIZED OFFICER OR AGENT

PRINTED NAME AND TITLE

MAILING ADDRESS

CITY, STATE, ZIP CODE

TELEPHONE NUMBER

TYPE: _________________________

_________________, 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 (SEAL) Notary Name, Printed, Typed or Stamped

Commission Number: _______________________ Commission Expires: ________________________

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STATEMENT OF QUALIFICATIONS

Please Note: All fields below must be completed. If the field does not apply to you, please note N/A in that field.

If you are a foreign corporation, you may be required to obtain a certificate from the Georgia Department of Revenue (https://dor.georgia.gov/taxes/register-new-business-georgia).

Company Name: (Legal Registration): ______________________________________________________

Address: _______________________________________________________________________________

City: __________________________________________State: _________________ Zip:______________

Telephone No. FAX No. Email: ____________________

Does your firm qualify for SBE MBE or WBE status: SBE __ MBE __ WBE __ LOCAL __

ADDENDUM ACKNOWLEDGEMENT - Bidder acknowledges that the following addenda have been received and are included in the bid submittal:

Addendum No. Date Issued Addendum No. Date Issued Addendum No. Date Issued

VARIANCES: State any variations to specifications, terms and conditions in the space provided below or reference in the space provided below all variances contained on other pages of RFP, attachments or RFP pages. No variations or exceptions by the Proposer will be deemed to be part of the proposal submitted unless such variation or exception is listed and contained within the proposal documents and referenced in the space provided below. If no statement is contained in the below space, it is hereby implied that your proposal submittal complies with the full scope of this solicitation. If this section does not apply to your proposal, simply mark N/A. If Bidder is requesting any variation(s) or exception(s) to the specifications, terms and conditions, you must submit a written statement with your bid submittal.

The below signatory hereby agrees to furnish the following article(s) or services at the price(s) and terms stated subject to all instructions, conditions, specifications addenda, legal advertisement, and conditions contained in the bid/proposal.

I have read all attachments including the specifications and fully understand what is required. By submitting this signed bid I will accept a contract if approved by the City and such acceptance covers all terms, conditions, and specifications of this bid. The below signatory also hereby agrees, by virtue of submitting or attempting to submit a response, hereby agrees that in no event shall the City’s liability for respondent’s indirect, incidental, consequential, special or exemplary damages, expenses, or lost profits arising out of this competitive solicitation process, including but not limited to public advertisement, bid conferences, site visits, evaluations, oral presentations, or award proceedings. This limitation shall not apply to claims arising under any provision of indemnification or the City’s protest ordinance contained in this competitive solicitation.

Submitted By: _______________________________ Signature: __________________________

Title: ____________________________ Date: _______________

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Sidewalk Design Services https://dor.georgia.gov/taxes/register-new-business-georgia

AUTHORIZED SIGNATORIES

The Bidder/Proposer represents that the following principals are authorized to sign bids, proposals, negotiate, and/or sign contracts and related documents to which the bidder/proposer will be duly bond. 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.

Name Title Telephone Number

__________________________________ Date: __________________ Authorized Signature / Name ________________________________ Federal Employer I.D. No. (FEIN): ________________ Title Dun and Bradstreet No.: ________________________ Legal Business Name Website Address: ___________________________________

Principal Place of Business Address:__________________________________________________________ (City/County/State)

Telephone Number: _________________________

Type of Business/Organization (check appropriate box):

(a) ___ Sole Proprietorship ___ Partnership ___ Non-Profit ___ Joint Venture ___ Corporation

___Other - Specify

(b) State of Incorporation: ___________________________

JOINT VENTURE FIRMS

Joint venture firms must complete and submit with their Bid/Proposal Response this form. Include a copy of the formal written and executed Joint Venture Agreement between all joint venture parties. This joint venture agreement must be executed and indicate the parties “respective roles, responsibilities, and levels of participation for the project. If proposing as a Joint Venture, the Joint Venture shall obtain and maintain all contractually required insurance in the name of the Joint Venture as required by the Contract. Individual insurance in the name of the parties to the Joint Venture will not be accepted. Failure to timely submit the required form along with the formal written and executed Joint Venture Agreement may result in disqualification of your Bid/Proposal Response.

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PURCHASING POLICY ADDENDUM

I, , hereby certify that I have received a copy of the City of Stonecrest, GA, Purchasing Policy which can be found at https://www.stonecrestga.gov/Procurement.aspx and agree to comply with all requirements of the City of Stonecrest, GA Purchasing Policy to the extent the policy is applicable to the undersigned.

THIS CERTIFICATION is submitted by ___________________________the________________________ (Authorized Officer or Agent Print) (Title) of _________________________________________________ (Name of Company)

SIGNATURE DATE

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Sidewalk Design Services https://www.stonecrestga.gov/Procurement.aspx

CONFLICT OF INTEREST DISCLOSURE FORM

Purpose

This Conflict-of-Interest Disclosure form is provided to assist Proposer’s in screening for potential organizational conflicts of interest. The award of this contract is subject to the State of Georgia Purchasing Act relating and O.C.G.A Conflict-of-Interest Disclosure requirements.

Term: The term “Conflict of Interest” refers to situations in which financial or other personal consideration may adversely affect or have the appearance of adversely affecting an employee’s professional judgement in exercising any City duty or responsibility in administration, management, instruction, research, or other professional activities.

All Proposers MUST disclose with their proposal the name of any officer, director, agent, or any relative of an officer, director or agent who is also an employee of the City. Further, all Proposers must disclose the name of any employee who owns, directly or indirectly, an interest of five percent (5%) or more in the Proposers company, firm or any of its subsidiaries. The Conflict-of-Interest Disclosure Form MUST be submitted along with your proposal submittal.

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 due to any other

Cities, Counties, contracts, or property interest for this Qualification.

_____ The undersigned firm, by attachment to this form, submits information which may be a potential conflict of interest due to other Cities, Counties, contracts, or property interest for this Qualification.

ACKNOWLEDGED BY:

Name:

Title:

Signature:

Company/Firm Name:

Address:

Phone: E-mail Address:

Date:

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AFFIDAVIT VERIFYING STATUS FOR CITY PUBLIC BENEFIT APPLICATION

By executing this affidavit under oath, as an applicant for a City of Stonecrest, Georgia Business License or Occupation Tax Certificate, Alcohol License, Taxi Permit, execution of contract or other public benefit as referenced in O.C.G.A. § 50-36-1, I am stating the following with respect to my application for a City of Stonecrest license/permit and /or contract for [Name of natural person applying on behalf of individual, business, corporation, partnership, or other private entity]:

1. I am a United States citizen

OR

2. I am a legal permanent resident 18 years of age or older or I am an otherwise qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years of age or older and lawfully present in the United States. *

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20.

Signature of Applicant: Date:

Printed Name:

* Alien Registration number for non-citizens:

** PLEASE INCLUDE A COPY OF YOUR PERMERMANENT RESIDENT CARD, EMPLOYMENT

AUTHORIZATION, GREEN CARD, PASSPORT WITH A COPY OF YOUR DRIVER LICENSE, OR

OTHER DOCUMENTATION AS ALLOWED UNDER THE LAW IF YOU ARE A LEGAL PERMANENT

RESIDENT (No. 2).

* Note: O.C.G.A.§ 50-36-1(e)(2) requires that aliens under the Federal Immigration and Nationality Act, Title 8 U.S.C., as amended, provide their alien registration number. Because legal permanent residents are included in the Federal definition of “alien”, legal permanent residents must also provide their alien registration number. Qualified aliens that do not have an alien registration number may supply another identifying number below:

Other Identifying Number: ______________________________________

_________________, who is (who are) personally known to me or who has produced _____________________________ as identification and who did (did not) take an oath.

_________________________________________ _______________________ (SEAL)

Notary Public Signature Commission Number Notary Name, Printed, Typed or Stamped Commission Expires

DRUG-FREE WORKPLACE

The undersigned certifies that the provisions of the Official Code of Georgia Annotated (O.C.G.A.) Sections 50-24-1 through 50-24-6 of, relating to the “Drug-free Workplace Act”, have been complied with in full.

The undersigned further certifies that:

(1) A drug-free workplace will be provided for the Contractor’s employees during the performance of the Contract; and

(2) Each Contractor who hires a subcontractor to work in a drug-free workplace shall secure from the subcontractor the following written certification:

“As part of the subcontracting agreement with (Contractor), ______________________________________ certifies to the Contractor that a drug-free workplace will be provided for the subcontractor’s employees during the performance of this Contract pursuant to subsection

(b) of O.C.G.A. Section 50-24-03.”

Also, the undersigned further certifies that he/she will not engage in the unlawful manufacture, sale, distribution, dispensation, possession, or use of a controlled substance or marijuana during the performance of the Contract.

THIS CERTIFICATION is submitted by ________________________________ the __________________ (Authorized Officer or Agent Print) (Title) of _________________________________________________ (Name of Company)

Signature Date

_________________, 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: ________________________

(SEAL)

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GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT AFFIDAVIT

“E-VERIFY”

Contractor(s) Name:

Address:

By executing this affidavit, the undersigned person or entity verifies its compliance with O.C.G.A. § 13- 10-91, stating affirmatively that the individual, firm, or corporation which is registered with, is authorized to participate in, and is participating in the federal work authorization program commonly known as E- Verify,* in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91.

The undersigned person or entity further agrees that it will continue to use the federal work authorization program throughout the contract period, and it will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the undersigned with the information required by O.C.GA. § 13-10-91(b).

The undersigned person or entity further agrees to maintain records of such compliance and provide a copy of each such verification to the City of Stonecrest within five (5) business days after any subcontractor(s) is/are retained to perform such service.

E Verify TM Company Identification Number Date of Authorization

BY: ______________________________________ ______________________

(Authorized Officer or Agent) Title

Date: _____________________________

* or any subsequent replacement operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99- 603.

Other Identifying Number: ______________________________________

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 (SEAL) Notary Name, Printed, Typed or Stamped

Commission Number: _______________________ Commission Expires: ________________________

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Subcontractor Affidavit under O.C.G.A. § 13-10-91(b)(3)

By executing this affidavit, the undersigned subcontractor 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 under a contract with (name of contractor) on behalf of (name of public employer) 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 subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned subcontractor will contract for the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the subcontractor with the information required by O.C.G.A.§ 13-10-91(b). Additionally, the undersigned subcontractor will forward notice of the receipt of an affidavit from a sub-subcontractor to the contractor within five business days of receipt. If the undersigned subcontractor receives notice that a sub-subcontractor has received an affidavit from any other contracted sub-subcontractor, the undersigned subcontractor must forward, within five business days of receipt, a copy of the notice to the contractor.

Subcontractor 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 Authorization

Name of Subcontractor

Name of Project

Name of Public Employer

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.

_________________________________________ (SEAL)

Notary Public Signature Notary Name, Printed, Typed or Stamped

Commission Number: _______________________

Commission Expires: ________________________

INDEMNIFICATION CLAUSE

Contractor shall indemnify and hold harmless the City, and the members (including, without limitation, members of the City’s Council, and members of the boards and of the City), officers, agents, representative and employees of each, from damages, losses, or expenses to the extent caused by or resulting from the negligence, recklessness, or intentionally wrongful conduct of the Contractor or other persons employed or utilized by the Contractor in the performance of the contract.

In any and all claims against the City, or any of their officers, members, agents, representatives, servants or employees, by any employee of the Contractor, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable, the indemnification obligation of the Contractor under this Section shall not be limited in any way by any limitation on the amount or type of damages, compensation or benefit payable by or for the Contractor or any subcontractor under Workers’ Compensation Acts, disability benefit acts or other employee benefit acts.

Proposer’s Name Signature Date

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: ________________________

(SEAL)

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NON-COLLUSION STATEMENT

By signing its Proposal, the Proposers certifies that its Proposal is made independently and free from collusion. Proposers shall complete and submit the Non-Collusion Affidavit Form, to their best knowledge, any City officer or employee, or any relative of any such officer or employee as defined in O.C.G.A Section 50-5-67 and State of Georgia Purchasing Act, who is an officer or director of, or has a material interest in, the supplier's business, who is in a position to influence this procurement. Any City officer or employee who has any input into the writing of specifications or requirements, solicitation of offers, decision to award, evaluation of offers, or any other activity pertinent to this procurement is presumed, for purposes hereof, to be in a position to influence this procurement. For purposes hereof, a person has a material interest if he/she directly or indirectly owns more than five percent (5%) of the total assets or capital stock of any business entity, or if they otherwise stand to personally gain if the contract is awarded to this Proposer.

Failure of a Proposers to disclose any relationship described herein shall be reason for debarment in accordance with the provisions of the City Purchasing Policy.

Proposer, if doing business under an assumed name, i.e., an Individual, Association, Partnership, Corporation, or otherwise, shall be registered with the State of Georgia, Corporations Division.

ACKNOWLEDGED BY:

Proposer’s Name Signature

Title Date

Company/Firm Name

Address

Phone Number

E-Mail Address

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 (SEAL) Notary Name, Printed, Typed or Stamped

Commission Number: _______________________ Commission Expires: ________________________

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VENDOR CERTIFICATION REGARDING

SCRUTINIZED COMPANIES LIST

Respondent Vendor Name:

Vendor FEIN:

Vendor’s Authorized Representative Name and Title:

Address:

City: State: Zip:

Phone Number: _____________________________ Email Address: _____________________________

Georgia law specifies that certain suppliers identified as “Scrutinized Companies” are ineligible to bid on state entity procurements. Please refer to O.C.G.A. § 50-5-84 “Scrutinized Companies” Conducting Business Operations in Sudan, O.C.G.A. § 50-5-84.1 “Scrutinized Companies” Owned by the Government of Russia or Belarus, and O.C.G.A. § 50-5-84.2 “Scrutinized Companies” Owned by the Government of China for additional information. This is applicable for contracts worth $100,000.00 or more.

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 O.C.G.A. § 50-5-84 the submission of a false certification may subject company to civil penalties, attorney’s fees, and/or costs.

CERTIFIED BY:

Name:

Title:

Signature:

Date:

INSURANCE

PROPOSER MUST SUBMIT PROOF OF INSURABILITY WITH THEIR PROPOSAL TO BE

CONSIDERED RESPONSIBLE TO THIS SOLICITATION.

The successful firm or individual entering a resulting contract with the City shall provide, pay for and maintain in full force and affect at all times during the services to be performed insurance as set forth below: (This may be modified, as the City deems appropriate)

The successful Proposer must maintain in full force and effect, during the life of this engagement. Certificates of liability insurance, satisfactory to the City shall be furnished to the City immediately upon commencement of any services, with complete copies of policies to be furnished upon the City’s request. Such certificates of insurance will provide the City with thirty (30) days prior written notice of any cancellation or non-renewal.

BIDDER REQUIRED REFERENCES

The Bidder shall provide three (3) references specific to providing Sidewalk Design Services in the State of Georgia. At least Two (2) reference shall be a local, county, state, or federal entity. FAILURE TO SUBMIT

REFERENCES WITH BID RESPONSE WIIL RESULT IN BIDDER BEING DEEMED NON-

RESPONSIVE.

Services must be for similar scope of services, similar to the requirements of the solicitation this solicitation, specifications, and scope of work.

Include the owner’s name, address, phone number, and current e-mail address.

Note: Do not include proposed team members or parent/subsidiary/affiliated companies as references in your submittals.

A. PRIME BIDDER’S NAME: __________________________________________________________

CLIENT NO. 1 - Name of company/firm to be contacted: ______________________________________

Address: _____________________________________________________________________________

Contact Person: ________________________________________________________________________

Phone No: (___) _______________________________________________________________________

Contact E-Mail Address: _________________________________________________________________

Project Performance Period: _________________ to _______________________ (Dates should be in mm/yy format) Project Name: ________________________________________________________________

Location of Project: _____________________________________________________________________

Description of the overall scope: _________________________________________________________

Description of work that was self-performed by Bidder:

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CLIENT NO. 2 - Name of company/firm to be contacted: ______________________________________

Address: _____________________________________________________________________________

Contact Person: ________________________________________________________________________

Phone No: (___) _______________________________________________________________________

Contact E-Mail Address: _________________________________________________________________

Project Performance Period: _________________ to _______________________ (Dates should be in mm/yy format) Project Name: ________________________________________________________________

Location of Project: _____________________________________________________________________

Description of the overall scope: _________________________________________________________

Description of work that was self-performed by Bidder:

CLIENT NO. 3 - Name of company/firm to be contacted: ______________________________________

Address: _____________________________________________________________________________

Contact Person: ________________________________________________________________________

Phone No: (___) _______________________________________________________________________

Contact E-Mail Address: _________________________________________________________________

Project Performance Period: _________________ to _______________________ (Dates should be in mm/yy format) Project Name: ________________________________________________________________

Location of Project: _____________________________________________________________________

Description of the overall scope: _________________________________________________________

Description of work that was self-performed by Bidder:

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