ATTACHMENT C - ENERGY ANALYST FIRM INFORMATION CERTIFICATION SHEET.docx

ATTACHMENT C – INFORMATION AND CERTIFICATION SHEET

OREGON BUYS SOLICITATION #S-33000-00017127; AGENCY RFQ #26-099 SEED

ATTACHMENT C –

ENERGY ANALYST INFORMATION AND CERTIFICATION SHEET

Legal Name of Energy Analyst Firm:

Address: ____________________________________________City/State/Zip: _________________________________

State of Incorporation:____________________________________________________Entity Type:______________

Contact Name:___________________________________Telephone:_____________Email: _____________________

Oregon Business Registration Number: _______________________

Any individual signing below hereby certifies they are an authorized representative of Energy Analyst Firm and that:

Energy Analyst Firm understands and accepts the requirements of OREGON BUYS SOLICITATION #S-33000-00017127; AGENCY RFQ #26-099 SEED. By submitting a Statement of Qualifications (“SOQ”), Energy Analyst Firm agrees to be bound by the Prequalified List Agreement terms and conditions in Attachment A and as modified by any Amendment, except for those terms and conditions that Agency has reserved for negotiation, as identified in the OREGON BUYS SOLICITATION #S-33000-00017127; AGENCY RFQ #26-099 SEED.

Energy Analyst Firm acknowledges receipt of any and all Addenda/Amendments to the OREGON BUYS SOLICITATION #S-33000-00017127; AGENCY RFQ #26-099 SEED Energy Analyst Firm’s SOQ is valid for 180 days following the Opening of the OREGON BUYS SOLICITATION #S-33000-00017127; AGENCY RFQ #26-099 SEED.

If awarded a Prequalified List Agreement, Energy Analyst Firm agrees to perform the statement of work and meet the performance standards set forth in the final negotiated statement of work of the Prequalified List Agreement.

I have knowledge regarding Energy Analyst Firm’s payment of taxes and by signing below. I hereby certify that, to the best of my knowledge, the Energy Analyst Firm is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

Energy Analyst Firm does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Energy Analyst Firm does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owned or an emerging small business. If applicable, Energy Analyst Firm has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into a contract with an anticipated contract price of $150,000 or more with an Energy Analyst Firm that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.

Energy Analyst Firm complies with ORS 652.220 and does not unlawfully discriminate against any of Energy Analyst Firm’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class. “Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.

Energy Analyst Firm’s continuing compliance constitutes a material element of Energy Analyst Firm’s Prequalified List Agreement and a failure to comply constitutes a breach that entitles Agency to terminate the Agreement for cause.

Energy Analyst Firm may not prohibit any of Energy Analyst Firm’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Energy Analyst Firm may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

Energy Analyst Firm is not engaged in the provision of broadband Internet access service, or if at any time Energy Analyst Firm is engaged in or may engage in the provision of broadband Internet access service Energy Analyst Firm is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Contract.

Energy Analyst Firm and Energy Analyst Firm’s employees, agents, and subcontractors are not included on:

the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or the government wide exclusions lists in the System for Award Management found at:

SAM.gov | Check Entity Status Energy Analyst Firm certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Energy Analyst Firm, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the OREGON BUYS SOLICITATION #S-33000-00017127; AGENCY RFQ #26-099 SEED . If any changes occur with respect to Energy Analyst Firm’s status regarding conflict of interest, Energy Analyst Firm shall promptly notify the State in writing.

Energy Analyst Firm certifies that all contents of Energy Analyst Firm’s SOQ submitted in response to OREGON BUYS SOLICITATION #S-33000-00017127; AGENCY RFQ #26-099 SEED (including any other forms or documentation, if required under the OREGON BUYS SOLICITATION/AGENCY RFQ ) and this Information and Certification Sheet are truthful and accurate and have been prepared independently from all other Energy Analysts Firms, and without collusion, fraud, or other dishonesty.

Energy Analyst Firm understands that any statement or representation it makes, in response to OREGON BUYS SOLICITATION #S-33000-00017127; AGENCY RFQ #26-099 SEED , if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Energy Analyst Firm’s resulting the Prequalified List Agreement being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

Energy Analyst Firm acknowledges these certifications are in addition to any certifications required in the Prequalified List Agreement and Statement of Work in Attachment A at the time of Prequalified List Agreement execution.

Authorized Signature

Date

(Printed Name and Title)

ATTACHMENT C – INFORMATION AND CERTIFICATION SHEET

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