Attachment E Investin MA Form~3.pdf
PDF 792 KB Posted
- Attached to
- RFR for Arbitrage Rebate Compliance Services
- Solicitation number
- BD-21-1211-MSBA-MASS-55580
- Issued by
- Massachusetts
About this file
This document is an Invest in Massachusetts Data Form that is part of a state and local contract opportunity. The form requires respondents to indicate whether at least 50% of the work hours for the contract will be performed in Massachusetts, as well as provide details on the number and location of jobs that will be created or preserved in Massachusetts as a result of the contract. Respondents who indicate that 50% or more of the work will be performed in Massachusetts are required to certify this commitment, which will be an essential part of any contract awarded. The related state and local contract opportunity is a Request for Response (RFR) for Arbitrage Rebate Compliance Services from the Massachusetts state government.
The Invest in Massachusetts Data Form is mandatory for this contract opportunity, unless the respondent indicates that less than 50% of the work hours will be performed in Massachusetts. The form requires respondents to provide their business name, contact information, and respond to three inquiries related to the in-state work and job creation or preservation. Respondents must sign the certification under pains and penalties of perjury if they indicate that 50% or more of the work will be performed in Massachusetts.
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Text version
INVEST IN MASSACHUSETTS DATA FORM
Instructions: Completing all parts of this form is mandatory unless directed otherwise.
Part I Respondent Information
Business Name:
Full Address: number, street, and apt. or suite no., city, state, zip
Contact Name: Phone # ( ) - Email address:
Part II Invest in Massachusetts Data (Please respond to the inquiries (1-3) listed below. If you answer "No" to Inquiry #1 of this Part
II, then you are not required to complete Part III of this IMD Form).
1. Will at least 50% or more of the work -hours performed as a result of a contract arising out of this proposal be performed in Massachusetts? Yes No
2. If you responded "Yes" to Inquiry #1, how many of those jobs performed in Massachusetts will be created and/or preserved as a result of a contract arising out of this proposal?
3. If you responded "Yes" to Inquiry #1, where in Massachusetts will those jobs be located?
Part III Certification Based on your responses in Part II of the IMD Form, those Respondents who have answered "Yes" to Inquiry #1 are required to certify the Respondent's commitment that 50% or more of the work-hours performed in connection with any contract arising out of the Respondent's RFR Response will be performed in Massachusetts. This certification must be signed by an individual authorized to bind the Respondent firm. Additionally, this commitment will be an essential part of any contract awarded by the MSBA and will be written into any formal agreement.
I, , hereby certify that the information contained in this IMD Form is true and accurate and I hereby certify on behalf of [Respondent Name] that, if awarded the contract, 50% or more of the work -hours performed in connection with any agreement arising out of the Respondent's RFR Response, will be performed in the Commonwealth of Massachusetts.
Signed under the pains and penalties of perjury.
Print Name Title
Authorized Signature ________________________________ Date
ATTACHMENT E
Invest in Massachusetts ejrobbins D:20110524123954- 04'00' D:20110525082154- 04'00'
INVEST IN MASSACHUSETTS DATA FORM
Instructions: Completing all parts of this form is mandatory unless directed otherwise.
Part I Respondent Information
Business Name:
Full Address: number, street, and apt. or suite no., city, state, zip
Contact Name:
Phone # ( ) -
Email address:
Part II Invest in Massachusetts Data (Please respond to the inquiries (1‐3) listed below. If you answer "No" to Inquiry #1 of this Part II, then you are not required to complete Part III of this IMD Form).
1.
Will at least 50% or more of the work‐hours performed as a result of a contract arising out of this proposal be performed in Massachusetts?
Yes
No 2.
If you responded "Yes" to Inquiry #1, how many of those jobs performed in Massachusetts will be created and/or preserved as a result of a contract arising out of this proposal?
3.
If you responded "Yes" to Inquiry #1, where in Massachusetts will those jobs be located?
Part III
Certification Based on your responses in Part II of the IMD Form, those Respondents who have answered "Yes" to Inquiry #1 are required to certify the Respondent's commitment that 50% or more of the work‐hours performed in connection with any contractarising out of the Respondent's RFR Response will be performed in Massachusetts. This certification must be signed by an individualauthorized to bind the Respondent firm. Additionally, this commitment will be an essential part of any contract awarded by the MSBAand will be written into any formal agreement.
I, , hereby certify that the information contained in this IMD Form is true and accurate and
I hereby certify on behalf of
[Respondent Name] that, if awarded the contract, 50% or more of the work‐hours performed in connection with any agreement arising out of the Respondent's RFR Response, will be performed in theCommonwealth of Massachusetts.
Signed under the pains and penalties of perjury.
Print Name
Title
Authorized Signature ________________________________
Date
Will at least 50% or more of the work-hours performed as a result ofa contract arising outof this proposal be performed in
ATTACHMENT E
| Business Name: |
| ContactName:: |
| Phone # ( ) - x: |
| Email address:: |
| Will at least 50% or more of the work-hours performed as a result ofa contract arising outof this proposal be performed in: |
| If you responded "Yes" to Inquiry #1, how many ofthose jobsperformed in Massachusetts will be created and/orpreserved asa: |
| If you responded "Yes" to Inquiry #1, where in Massachusetts will those jobs be located [1]: |
| If you responded "Yes" to Inquiry #1, where in Massachusetts will those jobs be located [2]: |
| If you responded "Yes" to Inquiry #1, where in Massachusetts will those jobs be located [3]: |
| If you responded "Yes" to Inquiry #1, where in Massachusetts will those jobs be located [4]: |
| I: |
| hereby certify that the information contained in this IMD Form is true and accurate and: |
| Signed under the pains and penalties of perjury: |
| undefined: |
| Authorized Signature: |
| Title: |
| Address: |
| PrintButton1: |
| PrintButton2: |
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