ATTACHMENT E - PROPOSER RESPONSIBILTY FORM.pdf

ATTACHMENT E

PROPOSER RESPONSIBILITY FORM

(PROPOSER'S QUALIFICATIONS AND FINANCIAL INFORMATION)

DECLARATION AND SIGNATURES

The undersigned hereby declares that he or she is duly authorized to complete and submit this Proposer Responsibility Form and that the statements contained herein are true and correct as of the date set forth below. Incomplete, incorrect or misleading information will be reason for a determination by the District of Proposer non-responsibility.

Date: _

B_ y:

(Signature of authorized official)

Name :

(Please type or print)

Tit_le:

{Please type or print)

F_or:

(Firm's name) (Please type or print)

Instruc�ons

1. The informa�on provided in this form is part of the OCDC inquiry concerning Proposer responsibility. Please print clearly or type.

2. If you need more space, use plain paper. Submit completed form with Proposal response.

3. Answer all ques�ons. Submission of a form with unanswered ques�ons, incomplete or illegible answers may result in a finding that the Proposer is not a responsible Proposer.

RELIABILITY

Has your company ever been declared in breach of any contract for unperformed or defective work? □ Yes. □No.

If "yes", explain.

Has any employee or agent of your company ever been convicted of a criminal offense arising out of obtaining, atemp�ng to obtain, or performing a public or private contract or subcontract? □ Yes. □No.

Has any employee or agent of your company been convicted under state or federal law of embezzlement, the�, forgery, bribery, falsifica�on or destruc�on of records, receiving stolen property or any other offense indica�ng a lack of business integrity or business honesty? □ Yes. □No.

Has your company or any employee or agent of your company been convicted under state or federal an�trust laws?

□ Yes. □No.

Has any Officer or Partner of your organiza�on ever been an Officer or Partner of another organiza�on that failed to complete a contract? □ Yes. □No.

FINANCIAL RESOURCES

Has your organiza�on ever been at any �me in the last ten years the debtor in a bankruptcy case? □ Yes. □No

Does your organiza�on have any outstanding judgements pending against it? □ Yes. □No

In the past ten years, has your organiza�on been a party to li�ga�on, arbitra�on or media�on where the amount in dispute exceeded $10,000? □ Yes. □No

If "yes", explain. (Include court, case number and party names)

In the past ten years, has your organiza�on been a party to li�ga�on, arbitra�on or media�on on a mater related to payment to subcontractors or work performance on a contract? Check “yes” even if the mater proceeded to arbitra�on or media�on without court li�ga�on. □ Yes. □No

If "yes", explain. (Include court, case number and party names)

Have your organiza�on or any of your affiliates discon�nued business opera�on with outstanding debts? □ Yes. □No

KEY PERSONNEL

List the principal individuals of your organiza�on, their current job �tle, the total years of experience they have in the industry and their current primary responsibility for your organiza�on. Corpora�ons list current officers and those who own 5% or more of the corpora�on's stock. Limited liability companies list members who own 5% or more of the company. Partnerships list all partners. Joint ventures list each firm that is a member of the joint venture and the percentage of ownership the firm has in the joint venture.

ITEM Principal Individual

A. Name

B. Position

C. Years in Position

D. Current Primary Responsibility

B. Position

B. Position

C. Years in Position

D. Current Primary Responsibility

ITEM Principal Individual

A. Name

B. Position

Person who will be in direct charge of work if your company is awarded this Contract:

ITEM PERSON IN DIRECT CHARGE

B. Position

C. Years in Position

D. Largest Project Supervised-$

E. Largest number of employees ever supervised

5.2.2 Response to Protest