Attachment F-Responsibility Inquiry_ITB S-DASOBO-00004975.doc

ITB # S-DASOBO-00004975 – Heat-Transfer Cigarette Tax Stamp Manufacturing and Distribution

Attachment F

ATTACHMENT F –

RESPONSIBILITY INQUIRY

Step 3 - Required form

DAS PS will determine responsibility of a Bidder prior to award and execution of a Price Agreement. In addition to this form, DAS PS may notify Bidder of other documentation required, which may include but is not limited to recent profit-and-loss history, current balance statements and cash flow information, assets-to-liabilities ratio, including number and amount of secured versus unsecured creditor claims, availability of short and long-term financing, bonding capacity, insurability, credit information, materials and equipment, facility capabilities, personnel information, record of performance under previous contracts, etc. Failure to promptly provide requested information or clearly demonstrate responsibility may result in a DAS PS finding of non-responsibility and rejection.

1. Does Bidder have available the appropriate financial, material, equipment, facility and personnel resources and expertise, or ability to obtain the resources and expertise, necessary to demonstrate the capability of Bidder to meet all contractual responsibilities? YES / NO .

2. Within the last five years, how many contracts of a similar nature has Bidder completed that, to the extent that the costs associated with and time available to perform the contract remained within Bidder′s control, Bidder stayed within the time and budget allotted, and there were no contract claims by any party? Number: ____ How many contracts did not meet those standards? Number: ____ If any, please explain.

Response:

3. Within the last three years has Bidder (incl. a partner or shareholder owning 10% or more of Bidder’s firm) or a major subcontractor (receiving 10% or more of a total contract amount) been criminally or civilly charged, indicted, or convicted in connection with:

· obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract,

· violation of federal or state antitrust statutes relating to the submission of bids, or

· embezzlement, theft, forgery, bribery, falsification, or destruction of records, making false statements, tax evasion, or receiving stolen property? YES / NO .

If "YES," indicate the jurisdiction, date of indictment, charge or judgment, and names and summary of charges in the response field below.

Response:

4. Within the last three years, has Bidder had:

· any contracts terminated for default by any government DAS PS, or

· any lawsuits filed against it by creditors or involving contract disputes? YES / NO .

If "YES," please explain. (With regard to judgments, include jurisdiction and date of final judgment or dismissal.)

Response:

5. Does Bidder have any outstanding or pending judgments against it? YES / NO .

Is Bidder experiencing financial distress or having difficulty securing financing? YES / NO .

Does Bidder have sufficient cash flow to fund day-to-day operations throughout the proposed Price Agreement period? YES / NO If "YES” on the first question or second question, or “NO” on the third question, please provide additional details.

Response:

6. Within the last three years, has Bidder filed a bankruptcy action, filed for reorganization, made a general assignment of assets for the benefit of creditors, or had an action for insolvency instituted against it? YES / NO .

If "YES," indicate the filing dates, jurisdictions, type of action, ultimate resolution, and dates of judgment or dismissal, if applicable.

Response:

7. Does Bidder have all required licenses, insurance and/or registrations, if any, and is Bidder legally authorized to do business in the State of Oregon? YES /NO .

If "NO," please explain.

Response:

8. Pay Equity Certificate. Does a current authorized representative of Bidder possess an unexpired Pay Equity Certificate issued by the Department of Administrative Services? YES / NO / N/A . If applicable, submit a copy of the certificate with this form.

Response:

AUTHORIZED SIGNATURE

By signature below, the undersigned Authorized Representative on behalf of Bidder certifies to the best of his or her knowledge and believes the responses provided on this form are complete, accurate, and not misleading.

Bidder Name:

ITB:

Project Name:

BIDDER, Authorized Representative Signature: _______________________________________________________________________________________

Print Name and Title: ___________________________________________________________________________

Date: _____________________________________________________________________________________________

Email: _____________________________________________________________________________________________

Telephone Number: (______) ____________________________________________________________________