Attachment G.1 - Invest in MA Form.doc

INVEST IN MASSACHUSETTS DATA FORM

Instructions: Completing all parts of this form is mandatory unless directed otherwise. Please read instructions in the Invest in Massachusetts Attachment included with the solicitation.

For a complete list of certified vendors please go to http://www.somwba.state.ma.us/BusinessDirectory/BusinessDirectory.aspx .

Part I Bidder/Proposer Information

Business Name:

Full Address: number, street, and apt. or suite no., city, state, zip

) - x 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).

f

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? FORMCHECKBOX Yes FORMCHECKBOX 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 Bidders/Proposers who have answered “Yes” to Inquiry #1 are required to certify the Bidder/Proposer’s commitment that 50% or more of the work-hours performed in connection with any contract arising out of the Bidder/Proposer’s RFR Response will be performed in Massachusetts. This certification must be signed by an individual authorized to bind the Bidder/Proposer firm. Additionally, this commitment will be an essential part of any contract awarded by the Treasury and will be written into any formal agreement.

f

I, Signed under the pains and penalties of perjury.

Print Name ► Authorized Signature ► ________________________________ Date ► f