ATTACHMENT K - Form C-76 - CONTRACTOR’S CERTIFICATE OF COMPLIANCE FOR STEEL & IRON ITEMS.pdf
PDF 411 KB Posted
- Attached to
- IFB 160941 JS Ferry Surry Shipyard Package
- Solicitation number
- IFB-126120
- Issued by
- Southampton County, Virginia
About this file
This is a Contractor's Certificate of Compliance form (Form C-76) issued by the Virginia Department of Transportation (VDOT) for compliance with federal "Buy America" requirements under 23 CFR 635.410. The form serves as a certification document that contractors must submit to VDOT at the time of delivery for any items containing steel or iron permanently incorporated into federally-funded highway projects. The form requires contractors to identify specific bid items, provide product descriptions, list quantities with applicable units of measurement (linear feet, square yards, cubic yards, etc.), and document the total cost of steel and iron components. Contractors must certify whether materials meet domestic sourcing requirements or acknowledge if manufacturing processes occurred outside the United States.
The form establishes two certification pathways: contractors may certify that all steel and iron manufacturing processes, including melting, mixing, extruding, rolling, bending, casting, forging, and coating applications, occurred entirely within the United States; alternatively, contractors may declare non-domestic material and track the cost of foreign-sourced ferrous materials to ensure compliance with maximum allowable thresholds. Supporting documentation demonstrating Buy America compliance, including mill test reports and manufacturer certifications, must be organized by submittal number and retained by the contractor from the delivery date through three years after project acceptance. The Prime Contractor's Project Superintendent must sign and date all certifications, with the form accommodating multiple bid items across extended pages as needed for comprehensive project tracking.
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Text version
Form C-76 Rev. 11-4-19
CONTRACTOR’S CERTIFICATE OF COMPLIANCE
FOR STEEL & IRON ITEMS
For Compliance with “Buy America” 23 CFR 635.410
Contract ID No. ______________ Page __1__ of _____
VDOT Project No. _____________________
FHWA Project No. _____________________
Buy America Submittal Number____________
Project Location & Description
The (Name of Manufacturer/Supplier) (Street Address) (City, State) (Phone) has furnished to (Name of Contractor) (Street Address) (City, State) (Phone) the following items containing iron or steel for permanent use in the above referenced project:
Bid Item No. Bid Item Description Product Description
(if only a portion of the Bid Item) Quantity
Unit
(LF,YD²,
YD³, etc.)
Total Cost of Non-Domestic Steel and Iron in this Item
Submit this form to VDOT at the time of delivery of any items containing steel or iron to the project. Supporting documentation to demonstrate compliance with Buy America provisions (such as mill test reports manufacturer/supplier certifications, etc.) shall be organized by Submittal Number and maintained by the contractor from the date of delivery until three years after project acceptance. (Note that documentation such as off-site test reports, etc., when also required for other material quality purposes, is still required at time of delivery.)
Contractor’s Statement of Certification Domestic Material. I hereby certify that all steel and iron manufacturing processes (including melting, mixing, extruding, rolling, bending, casting, forging, etc., and the application of any coating, as applicable), occurred in the United States for the above listed materials and that those materials do meet all other requirements as set forth in the plans and specifications.
Non-Domestic Material. Although the above listed materials do meet all other requirements as set forth in the plans and specifications, all or part of the steel or iron manufacturing process may have occurred outside the United States, so the material is considered non-domestic. The cost of the steel and iron in this material, as delivered to the project, is $ and will be tracked to ensure the total non-domestic ferrous material does not exceed the maximum allowable.
By Title (Name of Prime Contractor’s Project Superintendent, Typed or Printed)
Date (Signature of Prime Contractor’s Project Superintendent)
Form C-76 Rev. 11-4-19
CONTRACTOR’S CERTIFICATE OF COMPLIANCE
FOR STEEL & IRON ITEMS
For Compliance with “Buy America” 23 CFR 635.410
Item Page No. ______ of ______
Contract ID No.
Buy America Submittal VDOT Project No. Number____________
FHWA Project No.
Bid Item No. Bid Item Description Product Description
(if only a portion of the Bid Item) Quantity
Unit
(LF,YD²,
YD³, etc.)
Total Cost of Non-Domestic Steel and Iron in this Item
(Initials of Prime Contractor’s Project Superintendent)
| Contract ID No: |
| of: |
| VDOT Project No: |
| FHWA Project No: |
| Number: |
| Project Location Description: |
| Bid Item NoRow1: |
| Bid Item DescriptionRow1: |
| Product Description if only a portion of the Bid ItemRow1: |
| QuantityRow1: |
| Unit LFYD² YD³ etcRow1: |
| Total Cost of Steel and Iron in this ItemRow1: |
| Bid Item NoRow2: |
| Bid Item DescriptionRow2: |
| Product Description if only a portion of the Bid ItemRow2: |
| QuantityRow2: |
| Unit LFYD² YD³ etcRow2: |
| Total Cost of Steel and Iron in this ItemRow2: |
| Bid Item NoRow3: |
| Bid Item DescriptionRow3: |
| Product Description if only a portion of the Bid ItemRow3: |
| QuantityRow3: |
| Unit LFYD² YD³ etcRow3: |
| Total Cost of Steel and Iron in this ItemRow3: |
| Title: |
| Date: |
| Item Page No: |
| of_2: |
| Contract ID No_2: |
| VDOT Project No_2: |
| Number_2: |
| FHWA Project No_2: |
| Bid Item NoRow1_2: |
| Bid Item DescriptionRow1_2: |
| Product Description if only a portion of the Bid ItemRow1_2: |
| QuantityRow1_2: |
| Unit LFYD² YD³ etcRow1_2: |
| Total Cost of Steel and Iron in this ItemRow1_2: |
| Bid Item NoRow2_2: |
| Bid Item DescriptionRow2_2: |
| Product Description if only a portion of the Bid ItemRow2_2: |
| QuantityRow2_2: |
| Unit LFYD² YD³ etcRow2_2: |
| Total Cost of Steel and Iron in this ItemRow2_2: |
| Bid Item NoRow3_2: |
| Bid Item DescriptionRow3_2: |
| Product Description if only a portion of the Bid ItemRow3_2: |
| QuantityRow3_2: |
| Unit LFYD² YD³ etcRow3_2: |
| Total Cost of Steel and Iron in this ItemRow3_2: |
| Bid Item NoRow4: |
| Bid Item DescriptionRow4: |
| Product Description if only a portion of the Bid ItemRow4: |
| QuantityRow4: |
| Unit LFYD² YD³ etcRow4: |
| Total Cost of Steel and Iron in this ItemRow4: |
| Bid Item NoRow5: |
| Bid Item DescriptionRow5: |
| Product Description if only a portion of the Bid ItemRow5: |
| QuantityRow5: |
| Unit LFYD² YD³ etcRow5: |
| Total Cost of Steel and Iron in this ItemRow5: |
| Bid Item NoRow6: |
| Bid Item DescriptionRow6: |
| Product Description if only a portion of the Bid ItemRow6: |
| QuantityRow6: |
| Unit LFYD² YD³ etcRow6: |
| Total Cost of Steel and Iron in this ItemRow6: |
| Bid Item NoRow7: |
| Bid Item DescriptionRow7: |
| Product Description if only a portion of the Bid ItemRow7: |
| QuantityRow7: |
| Unit LFYD² YD³ etcRow7: |
| Total Cost of Steel and Iron in this ItemRow7: |
| Bid Item NoRow8: |
| Bid Item DescriptionRow8: |
| Product Description if only a portion of the Bid ItemRow8: |
| QuantityRow8: |
| Unit LFYD² YD³ etcRow8: |
| Total Cost of Steel and Iron in this ItemRow8: |
| Bid Item NoRow9: |
| Bid Item DescriptionRow9: |
| Product Description if only a portion of the Bid ItemRow9: |
| QuantityRow9: |
| Unit LFYD² YD³ etcRow9: |
| Total Cost of Steel and Iron in this ItemRow9: |
| Bid Item NoRow10: |
| Bid Item DescriptionRow10: |
| Product Description if only a portion of the Bid ItemRow10: |
| QuantityRow10: |
| Unit LFYD² YD³ etcRow10: |
| Total Cost of Steel and Iron in this ItemRow10: |
| Bid Item NoRow11: |
| Bid Item DescriptionRow11: |
| Product Description if only a portion of the Bid ItemRow11: |
| QuantityRow11: |
| Unit LFYD² YD³ etcRow11: |
| Total Cost of Steel and Iron in this ItemRow11: |
| Bid Item NoRow12: |
| Bid Item DescriptionRow12: |
| Product Description if only a portion of the Bid ItemRow12: |
| QuantityRow12: |
| Unit LFYD² YD³ etcRow12: |
| Total Cost of Steel and Iron in this ItemRow12: |
| Bid Item NoRow13: |
| Bid Item DescriptionRow13: |
| Product Description if only a portion of the Bid ItemRow13: |
| QuantityRow13: |
| Unit LFYD² YD³ etcRow13: |
| Total Cost of Steel and Iron in this ItemRow13: |
| Bid Item NoRow14: |
| Bid Item DescriptionRow14: |
| Product Description if only a portion of the Bid ItemRow14: |
| QuantityRow14: |
| Unit LFYD² YD³ etcRow14: |
| Total Cost of Steel and Iron in this ItemRow14: |
| Bid Item NoRow15: |
| Bid Item DescriptionRow15: |
| Product Description if only a portion of the Bid ItemRow15: |
| QuantityRow15: |
| Unit LFYD² YD³ etcRow15: |
| Total Cost of Steel and Iron in this ItemRow15: |
| Bid Item NoRow16: |
| Bid Item DescriptionRow16: |
| Product Description if only a portion of the Bid ItemRow16: |
| QuantityRow16: |
| Unit LFYD² YD³ etcRow16: |
| Total Cost of Steel and Iron in this ItemRow16: |
| Steel/Iron Cost Total: |
| Initials: |
| Domestic Check: Off |
| NonDomestic Check: Off |
| Super Name: |
| Manufacturer Name: |
| Manufacturer Address: |
| Manufacturer Phone: |
| Contractor Name: |
| Contractor Address: |
| Contractor Phone: |
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