Bid 24-16 Container Haul Bid.pdf

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Invitation for Public Bid # 24-16

Container Haul Bid Services

City of Cape May, Cape May County, N.J.

June 18, 2024 at 10:30A.M.

MAYOR & COUNCIL

Mayor Zachary Mullock

Councilmember Lorraine Baldwin

Councilmember Shaine P. Meier

Councilmember Michael Yeager

Councilmember Maureen K. McDade

Erin C. Burke, RMC, City Clerk

Paul Dietrich, City Manager

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LEGAL NOTICE

Notice is hereby given by the City of Cape May that a invitation for public bid will be received by the City on June 18, 2024 at 10:30A.M. prevailing time conducted on electronic platform, in accord with N.J.A.C. 5:34-1 et. Seq., on BIDNET at www.bidnetdirect.com//capemaycity

BID# 24-16 Container Haul Services Bid

NOTE:

It is the bidder’s responsibility to ensure that the bid package is uploaded onto the e-procurement site by the bid opening date and time. Any bid document received after the deadline established by the Department of Purchasing will not be accepted, regardless of the method of delivery.

Bidders must comply with the requirements of N.J.S.A. 10:5-31 et seq., and

N.J.A.C. 17:27 et. Seq., For zoom contact and opening invitation please contact the Qualified Purchasing Agent at scanning@thecanninggroup.org

The City of Cape May will award this bid to the lowest responsible bidder in accord with

N.J.S.A. 40A:11-4A.

This procurement has been advertised in accordance with the “Fair and Open Basis”

(N.J.S.A. 19:44A-20.5).

Date: May 29, 2024 Erin C. Burke

City Clerk http://www.bidnetdirect.com/capemaycity mailto:scanning@thecanninggroup.org

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Applicable to Bid if marked “X”

DOCUMENTATION REQUIRED OR REVIEWED

Initials When Due

Bid Guarantee (Bid Bond or Certified/Cashier’s Check) (with

POA for full amount of Bid Bond)

With Bid

Submission

Consent of Surety (Certificate from Surety company)

Performance Bond and Labor and Material Payment Bond

(Required from the Awarded Contractor)

At signing of contract

Maintenance Bond in the Amount of 100 % for a period indicated in “General Conditions” Required from the Awarded

Contractor Upon Acceptance of Project

Upon

Acceptance of

Project

Acknowledgement of Receipt of Addenda (To be Completed if Addenda are Issued)

X Ownership Disclosure Form With Bid

Submission

Named Subcontractors in Bid for Listed Specialty Trades

Public Works Contractor Registration Certificate(s) for the

Bidder and all Sub Contractors

Prior to Award, but effective at time of bid

X Business Registration Certificate – Bidder and all Sub

Contractors

Prior to

Contract

Award

X Non-Collusion Affidavit With Bid

Submission

X Experience and Qualifications With Bid

Submission

X Insurance and Indemnification Certificate

Prior to

Contract

Award

X Disclosure of Investment Activities in Russia/ Iran Form

Prior to

Contract

Award

Federal debarment Form

Prior to

Contract

Award

Prevailing Wage Certification (PL 2021, C301)

Prior to

Contract

Award

X Equipment Certification

EEO/AA Form AA-201

After Notice of

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Award, Prior to

Signing

Contract

X EEO/AA Form AA-302 or Letter of Federal Approval or

Certificate of Employee Information Report

After Notice of

Award, Prior to

Signing

Contract

X Bidder’s Checklist

This checklist is provided for bidder’s use in assuring compliance with required documentation; however, it does not include all specifications requirements and does not relieve the bidder of the need to read and comply with the specifications.

Bidder

Name:

Date:

Authorized

Representative:

Signature:

Print Name &

Title:

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S P E C I F I C A T I O N S

1.0 PURPOSE AND SCOPE

1.1 This bid is for the purchase of container hauling services for the City of Cape May at its public works location of:

1.2 Address

1.3 The term of the contract shall be for one (1) year with a term ending December 31, 2024.

The contract may be renewed for one (1), two (2) year term, or two (2), one (1), year terms consistent with N.J.S.A. 40A:11-15.

1.4 All bids and questions must be conducted through bidnet direct at www.bidnetdirect.com//capemaycity no physical or emailed bids will be accepted

1.5 The method of award shall be to the lowest responsible bidder in accord with

N.J.S.A.40A:11-4a.

2.0 SCOPE OF WORK

2.1 The following specifications are a statement of the minimum level of work and services which Contractor must provide and should not be construed as maximum performance levels.

3.0 Insurance

3.1 The Contractor shall carry or require that there be carried:

3.2 Workmen's Compensation Insurance

3.3 Manufacturer's and Contractor's Liability for:

3.4 Personal Injury

3.5 Property Damage

3.6 Automotive Liability

3.7 Owner's Protective Liability for the City of Cape May, in the name of the City of

Cape May.

3.8 The Contractor shall, at all times, indemnify and save harmless the City of Cape May, its agents and employees, from and against all loss and expense (including attorney's fees) by reason of liability imposed by law upon the City of Cape May for damages because of bodily injury, including death at any time resulting therefrom, sustained by any person or persons, or on account of damage to property including loss of use thereof, arising out of or in consequence of the performance of this work, whether such injury to persons, or damage to property, is due or claimed to be due http://www.bidnetdirect.com/capemaycity

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May.

3.9 The following will be the limits of coverage required for this Contract:

3.9.1 Manufacturer's and Contractor's Liability:

3.9.2 Personal Injury Liability Insurance will have limits of $1,000,000 (per occurrence)/$2,000,000 (aggregate), said limits to apply also during the period when completed operations clauses are in effect.

3.9.3 Property Damage Liability Insurance will have limits of $500,000 (per occurrence)/$1,000,000 (aggregate), said limits to apply also during the period when completed operations clauses are in effect.

LOCATION SIZE

CONTAINER/

QTY

APPROXIMATE

HAULS PER

YEAR

PICKUP

SCHEDULE

TYPE

DPW 30 YARD/(8) 244 Brush, Concrete, Construction, Single

Stream Recycling, other

15 YARD/(2) 72 BRUSH

10 YARD(1) 12

PROPOSAL FORM

ITEM SIZE PRICE PER HAUL

1 30 YARD $

2 15 YARD $

3 10 YARD $

Company Name Federal ID # or Social Security #

Address

Signature of Authorized Agent Type or Print Name

Telephone Number Date

Fax Number E-mail address

EXHIBIT A

MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE

N.J.S.A. 10:5-31 et seq. (P.L.1975, c.127)

N.J.A.C. 17:27-1.1 et seq.

GOODS, GENERAL SERVICES, AND PROFESSIONAL SERVICES CONTRACTS

During the performance of this contract, the contractor agrees as follows:

The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will ensure that equal employment opportunity is afforded to such applicants in recruitment and employment, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affection- al or sexual orientation, gender identity or expression, disability, nationality or sex. Such equal employment opportunity shall include, but not be limited to the following: employment, up- grading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprentice- ship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause.

The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

The contractor or subcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting officer, advising the labor union of the contractor's commitments under this chapter and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act.

The contractor or subcontractor agrees to make good faith efforts to meet targeted county employment goals established in accordance with N.J.A.C. l7:27-5.2.

EXHIBIT A (Cont)

The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices.

The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job-related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions.

In conforming with the targeted employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions.

The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents:

Letter of Federal Affirmative Action Plan Approval; Certificate of Employee

Information Report; or

Employee Information Report Form AA-302 (electronically provided by the Division through the Division’s website at: http://www.state.nj.us/treasury/contract_compliance.

The contractor and its subcontractors shall furnish such reports or other documents to the Division of Purchase &

Property, CCAU, EEO Monitoring Program as may be request- ed by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of Purchase & Property, CCAU, EEO Monitoring Program for conducting a compliance investigation pursuant to N.J.A.C.

17:27-1.1 et seq.

http://www.state.nj.us/treasury/contract_compliance

NEW JERSEY ANTI-DISCRIMINATION PROVISIONS

N.J.S.A. 10:2-1 ET SEQ.

Pursuant to N.J.S.A. 10:2-1, if awarded a contract, the contractor agrees that:

a. In the hiring of persons for the performance of work under this contract or any subcontract hereunder, or for the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under this contract, no contractor, nor any person acting on behalf of such contractor or subcontractor, shall, by reason of race, creed, color, national origin, ancestry, marital status, gender identity or expression, affectional or sexual orientation or sex, discriminate against any person who is qualified and available to perform the work to which the employment relates;

b. No contractor, subcontractor, nor any person on his behalf shall, in any manner, discriminate against or intimidate any employee engaged in the performance of work under this contract or any subcontract hereunder, or engaged in the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under such contract, on account of race, creed, color, national origin, ancestry, marital status, gender identity or expression, affectional or sexual orientation or sex;

c. There may be deducted from the amount payable to the contractor by the contracting public agency, under this contract, a penalty of $50.00 for each person for each calendar day during which such person is discriminated against or intimidated in violation of the provisions of the contract; and

d. This contract may be canceled or terminated by the contracting public agency, and all money due or to become due hereunder may be forfeited, for any violation of this section of the contract occurring after notice to the contractor from the contracting public agency of any prior violation of this section of the contract.

Experience & Qualifications Questionnaire

This questionnaire must be filled out and submitted as a part of the Proposal. Failure to complete this form or to provide any of the requested information will be grounds for the rejection of the bid proposal. If additional space is required, the respondent shall add additional sheets, which identify the question being answered.

Number of years in business under present name & address:

If less than 5 years, list previous names and address:

Within the last 5 years has the business or any officer/partner failed to complete a contract awarded to them: . If yes, provide the details in on a separate page.

Have any liens and lawsuits been filed against the company in the past 5 years:

If yes, please provide details:

List similar services you are now providing for which you have signed contract, but not yet started work:

List all major subcontractors to be used to complete the service and the area of their responsibility:

Please provide at least 3 references below:

Name: Phone:

Address:

Equipment/Service Provided:

Contract Amount:

New Jersey Business Registration Certification

Pursuant to N.J.S.A. 52:32-44, The City of Cape May (“Contracting Agency”) is prohibited from entering into a contract with an entity unless the bidder/proposer/contractor, and each subcontractor that is required by law to be named in a bid/proposal/contract has a valid Business Registration Certificate on file with the

Division of Revenue and Enterprise Services within the Department of the Treasury.

Prior to contract award or authorization, the contractor shall provide the Contracting Agency with its proof of business registration and that of any named subcontractor(s).

Subcontractors named in a bid or other proposal shall provide proof of business registration to the bidder, who in turn, shall provide it to the Contracting Agency prior to the time a contract, purchase order, or other contracting document is awarded or authorized.

During the course of contract performance:

(1) the contractor shall not enter into a contract with a subcontractor unless the subcontractor first provides the contractor with a valid proof of business registration.

(2) the contractor shall maintain and submit to the Contracting Agency a list of subcontractors and their addresses that may be updated from time to time.

(3) the contractor and any subcontractor providing goods or performing services under the contract, and each of their affiliates, shall collect and remit to the Director of the Division of Taxation in the Department of the Treasury, the use tax due pursuant to the Sales and Use Tax Act, (N.J.S.A.

54:32B-1 et seq.) on all sales of tangible personal property delivered into the State. Any questions in this regard can be directed to the Division of Taxation at (609)292-6400. Form NJ-REG can be filed online at http://www.state.nj.us/treasury/revenue/busregcert.shtml.

Before final payment is made under the contract, the contractor shall submit to the Contracting Agency a complete and accurate list of all subcontractors used and their addresses.

Pursuant to N.J.S.A. 54:49-4.1, a business organization that fails to provide a copy of a business registration as required, or that provides false business registration information, shall be liable for a penalty of $25 for each day of violation, not to exceed $50,000, for each proof of business registration not properly provided under a contract with a contracting agency.

Emergency Purchases or Contracts

For purchases of an emergent nature, the contractor shall provide its Business Registration Certificate within two weeks from the date of purchase or execution of the contract or prior to payment for goods or services, whichever is earlier.

http://www.state.nj.us/treasury/revenue/busregcert.shtml

SAMPLE BUSINESS REGISTRATION CERTIFICATE

Americans with Disabilities Act of 1990

The CONTRACTOR and the OWNER do hereby agree that the provisions of Title 11 of the Americans

With Disabilities Act of 1990 (the "ACT") (42 U.S.C~ S12101 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant thereunto, are made a part of this contract. In providing any act benefit, or service on behalf of the OWNER pursuant to this contract, the CONTRACTOR agrees that the performance shall be in strict compliance with the Act. In the event that the Contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the CONTRACTOR shall defend the

OWNER in any action or administrative proceeding commenced pursuant to this Act. The Contractor shall indemnify, protect, and save harmless the OWNER, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The CONTRACTOR shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the OWNER grievance procedure, the CONTRACTOR agrees to abide by any decision of the OWNER which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the OWNER or if the OWNER must any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the CONTRACTOR shall satisfy and discharge the same at its OWN expense.

The OWNER shall, as soon as practicable after a claim has been made against it, give written notice thereof to the CONTRACTOR along with frill and complete particulars of the claim. if any action or administrative proceedings is brought against the OWNER or any of its agents, servants, and employees, the OWNER shall expeditiously forward or have forwarded to the

CONTRACTOR every demand, complaint, notice, summons, pleading, or other process received by the OWNER or its representatives.

It is expressly agreed and understood that any approval by the OWNER of the services provided by the CONTRACTOR pursuant to this contract will not relieve the CONTRACTOR of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the

OWNER pursuant to this paragraph.

It is further agreed and understood that the OWNER assumes no obligation to indemnify or save harmless the CONTRACTOR, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the CONTRACTOR expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the CONTRACTOR'S obligations assumed in this Agreement, nor shall they be construed to relieve the CONTRACTOR from any liability, nor preclude the OWNER from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

Furthermore, the contractor expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the contractor’s obligations assumed in this Agreement, nor shall they be construed to relieve the contractor from any liability, nor preclude the owner from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

Business Name (Print):

Representative’s Name (Print):

Representative’s Title:

Representative’s Signature:

Phone: Date:

STATEMENT OF OWNERSHIP DISCLOSURE

N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43)

This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal.

Name of Organization:

Organization Address:

Part I Check the box that represents the type of business organization:

Sole Proprietorship (skip Parts II and III, execute certification in Part IV)

Non-Profit Corporation (skip Parts II and III, execute certification in Part IV)

For-Profit Corporation (any type) Limited Liability Company (LLC)

Partnership Limited Partnership Limited Liability Partnership (LLP)

Other (be specific):

Part II

The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION)

OR

No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV)

(Please attach additional sheets if more space is needed):

Name of Individual or Business Entity Address

Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR

LLC MEMBERS LISTED IN PART II

If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange

Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed.

Website (URL) containing the last annual SEC (or foreign equivalent) filing Page #’s

Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-24.2 has been listed. Attach additional sheets if more space is needed.

Stockholder/Partner/Member and

Corresponding Entity Listed in Part II

Address

Part IV Certification

I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that the City is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with City to notify the City in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the City to declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print):

Signature:

Date:

PAY TO PLAY ADVISORY

Disclosure Requirement

P.L. 2005, Chapter 271, Section 3 Reporting (N.J.S.A. 19:44A

– 20.27)

Any business entity that has received $50,000 or more in contracts from government entities in a calendar year will be required to file an annual disclosure report with ELEC.

The report will include certain contributions and contract information for the current calendar year.

At a minimum, a list of all business entities that file an annual disclosure report will be listed on ELEC’s website at www.elec.state.nj.us.

If you have any questions please contact ELEC at: 1-888-313- ELEC (toll free in NJ) or

609-292-8700

An analyst from ELEC’s Special Programs Section will assist you.

Initials http://www.elec.state.nj.us/

Name of Person or Entity

Prohibited Russia-Belarus Activities & Iran Investment Activities

Pursuant to law, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter into or renew a contract for goods or services, must complete the certification below prior to contract award to attest, under penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary or affiliate, is identified on the Department of Treasury's Russia-Belarus list or Chapter 25 list as a person or entity engaging in prohibited activities in Russia, Belarus or Iran. Before a contract for goods or services can be amended or extended, a person or entity, parent entity, or a subsidiary must certify that they are not on the lists. The lists can be found on the following web addresses:

http://www.nj.gov/treasury/adminstration/pdf/RussiaBelarusEntityList.pdf www.state.nj.us/treasury/purchase/pdf/chapter25list.pdf

The above lists must be reviewed prior to completing the below certification.

A person or entity unable to make the certification must provide a detailed, accurate and precise description of the activities of the person, or of a parent entity, subsidiary or affiliate, engaging in prohibited activities in Russia, Belarus and/or investment activities in Iran. The person or entity must cease engaging in any prohibited activities and provide an updated certification before the contact can be entered into.

If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may be provided by law, rule or contract, including but not limited to imposing sanctions, seeking compliance, recovering damages, declaring the party in default and seeking debarment or suspension of the party.

Part 1: Certification

INSTRUCTIONS: CHECK ONE OF THE THREE BOXES BELOW

CONTRACT AWARDS AND RENEWALS

I certify, pursuant to law, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate appears on the N.J. Department of Treasury's lists of entities engaged in prohibited activities in Russia or Belarus

□ pursuant to P.L. 2022, c.3 or in investment activities in Iran pursuant to P.L. 2012 c. 25 ("Chapter 25

List"). I further certify that I am the person listed above or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf.

(IF APPLIES, CHECK THIS BOX, SKIP PART 2 AND PROCEED TO PART 3)

http://www.nj.gov/treasury/adminstration/pdf/RussiaBelarusEntityList.pdf http://www.state.nj.us/treasury/purchase/pdf/chapter25list.pdf

CONTRACT AMENDMENTS AND EXTENSIONS

I certify, pursuant to law, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate appears on the N.J. Department of Treasury's lists of entities engaged in prohibited activities in Russia or Belarus

□ pursuant to P.L. 2022, c.3 or in investment activities in Iran pursuant to P.L. 2012 c. 25 ("Chapter 25

List"). I further certify that I am the person listed above or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf.

(IF APPLIES, CHECK THIS BOX, SKIP PART 2 AND PROCEED TO PART 3)

IF UNABLE TO CERTIFY

I am unable to certify as above because the person or entity and/or a parent entity, subsidiary or affiliate is listed on the Department's Russia-Belarus list and/or Chapter 25 Iran list. I will provide a detailed, accurate and precise description of the activities as directed in Part 2 below, and sign and complete the Certification below. Failure to provide such will prevent the award of contract to the person or entity, and appropriate penalties, fines and/or sanctions will be assessed as provided by law.

(IF APPLIES, CHECK THIS BOX AND PROCEED TO PART 2)

Part 3: Certification of True and Complete

Information

I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments, to the best of my knowledge, are true and complete. I attest that I am authorized to execute this certification on behalf of the above- referenced person or entity.

I acknowledge that the Contracting Unit is relying on the information contained herein and herby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the Contracting Unit to notify the Contracting Unit in writing of any changes to the answers of information contained herein.

I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification. If I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Contracting Unit and that the Contracting Unit at its option may declare any contract(s) resulting from this certification void and unenforceable.

INSTRUCTIONS: PROVIDE FURTHER INFORMATION RELATED TO PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS

AND/OR INVESTMENT ACTIVITIES IN IRAN

You must provide a detailed, accurate and precise description of the activities of the person or entity, or of a parent entity, subsidiary or affiliate, engaging in prohibited activities in Russia or Belarus and/or investment activities in Iran in the space below and if needed, on additional sheets provided by you.

Part 2: Additional

Information

Full Name (Print)

Title

Signature

Date

EQUIPMENT CERTIFICATION

The undersigned Bidder hereby certifies as follows:

The bidder owns, controls, has proof of lease, rental of all the necessary equipment required to accomplish the work described in the specifications.

Name of Bidder: ___________________________________

By: ___________________________________ (Signature)

Name of above: __________________________________________ (Print)

Title: __________________________

Date:________________________