NATURAL RESOURCES AGENCY OF CALIFORNIA

DEPARTMENT OF PARKS AND RECREATION

MALIBU CREEK SP

Roadway and Parking Lot Rehabilitation Project Los Angeles County, California

Bid Number: C25915009

Bidder’s Checklist

Items below must be submitted with your bid.

Public Works Bid Form (DPR 482B) and subsequent pages

DVBE Notice (DPR 479IP)

__ Bidder Declaration (GSPD 05-105)

DVBE Declarations (DGS PD 843) for each listed DVBE on Bidder’s DVBE Participation Form

__ Printout(s) from the eProcurement website http://www.caleprocure.ca.gov showing each DVBE’s supplier ID and status of certification

__ Commercially Useful Function – Bidder Certification (DPR 87)

__ Non-Collusion Affidavit (DPR 837)

__ Bidder’s Bond (DPR 495), for projects in excess of $250,000

Printout from the eProcurement web: site http://www.caleprocure.ca.gov showing each Small Business’ supplier ID and status of certification, if applicable

__ California Public Contract Code Section 10162 Questionnaire (DPR 20)

__ Darfur Contracting Act Form (DPR 74), if applicable

__ Fair Chance Employment Act (DPR 282PW)

__ Artificial Intelligence (AI) Disclosure Form (DPR 97B)

__ California Civil Rights Law Certification (DGS OLS 04)

__ Contractor and Subcontractor registration with the Department of Industrial Relations pursuant to Labor Code section 1725.5 http://www.dir.ca.gov/Public- Works/SB854.html

__ Payee Data Record (STD 204)

__ Payee Data Record Supplement (STD 205)

__ Contractor Certification Clause (CCC 04/2017)

Bid Date: Monday, May 4, 2026 at 2:00 PM

Bids will be accepted Via US Mail:

Department of Parks and Recreation Inland Empire District 1925 Las Virgenes Road.

Calabasas, CA 91302 http://www.caleprocure.ca.gov/ http://www.caleprocure.ca.gov/ http://www.dir.ca.gov/Public-Works/SB854.html http://www.dir.ca.gov/Public-Works/SB854.html

2:00 P.M. May 4, 2026

Nondiscrimination Compliance Statement: The prospective contractor's signature affixed hereon and dated shall constitute a certification under penalty of perjury under the laws of the State of California that the bidder has, unless exempted, complied with the nondiscrimination program requirements of Government Code Section 12990 and Title 2, California Code of Regulations, Section 8103.

Verification: By signing this Bid Form, the bidder assures the state that it has not been convicted of violating a state or federal law regarding the employment of undocumented aliens, in the preceding five years.

The prospective contractor's signature affixed hereon and dated shall constitute a certification that the representations made by the prospective contract in the bid are made under penalty of perjury under the laws of the State of California.

Important: Pursuant to Title 2, California Code of Regulations, Section 8103 and Business and Professions Code Section 7028.15, no bid will be considered unless it contains the certifications and license information requested on this form. The State reserves the right to waive any irregularity in any bid or to reject any or all bids.

LICENSE NO.

DPR 482B (Rev. 10/2003)(Excel 10/15/2003)

C25915009 Roadway and Parking Lot Rehabilitation Project

KIND OF WORK NAME AND ADDRESS

MALIBU CREEK SP

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

PUBLIC WORKS BID FORM

PROJECT LOCATION

PROJECT NAME

STATUS OF BUSINESS (Check appropriate box.)

Individual.

Corporation. State in which incorporated:

Partnership. Full names of partners:

Listed hereinafter are the names, addresses and contractor's license numbers of all subcontractors who will perform work or labor or render services in an amount in excess of one-half of one percent of the general contractor's total bid if this bid is accepted and the portion of the work that each will perform. Material vendors are not included.

FAX NO.

BY (Authorized Signature)

EMAIL

PRINTED NAME AND TITLE OF PERSON SIGNING

CONTRACTOR/BIDDER FIRM NAME (Printed) - AS IT APPEARS ON LICENSE

MAILING ADDRESS CITY/STATE/ZIP CODE

LICENSE CLASSIFICATION

DATE

BID DATEBID TIME

CERTIFICATION

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective Contractor to the clause(s) listed above. This certification is made under the laws of the State of California. I understand that failure to submit the Public Works Bid Form with the appropriate bidder signature will result in rejection of the bid.

LICENSE EXPIRATION DATELICENSE NO.

Exhibit B, Attachment 1

PHONE NO.

BID FORM

Bid Number: C25915009 Contractor / Bidder Firm Name: ____________________________________

The bidder hereby proposes to furnish all labor, materials, tools and equipment necessary to repave the roadways and parking lots MALIBU CREEK SP in Angeles County California, complete and ready for use in accordance with the contract documents therefore, for the following lump sum which shall include all applicable taxes and other expenses:

Base Bid Lump Sum Total: $___________________

Base Bid Lump Sum Total Written Out:

Approx.

Quantity

Description

Item Total

ADDITIVE ALTERNATES

1.

Lump Sum

Additive Alternate 01: Phase 04 Upper Parking Lot

2.

Additive Alternate 02: Phase 05 Entrance Station

3.

Additive Alternate 03: Phase 06 Crags Road Waycross Drive

ADDENDUM ACKNOWLEDGEMENT (Please initial for Addenda received)

Addendum #1 ____________ Addendum #4 ____________

Addendum #2 ____________ Addendum #5 ____________

Addendum #3 ____________ Addendum #6 ____________

The bidder agrees to complete all work within THREE HUNDRED SIXTY-FIVE (365) calendar days from the date of written notice to commence work. This time includes ten (10) calendar days allowed for the contractor to begin work.

State of California � Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

COMMERCIALLY USEFUL FUNCTION � BIDDER CERTIFICATION

All California Certified Small Business (SB), Micro Business (MB), and Disabled Veteran Business Enterprise (DVBE) suppliers contracting and subcontracting must complete this certification form.

LEGAL BUSINESS NAME (including �Doing Business As� DBA name) DPR REFERENCE/AGREEMENT NUMBER

CERTIFICATIONS (mark all that apply)

Small Business Micro Business DVBE

DGS CERTIFICATION NUMBER

(OSDS)

EXPIRATION DATE

For this agreement, this business is the: Prime Contractor Subcontractor

All Certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code Section 14837(d)(4)(A) for Small and Micro Businesses, and Military and Veterans Code Section 999(b)(5)(B)(i) for DVBEs.

A. Is the GSPD-05-105, Bidder Declaration attached? Yes No

B. Is the DGS PD 843, Disabled Veteran Business Enterprise Declarations form attached if applicable?

Yes No N/A

Please answer the following 5 questions as they apply to your company for the goods and/or services being acquired in this solicitation:

Will your business be responsible for the execution of a distinct element of the resulting work?

Yes No

Will your business carry out the obligation of the contract by actually performing, managing or supervising the work involved?

Yes No

3 Will you perform work that is normal for your business, service and functions? Yes No

Will your business be responsible for products, inventories, materials, suppliers required for the contract, negotiating price, determining quality and quantity, ordering, installing (if applicable) and making payment?

(Note: This only applies to GOODS. If this is a service, mark N/A and skip to #5.)

Goods Services

Yes No N/A

If subcontracting a portion of the work, is it a normal portion as expected by current industry practices? (Also answer Yes if not subcontracting any portion.)

Yes No

A response of �No� may result in your quote being deemed non-responsive and disqualified.

BIDDER�S CERTIFICATION

The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.

PRINTED NAME AND TITLE OF AUTHORIZED SIGNER SIGNATURE DATE

DEPARTMENT OF PARKS AND RECREATION USE

APPROVED DENIED

DPR BUYER/EVALUATOR PRINTED NAME SIGNATURE DATE

DPR 87 (Rev. 5/2025)(Word to PDF 5/28/2025)

DPR 837 (Rev. 6/21) THIS FORM MUST REMAIN WITH THE BID

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

NON-COLLUSION DECLARATION TO BE EXECUTED

BY BIDDER AND SUBMITTED WITH BID FOR PUBLIC WORKS

The undersigned declares:

I am the of , the party (Position Title) (Company Name) making the foregoing bid.

The bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation. The bid is genuine and not collusive or sham. The bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid. The bidder has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or to refrain from bidding. The bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the bidder or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other bidder. All statements contained in the bid are true. The bidder has not, directly, or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof, to effectuate a collusive or sham bid, and has not paid, and will not pay, any person or entity for such purpose.

Any person executing this declaration on behalf of a bidder that is a corporation, partnership, joint venture, limited liability company, limited liability partnership, or any other entity, hereby represents that he or she has full power to execute, and does execute, this declaration on behalf of the bidder

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this declaration is executed on

, at , (Date) (City) (State/Zip Code)

(Print or Type Name)

(Signature)

That we, , as Principal, and as Surety, are held and firmly bound unto the State of California, hereinafter called the State, in the penal sum of ten percent (10%) of the total amount of the bid of the Principal above named, submitted by said Principal to the State of California, Department of Parks and Recreation for the work described below, for the payment of which sum in lawful money of the United States, well and truly to be made, we bind ourselves, our heirs, executors, administrators and successors, jointly and severally, firmly by these presents.

WHEREAS, the Principal has submitted the above-mentioned bid to the State of California, Department of Parks and Recreation, for certain construction specifically described as follows, for which bids are to be opened at for

NOW, THEREFORE, If the aforesaid Principal is awarded the contract and, within the time and manner required under the specifications, after the prescribed forms are presented to him or her for signature, enters into a written contract, in the prescribed form, in accordance with the bid, and files the two bonds with the Department, one to guarantee faithful performance and the other to guarantee payment for labor and materials, as required by law, then this obligation shall be null and void; otherwise, it shall be and remain in full force and virtue.

In the event suit is brought upon this bond by the Obligee and judgment is recovered, the Surety shall pay all costs incurred by the Obligee in such suit, including a reasonable attorney's fee to be fixed by the court.

IN WITNESS WHEREOF, We have hereunto set our hands and seals on this day of , 20

(SEAL)

(SEAL)

(SEAL)

(SEAL)

(SEAL)

(SEAL)

NOTE: Signatures of those executing for the Surety must be properly acknowledged.

County of ss

On this day of before me, a notary public in and for the county and state aforesaid, personally appeared, known to me to be the person whose name is subscribed to the within instrument and known to me to be the attorney-in-fact of and acknowledged to me that he subscribed the name of the said company thereto as surety, and his own name as attorney-in-fact.

DPR 495 (Rev. 11/2002)(Excel 11/8/2002)

KNOW ALL PEOPLE BY THESE PRESENTS:

CERTIFICATE OF ACKNOWLEDGEMENT

BIDDER'S BOND

State of California - The Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

THE CONDITION of this obligation is such that:

Surety

Principal

State of California

(SEAL)

Notary Public

(Insert date of bid opening)

(Insert place where bids will be opened)

(Copy here the exact description of work, including location, as it appears on the proposal) in the year of 20 on

Bidders are cautioned that making false certification may subject the certifier to criminal prosecution.

The Department of Parks and Recreation (DPR) reserves the right under California Public Contract Code Section 10162 to reject any bidder, any officer of such bidder, or any employee of such bidder who has a proprietary interest in such bidder who has been disqualified, removed or otherwise prevented from bidding on, or completing a federal, state or local govern-ment project because of a violation of law or violation of safety regulations.

Failure to return this form with the bid shall not be cause for rejection; however, bidders must furnish the completed form within the time frame prescribed by the DPR. Failure to submit this form within the time frame prescribed by the DPR may be deemed refusal of an award which shall be cause for forfeiture of bidder's security.

By my signature, I certify under penalty of perjury under the laws of the State of California that the foregoing questionnaire and statements pursuant to California Public Contract Code Section 10162 are true and correct

DPR 20 (New 10/2003)(Excel 10/24/2008)

NOTICE TO BIDDERS

CERTIFICATION

State of California - The Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

CALIFORNIA PUBLIC CONTRACT CODE SECTION 10162

PARK UNIT NAME

In accordance with Section 10162 of the California Public Contract Code, bidders shall complete, HAVE YOU, ANY OFFICER OF YOUR BUSINESS, OR ANY EMPLOYEE OF YOUR BUSINESS WHO HAS PROPRIETARY INTEREST IN YOUR BUSINESS EVER BEEN DISQUALIFIED, REMOVED, OR OTHERWISE PREVENTED FROM BIDDING ON, OR COMPLETING A FEDERAL, STATE, OR LOCAL GOVERNMENT PROJECT BECAUSE OF A VIOLATION OF LAW OR VIOLATION OF SAFETY REGULATIONS? Yes (Explain circumstances below. Attach additional pages if needed.) No

BIDDER SIGNATURE PRINTED NAME DATE

under penalty of perjury, the question below. Please answer the following:

— Questionnaire —

PROJECT NAME

NAME OF BUSINESS

DPR 74 (Rev. 5/2013)(Excel 5/16/2013)

DO NOT COMPLETE THIS FORM UNLESS YOUR COMPANY MEETS THE CRITERIA OF OPTION #1 OR OPTION #2.

FOR DEPARTMENT USE ONLYState of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

DARFUR CONTRACTING ACT CERTIFICATION

Public Contract Code Sections 10475 -10481 applies to any company that currently or within the previous three years has had business activities or other operations outside of the United States. For such a company to bid on or submit a proposal for a State of California contract, the company must certify that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit a proposal.

DO NOT COMPLETE OR RETURN THIS FORM IF: Within the previous three years, your company HAS NOT had any business activities or other operations outside of the United States.

AGREEMENT/PAPO NO.

OPTION #1 - CERTIFICATION

If your company, within the previous three years, has had business activities or other operations outside of the United States, in order to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete the certification below.

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that a) the prospective proposer/bidder named below is not a scrutinized company per Public Contract Code 10476; and b) I am duly authorized to legally bind the prospective proposer/bidder named below. This certification is made under the laws of the State of California.

COMPANY/VENDOR NAME (Printed)

BY (Authorized Signature)

PRINTED NAME AND TITLE OF PERSON SIGNING

DATE EXECUTED EXECUTED IN THE COUNTY AND STATE OF

FEDERAL ID NUMBER

OPTION #2 - WRITTEN PERMISSION FROM DGS

Pursuant to Public Contract Code section 10477(b), the Director of the Department of General Services may permit a scrutinized company, on a case-by-case basis, to bid on or submit a proposal for a contract with a state agency for goods or services, if it is in the best interests of the state. If you are a scrutinized company that has obtained written permission from the DGS to submit a bid or proposal, complete the information below.

We are a scrutinized company as defined in Public Contract Code section 10476, but we have received written permission from the Department of General Services to submit a bid or proposal pursuant to Public Contract Code section 10477(b). A copy of the written permission from DGS is included with our bid or proposal.

COMPANY/VENDOR NAME (Printed)

INITIALS OF SUBMITTER

PRINTED NAME AND TITLE OF PERSON INITIALING

FEDERAL ID NUMBER

All other companies, complete Option #1 or Option #2 and return:

State of California - Natural Resources Agency

CALIFORNIA DEPARTMENT OF PARKS AND RECREATION

FAIR CHANCE EMPLOYMENT ACT

Public Contract Code 10186:

(a) This section shall be known, and may be cited, as the "Fair Chance Employment Act."

(b) Any person submitting a bid to the state on a contract involving onsite construction-related services shall certify that the person will not ask an applicant for onsite construction-related employment to disclose orally or in writing information concerning the conviction history of the applicant on or at the time of an initial employment application.

(c) This section shall not apply to a position for which the person or the state is otherwise required by state or federal law to conduct a conviction history background check or to any contract position with a criminal justice agency, as that term is defined in Section 13101 of the Penal Code.

(d) This section shall not apply to a person to the extent that he or she obtains workers from a hiring hall pursuant to a bona fide collective bargaining agreement.

CERTIFICATION

By my signature, I certify under penalty of perjury under the laws of the State of California that I have read, understand and will abide by California Public Contract Code Section 10186.

DPR 282PW (New 8/2016)(Word8/11/2016)

Contractor/Bidder Firm Name (Printed)

Federal ID Number

By (Authorized Bidders Signature)

Printed Name and Title of Person Signing

Date Executed

Executed in the County of

State of California � Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

ARTIFICIAL INTELLIGENCE (AI) FORM

Instructions for this form are on Page 3.

I. BIDDER CONTACT INFORMATION

BUSINESS NAME SOLICITATION NUMBER

REPRESENTATIVE NAME BUSINESS TELEPHONE NUMBER

BUSINESS ADDRESS CITY STATE ZIP CODE

Description of Services:

Describe in detail the services being provided. Include names of products and large language model.

II. DISCLOSURE

Will you and/or your subcontractor(s) be using or offering AI technology, model, service, or system (collectively, �product�) for this product in question?

No. (Skip to Section IIII) Yes. (Answer 1-5 below)

1. What type of AI is included?

Traditional AI Generative AI

2. Is the AI required for this product?

No Yes Other:

DPR 97B ( /2025)(Word to PDF /2025)(Page 1 of 3)

The scope of work includes 2” to 3” asphalt pulverization throughout the identifies areas of Malibu Creek State Park, followed by grading and compaction, and the installation of 3” of asphalt concrete (AC) overlay. New asphalt curbing shall be installed where necessary to ensure proper stormwater drainage into existing culverts and drainage structure and per the State Representative during the walk through will be further identified.

Campsite parking spaces will be reconfigured and extended to approximately 22 feet in width and 24 feet in depth to accommodate the modern vehicles’ sizes and improve maneuverability within the campground.

Existing Concrete parking stops located within parking areas and campsites shall be removed and replaced in-kind with new concrete parking stops. New stops shall be secured using 18 inches of #4 rebar or larger and painted according to the designated use Blue for ADA parking, Red for No Parking, Green for 15 minute parking.

The contractor shall remove and properly dispose of existing deteriorated asphalt pavement, asphalt curbing where required, failed aggregate base material, existing pavement striping, and concrete parking sops as necessary to complete the work. All legal material shall be legally disposed of off-site unless otherwise approved for reuse. Areas requiring reconstruction shall be regraded and compacted prior to installation of new asphalt concrete and aggregated base as required.

ARTIFICIAL INTELLIGENCE (AI) FORM (Continued)

3. What is the model and version of this product?

4. What is the license tier of the AI product, if applicable (free, enterprise, platinum, etc.)?

5. How is the AI solution delivered: IaaS, PaaS, SaaS, or will it be deployed on-premises? (Indicate if this is a thin client, thick client, web extension, plugin, etc.)

Provide the best contact for information related to questions related to the AI included in the product (if different than the representative listed in Section I.)

NAME E-MAIL PHONE NUMBER

III. SIGNATURE

By signing this document, I have identified and reported any AI use in the performance of this product in question.

Signature Date

DPR 97B ( /2025)(Page 2 of 3)

ARTIFICIAL INTELLIGENCE (AI) FORM (Instructions)

Instructions:

The Department of Parks and Recreation (DPR) is required to track and complete risk assessments for any Generative Artificial Intelligence (GenAI) purchases. This document is intended to help DPR identify GenAI and assess the risk related to any GenAI purchases.

Section I:

Bidders shall fill in their contact information.

The DPR staff shall fill out the Description of Services in detail and/or reference the applicable Statement of Work or attachment(s). Include the services to be provided related to AI and include the names of products and large language model. It is important to include as much detail as possible related to any AI aspect of the potential purchase.

Section II:

Bidders shall disclose any aspect of AI related to the purchase.

If �no� is selected, no further information is required in this section.

If �yes� is selected, the Bidder shall fill out answers to questions 1-5. Bidders should provide as much detail as possible related to the AI technology, model, service or system as it relates to what the DPR is soliciting for.

If GenAI is selected and the DPR staff intends to pursue the product, the DPR staff must complete the SIMM 5305-F GenAI Intelligence Risk Assessment, Data Classification section and the Risk Assessment Questionnaire questions a-j; and submit it to ISPO@parks.ca.gov

Contact ISPO@parks.ca.gov for assistance with completing this assessment.

Upon review, ISPO will contact the DPR staff for more information, if needed, prior to submitting the finalized document to the California Department of Technology.

Procurement efforts will be placed on temporary hold pending CDT approval.

Definitions:

IaaS � Infrastructure as a Service is a cloud computing model that provides on-demand access to virtualized computing resources like servers, storage, and networking.

PaaS � Platform as a Service is a cloud computing model that provides a complete platform for developing, running, and managing applications.

SaaS � Software as a Service a cloud-based software delivery model where users access and use applications over the internet via a subscription rather than purchasing and installing software locally.

Section III:

Bidder signatures are required to certify all provided information on this document is true and accurate to the best of their knowledge.

DPR 97B ( /2025)(Page 3 of 3)

STATE OF CALIFORNIA – STATE CONTROLLERS OFFICE

PAYEE DATA RECORD SUPPLEMENT

(This form is optional. Form is used to provide remittance address information if different than the mailing address on the STD 204 – Payee Data Record.

Use this form to provide additional remittance addresses and additional Authorized Representatives of the Payee not identified on the STD 204.)

STD 205 (New 03/2021)

Payee Information (must match the STD 204) NAME (Required. Do not leave blank.)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

TAX ID NUMBER (Required) SSN, ITIN, or FEIN that matches Tax ID number provided on STD 204

Additional Remittance Address Information

• Use the fields below to provide remittance addresses for payee if different from the mailing address on the STD 204.

• The addresses provided below are for remittance purposes only. 1099 information returns will be sent to the mailing address specified on the STD 204.

REMITTANCE ADDRESS (number, street, apt or suite no.)

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

Additional Contact Information Use the fields below to provide additional Authorized Representatives for the Payee if applicable.

CONTACT NAME

TELEPHONE (Include area code) EMAIL

CONTACT NAME

TELEPHONE EMAIL

CONTACT NAME

TELEPHONE EMAIL

Certification I hereby certify under penalty of perjury that the information provided on this supplemental document is true and correct.

By signing this document, I authorize the State of California to remit payment to the addresses specified on this supplemental form (STD 205) and certify that all persons identified on this form are authorized representatives of this payee. Payments remitted to any of the listed addresses may be reported on 1099 information returns to the tax liable entity identified on the accompanying Payee Data Record - STD 204.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE

(Print or Type name)

TITLE E-MAIL ADDRESS

SIGNATURE

X___________________________________________

DATE TELEPHONE (Include area code)

Print Form Reset Form

STATE OF CALIFORNIA – STATE CONTROLLERS OFFICE

PAYEE DATA RECORD SUPPLEMENT

(This form is optional. Form is used to provide remittance address information if different than the mailing address on the STD 204 – Payee Data Record.

Use this form to provide additional remittance addresses and additional Authorized Representatives of the Payee not identified on the STD 204.)

STD 205 (New 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record Supplement, STD 205. Sign, date, and return to the state agency/department with a completed STD 204. Prompt return of the fully completed forms will prevent delays when processing payments.

Purpose – Completion of this form (STD 205) is optional. Payees may use this form to provide remittance addresses or contact information in addition to the 1099 information return mailing address provided on the STD 204. This form shall only be used in conjunction with the STD 204, and will not be accepted without a STD 204.

Please note: The State of California Government will issue 1099 information returns to the mailing address provided on the most recently dated form STD 204 validated by the Payee. Addresses provided on this form (STD 205) will be used for remittance purposes only. If the payee would like to update the address for receiving 1099 information returns, please complete the STD 204.

Payee Information: The Payee’s Tax ID number (TIN) and Name (including any Business, DBA, or Disregarded LLC names) are required. This information is subject to TIN matching via the IRS database for validation. Payee Information provided in this section must clearly match the STD 204. Any discrepancies may result in delays of payment, up to and including denial of the request.

Name – Enter the name of the Payee. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Tax ID Number-The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Additional Remittance Address Information - Enter the Payee’s additional remittance address(s) that are not listed on STD 204. Up to five (5) addresses may be provided on this form. The Payee may provide additional remittance addresses on a second STD 205 form if needed.

Additional Contact Information - Enter the Payee’s additional or updated contact information. Up to three contacts may be identified on this form. Payee may provide additional contacts on a second STD 205 if needed.

PRIVACY STATEMENT

Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it.

It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000.

You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of the STD 204 form.

Contractor Certification Clause

CCC 04/2017

CERTIFICATION

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective Contractor to the clause(s) listed below. This certification is made under the laws of the State of California.

Contractor/Bidder Firm Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County of

CONTRACTOR CERTIFICATION CLAUSES

STATEMENT OF COMPLIANCE:

Contractor has, unless exempted, complied with the nondiscrimination program requirements. (GC 12990 (a-f) and CCR, Title 2, Section 8103) (Not applicable to public entities.)

DRUG-FREE WORKPLACE REQUIREMENTS:

Contractor will comply with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free workplace by taking the following actions:

a) Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations.

b) Establish a Drug-Free Awareness Program to inform employees about:

1. the dangers of drug abuse in the workplace;

2. the person's or organization's policy of maintaining a drug-free workplace;

3. any available counseling, rehabilitation and employee assistance programs; and,

4. penalties that may be imposed upon employees for drug abuse violations.

c) Provide that every employee who works on the proposed Agreement will:

1. receive a copy of the company's drug-free policy statement; and,

2. agree to abide by the terms of the company's statement as a condition of employment on the Agreement.

Failure to comply with these requirements may result in suspension of payments under the Agreement or termination of the Agreement or both and Contractor may be ineligible for award of any future State agreements if the department determines that any of the following has occurred: (1) the Contractor has made false certification, or violated the certification by failing to carry out the requirements as noted above. (GC 8350 et seq.)

NATIONAL LABOR RELATIONS BOARD CERTIFICATION:

Contractor certifies that no more than one (1) final unappealable finding of contempt of court by a Federal court has been issued against Contractor within the immediately preceding two-year period because of Contractor's failure to comply with an order of a Federal court which orders Contractor to comply with an order of the National Labor Relations Board. (PCC 10296) (Not applicable to public entities.)

CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO

REQUIREMENT:

Contractor hereby certifies that contractor will comply with the requirements of Section 6072 of the Business and Professions Code, effective January 1, 2003.

Contractor agrees to make a good faith effort to provide a minimum number of hours of pro bono legal services during each year of the contract equal to the lessor of 30 multiplied by the number of full time attorneys in the firm’s offices in the State, with the number of hours prorated on an actual day basis for any contract period of less than a full year or 10% of its contract with the State.

Failure to make a good faith effort may be cause for non-renewal of a state contract for legal services, and may be taken into account when determining the award of future contracts with the State for legal services.

EXPATRIATE CORPORATIONS:

Contractor hereby declares that it is not an expatriate corporation or subsidiary of an expatriate corporation within the meaning of Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the State of California.

SWEATFREE CODE OF CONDUCT:

a. All Contractors contracting for the procurement or laundering of apparel, garments or corresponding accessories, or the procurement of equipment, materials, or supplies, other than procurement related to a public works contract, declare under penalty of perjury that no apparel, garments or corresponding accessories, equipment, materials, or supplies furnished to the state pursuant to the contract have been laundered or produced in whole or in part by sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor. The contractor further declares under penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the California Department of Industrial Relations website and Public Contract Code Section 6108.

b. The contractor agrees to cooperate fully in providing reasonable access to the contractor’s records, documents, agents or employees, or premises if reasonably required by authorized officials of the contracting agency, the Department of Industrial Relations, or the Department of Justice to determine the contractor’s compliance with the requirements under paragraph (a).

DOMESTIC PARTNERS:

For contracts of $100,000 or more, Contractor certifies that Contractor is in compliance with Public Contract Code section 10295.3.

GENDER IDENTITY:

For contracts of $100,000 or more, Contractor certifies that Contractor is in compliance with Public Contract Code section 10295.35.

DOING BUSINESS WITH THE STATE OF CALIFORNIA

The following laws apply to persons or entities doing business with the State of California.

CONFLICT OF INTEREST:

Contractor needs to be aware of the following provisions regarding current or former state employees. If Contractor has any questions on the status of any person rendering services or involved with the Agreement, the awarding agency must be contacted immediately for clarification.

a) Current State Employees (PCC 10410):

1. No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee receives compensation or has a financial interest and which is sponsored or funded by any state agency, unless the employment, activity or enterprise is required as a condition of regular state employment.

2. No officer or employee shall contract on his or her own behalf as an independent contractor with any state agency to provide goods or services.

b) Former State Employees (PCC 10411):

1. For the two-year period from the date he or she left state employment, no former state officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning, arrangements or any part of the decision-http://www.dir.ca.gov/ making process relevant to the contract while employed in any capacity by any state agency.

2. For the twelve-month period from the date he or she left state employment, no former state officer or employee may enter into a contract with any state agency if he or she was employed by that state agency in a policy-making position in the same general subject area as the proposed contract within the 12-month period prior to his or her leaving state service.

If Contractor violates any provisions of above paragraphs, such action by Contractor shall render this Agreement void. (PCC 10420)

Members of boards and commissions are exempt from this section if they do not receive payment other than payment of each meeting of the board or commission, payment for preparatory time and payment for per diem. (PCC 10430 (e))

LABOR CODE/WORKERS' COMPENSATION:

Contractor needs to be aware of the provisions which require every employer to be insured against liability for Worker's Compensation or to undertake self-insurance in accordance with the provisions, and Contractor affirms to comply with such provisions before commencing the performance of the work of this Agreement.

(Labor Code Section 3700)

AMERICANS WITH DISABILITIES ACT:

Contractor assures the State that it complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination on the basis of disability, as well as all applicable regulations and guidelines issued pursuant to the ADA. (42 U.S.C.

12101 et seq.)

CONTRACTOR NAME CHANGE:

An amendment is required to change the Contractor's name as listed on this Agreement. Upon receipt of legal documentation of the name change the State will process the amendment. Payment of invoices presented with a new name cannot be paid prior to approval of said amendment.

CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:

a) When agreements are to be performed in the state by corporations, the contracting agencies will be verifying that the contractor is currently qualified to do business in California in order to ensure that all obligations due to the state are fulfilled.

b) "Doing business" is defined in R&TC Section 23101 as actively engaging in any transaction for the purpose of financial or pecuniary gain or profit.

Although there are some statutory exceptions to taxation, rarely will a corporate contractor performing within the state not be subject to the franchise tax.

c) Both domestic and foreign corporations (those incorporated outside of California) must be in good standing in order to be qualified to do business in California. Agencies will determine whether a corporation is in good standing by calling the Office of the Secretary of State.

RESOLUTION:

A county, city, district, or other local public body must provide the State with a copy of a resolution, order, motion, or ordinance of the local governing body which by law has authority to enter into an agreement, authorizing execution of the agreement.

AIR OR WATER POLLUTION VIOLATION:

Under the State laws, the Contractor shall not be: (1) in violation of any order or resolution not subject to review promulgated by the State Air Resources Board or an air pollution control district; (2) subject to cease and desist order not subject to review issued pursuant to Section 13301 of the Water Code for violation of waste discharge requirements or discharge prohibitions; or (3) finally determined to be in violation of provisions of federal law relating to air or water pollution.

PAYEE DATA RECORD FORM STD. 204:

This form must be completed by all contractors that are not another state agency or other government entity.