C2023623_Attach A_CoverSheetandCertifications_Fillable.pdf

RFP ATTACHMENT A - COVER SHEET & CERTIFICATIONS

STATEMENT OF PROPOSAL to Oregon Business Development Department

__________________________________________ (Legal Name of Proposer) accepts all the terms and conditions contained in the “Tide Gates Pasture Productivity Tool” RFP, and a standard State of Oregon contract (as they may have been modified or reserved for negotiation).

Corporation Professional Corporation Partnership Limited Partnership Ltd. Liability Company Ltd. Liability Partnership Sole Proprietorship Other __________

Mailing Address ________________________________________________________

Type name of contact/authorized representative _________________________________ Email address __________________________________________________________ Telephone __________________________ Other ____________________________ Type name of person(s) authorized to sign Contract _____________________________

Nondiscrimination and Good Faith Efforts with COBID Office: The State of Oregon prohibits unlawful discrimination in employment, including but not limited to: discrimination because of race, national origin, color, sex, gender identity, sexual orientation, age, religion, physical or mental disability, military status, marital status or family status. Proposer certifies that Proposer understands and will follow applicable civil rights and employment laws.

Proposer certifies that to the best of Proposer’s knowledge, that Proposer has not discriminated and will not discriminate, in violation of ORS 279A.110(1), against a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a service-disabled veteran-owned business or an emerging small business enterprise certified under ORS 200.055 in awarding a subcontract. Proposer certifies that Proposer will make good faith efforts to encourage disadvantaged business enterprises, minority-owned businesses, woman-owned businesses, service-disabled veteran-owned businesses and emerging small businesses to participate in any subcontracting by Proposer by taking the actions listed in ORS 200.045(3)(a)-(j). Such good faith efforts include working with the Certification Office for Business Inclusion and Diversity (COBID) and utilizing the list of certified enterprises and businesses.

Responsibility Certifications Has your company ever been declared in breach of any contract to provide services for unperformed or defective work?

Yes No If “yes,” explain.

Has any employee or agent of your company been convicted under state or federal law of embezzlement, theft, forgery, bribery, falsification or destruction of records, receiving stolen property or any other offense indicating a lack of business integrity or business honesty?

Yes No If “yes,” explain.

Has your company or any employee or agent of your company been indicted under state or federal false claims or antitrust laws, or charged with any other criminal offense arising out of obtaining, attempting to obtain, or performing a public or private contract or subcontract? Yes No If “yes,” explain.

During the last ten years, has your firm changed majority ownership or been the debtor in a bankruptcy case? Yes No

If “yes,” explain.

Does your firm have any outstanding judgments pending against it? Yes No If “yes,” explain.

During the last ten years, has your firm been a party to litigation, arbitration or mediation where the amount in dispute exceeded $10,000? Yes No If “yes,” explain. (Include court, and party names.) ________________________________________ Conflicts of Interest: Please select (only) one of the following three options:

Our firm has no current, known actual, potential, or reasonably perceived, financial or other interest in the outcome of the services described in this RFP.

Our firm has a potential or reasonably perceived financial or other interest in the outcome of the services described in this RFP as described here: ___________________. Our firm proposes to mitigate the potential or perceived conflict according to the following plan: ___________________________.

Our firm has an actual financial or other interest in the outcome of the services described in this RFP as described here: ___________________.

What does “financial interest” mean?

If your firm, or employee of your firm working on the project (or a member of the employee’s household), will/may or may be perceived to receive or lose private income depending on government business choices based on your firm’s services, findings or recommendations, this must be listed as a financial interest. An example would be ownership in physical assets affected by government business choices related to these services. The possibility of contracting for further consulting services is not included in this definition and is not prohibited.

What does “other interest” mean?

If your firm, or employee of your firm working on the project (or a member of the employee’s household), will/may or may be perceived to have political, legal or any other interests that will affect what goes into your firm’s services, findings or recommendations, or will be/may be, or may be perceived to be, affected by government business choices related to these services, this must be listed as an other interest.

Tax Information and Tax Compliance: The undersigned certifies and swears under penalty of perjury that: I am authorized to act on behalf of Contractor, I have authority and knowledge regarding Contractor’s payment of taxes, the taxpayer identification number and other information provided on Contractor’s IRS W-9 form is correct, Contractor is not subject to tax withholding, and Contractor is not in violation of any Oregon tax laws, including but not limited to a state tax imposed by ORS 320.005 to 320.150 and 403.200 to 403.250 and ORS chapters 118, 314, 316, 317, 318, 321 and 323 and the elderly rental assistance program under ORS 310.630 to 310.706 and local taxes administered by the Department of Revenue under ORS 305.620. Contractor shall continue to comply with the tax laws of this state or a political subdivision of this state during the term of the public contract.

Signature of Authorized Representative certifying the truth of all statements:

[signature]_________________________________________ [Type name] Date