C24925022_-_Bidder_Packet.pdf

Bid Document Checklist

Contract Number: C24925022 Multi Park Roll-Up Garage Doors

Attach this checklist to bid and other required documentation listed below. When submitting bid forms, do not include form instruction pages.

IMPORTANT : Bids missing any of the following documents will be regarded as non-responsive and therefore rejected. If the form is not applicable mark “N/A” on the form and return with bid.

Forms and Description

☐ Bid Document Checklist

Public Works Bid Form (DPR 482B) and subsequent attachments (Exhibit B, Attachment 1)

☐ Bidder Declaration - GSPD-05-105

☐ Small Business Preference and Certification Request – STD 811

☐ DARFUR Contracting Act Certification - DPR 74 If not applicable, sign & write “n/a”

☐ Contractor Certification Clauses – CCC 04/2017

☐ Fair Chance Employment Act – DPR 282PW

☐ Non-Collusion Affidavit – DPR 837

☐ DVBE Checklist – DPR 479

☐ Disabled Veteran Business Enterprise Declarations - DGS PD 843

☐ Commercially Useful Function – DPR 87

☐ Gen AI Reporting and Factsheet – STD 1000

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

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

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

Note: Certificates of Insurance & Payee Data Record will be required after the award of contract. Reference Exhibit D, item 1 and STD 204, 205 / DPR 88 https://gcc02.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.caleprocure.ca.gov%2F&data=05%7C02%7CRyan.Thorne%40parks.ca.gov%7C0a9cc494ad6547f931e708dc63236c94%7C06fd3d24656448018226b407c4d26b68%7C0%7C0%7C638494251521946198%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=2SNQ%2FFJAPiz%2FNDTCe%2BL73XI3qBjotF%2F53DSz2SfU%2FlU%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.caleprocure.ca.gov%2F&data=05%7C02%7CRyan.Thorne%40parks.ca.gov%7C0a9cc494ad6547f931e708dc63236c94%7C06fd3d24656448018226b407c4d26b68%7C0%7C0%7C638494251521946198%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=2SNQ%2FFJAPiz%2FNDTCe%2BL73XI3qBjotF%2F53DSz2SfU%2FlU%3D&reserved=0 http://www.dir.ca.gov/Public-Works/SB854.html http://www.dir.ca.gov/Public-Works/SB854.html

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)

KIND OF WORK NAME AND ADDRESS

State of California - The 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)

CITY/STATE/ZIP CODE

PRINTED NAME AND TITLE OF PERSON SIGNING

CONTRACTOR/BIDDER FIRM NAME (Printed)

ADDRESS

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 without the appropriate bidder signature will result in rejection of the bid.

LICENSE EXPIRATION DATELICENSE NO.

Exhibit B, Attachment 1

PHONE NO.

C24925022 Multi Park Roll-Up Garage Door

Exhibit B, Attachment 1: Bid Forms: Cost Sheet

Location 1: Bolsa Chica Lifeguard Headquarters

Materials: (1) One: Cornell Cookson Company Model

ESD 10: 17’x11” X (4) Four

Total Cost: (4) Four, (17’x11”)

Materials: (1) One: Cornell Cookson Company Model ESD 10: 8’x11”

Cost:

Materials: Cornell Cookson Company Model ESD 10 Cost

(4) Four, 17’x11” $

(1) One, 8’x11” $

Location 1 Total Materials Cost $ Specs: Gray factory finish steel flat slat type curtain, 50,000 cycle spring, 3-piece steel guide angles, extruded aluminum bottom bar with seal, and hood cover for coil to match curtain. Factory provided weather stripping required.

Labor/Cost per Hour

X Number of Hours Location 1 Labor

Cost

Location 1 Total Materials

Location 1 Total Labor Cost Location 1 Total Cost

Location 2: Bolsa Chica Maintenance Shop

Materials: (1) One: Cornell Cookson Company

Model ESD 10: 10’x10” X (7) Seven

Total Cost: (7) Seven, (10’x10”)

Location 2 Total Materials Cost $ Specs: Gray factory finish steel flat slat type curtain, 50,000 cycle spring, 3-piece steel guide angles, extruded aluminum bottom bar with seal, and hood cover for coil to match curtain. Factory provided weather stripping required.

Labor/Cost per Hour

X Number of Hours Location 2 Labor

Location 2 Total Materials

Location 2 Total Labor Cost Location 2 Total Cost

C24925022 Multi Park Roll-Up Garage Door

Location 3: Crystal Cove Moro Lifeguard Headquarters

Materials: (1) One:

or New Industrial Duty Rolling Steel: 16’x7’4”

X (2) Two Total Cost: (2) Two, (16’7’4”)

Location 3 Total Materials Cost $ Includes: Two new gear head motor operators. Factory provided weather stripping is required.

Labor/Cost per Hour

X Number of Hours Location 3 Labor

Location 3 Total Materials

Location 3 Total Labor Cost Location 3 Total Cost

Total Cost

Location Cost

Location 1: Bolsa Chica Lifeguard Headquarters Location 2: Bolsa Chica Maintenance Shop

Location 3: Crystal Cove Moro Lifeguard Headquarters Total Cost

Signature____________________

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:

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-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.

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

b) DGS PD 843, DVBE Declaration

DPR 479IP (Rev. 12/2022)(Excel 12/20/2022)(Page 6 of 6)

a) GSPD 05-105, Bidder Declaration

DISABLED VETERAN BUSINESS ENTERPRISE (DVBE)

DVBE Documentation Checklist

1. The State of California acknowledges the service and sacrifice of its disabled veterans, in part, through the “Disabled Veteran Business Enterprise (DVBE) Participation Program.” As mandated by law, state agencies have a goal to award at least 3% of their annual contract dollars to certified DVBE’s.

2. When a firm bids on a state DPR contract that contains DVBE participation, the the dollar amount of the bid must meet the 6% participation requirement set by DPR.

3. INCOMPLETE DOCUMENTATION (GSPD 05-105 AND DGS PD 843) MUST RESULT IN

DISQUALIFICATION FROM FURTHER PARTICIPATION IN THE SELECTION PROCESS FOR

THE CONTRACT.

4. The following checklist is provided to assist bidders with their DVBE participation documentation:

All DVBE participation is indicated.

The names of each participating DVBE company is listed with the dollar value and applied percentage of the bid.

A copy of the printout from eProcurement system showing the company’s DVBE certification status.

The DVBE participation percentage listed agrees with the dollar value claimed.

A completed and signed DGS PD 843 is included with the bid for every DVBE (whether prime contractor or subcontractor) included.

STATE OF CALIFORNIA – DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

(Rev. /20 )

Instructions: The disabled veteran (DV) owner(s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment [Military and Veterans Code Section 999.2]. Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.

SECTION 1

Name of certified DVBE: DVBE Ref. Number:

Description (materials/supplies/services/equipment proposed):

Solicitation/Contract Number: SCPRS Ref. Number:__________________________

(FOR STATE USE ONLY)

SECTION 2

APPLIES TO ALL DVBEs. Check only one box in Section 2 and provide original signatures.

I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2 (b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.

Pursuant to Military and Veterans Code Section 999.2 (f), I (we) declare that the DVBE is a broker or agent for the principal(s) listed below or on an attached sheet(s). (Pursuant to Military and Veterans Code 999.2 (e), State funds expended for equipment rented from equipment brokers pursuant to contracts awarded under this section shall not be credited toward the 3-percent DVBE participation goal.)

All DV owners and managers of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Owner/Manager) (Signature of DV Owner/ Manager) (Date Signed)

(Printed Name of DV Owner/Manager) (Signature of DV Owner/Manager) (Date Signed)

Firm/Principal for whom the DVBE is acting as a broker or age nt:

(If more than one firm, list on extra sheets.) (Print or Type Name)

Firm/Principal Phone: Address:

SECTION 3

APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AND DECLARE THE DVBE IS NOT A BROKER.

Pursuant to Military and Veterans Code Section 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.

The undersigned owner(s) own(s) at least 51% of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsections (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax return(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections

(c) and (g), will result in the DVBE being deemed an equipment broker.

Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):

(Printed Name) (Signature) (Date Signed)

(Address of Owner) (Telephone) (Tax Identification Number of Owner)

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Manager) (Signature of DV Manager) (Date Signed)

Page of

PRINT CLEAR

STATE OF CALIFORNIA DEPARTMENT OF GENERAL SERVICES

GENAI REPORTING AND FACTSHEET PROCUREMENT DIVISION

STD 1000 (REV. 07/2024)

Generative Artificial Intelligence (GenAI) Reporting and Factsheet

Section 1: Bidder / Offeror / Contractor Information

Solicitation / Contract Number Bidder ID / Vendor ID (optional)

Business Name Business Telephone Number

Business Address City State Zip Code

Contract / Description of Purchase

Section 2: Reporting and Factsheet

Will you and/or your subcontractor(s) be using or offering GenAI technology, model, service, or system (collectively, “product”)? Yes No (If no, skip to Signature section of this form.)

If yes, provide details regarding the GenAI system. See GenAI Reporting and Factsheet Instructions at the end of this form for more information.

Failure to provide information requested on this form may result in disqualification or may void any resulting contract.

1.. GenAI Model Name LLM Version (Including number of parameters) All Model Names/ Owners for The Solution or Offering

STD 1000 (REV. 07/2024)

3. Product

Description

4. Use Case(s)

5. Intended

Information Domain

6. Explain how the GenAI system is not adversely affecting decisions that materially impact access to, or approval for, housing or accommodations, education, employment, credit, health care, and criminal justice.

Signature

By signing this document, I have identified and reported any GenAI use in the performance of this contract. If any new or previously unreported GenAI use is identified in the future in the performance of this contract, we will complete and submit to the State an updated STD 1000.

Signature Date

Submit completed form to the awarding department.

2. Applications / Product Owner

(GenAI powered or driven)

STD 1000 (REV. 07/2024)

GenAI Reporting and Factsheet Instructions

Please use the following definitions and instructions to complete the GenAI Reporting and Factsheet:

1. GenAI Model Name, LLM Version (including number of parameters) and All Model Names/Owners for The

Solution or Offering

a. Definition: The unique identifier or name assigned to the specific GenAI model or service.

b. Purpose: Allows users to refer to and distinguish between different GenAI models.

2. Applications/Product Owner (GenAI powered or driven):

a. Definition: The name of the organization or entity responsible for creating or deploying the GenAI model or service.

b. Purpose: Helps identify the source and accountability for the GenAI system.

3. Product Description:

a. Definition: A concise summary of the GenAI model’s purpose, functionality, and key characteristics.

b. Purpose: Provides a high-level understanding for users and stakeholders.

4. Use Case(s):

a. Definition: The intended use or goal of the GenAI model (e.g., image recognition, natural language processing, text summarization).

b. Purpose: Helps users assess whether the GenAI model aligns with their needs.

5. Intended Information Domain:

a. Definition: The context, subject matter, or domain for which the GenAI model is designed to operate effectively.

b. Purpose: Helps users determine if the GenAI model is suitable for their specific use case.

6. Adverse Impact:

a. Explain below how you are ensuring the GenAI system is not adversely affecting decisions that materially impact access to, or approval for, housing or accommodations, education, employment, credit, health care, and criminal justice.

7. Signature:

a. The signatory for the Contract shall also sign the STD 1000