C25680009_FormsAndCerts.pdf

Request for Proposals (Secondary) for Benicia State Recreation Area Weed Control

Form A: GSPD 05-105- Bidder Declaration

Form A: GSPD 05-105- Bidder Declaration

Please complete and submit the GSPD 05-105- Bidder Declaration to document the proposed Prime, SB, DVBE, and/or subcontractors, including the nature of their work on the proposal and percent of the Proposal. The form is located here:

https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd05-105.pdf

Attachment E: Sample Agreement, including Exhibit A (Scope of Work) through Exhibit F

Form B: Disabled Veteran Business Enterprise Declarations

Please complete and submit the DPR 486 – Bidder’s DVBE Participation to document the proposed Prime and subcontractors, including their roles and responsibilities. The form is located here:

https://calparks.sharepoint.com/sites/EXT-Business_Management_Services- Contracts/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FEXT%2DBusiness%5F Management%5FServices%2DContracts%2FShared%20Documents%2FTemplates%2FSolicita tion%20and%20Contract%20Templates%2FRFP%20Template%20Documents&viewid=45adc6 82%2D61a6%2D401b%2D9ac0%2Dc14d0e8c4a1a

Please complete and submit the STD 843 – Disabled Veteran Business Enterprise Declarations for all DVBEs proposed. The form is located at:

https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/pd_843.pdf.

DPR 486 (New 1/2010)(Excel 1/26/2010)

COMPANY INFORMATION

COMPANY INFORMATION: List the information (Company Name, Contact information) of subcontractor(s) and supplier(s) proposed for DVBE. If prime contractor is a DVBE, the name must be listed for participation.

COMPLETION INSTRUCTIONS

PART 1 — SUMMARY OF DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) PARTICIPATION

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

COMPANY NAME

CONTACT

COMPANY NAME

CONTACT

I hereby certifiy that I have made a diligent effort to ascertain the facts with regard to the representations made herein. In making this certification, I am aware of Section 12650 et seq. of the Government Code providing for the imposition of treble damages for making false claims against the State and Section 10115.10 of the Public Contract Code making it a crime for intentionally making an untrue statement in this certificate.

PART 2 — BIDDER'S CERTIFICATION

BIDDING COMPANY'S NAME

SIGNATURE

DATE

TITLE (e.g. BUSINESS OWNER/CHIEF EXECUTIVE OFFICER, ETC.)

CONTRACTING WITH: Show the name of the department or company with which the company listed is contracting.

PRINT OUT: In order to claim DVBE participation credit, a printout from the eProcurement system showing their supplier ID and the status of their certification must be furnished with the bidder's bid or upon the signing of contract documents. Check mark if a copy of the printout is included.

NATURE OF WORK: Identify the proposed work (or materials or equipment) to be provided.

TIER: Bidder may count toward its participation goal the dollar value of work and supplies to be obtained by its primary subcontractors and suppliers from DVBE firms as second and third level tier subcontractors/suppliers. Contracting tier should be indicated with the following designations:

DVBE company listed for participation.

0 = Prime or Joint Contractor 1 = Primary Subcontractor or Supplier 2 = Subcontractor/Supplier of Level 1 Subcontractor/Supplier 3 = Subcontractor/Supplier of Level 2 Subcontractor/Supplier

DOLLAR VALUE: The dollar amount of the bid to be performed by the listed company’s own forces.

PERCENTAGE OF BID: The percentage of the total bid amount the dollar value represents.

CONTRACTING WITH

PERCENT OF BID

PRINT-

OUT

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

COMPANY NAME

CONTACT

CONTRACTING WITH

PERCENT OF BID

PRINT-

OUT

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

COMPANY NAME

CONTACT

CONTRACTING WITH

PERCENT OF BID

PRINT-

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

COMPANY NAME

CONTACT

COMPANY NAME

CONTACT

CONTRACTING WITH

PERCENT OF BID

PRINT-

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

BIDDER'S DVBE PARTICIPATION

PRINTED NAME

OUT

OUT

SOLICITATION NUMBER

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.: Provide the DVBE Certification Number assigned to company.

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

Cert. 1: CCC-04/2017 and STD 204/DPR 88

Cert. 1: CCC-04/2017 and STD 204/DPR 88

Please complete and submit the CCC-04/2017 form located at:

https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List- Folder/Standard-Contract-Language

Also complete and submit the STD 204 form located at:

https://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf

Contractor/Bidder Firm Name (Printed) Federal ID Number

Date Executed Executed in the County of

Contractor Certification Clauses

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.

By (Authorized Signature)

Printed Name and Title of Person Signing

CONTRACTOR CERTIFICATION CLAUSES

1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the nondiscrimination program requirements. (Gov. Code §12990 (a-f) and CCR, Title 2, Section 11102) (Not applicable to public entities.)

2. 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. Every employee who works on the proposed Agreement will:

1) receive a copy of the company's drug-free workplace 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: the Contractor has made false certification, or violated the certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et seq.)

3. 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. (Pub. Contract Code §10296) (Not applicable to public entities.)

4. 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.

5. 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.

6. 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 located at www.dir.ca.gov, 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 http://www.dir.ca.gov/ 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).

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

8. 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.

1. 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.

Current State Employees (Pub. Contract Code §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.

Former State Employees (Pub. Contract Code §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. (Pub. Contract Code §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. (Pub. Contract Code §10430 (e))

2. 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)

3. 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.)

4. 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.

5. 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.

6. 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.

7. 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.

8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all contractors that are not another state agency or other governmental entity.

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

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

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

Print Form Reset Form

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.

Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

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

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification 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.

Section 4 – Payee Residency Status Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at time of death.

A trust is a resident if at least one trustee is a California resident.

o For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

Section 5 – Certification Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signee can provide a power of attorney documented for the individual.

Section 6 – Paying State Agency This section must be completed by the state agency/department requesting the STD 204.

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 this form.

Cert. 2: Iran Contracting Certification

Cert. 2: Iran Contracting Certification

Section 2200 et seq. of the California Public Contract Code prohibits a person from submitting a proposal for a contract with a public entity for goods and services of $1,000,000 or more if that person is identified on a list created by the Department of General Services (DGS) pursuant to section 2203(b) of the California Public Contract Code. The list will include persons providing goods or services of $20,000,000 or more in the energy sector of Iran and financial institutions that extend $20,000,000 or more in credit to a person that will use the credit to provide goods or services in the energy sector in Iran. DGS is required to provide notification to each person that it intends to include on the list at least 90 days before adding the person to the list.

In accordance with section 2204 of the California Public Contract Code, the undersigned hereby certifies that

It is not identified on a list created pursuant to section 2203(b) of the California Public Contract Code as a person engaging in investment activities in Iran described in section 2202.5(a), or as a person described in section 2202.5(b), as applicable; or

It is on such a list but has received permission pursuant to section 2203(c) or (d) to submit a proposal in response to this RFP.

Note: Providing a false certification may result in civil penalties and sanctions.

Date:

Entity:

Signature:

Printed Name

Title:

Note: Duplicate this form so that it is signed by the Proposer and all joint venture members of the Proposer.

Cert. 3: Darfur Contracting Act Certification

Cert. 3: Darfur Contracting Act Certification

PLEASE READ THE DIRECTIONS OF THIS CERTIFICATION CAREFULLY. DO NOT

COMPLETE THE SIGNATURE BOX UNLESS YOU HAVE INITIALED PARAGRAPH No. 3.

Pursuant to Public Contract Code section 10478, if a Proposer currently or within the previous three (3) years has had business activities or other operations outside of the United States, it must certify that it is not a “scrutinized” company as defined in Public Contract Code section 10476.

Therefore, to be eligible to submit a bid or proposal, please complete only one of the following three paragraphs (via initials for Paragraph No. 1 or Paragraph No. 2, or via initials and certification for Paragraph No. 3):

1. We do not currently have, or we have not had within the previous three years, business activities or other operations outside of the United States. Initials

OR

2. 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 (DGS) 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.

Initials

OR

3. We currently have, or we have had within the previous three years, business activities or other operations outside of the United States, but we certify below that we are not a scrutinized company below as defined in Public Contract Code section 10476.

Initials

CERTIFICATION for Paragraph No. 3

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the Proposer to the clause listed above in Paragraph No. 3. This certification is made under the laws of the State of California.

Proposer Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title

Date Executed Executed in the County and State of

Cert. 4: Major Participant Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Cert. 4: Major Participant Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Primary Covered Transactions

This certification applies to the offer submitted in response to this solicitation, and will be a continuing requirement throughout the term of the Agreement.

In accordance with the provisions of 2 C.F.R. Part 180, the Proposer certifies to the best of its knowledge and belief, that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency.

2. Have not within a 3-year period preceding this offer been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, State, or local) transaction or contract under a public transaction; violation of federal or State antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, State, or local) with commission of any of the offenses enumerated in item b of this certification.

4. Have not within a 3-year period preceding this offer had one or more public transactions (federal, State, or local) terminated for cause or default.

(Mark one, below, with an “x”)

Certify to the above Cannot certify to the above.

If the “cannot certify” box is checked, attach an explanation of the reasons.

Organization Name, Address, and Telephone

Signature of Person Certifying

Printed Name

Title

Date

Cert. 5: Subcontractor Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Cert. 5: Subcontractor Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Subcontractor Covered Transactions

This certification applies to a subcontract at any tier expected to be under $25,000, and will be a continuing requirement throughout the term of the Agreement.

In accordance with the provisions of 2 C.F.R. Part 180, the prospective Subcontractor certifies to the best of its knowledge and belief, that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency.

2. Have not within a 3-year period preceding this offer been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, State, or local) transaction or contract under a public transaction; violation of federal or State antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, State, or local) with commission of any of the offenses enumerated in item b of this certification.

4. Have not within a 3-year period preceding this offer had one or more public transactions (federal, State, or local) terminated for cause or default.

(Mark one, below, with an “x”)

Certify to the above Cannot certify to the above.

If the “cannot certify” box is checked, attach an explanation of the reasons.

Organization Name, Address, and Telephone

Cert. 6: Non-Collusion Certification

Cert. 6: Non-Collusion Certification

The undersigned declares:

I am the of , (Position / Title) (Company)

The party submitting the foregoing Proposal, and that the Proposal is:

NOT made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation

Genuine and NOT collusive or a sham.

That the Proposer has NOT directly or indirectly induced or solicited any other Proposer to:

Put in a false or sham Proposal; and

Colluded, conspired, connived or agreed with any Proposer or anyone else to put in a sham Proposal or that anyone shall refrain from bidding.

That the Proposer has NOT, in any manner directly or indirectly, sought by agreement, communication or conference with anyone to:

Fix the Price Proposal of the Proposer or any other Proposer, or

Fix any overhead, profit, or cost element, or that of any other Proposer, or

Secure any advantage against the public body awarding the contract or anyone interested in the proposed contract.

That all statements contained in the Proposal are true.

The Proposer has not and will not, directly or indirectly, for the purposes of effectuating a collusive or sham negotiation, submitted his or her schedule of rates or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, for payment to any corporation, partnership, company, association, organization, bid depository, or any member or agent thereof.

Organization Name, Address, and Telephone

Cert. 7: California Civil Rights Laws Certification

Cert. 7: California Civil Rights Laws Certification

Pursuant to Public Contract Code section 2010, if a Proposer executes or renews a contract over $100,000 on or after January 1, 2017, the bidder or proposer hereby certifies compliance with the following:

1. California Civil Rights Laws: For contracts over $100,000 executed or renewed after January 1, 2017, the Proposer certifies compliance with the Unruh Civil Rights Act (section 51 of the Civil Code) and the Fair Employment and Housing Act (section 12960 of the Government Code); and

2. Employer Discriminatory Policies: For contracts over $100,000 executed or renewed after January 1, 2017, if a Contractor has an internal policy against a sovereign nation or peoples recognized by the United States government, the Proposer certifies that such policies are not used in violation of the Unruh Civil Rights Act (section 51 of the Civil Code) or the Fair Employment and Housing Act (section 12960 of the Government Code).

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

Title of Company Official

By (Authorized Signature)

Printed Name and Title

Date Executed Executed in the County and State of

Cert. 8: Executive Order N-6-22- Russia Sanctions

Cert. 8: Executive Order N-6-22- Russia Sanctions

On March 4, 2022, Governor Gavin Newsom issued Executive Order N-6-22 (the EO) regarding Economic Sanctions against Russia and Russian entities and individuals. “Economic Sanctions” refers to sanctions imposed by the U.S. government in response to Russia’s actions in Ukraine, as well as any sanctions imposed under state law. By submitting a bid or proposal, Contractor represents that it is not a target of Economic Sanctions. Should the State determine Contractor is a target of Economic Sanctions or is conducting prohibited transactions with sanctioned individuals or entities, that shall be grounds for rejection of Contractor’s bid/proposal any time prior to contract execution, or, if determined after contract execution, shall be grounds for termination by the State.

Cert. 9: GenAI Reporting and Factsheet

Cert. 9: GenAI Reporting and Factsheet

The State of California seeks to realize the potential benefits of GenAI, through the development and deployment of GenAI tools, while balancing the risks of these new Technologies.

Bidder / Offeror must notify the State in writing if it: (1) intends to provide GenAI as a deliverable to the State; or (2), intends to utilize GenAI, including GenAI from third parties, to complete all or a portion of any deliverable that materially impacts: (i) functionality of a State system, (ii) risk to the State, or (iii) Contract performance. For avoidance of doubt, the term “materially impacts” shall have the meaning set forth in State Administrative Manual (SAM) § 4986.2 Definitions for GenAI.

Failure to report GenAI to the State may result in disqualification. The State reserves the right to seek any and all relief to which it may be entitled to as a result of such nondisclosure.

Upon notification by a Bidder / Offeror of GenAI as required, the State reserves the right to incorporate GenAI Special Provisions into the final contract or reject bids/offers that present an unacceptable level of risk to the State.

Government Code 11549.64 defines “Generative Artificial Intelligence (GenAI)” as an artificial intelligence system that can generate derived synthetic content, including text, images, video, and audio that emulates the structure and characteristics of the system’s training data.

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?

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

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)

C25680009

Control target invasive plant species within high-priority natural resource protection areas within Benicia State Recreation Area and Southampton Marsh Natural Preserve.

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)