CDPH_9096A_-_CUF_Certification_(1).pdf

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State of California-Health and Human Services Agency California Department of Public Health

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION

Every certified SB, MB & DVBE (prime or subcontractor) must complete this form if they will perform an element of the work. Solicitation Number:

1. LEGAL BUSINESS NAME including "Doing Business As" (DBA) name:

OSDS CERTIFICATION #: Expiration Date:

2. COMMERCIALLY USEFUL FUNCTIONS (CUF)

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) (for SB) and Military and Veterans Code, Section 999(b)(5)

(B) (for DVBE).

Yes NoA. Is the GSPD-05-105 or GSPD-05-106 attached?

B. Std. 843 form attached, if applicable? Yes No

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

Mark all that apply: DVBE Small Business Micro Business

1 Will your business be responsible for the execution of a distinct element of the resulting work? Yes No

2 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

4 Will your business subcontract a portion of the work greater than would be expected by normal industry practices? Yes No

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

Yes No

A response of "No" in questions 1, 2, 3, & 5 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.

AUTHORIZING SIGNATURE (REQUIRED)

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.

AUTHORIZED REPRESENTATIVE SIGNATURE: TITLE:

PRINTED NAME: DATE:

CDPH PSB USE ONLY: Approved Denied

CDPH CPSS BUYER SIGNATURE: PRINTED NAME: DATE:

CDPH 9096 A (2/20)