Certification Statement.pdf

Vendor Name: ______________________________________________________________

CERTIFICATION STATEMENTS

Bidders claiming preference for Domestic Source End Products, the Ohio preference, and/or the Veteran Friendly Business Enterprise (VBE) must complete the following information. Any bidder who intentionally submits false or misleading information in an attempt to receive a bid preference will be immediately disqualified and may be subject to legal action up to and including debarment. The Department reserves the right to clarify any information during the evaluation process.

***BIDDERS MUST COMPLETE THIS CERTIFICATION TO RECEIVE ANY PREFERENCES***

A. DOMESTIC PREFERENCE (BUY AMERICAN): Revised Code 125:11 and Administrative Code 123:5-1(K) [Not applicable to "Excepted Products"]

1. Where is each product/services being offered mined, raised, grown, produced or manufactured?

United States: (State) (Go to B-1)

Other: ________________________________ (Specify Country) (Go to A-2)

2. End product is manufactured outside the United States and at least 50% of the cost of its components are produced, mined, raised, grown or manufactured within the United States. The cost of components may include transportation costs to the place of manufacture and, in the case of components of foreign origin, duty whether or not a duty free entry certificate is issued.

Yes (Go to Section B-1) No (Go to Section A-3)

3. The Bidder hereby certifies that each end product, except the products listed below, is a domestic source end product as defined in the Buy American Act and that components of unknown origin have been considered to have been mined, produced, grown or manufactured outside the United States.

(Item) _____________________________ (Country of Origin) __________________________

(Item) _____________________________ (Country of Origin) __________________________

B. OHIO PREFERENCE (BUY OHIO): Revised Code 125:09 and Administrative Code 123:5-1-06

1. The products/services being offered are raised, grown, produced, mined or manufactured in Ohio.

Yes No (Go to B-2)

2. Bidder has significant economic presence within the state of Ohio.

Yes (Answer a, b, c, d below) No (Go to B-3)

a) Bidder has paid the required taxes due the State of Ohio

Yes No

b) Bidder is registered with the Ohio Secretary of State

Yes (Charter/Registration No: _______________)

c) Bidder has ten or more employees based in Ohio or border state.

Yes No (Go to B-2d)

d) Bidder has seventy-five percent or more employees based in Ohio or border state Yes No (Go to B-3)

3. Border state bidder?

Yes (Specify which state then go to B-2c): KY MI NY PA IN No (Go to B-4 below)

4. Border state bidder: mined products mined in respective border state Yes No Not Applicable

Name of person completing form (printed): __________________________________________________

Signature of person completing form: _______________________________________________________

C. VETERANS PREFERENCE (BUY VETERAN): Revised Code 9.318 and Administrative Code 123:5-1-16

Is the bidder a certified Veteran Friendly Business Enterprise as defined in Administrative Code 123:5-1-01(KK)

Yes No