Chapter 30 Bidding Package DRM2014-05.docx

For C. 30, §39M Site Work Projects up to $50,000

Executive Office of Public Safety and Security

GENERAL CONTRACTOR: ____________________________________

CONTRACT

— FOR —

DRM 2014-05

Cathodic Protection of Two Water Storage Tanks

50 Maple Street, Suite 3 Milford, Massachusetts 01757-3698 (508)422-3300

TABLE OF CONTENTS FOR DOC BID PACKAGE

PART I Instructions to Bidders Attachment A: Minimum Wage Rates Attachment B: Form for General Bid

PART II Forms Used During Contract Award and Execution:

Owner-Contractor Agreement Payment Bond Request for Taxpayer Identification Number and Certification (W-9) Commonwealth Terms and Conditions Electronic Funds Transfer Sign Up

PART III Specifications

BID PACKAGE

PART I

INSTRUCTIONS TO BIDDERS

Instructions to Bidders Attachment A: Minimum Wage Rates Attachment B: Form for General Bid

COMMONWEALTH OF MASSACHUSETTS

INSTRUCTIONS TO BIDDERS

Awarding Authority:

Department of Correction Fiscal Services 50 Maple Street – Suite 3 Milford, MA 01757 Telephone: (508) 422-3427

DRM Project Number: DRM 2014-05 Title: Cathodic Protection of Two Water Storage Tanks

Project Description and Scope: Cathodic Protection of Two Water Storage Tanks

Deadline for filing General Bids is: Wednesday, 2/15/17 at 2:00 p.m.

The minimum wage rate requirements for this Contract are located in Attachment A to these Instructions to Bidders.

Pursuant to M.G.L. c. 30, §39S(a) (2) all employees to be employed on the project must have successfully completed a course in construction safety and health approved by OSHA and of at least 10 hours in duration.

Bid forms for this Contract are located in Attachment B to these Instructions to Bidders.

The time for completion of the Work is specified in Article 2 of the Owner - Contractor Agreement. Liquidated damages for failure to complete work on time are as stated in Article 7 of the Owner - Contractor Agreement.

SECTION 1 - SUBMISSION OF BIDS

1.1 Each General Bid shall be enclosed in a sealed envelope with the following plainly marked on the outside:

General Bid for: DRM Project No.: DRM 2014-05 Title: Cathodic Protection of Two Water Storage Tanks

General Bidders name, business address, and telephone number.

1.2 All Bids must be received by the Awarding Authority at the address specified on page 1 of these Instructions to Bidders no later than the applicable date and time specified on page 1 of these Instructions to Bidders. Any Bid not received by the applicable deadline will not be accepted.

1.3 Bidding results be posted on www.commbuys.com by 1:00 PM of the day following the Bid opening. Bidding results will not be given over the telephone prior to 1:00 PM of the day following the Bid opening.

SECTION 2 - EXECUTION OF CONTRACTS

2.1 Upon receipt of the Award, the General Bidder awarded the Contract shall submit one (1) properly executed original of each of the following documents prior to execution of the Contract by the Awarding Authority. All such documents shall be in the form prescribed by the Awarding Authority.

· Payment Bond (for 50% of contract price) with power of attorney attached

· Certificates of Insurance evidencing coverage in amounts required by the Contract Documents

· Any other documents that the Awarding Authority may reasonably require in connection with the Contractor's execution of the Contract.

ATTACHMENT A

PREVAILING WAGE SCHEDULE

The minimum wage rates included in this package have been provided by the Division of Occupational Safety of the Massachusetts Department of Labor and Workforce Development. The Awarding Authority is not responsible for errors or omissions in such wage rates.

You can find the Wage Rates at www.commbuys.com under the “Attachments” Tab for this solicitation.

M.G.L. c. 149, s. 26 and 27 provide as follows:

". . . Payments by employers to health and welfare plans, pension plans and supplementary unemployment benefit plans under collective bargaining agreements or understandings between organized labor and employers shall be included for the purpose of establishing minimum wage rates as herein provided.

. . . The aforesaid rates of wages in the schedule of wage rates shall include payments by employers to health and welfare plans, pension plans and supplementary unemployment benefit plans as provided in said section twenty-six, and such payments shall be considered as payments to persons under this section performing work as herein provided. Any employer engaged in the construction of such works who does not make payments to a health and welfare plan, a pension plan and a supplementary unemployment benefit plan, where such payments are included in said rates of wages, shall pay the amount of said payments directly to each employee engaged in said construction "

ATTACHMENT B

Massachusetts Department of Correction Division of Resource Management 21 Needham Street Norfolk, MA 02056 Telephone: (508) 541-5301

FORM FOR GENERAL BID

For M.G.L. c. 30, §39 M Public Works Projects up to $50,000

FORM FOR GENERAL BID

To the Awarding Authority: Department of Correction

A. The undersigned proposes to furnish all labor and materials required for Project No. DRM 2014-05, Project Name: Design and installation of complete ice-free, impressed current cathodic protection systems for two water storage tanks. The design shall be done by a corrosion specialist. Location: Old Colony Correctional Center Power Plant; 12A Titicut Street, Bridgewater, MA.

B. This bid includes addenda numbered _______________________________________.

C. The proposed contract price is ______________________________________________________($_______________).

(Total bid in words)

For Alternate No. 1: Add $_______________ Subtract $________________

Name of General Bidder ________________________________________________

D. The undersigned agrees that, if it is selected as general contractor, it will within five days, Saturdays, Sundays and legal holidays excluded, after presentation thereof by the awarding authority, execute a contract in accordance with the terms of this bid and furnish a payment bond of a surety company qualified to do business under the laws of the Commonwealth and satisfactory to the awarding authority and each in the sum of 50% of the contract price, the premiums for which are to be paid by the general contractor and are included in the contract price.

The undersigned hereby certifies that he/she is able to furnish labor that can work in harmony with all other elements of labor employed or to be employed on the work: that all employees to be employed at the worksite will have successfully completed a course in construction safety and health approved by the United States Occupational Safety and Health Administration (OSHA) that is at least ten hours in duration at the time the employee begins work and who shall furnish documentation of successful completion of said course with the first certified payroll report for each employee: and that he will comply fully with all laws and regulations applicable to awards made subject to section 39M of Chapter 30 of the General Laws.

The undersigned further certifies under penalties of perjury that the undersigned is not debarred from doing public construction work under any law, rule or regulation of the federal government.

The undersigned hereby declares that the undersigned has carefully examined the Advertisement, Instructions to Bidders, Owner - Contractor Agreement, Plans and Specifications, all other Contract Documents, and also the Site upon which the proposed work is to be performed. The undersigned further declares that in regard to the conditions affecting the work to be done and the labor and materials needed, this proposal is based solely on the undersigned's own investigation and research and not in reliance upon any representation of any employee, officer or agent of the Commonwealth

The undersigned further certifies under the penalties of perjury that:

· this bid is in all respects bona fide, fair and made without collusion or fraud with any other person;

· we are the only persons interested in this proposal;

· that it is made without any connection with any other person making any bid for the same work and without directly or indirectly influencing or attempting to influence any other person to bid to refrain from bidding or to influence the amount of the bid of any other person or corporation;

· that no person acting for, or employed by, the Commonwealth of Massachusetts is directly or indirectly interested in this proposal, or in any contract which be made under it, or in expected profits to arise therefrom.

· As used above the word "person" shall mean natural person, joint venture, partnership, corporation or other business or legal entity.

Should the Contract Documents require submission of special data to accompany the bid, the Awarding Authority reserves the right to rule the bidder's failure to submit such data an informality and to receive said data subsequently within a reasonable time as set by the Awarding Authority.

Date______________________, 20___.

(Name of General Bidder)

By____________________________________________________ (Name of Person Signing Bid and Title)

(Business Address)

(City and State)

(Telephone Number)

(Facsimile Number)

(e-mail Address)

(Website)

PART II

Forms for Contract Execution

Forms Used During Contract Award and Execution:

Owner-Contractor Agreement Payment Bond Request for Taxpayer Identification Number and Certification (W-9) Commonwealth Terms and Conditions Electronic Funds Transfer Sign Up

STANDARD CONSTRUCTION CONTRACT

For Site Work Projects Only Subject to G.L. c. 30, §39M

OWNER - CONTRACTOR AGREEMENT

Awarding Authority: Department of Correction Department Code: DOC

This agreement ("Contract") is made as of the ____ day of ___________, 20____, by and between the Commonwealth of Massachusetts acting by and through the Awarding Authority identified above with a principal place of business at 50 Maple Street, Suite 3 Milford, Massachusetts 01757 , and____________________________________________________________________, a ______________________ with a principal place of business at ________________________________________________________, _________________________________________________________, hereinafter called the "Contractor".

Terms used in this Owner - Contractor Agreement which are defined in the General Conditions of the Contract shall have the meanings designated therein.

The Awarding Authority and the Contractor agree as follows:

Article 1. Scope of Work. The Work under this Contract is defined as all work required by the Contract Documents for the construction of Cathodic Protection of Two Water Storage Tanks, Design and installation of complete ice-free, impressed current cathodic protection systems for two water storage tanks. The design shall be done by a corrosion specialist.

Contract No. DRM 2014-05, in accordance with and as described in the Plans and Specifications dated __October 10, 2016__, 2016__, prepared by DOC Division of Resource Management (“Designer"), as modified by Addenda Nos.____________________ dated ____________________, 20_____.

Article 2. Time for Completion. The Contractor shall commence the Work under this Contract on the date specified in the written "Notice to Proceed," and shall, within 90 days after such date, bring the Work to Substantial Completion and to the point at which a Certificate of Agency Use and Occupancy may be issued, and shall bring the Work to Final Acceptance within 30 days after the date specified for Substantial Completion.

Article 3. Contract Price. The Awarding Authority shall pay the Contractor, in current funds, for the performance of the Work, subject to additions and deductions by Approved Change Order(s), the Contract Price of ____________________________________ dollars ($ ______________________). The Unit Prices, if any, approved by the Awarding Authority are those included in the Contractor's General Bid. The following Alternates have been accepted and their costs are included in the Contract Price:

Alternate No(s): ______________________________________________________________________

Article 4. Approved Subcontractors. No subcontractors shall be used for these or any other portions of the Work without the prior written approval of the Awarding Authority.

Article 5. Certifications. Pursuant to M.G.L. c. 62(c), s.49 (a), the individual signing this Contract on behalf of the Contractor hereby certifies, under the penalties of perjury, that to the best of his or her knowledge and belief the Contractor has complied with any and all applicable state and federal tax laws. The individual signing this Contract on behalf of the Contractor further certifies under penalties of perjury that the Contractor is not presently debarred from doing public construction work in the Commonwealth under the provisions of M.G.L. c. 29, s. 29F, or any other applicable debarment provisions of any other chapter of the General Laws or any rule or regulation promulgated thereunder and is not presently debarred from doing public construction work by any agency of the United States.

Article 6. The Contract Documents: The following documents form the Contract, are incorporated by reference herein, and are referred to as the "Contract Documents:"

· The Instructions to Bidders

· The General Bid submitted by the Contractor

· This Owner – Contractor Agreement

· The Plans and Specifications, including Addenda identified in Article 1 above

· All Approved Change Orders issued after execution of this Owner - Contractor Agreement

Article 7. Liquidated Damages. For the purposes of Article VI of the General Conditions of the Contract, liquidated damages for delay shall be as follows: $1000 per day for every day beyond the contract completion date or completion date as extended will be withheld as a special reserve to be applied as liquidated damages, if any, the amount of said damages to be determined as per the above mentioned method.

CONTRACTOR:

By: ____________________________________________

Name: __________________________________________

Title: ___________________________________________

Date: ___________________________________________

AWARDING AUTHORITY:

By executing this Agreement, the undersigned authorized signatory of the Awarding Authority, who incurs no personal liability by reason of the execution hereof or anything herein contained, hereby certifies under penalties of perjury that this Contract is executed in accordance with a prior approval of the Division of Capital Asset Management and Maintenance, and further certifies under the penalties of perjury that all the applicable provisions of M.G.L. c. 149, s. 44J, have been complied with.

By: ____________________________________________

Name: __________________________________________

Title: ___________________________________________

Date: ___________________________________________

PAYMENT BOND

Know all men by these presents, that ____________________as principal, and ____________________________as surety, are held and firmly bound unto the Commonwealth of Massachusetts in the sum of _______________ in lawful money of the United States of America, to be paid to the Commonwealth of Massachusetts, for which payments, well and truly to be made, we bind ourselves, our respective heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.

Whereas, the said principal has made a Contract with the Commonwealth acting through its Department of Correction (“Awarding Authority”) bearing date of ______________________, for the construction of Project No. DRM 2014-05, Project Name Design and installation of complete ice-free, impressed current cathodic protection systems for two water storage tanks. The design shall be done by a corrosion specialist.

Now the condition of this obligation is such that if the principal shall pay for all labor performed or furnished and for all materials used or employed in said Contract and in any and all duly authorized modifications, alterations, extensions of time, changes or additions to said Contract that may hereafter be made, notice to the surety of such modifications, alterations, extensions of time, changes or additions being hereby waived, the foregoing to include any other purpose or items set out in, and to be subject to, provisions of Massachusetts General Laws Chapter 30, section 39A, and Chapter 149, section 29, as amended, then this obligation shall become null and void; otherwise it shall remain in full force and virtue.

In witness whereof we hereunto set our hand and seals this _________ day of _________________________, 20__.

Surety Address _________________________

COMMONWEALTH OF MASSACHUSETTS

OFFICE OF THE COMPTROLLER

Electronic Funds Transfer Sign Up Form

Request type must be checked: Initial Request Changing Existing Account Closing Account

I _________________________, hereby certify that the account/s indicated on this form is under my direct control and access; therefore, I authorize the State Treasurer as fiscal agent for the State of Massachusetts to initiate, change or cancel credit entries to that account/s as indicated on this form.

For ACH debits consistent with the International/ACH Transaction (IAT) rules, check one:

I affirm that payments authorized hereunder are not to an account that is subject to being transferred to a foreign bank account.

I affirm that payments authorized hereunder are to an account that is subject to being transferred to a foreign bank account.

This authority is to remain in full force and effect until the Office of the Comptroller has received written notification from either me or an authorized officer of the organization of the account’s termination in such time and in such a manner as to afford CTR a reasonable opportunity to act upon it.

VENDOR BANK INFORMATION

Filling out this field is a requirement for changing account number

VENDOR INFORMATION

This authorization will remain in effect until either canceled in writing or an updated form changing information is sent to the Department you currently do business with.

AUTHORIZED SIGNATURE:

Print Name: Title: Date:

Form forwarded to Commonwealth Department:

Attach a voided check here:

PART III

SPECIFICATIONS AND DRAWINGS

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Microsoft_Word_97_-_2003_Document1.doc Form W-9

(Massachusetts Substitute W-9 Form)

Rev. April 2009

Request for Taxpayer

Identification Number and Certification

Completed form should be given to the requesting department or the department you are currently doing business with.

Name ( List legal name, if joint names, list first & circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2)

Business name, if different from above. (See Specific Instruction on page 2)

Check the appropriate box: □ Individual/Sole proprietor □ Corporation □ Partnership □ Other ►-----------------------------------------------

Legal Address: number, street, and apt. or suite no.

Remittance Address: if different from legal address number, street, and apt. or suite no.

City, state and ZIP code

City, state and ZIP code

Phone # ( ) Fax # ( ) Email address:

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 2.

Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter.

Vendors:

Dunn and Bradstreet Universal Numbering System (DUNS))

Social security number

OR

Employer identification number

DUNS

f

Part II Certification f

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Services (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am an U.S. person (including an U.S. resident alien).

4. I am currently a Commonwealth of Massachusetts’s state employee: (check one): No____ Yes _____ If yes, in compliance with the State Ethics Commission requirements.

Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.

Sign

Here

Authorized Signature ► Date ►

Purpose of Form

A person who is required to file an information return with the IRS must get your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to give your correct TIN to the person requesting it (the requester) and , when applicable, to:

1. Certify the TIN you are giving is correct (or you are waiting for a number to be issued).

2. Certify you are not subject to backup withholding

If you are a foreign person, use the appropriate Form W-8. See Pub 515, Withholding of Tax on Nonresident Aliens and Foreign Corporations.

What is backup withholding? Persons making certain payments to you must withhold a designated percentage, currently 28% and pay to the IRS of such payments under certain conditions. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

If you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return, payments you receive will not be subject to backup withholding. Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester, or

2. You do not certify your TIN when required (see the Part II instructions on page 2 for details), or

3. The IRS tells the requester that you furnished an incorrect TIN, or

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See the Part II instructions on page 2.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.

Please print or type

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Form MA- W-9 (Rev. April 2009) image6.emf

Microsoft_Word_97_-_2003_Document2.doc

Specific Instructions

Name. If you are an individual, you must generally enter the name shown on your social security card. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first and then circle the name of the person or entity whose number you enter in Part I of the form.

Sole proprietor. Enter your individual name as shown on your social security card on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name” line.

Limited liability company (LLC). If you are a single-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301.7701-3, enter the owner’s name on the “Name” line. Enter the LLC’s name on the “Business name” line.

Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8.

Other entities. Enter your business name as shown on required Federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name” line.

Part I - Taxpayer Identification

Number (TIN)

Enter your TIN in the appropriate box.

If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are an LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) above), and are owned by an individual, enter your SSN (or “pre-LLC” EIN, if desired). If the owner of a disregarded LLC is a corporation, partnership, etc., enter the owner’s EIN.

Note: See the chart on this page for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office. Get Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can get Forms W-7 and SS-4 from the IRS by calling 1-800-TAX-FORM (1-800-829-3676) or from the IRS’s Internet Web Site www.irs.gov.

If you do not have a TIN, write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments.

The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note: Writing “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Part II - Certification

To establish to the paying agent that your TIN is correct or you are a U.S. person, or resident alien, sign Form W-9.

For a joint account, only the person whole TIN is shown in Part I should sign (when required).

Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

Dunn and Bradstreet Universal Numbering System (DUNS) number requirement –

The United States Office of Management and Budget (OMB) requires all vendors that receive federal grant funds have their DUNS number recorded with and subsequently reported to the granting agency. If a contractor has multiple DUNS numbers the contractor should provide the primary number listed with the Federal government’s Central Contractor Registration (CCR) at /www.ccr.gov . Any entity that does not have a DUNS number can apply for one on-line at http://www.dnb.com under the DNB D-U-N Number Tab.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to give your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or MSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold a designated percentage, currently 28% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

What Name and Number to Give the Requester

For this type of account:

Give name and SSN of:

1. Individual

2. Two or more individuals (joint account)

3. Custodian account of a minor (Uniform Gift to Minors Act)

4. a. The usual revocable savings trust (grantor is also trustee)

b. So-called trust account that is not a legal or valid trust under state law

5. Sole proprietorship

The individual

The actual owner of the account or, if combined funds, the first individual on the account 1

The minor 2

The grantor-trustee 1

The actual owner 1

The owner 3

For this type of account:

Give name and EIN of:

6. Sole proprietorship

7. A valid trust, estate, or pension trust

8. Corporate

9. Association, club, religious, charitable, educational, or other tax-exempt organization

10. Partnership

11. A broker or registered nominee

12. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The owner 3

Legal entity 4

The corporation

The organization

The partnership

The broker or nominee

The public entity

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name, but you may also enter your business or “DBA” name. You may use either your SSN or EIN (if you have one).

4. List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.)

Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

If you have questions on completing this form, please contact the Office of the State Comptroller. (617) 973-2468.

Upon completion of this form, please send it to the Commonwealth of Massachusetts Department you are doing business with.

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