COH_Forms.pdf

1 COH FORMS

FORMS TO BE SUBMITTED WITH RFQ SUBMITTAL

The following items must be completed and uploaded as part of your electronic submittal.

Failure to complete and return required forms may result in your submittal being deemed non-responsive and not considered for award.

These forms must be downloaded, completed, and uploaded as a part of the submittal.

ATTACHMENT A - AMERICANS WITH DISABILITIES ACT (ADA) DISABILITY

NONDISCRIMINATION STATEMENT

ATTACHMENT B - BUSINESS ENTITY AFFIDAVIT/CONFLICT OF INTEREST

ATTACHMENT C - CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND

OTHER RESPONSIBILITY MATTERS PRIMARY COVERED TRANSACTIONS

ATTACHMENT D - DRUG-FREE WORKPLACE PROGRAM AFFIDAVIT

ATTACHMENT E - SCRUTINIZED COMPANIES FORM

ATTACHMENT F - E-VERIFY

ATTACHMENT G - SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a), FLORIDA

STATUTES, ON PUBLIC ENTITY CRIMES

ATTACHMENT H - PERFORMANCE SURVEYS

ATTACHMENT I - NOTIFICATION OF SOCIAL SECURITY NUMBER COLLECTION AND

USAGE

ATTACHMENT J - W-9 FORM

ATTACHMENT K - AFFIDAVIT ATTESTING TO NONCOERCIVE CONDUCT FOR LABOR OR

SERVICES

ATTACHMENT L - AFFIDAVIT REGARDING PROHIBITION ON CONTRACTING WITH

ENTITIES OF FOREIGN COUNTRIES OF CONCERN

ATTACHMENT M - PROPOSER'S CERTIFICATION

2 COH FORMS

ATTACHMENT A

AMERICANS WITH DISABILITIES ACT (ADA) DISABILITY

NONDISCRIMINATION STATEMENT

THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR

OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.

This sworn statement is submitted to the CITY OF HOMESTEAD, FLORIDA by: ________________________________________________________________________ (print individual’s name and title) for: _______________________________________________________________________ (print name of entity submitting sworn statement) whose business address is: _____________________________________________________ and (if applicable) its Federal Employer Identification Number (FEIN) is: _______________

(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement: _______-_________-_______.)

I, being duly first sworn state:

That the above named firm, corporation or organization is in compliance with and agreed to continue to comply with, and assure that any subcontractor, or third party contractor under this project complies with all applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation, communications, access to facilities, renovations, and new construction.

The American with Disabilities Act of 1990 (ADA), Pub. L. 101-336, 104 Stat 327, 42 USC 1210112213 and 47 USC

Sections 225 and 661 including Title I, Employment; Title II, Public Services; Title III, Public Accommodations and

Services Operated by Private entities; Title IV, Telecommunications; and Title V, Miscellaneous Provisions.

The Florida Americans with Disabilities Accessibility Implementation Act of 1993, Section 553.501-553.513, Florida

Statutes:

The Rehabilitation Act of 1973, 229 USC Section 794;

The Federal Transit Act, as amended 49 USC Section 1612;

The Fair Housing Act as amended 42 USC Section 3601-3631.

Signature

STATE OF FLORIDA )

COUNTY OF MIAMI-DADE )

Sworn to (or affirmed) and subscribed before me by means of ____ physical presence or ____ online notarization, this _____ day of ______________________, 20___, by _________________________________________.

(Name of person making statement)

Personally known to me _____ or has produced Identification _____, type of identification produced________________________________________.

(NOTARY SEAL HERE) SIGNATURE OF NOTARY PUBLIC

3 COH FORMS

ATTACHMENT B

BUSINESS ENTITY AFFIDAVIT/CONFLICT OF INTEREST

(VENDOR / BIDDER DISCLOSURE)

CITY OF HOMESTEAD BUSINESS ENTITY STATEMENT (VENDOR/BIDDER DISCLOSURE)

Bidder or Vendor hereby recognizes and certifies that no elected official, board member, or employee of the City of Homestead (the "City") shall have a financial interest directly or indirectly in this transaction or any compensation to be paid under or through this transaction, and further, that no City employee, nor any elected or appointed officer (including City board members) of the City, nor any spouse, parent or child of such employee or elected or appointed officer of the City, may be a partner, officer, director or proprietor of Bidder or Vendor, and further, that no such City employee or elected or appointed officer, or the spouse, parent or child of any of them, alone or in combination, may have a material interest in the Vendor or Bidder. Material interest means direct or indirect ownership of more than 5% of the total assets or capital stock of the Vendor or Bidder. Any exception to these above-described restrictions must be expressly provided by applicable law or ordinance and be confirmed in writing by City. Further, Bidder or Vendor recognizes that with respect to this transaction or bid, if any Bidder or Vendor violates or is a party to a violation of the ethics ordinances or rules of the City, the provisions of Miami-Dade County Code Section 2-11.1, as applicable to City, or the provisions of Chapter 112, part III, Fla.

Stat., the Code of Ethics for Public Officers and Employees, such Bidder or Vendor may be disqualified from furnishing the goods or services for which the bid or proposal is submitted and may be further disqualified from submitting any future bids or proposals for goods or services to City. Bidder or Vendor must complete and execute the Business Entity Affidavit form. The terms "Bidder" or "Vendor," as used herein, include any person or entity making a proposal herein to City or providing goods or services to City.

I, _____________________________________________________, being first duly sworn state:

The full legal name and business address of the person(s) or entity contracting or transacting business with the

City of Homestead ("City") are (Post Office addresses are not acceptable), as follows:

Federal Employer Identification Number (If none, Social Security #):

Name of Entity, Individual, Partners, or Corporation

Doing business as, if same as above, leave blank

Street Address Suite City State Zip

OWNERSHIP DISCLOSURE AFFIDAVIT

1. If the contact or business transaction is with a corporation, the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirectly five percent (5%) or more of the corporation's stock. If the Contract or business transaction is with a trust, the full legal name and address shall be provided for each trustee and

4 COH FORMS

each beneficiary. All such names and addresses are (Post Office addresses are not acceptable), as follows:

Full Legal Name Address Ownership

2. The full legal names and business address of any other individual (other than subcontractors, materialmen, suppliers, laborers, or lenders) who have, or will have, any interest (legal, equitable, beneficial or otherwise) in the Contract or business transaction with the City are

(Post Office addresses are not acceptable), as follows:

Signature of Affiant Date

Printed Name of Affiant

Sworn to (or affirmed) and subscribed before me by means of ____ physical presence or ____ online notarization, this _____ day of ______________________, 20___, by _________________________________________.

(NOTARY SEAL HERE) SIGNATURE OF NOTARY PUBLIC

5 COH FORMS

ATTACHMENT C

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER

RESPONSIBILITY MATTERS

PRIMARY COVERED TRANSACTIONS

This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 13 CFR Part 145. The regulations were published as Part VII of the May 26, 1988

Federal Register (pages 19160-19211). Copies of the regulations are available from local offices of the

U.S. Small Business Administration.

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)

(1) The prospective primary participant certifies to the best of its knowledge and belief that it and its principals:

(a) Are not presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

(b) Have not within a three-year period preceding this application 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;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity

(Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and

(d) Have not within a three-year period preceding this application had one or more public transactions

(Federal, State, or local) terminated for cause or default.

(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective primary participant shall attach an explanation to this proposal.

Business Name________________________________________________________________

Date_________________________ By______________________________

Name and Title of Authorized Representative

Signature of Authorized Representative

6 COH FORMS

INSTRUCTIONS FOR CERTIFICATION

1 By signing and submitting this proposal, the prospective primary participant is providing the certification set out below.

2 The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction.

3 The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.

4 The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

5 The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person,"

"primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is submitted for assistance in obtaining a copy of those regulations (13 CFR Part 145).

6 The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction.

7 The prospective primary participant further agrees by submitting this proposal that it will include the clause titled "Certification

Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transactions," provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

8 A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the ineligibility of its principals.

Each participant may, but is not required to, check the Non-procurement List.

9 Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

10 Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.

7 COH FORMS

ATTACHMENT D

DRUG-FREE WORKPLACE PROGRAM AFFIDAVIT

IDENTICAL TIE BIDS - Preference shall be given to businesses with drug-free workplace programs.

Whenever two or more Bids which are equal with respect to price, quality, and service are received by the State or by any political subdivision for the procurement of commodities or contractual services, a Bid received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. Established procedures for processing tie Bids will be followed if none of the tied Bidders have a drug-free workplace program. In order to have a drug-free workplace program, a business shall:

1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

2. Inform employees about the dangers of drug abuse in the workplace, the business’s policy of maintaining drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

3. Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1).

4. In the statement specified in subsection (1), notify the employee that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of chapter 893 or of any controlled substance law of the United

States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction.

5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee’s community, by any employee who is so convicted.

6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.

As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements.

BIDDER’S SIGNATURE PRINTED NAME

NAME OF COMPANY

8 COH FORMS

ATTACHMENT E

SCRUTINIZED COMPANIES FORM

The undersigned CONTRACTOR in accordance with Section 287.135, Florida Statutes, hereby certifies that:

1. CONTRACTOR is not participating in a boycott of Israel;

2. CONTRACTOR is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized

Companies with Activities in the Iran Petroleum Energy Sector List;

3. CONTRACTOR does not have business operations in Cuba or Syria.

Signature (Blue ink only)

Print Name

Title

Date

The foregoing instrument was acknowledged before me by means of ____ physical presence or ____ online notarization, this _____ day of ______________________, 20___, by ________________________________________ as

________________________________________ (Name of person acknowledging)

(Title) for _______________________________________.

(Company name)

PRINT, TYPE/STAMP NAME OF NOTARY

9 COH FORMS

ATTACHMENT F

E-VERIFY

“Effective January 1, 2021, public and private employers, contractors and subcontractors will begin required registration with, and use of, the E-verify system in order to verify the work authorization status of all newly hired employees. Contractor acknowledges and agrees to utilize the U.S. Department of Homeland Security’s

E-Verify System to verify the employment eligibility of:

a) All persons employed by Contractor to perform employment duties within Florida during the term of the contract; and

b) All persons (including sub-vendors/subconsultants/subcontractors) assigned by Contractor to perform work pursuant to the contract with the City. The Contractor acknowledges and agrees that use of the U.S. Department of Homeland Security’s E-Verify System during the term of the contract is a condition of the contract with the City of Homestead.

Should Vendor become the successful Contractor awarded for the above-named project, by entering into this

Agreement, the Contractor becomes obligated to comply with the provisions of § 448.095, FL. Statutes, as amended from time to time. This includes but is not limited to utilization of the E-Verify System to verify the work authorization status of all newly hired employees; and requiring all Subcontractors to provide an affidavit attesting that the Subcontractor does not employ, contract with, or subcontract with, an unauthorized alien. The

Contractor shall maintain a copy of such affidavit for the duration of the contract. Failure to comply will lead to termination of this Contract, or if a Subcontractor knowingly violates the statute, the Subcontract must be terminated immediately. Any challenge to termination under this provision must be filed in the Circuit Court no later than 20 calendar days after the date of termination. If this contract is terminated for a violation of the statute by the Contractor, the Contractor may not be awarded a public contract by the City for a period of 1 year after the date of termination. By signing below, the Vendor acknowledges these terms shall be an integral part of its bid and the Contract.

ATTEST Company Name

Signature of Corporate Secretary Signature

Type/Print Name of Corporate Secy. Type/Print Name

(CORPORATE SEAL)

10 COH FORMS

ATTACHMENT G

SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a), FLORIDA

STATUTES, ON PUBLIC ENTITY CRIMES

THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A

NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.

1. This sworn statement is submitted to the CITY OF HOMESTEAD, FLORIDA by: ________________________________________________________________________ (print individual’s name and title) for: _______________________________________________________________________ (print name of entity submitting sworn statement) whose business address is: _____________________________________________________ and (if applicable) its Federal Employer Identification Number (FEIN) is: _______________

(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement: _______-_________-_______.)

2. I understand that a “public entity crime” as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or of the United

States, including but not limited to, any Bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentations.

3. I understand that “convicted” or “conviction” as defined in Paragraph 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July

1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere.

4. I understand that an “affiliate” as defined in Paragraph 287.133(1)(a), Florida Statutes, means:

1. A predecessor or successor of a person convicted of a public entity crime; or

2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term “affiliate” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm’s length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.

5. I understand that a “person” as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term “person” includes those officers, directors, executives, and partners. Shareholders, employees, members, and agents who are active in management of an entity.

6. Based on information and belief, the statement, which I have marked below, is true in relations to the entity submitting this sworn statement. (Indicate which statement applies.)

11 COH FORMS

Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July

1, 1989.

The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July

1, 1989.

The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July

1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of

Florida , Division of Administrative Hearings and the final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list (attach a copy of the final order).

I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY

IDENTIFIED IN PARAGRAPH 1 ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND THAT THIS FORM IS VALID

THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM

REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE

THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY

CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.

Sworn to (or affirmed) and subscribed before me by means of ____ physical presence or ____ online notarization, this

_____ day of ______________________, 20___, by _________________________________________.

12 COH FORMS

ATTACHMENT H

PERFORMANCE SURVEYS

The City of Homestead will be conducting quarterly performance surveys and post project surveys for vendors whom are awarded bids and contracts. Surveys will be sent to the user-departments and will be used as a quarterly monitoring device to gauge performance and to utilize when awarding or renewing contracts.

Definitions:

Monthly Surveys- Vendors whom are performing services on a weekly basis.

Quarterly Surveys- Vendors whom are performing services on a monthly basis.

Post Project Surveys- Vendors who perform a service with a completion deadline [i.e.

construction].

Below are some basic questions. Please provide the City with any additional questions you may want included should you be awarded a contract/bid.

Evaluation Instructions

Each evaluator shall provide a score for each criterion shown below, on the basis of the following scale:

5 = Exceeds Expectation 4 = Meets Expectation 3 = Marginally 2 = Below Expectation 1 = Unsatisfactory

N/A 5 4 3 2 1 Remarks

Public relations/ customer service

Vendor's performance level

Ability to meet completion times

Quality of product/ service provided

Responsiveness to Emergencies

Invoice is consistent with contract pricing

Please add any additional questions you may want for personal reporting.

I understand the above information and have been given a copy of this document.

Company Name (Print)

Authorized Representative Name Authorized Representative Name Date

(Print) (Signature)

13 COH FORMS

ATTACHMENT I

NOTIFICATION OF SOCIAL SECURITY NUMBER COLLECTION AND USAGE

In compliance with Florida Statutes §119.071(5), the City of Homestead Procurement & Contracts Division collects and uses your Social Security number only for the following purposes in performance of the City’s duties and responsibilities.

Your Social Security number is used for legitimate employment business purposes in compliance with:

• Completing a Vendor Application in lieu of a FEIN.

NOTIFICATION

Providing a Social Security number in lieu of a FEIN is a condition of becoming a vendor with the City of

Homestead.

The City may disclose Social Security numbers to another agency or governmental entity if such disclosure is necessary for the receiving agency or entity to perform its duties and responsibilities.

The City may not deny a commercial entity engaged in the performance of a commercial activity access to

Social Security numbers, provided the Social Security numbers will be used only in the performance of a commercial activity, and provided the commercial entity makes a written request for the Social Security numbers.

I understand the above information and have been given a copy of this document.

Company Name (Print)

Authorized Representative Name Authorized Representative Name Date

(Print) (Signature)

14 COH FORMS

ATTACHMENT J - W-9 FORM

15 COH FORMS

16 COH FORMS

17 COH FORMS

18 COH FORMS

19 COH FORMS

20 COH FORMS

ATTACHMENT K

AFFIDAVIT ATTESTING TO NONCOERCIVE CONDUCT FOR LABOR OR SERVICES

Nongovernment Entity name: _________________________________________________(“Vendor”)

Vendor FEIN:_________________________________________________________________________

Address:_____________________________________________________________________________

City:________________________________________________ State: _____________Zip:___________

Phone number:______________________Email Address: _____________________________________

As a nongovernmental entity executing, renewing, or extending a contract with the City of Homestead, Florida, Vendor is required to provide an affidavit under penalty of perjury attesting that Vendor does not use coercion for labor or services, and is in compliance with Section 787.06, Florida Statutes.

As defined in Section 787.06(2)(a), Florida Statutes, coercion means:

1. Using or threating to use physical force against any person;

2. Restraining, isolating, or confining or threating to restrain, isolate, or confine any person without lawful authority and against her or his will;

3. Using lending or other credit methods to establish a debt by any person when labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt, the length and nature of the labor or service are not respectively limited and defined;

4. Destroying, concealing, removing, confiscating, withholding, or possessing any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person;

5. Causing or threating to cause financial harm to any person;

6. Enticing or luring any person by fraud or deceit; or

7. Providing a controlled substance as outlined in Schedule I or Schedule II of Section 893.03, Florida Statutes to any person for the purpose of exploitation of that person.

As a person authorized to sign on behalf of Vendor, I certify that Vendor does not use coercion for labor or services, and is in compliance with Section 787.06, Florida Statutes.

Written Declaration

Under penalties of perjury, I declare that I have read the foregoing Affidavit and that the facts stated in it are true.

By: ______________________________________

Authorized Signature

Print Name and Title: ________________________

Date: _____________________________________

STATE OF FLORIDA)

COUNTY OF MIAMI-DADE)

Sworn to (or affirmed) and subscribed before me by means of physical presence or online notarization, this _____ day of , 20 , by ____________________ ____________________________ (Name of person making statement).

Personally known to me ________

Or has produced identification _____, type of identification produced _________

PRINT, TYPE/STAMP NAME OF NOTARY

21 COH FORMS

ATTACHMENT L

AFFIDAVIT REGARDING PROHIBITION ON CONTRACTING WITH

ENTITIES OF FOREIGN COUNTRIES OF CONCERN

Pursuant to Section 287.138, Florida Statutes (which is expressly incorporated herein by reference), a governmental entity may not knowingly enter into a contract with an entity which would give access to an individual’s personal identifying information if (a) the entity is owned by ethe government of a foreign country of concern; (b) the government of a foreign country of concern has a controlling interest in the entity; or (c) the entity is organized under the laws of or has its principal place of business in a foreign country of concern.

This affidavit must be completed by an officer or representative of an entity submitting a bid, proposal, or reply to, or entering into, renewing, or extending, a contract with a governmental entity which would grant the entity access to an individual’s personal identifying information.

1. (“entity”) does not meet any of the criteria in paragraphs (2)(a)-(c) of Section 287.138, F.S.

In the presence of: Under penalties of perjury, I declare that I have read the foregoing and the facts stated in it are true:

Witness #1 Print Name: Print Name:

Title:

Witness #2 Print Name: Entity Name:

OATH OR AFFIRMATION

State of Florida

County of

Sworn to (or affirmed) and subscribed before me by means of ☐ physical presence or ☐ online notarization, this day of , 20 , by (name of person) as

(type of authority) for (name of party on behalf of whom instrument is executed).

Notary Public (Print, Stamp, or Type as Commissioned)

Personally known to me; or

Produced identification (Type of Identification: )

Did take an oath

22 COH FORMS

ATTACHMENT M

PROPOSER'S CERTIFICATION

I have carefully examined the Request for Qualifications and any other documents accompanying or made a part of this Request for

Qualifications.

I hereby propose to furnish the goods or services specified in the Request for Qualifications. I agree that my proposal will remain firm for a period of 365 days in order to allow the City adequate time to evaluate the proposals.

I certify that all information contained in this proposal is truthful to the best of my knowledge and belief. I further certify that I am duly authorized to submit this proposal on behalf of the firm as its act and deed and that the firm is ready, willing and able to perform if awarded the contract.

I further certify, under oath, that this proposal is made without prior understanding, agreement, connection, discussion, or collusion with any other person, firm or corporation submitting a proposal for the same product or service; no officer, employee or agent of the

City of Homestead or any other proposer is interested in said proposal; and that the undersigned executed this Proposer's Certification with full knowledge and understanding of the matters therein contained and was duly authorized to do so.

A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crimes may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a public entity , and may not transact business with any public entity in excess of the threshold amount provided in Sec. 287.017, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list.

Name of Business

BY:

Name and Title, Typed or Printed

Mailing Address

City, State, Zip Code

Telephone Number

The foregoing instrument was acknowledged before me by means of ____ physical presence or ____ online notarization, this _____ day of ______________________, 20___, by ________________________________________ as

________________________________________ (Name of person acknowledging) (Title) for _______________________________________.

(Company name)