Compliance_Documents,_PEC,DFW,UA,COI.pdf

PUBLIC ENTITY CRIMES

Board of County Commissioners, Walton County, Florida

This sworn statement is submitted to The Board of County Commissioners, Walton County, Florida by ____________________________________________, who holds the position of _________________________________________________, [Title] for _____________________________________________________________, whose [name of entity submitting sworn statement] 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 understand that a "public entity crime" as defined in Paragraph 287.133(l)(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 any agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

• I understand that "convicted" or "conviction" as defined in Paragraph 287.133(l)(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, nonjury trial, or entry of a plea of guilty or nolo contenders.

Sworn Statement Under Section 287.133(3)(a), Florida Statutes, on Public Entity Crimes

This form must be signed in the presence of a Notary Public or other officer authorized to administer oaths:

• I understand that an "affiliate" as defined in Paragraph 287.133(l)(a), Florida Statutes, means:

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

• I understand that "person" as defined in Paragraph 287.133(l)(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, partners, shareholders, employees, members, and agents who are active in management of an entity.

• Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. [indicate which statement applies.]

__________ 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, 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, 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 ONE (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.

BIDDER: _____________________________

By: __________________________________ Printed Name: _________________________ As Its: ________________________________

Date: ________________________________

STATE OF FLORIDA

COUNTY OF ___________

____________________ who is personally known to me or who produced the following identification of___________________________, and who after first being sworn by me, the undersigned authority, executed the foregoing instrument by means of ☐ physical presence or

☐ online notarization on this_____ day of _____________________, 2020.

[SEAL] ____________________________________

NOTARY PUBLIC

Drug Free Workplace Certification

BOARD OF COUNTY COMMISSIONERS,

WALTON COUNTY, FLORIDA

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 certified 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 vendors 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 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 a drug-free workplace, available drug counseling, rehabilitation providing 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 of contractual services that are under bid a copy of the statement specified in paragraph #1.

4. In the statement specified in paragraph #1, notify the employees 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 no contest to, and violation of chapter 893 or of any controlled substance law of the united states or any state, for a violation occurring in the work place 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

This form must be completed and attached to bid.

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

Company Name Authorized Signature

Federal ID Number or SSN Print Name

Date

Board of County Commissioners

Walton County, Florida

UNAUTHORIZED ALIENS

Inasmuch as the employment of unauthorized aliens is prohibited by §448.09, Florida Statutes, the County prohibits contracting with firms that knowingly utilize services of unauthorized aliens in the performance of contracts for goods or services with the County. Additionally such firms may not knowingly contract with sub-contractors who utilize the services of unauthorized aliens.

By signing below the bidder swears or affirms that:

His/her company does not knowingly utilize the services of unauthorized aliens in the performance of contracts. The company agrees that the County may conduct random checks of personnel records as they pertain to this issue. Violation of this requirement may result in immediate termination of the contract. Additionally violation of this requirement may result in the company being prohibited from submitting bids/proposals for County contracts for a period of five years. (See Procedure PP-022, Walton County Purchasing Policies and Procedures Manual.)

Signature

Printed Name

Title

Date

STATE OF FLORIDA;

COUNTY OF _______________;

Subscribed, sworn to and executed the foregoing instrument by means of ☐ physical presence or

☐ online notarization this________ day of___________________, 2020.

_________________________________ [SEAL]

Notary Public

My commission expires__________________

[ ] Personally known [ ] Produced Identification Type of Identification: _____________________________

CONFLICT OF INTEREST DISCLOSURE FORM

For purposes of determining any possible conflict of interest, all bidders must disclose if any Walton County employee(s), elected official(s), or if any of its agencies is also an owner, corporate officer, agency, employee, etc., of their business.

Indicate either “YES” (a county employee, elected official, or agency is also associated with your business), or “NO”. If yes, give person(s) name(s) and position(s) with your business.

YES NO

NAME(S) POSITION(S)

FIRM NAME:

BY (printed):

BY (signature):

TITLE:

ADDRESS:

PHONE #:

E-MAIL:

DATE:

W:\Board of County Commissioners\Legal Services\Legal\CONTRACTS\# - CONTRACT FORMS\# BID DOC FORMS\Compliance Documents REV 2-13-2018.doc