Construction Documents.pdf

West Virginia Ethics Commission

Disclosure of Interested Parties to Contracts

Pursuant to W. Va. Code § 6D-1-2, a state agency may not enter into a contract, or a series of related contracts, that has/have an actual or estimated value of $1 million or more until the business entity submits to the contracting state agency a Disclosure of Interested Parties to the applicable contract. In addition, the business entity awarded a contract is obligated to submit a supplemental Disclosure of Interested Parties reflecting any new or differing interested parties to the contract within 30 days following the completion or termination of the applicable contract.

For purposes of complying with these requirements, the following definitions apply:

"Business entity" means any entity recognized by law through which business is conducted, including a sole proprietorship, partnership or corporation, but does not include publicly traded companies listed on a national or international stock exchange.

"Interested party" or "Interested parties" means:

(1) A business entity performing work or service pursuant to, or In furtherance of, the applicable contract, including specifically sub-contractors;

(2) the person(s) who have an ownership interest equal to or greater than 25% in the business entity performing work or service pursuant to, or In furtherance of, the applicable contract. (This subdivision does not apply to a publicly traded company); and

(3) the person or business entity, if any, that served as a compensated broker or intermediary to actively facilitate the applicable contract or negotiated the terms of the applicable contract with the state agency.

(This subdivision does not apply to persons or business entities performing legal services related to the negotiation or drafting of the applicable contract.)

"State agency" means a board, commission, office, department or other agency In the executive, judicial or legislative branch of state government, including publicly funded Institutions of higher education:

Provided, that for purposes of W. Va. Code § 6D-1-2, the West Virginia Investment Management Board shall not be deemed a state agency nor subject to the requirements of that provision.

The contracting business entity must complete this form and submit it to the contracting state agency prior to contract award and to complete another form within 30 days of contract completion or termination.

This form was created by the State of West Virginia Ethics Commission, 210 Brooks Street, Suite 300, Charleston, WV 25301-1804. Teiephone: (304)558-0664; fax: (304)558-2169; e-maii: eff?/'cs@wv.gov;

website: www.ethics. wv.aov.

Revised June 8, 2018

WV-72

Approved / Revised 08/01/15

State of West Virginia Purchasing Division

CERTIFIED DRUG-FREE WORKPLACE REPORT COVERSHEET

In accordance with West Virginia Code § 21-1 D-7b, no less than once per year, or upon completion of the project, every contractor shall provide a certified report to the public authority which let the contract. That report must include each of the items identified below in the Required Report Content section.

Instructions: Vendor should complete this coversheet, attach it to the required report, and submit it to the appropriate location as follows: For contracts more than $25,000, the report should be mailed to the West Virginia Purchasing Division at 2019 Washington Street East, Charleston, WV 25305. For contracts of $25,000 or less, the vendor should mail the report to the public authority issuing the contract.

Contract Identification:

Contract Number:

Contract Purpose:

Agency Requesting Work:

Required Report Content: The attached report must include each of the items listed below. The vendor should check each box as an indication that the required Information has been included in the attached report.

□ Information indicating the education and training service to the requirements of West Virginia Code § 21-1D-5 was provided;

□ Name of the laboratory certified by the United States Department of Health and Human Services or its successor that performs the drug tests;

□ Average number of employees in connection with the construction on the public improvement;

□ Drug test results for the following categories including the number of positive tests and the number of negative tests: (A) Pre-employment and new hires; (B) Reasonable suspicion; (C) Post-accident; and

(D) Random.

Vendor Contact Information:

Vendor Name: Vendor Telephone:

Vendor Address: Vendor Fax:

Vendor E-Mail:

WV-73

Approved / July 7, 2017

State of West Virginia

DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT

West Virginia Code §21-lD-5

STATE OF WEST VIRGINIA,

COUNTY OF TO-WIT:

after being first duly sworn, depose and state as follows:

1. I am an employee of

2. I do hereby attest that

(Company Name)

(Company Name) and, maintains a written plan for a drug-free workplace policy and that such plan and policy are in compliance with West Virginia Code §21-1D.

The above statements are sworn to under the penalty of perjury.

Printed Name:

Signature:

Title:

Company Name:.

Date:

Taken, subscribed and sworn to before me this .day of

By Commission expires

(Seal)

(Notary Public)

Rev. July 7, 2017

BID BOND PREPARATION INSTRUCTIONS

RFQ/RFP#.

AGENCY f A) m.

(A) WV State Agency (Stated on Page 1 "Spending Unit")

(B) Request for Quotation Number (upper right comer of page #1)

(C) Your Business Entity Name (or Individual Name if Sole Proprietor)

(D) City, Location of your Company

(E) State, Location of your Company

(F) Surety Corporate Name

(G) City, Location of Surety

(H) State, Location of Surety

(I) State of Surety Incorporation

(J) City of Surety's Principal Office

(K) Minimum amount of acceptable bid bond is

5% of total bid. You may state "5% of bid" or a specific amount on this line in words.

(L) Amount of bond in numbers

(M) Brief Description of scope of work

(N) Day of the month

(0) Month

(P) Year

(Q) Name of Business Entity (or Individual Name if Sole Proprietor)

(R) Seal of Principal

(S) Signature of President, Vice President, or

Authorized Agent

(T) Title of Person Signing for Principal

(U) Seal of Surety

(V) Name of Surety

(W) Signature of Attomey in Fact of the Surety

NOTE I: Dated Power of Attorney with Surety Seal must accompany this bid bond.

as Principal, and _

(HL

Bid Bond

KNOW ALL MEN BY THESE PRESENTS, That we, the undersigned,

(C) of (D) , (EL iEL of iSL of the State of M.

a corporation organized and existing under the laws . with its principal office in the City of

(J) , as Surety, are held and firmly bound unto The State of West Virginia, as Obligee, in the penal sum of (IQ iU. _) for the payment of which, well and truly to be made.($_ we jointly and severally bind ourselves, our heirs, administrators, executors, successors and assigns.

The Condition of the above obligation is such that whereas the Principal has submitted to the Purchasing Section of the Department of Administration a certain bid or proposal, attached hereto and made a part hereof to enter into a contract in writing for

NOW THEREFORE

(a) If said bid shall be rejected, or

(b) If said bid shall be accepted and the Principal shall enter into a contract in accordance with the bid or proposal attached hereto and shall furnish any other bonds and insurance required by the bid or proposal, and shall in all other respects perform the agreement created by the acceptance of said bid then this obligation shall be null and void, othenvise this obligation shall remain in full force and effect. It is expressly understood and agreed that the liability of the Surety for any and all claims hereunder shall, in no event, exceed the penal amount of this obligation as herein stated

The Surety for value received, hereby stipulates and agrees that the obligations of said Surety and its bond shall be in no way impaired or affected by any extension of time within which the Obligee may accept such bid; and said Surety docs hereby waive notice of any such extension.

WITNESS, the following signatures and seals of Principal and Surety, executed and sealed by a proper officer of Principal and Surety, or by Principal individually if Principal is an individual, the _(N) .day of fOl , 20 fP) .

Principal Seal iOL

(R) By_

(Name of Principal)

(S) (Must be President, Vice President, or

Duly Authorized Agent) ilL Title

Surety Seal (U) m (Name of Surety)

Attomey-in-Fact

IMPORTANT - Surety executing bonds must be licensed in West Virginia to transact surety insurance, must affix its seal, and must attach a power of attorney with its seal affixed.

REV. 6/2013