Contractor_Responsibility_Form.pdf

CONTRACTOR RESPONSIBILITY INFORMATION (2 pages)

The Apparent Low Bidder must complete and submit this form by 4:00 p.m. local time on the fifth (5th) full business day after bid opening and notification of Apparent Low Bidder.

A.R.S. Title 34 requires an agent to contract with the lowest responsible bidder. To be deemed responsible, a contractor must have adequate financial resources, the ability to meet delivery/performance schedules, a satisfactory performance record, demonstrated integrity/ethics, adequate experience, technical expertise and quality controls, and access to necessary equipment. The City of Tucson has processes in place to ensure that contractors engaged with the City meet required standards for award of contract. These include reviews of bids and inquiries to the State of Arizona Registrar of Contractors (AZROC), as well as review of the information requested below. Contract Officers may solicit additional information from or about the Contractor.

Please complete the following:

Company Name (“Contractor”):_____________________________________________________________

Project Name and Solicitation Number: ___________________________________________________

Contractor certifies, to the best of its knowledge and belief, that—

Contractor and/or any of its Principals—

(A) Are [___] are not [___] presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any agency.

(B) Have [___] have not [___], within the three-year period preceding this certification, 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) contract or subcontract; violation of Federal or State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiving stolen property.

Certification of Prior Contract Performance

Please respond “Yes” or “No” as applicable for the following questions, for any “Yes” responses, provide additional detail. In the last three (3) years -

Has Contractor paid liquidated damages on any contracts? Yes [ ] No [ ]

Has Contractor been terminated on a project for poor performance? Yes [ ] No [ ]

Has a claim been made against Contractor for improper, delayed or Yes [ ] No [ ] non-compliant work or failure to meet warranty obligations?

Has a formal legal action been filed against Contractor Yes [ ] No [ ] asserting that Contractor failed to make payments to anyone? If so, describe the outcome or current status.

Has a successful claim been made against a Bid, Performance, or Payment Bond supplied by Contractor in connection with a project? Yes [ ] No [ ]

260236- Blacklidge Drive Bicycle Boulevard- FHWA

Provide current Experience Modification (EMod) Rating: _______ (Additional documentation may be requested)

Describe three (3) representative projects completed by Contractor that are similar to the scope of work for this Project. Include the following information for each of the three (3) projects:

• Name and location of the Project

• Owner References including contact information. The City reservices the right to contact the references provided.

• Description of work performed by Contractor

• Description of any specialty subcontractors and their scope of work

• The Total Project Value, including the original amount and final amount and a description of Change Orders, if applicable.

• The Original Construction Schedule and Actual Construction Schedule, including a description of discrepancies, if applicable.

Is Contractor currently, or do you have reason to expect Contractor will be subject to legal action or bankruptcy proceedings that could materially impact Contractor’s ability Yes [ ] No [ ] to perform the Project?

List current workload and % of availability of resources (personnel and equipment) that you intend to use to complete the Project by the fixed delivery date for the Project. It may be advantageous to identify key personnel and equipment availability by date, if not currently available, in order to support a claim that work can be completed in the time allotted.

NOTE: Additional pages may be attached to support or explain any item on this certification. Failure to provide sufficient explanation of any item on this certification may result in the City being unable to reach a favorable responsibility determination.

By signing below, you acknowledge that this certification will be considered in connection with a determination of Contractor’s responsibility, that the obligation to demonstrate responsibility is on Contractor, and that, although the City reserves the right to make additional inquiries, it is not obligated to do so in the absence of sufficient supporting information. Failure to furnish a certification or provide any additional information requested the City of Tucson Contract Officer may result in Contractor being found Non-Responsible.

This certification is a material representation of fact upon which the City will rely when making this award. If it is later determined that Contractor knowingly made an erroneous factual statement in this certification, the City may, in addition to any other available remedies, terminate the contract resulting from this solicitation.

SIGNATURE: DATE:

PRINTED NAME & TITLE: