CV_012_CUF_Certification_Form.pdf
PDF 184 KB Posted
- Attached to
- 26LS0005 - Temporary Relief Physician Services
- Solicitation number
- 0000039962
- Issued by
- Los Angeles County, California
About this file
CV_012_CUF_Certification_Form Summary
This is a Commercially Useful Function (CUF) Certification Form issued by the California Department of Veterans Affairs for solicitation 26LS0005 regarding temporary relief physician services at the Veterans Home of California - Lancaster. Every certified Small Business (SB), Micro Business (MB), and Disadvantaged Veteran Business Enterprise (DVBE) that will perform an element of the work must complete this form. The form requires contractors to confirm their ability to execute a distinct element of the work, carry out contractual obligations through actual performance, management, or supervision, perform work normal to their business functions, and avoid excessive subcontracting beyond normal industry practices. Contractors must also demonstrate that their role is substantive rather than serving merely as a pass-through entity to create the appearance of SB/DVBE participation.
Responses of "No" to questions 1 through 3 or a "Yes" response to question 4 regarding excessive subcontracting will result in the quote being deemed non-responsive and disqualified. The form requires a written statement detailing the role, services, and goods the company will provide to satisfy commercially useful function requirements. All responses must be certified under penalty of perjury by the certified business owner or an authorized corporate representative, with signature, title, printed name, and date required on the form.
View the file
Other files
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| Sample_Insurance_Template.pdf | ||
| 26LS0005_-_Bid_Rate_Sheet.xlsx | XLSX spreadsheet | |
| DVBE_Program_Requirements.pdf | ||
| Contractor_Certification_Clauses__CCC_.pdf | ||
| IFB_Letter.pdf | ||
| STD_204.pdf | ||
| Iran_Contracting_Act.pdf | ||
| Bidders_Certification.pdf | ||
| DVBE_Declarations.pdf | ||
| California_Civil_Rights_Laws_Certification.pdf | ||
| STD_213__Sample_.pdf | ||
| Exhibits_A-E.pdf | ||
| GSPD-05-105_-_Bidder_Declaration.pdf | ||
| Non-Collusion_Declaration.pdf | ||
| Bidder_s_Checklist.pdf | ||
| Darfur_Contracting_Act_Certification.pdf |
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Text version
State of California Department of Veterans Affairs
COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM
CV 012 (REV. 08/2023) Page 1 of 2
Solicitation Number:
Every certified SB, MB & DVBE must complete this form if they will perform an element of the work.
1. CONTRACTOR NAME (Completing Form) "DOING BUSINESS AS" (DBA) NAME: OSDS REF # (Currently certified firms only): Expiration Date:
2. COMMERCIALLY USEFUL FUNCTIONS (CUF)
All certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code, Section 14837 (d)(4) (for SB) and Military and Veterans Code, Section 999(b)(5)(B) (for DVBE).
Please answer the following questions, as they apply to your company for the goods and services being acquired in this solicitation:
Mark all that apply: DVBE Small Business Micro Business
1 If awarded a contract, will your business be responsible for the execution of a distinct element of the resulting work? Yes No
2 If awarded a contract, will your business carry out the obligation of the contract by actually performing, managing, or supervising the work involved? Yes No
3 If awarded a contract, will you perform work that is normal for your business, service and functions? Yes No
4 If awarded a contract, will your business subcontract a portion of the work greater than would be expected by normal industry practices? Yes No
5 If awarded a contract, will your business role be limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation? Yes No
A response of "No" in questions 1-3 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.
3. WRITTEN STATEMENT
Provide a written statement below detailing the role, services and goods your company will provide to meet the commercially useful function requirement. At the State's option prior to award, you may be required to submit additional clarifying information
State of California Department of Veterans Affairs
CV 012 (REV. 08/2023) Page 2 of 2
AUTHORIZING SIGNATURE (REQUIRED)
The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.
AUTHORIZED REPRESENTATIVE SIGNATURE: TITLE:
PRINTED NAME: DATE:
State of California Department of Veterans Affairs
CV 012 (REV. 08/2023) Page 1 of 2 Every certified SB, MB & DVBE must complete this form if they will perform an element of the work.
1. CONTRACTOR NAME (Completing Form)
2. COMMERCIALLY USEFUL FUNCTIONS (CUF)
All certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code, Section 14837 (d)(4) (for SB) and Military and Veterans Code, Section 999(b)(5)(B) (for DVBE).
Please answer the following questions, as they apply to your company for the goods and services being acquired in this solicitation:
Mark all that apply:
If awarded a contract, will your business be responsible for the execution of a distinct element of the resulting work?
If awarded a contract, will your business carry out the obligation of the contract by actually performing, managing, or supervising the work involved?
If awarded a contract, will you perform work that is normal for your business, service and functions?
If awarded a contract, will your business subcontract a portion of the work greater than would be expected by normal industry practices?
If awarded a contract, will your business role be limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation?
A response of "No" in questions 1-3 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.
3. WRITTEN STATEMENT
State of California Department of Veterans Affairs
COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM
CV 012 (REV. 08/2023) Page 2 of 2
AUTHORIZING SIGNATURE (REQUIRED)
The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.
9.0.0.2.20101008.1.734229
| SolicitationNumber: 26LS0005 |
| DoingBusinessAs: |
| OSDSRefNumber: |
| ExpirationDate: |
| : |
| Yes: |
| No: |
| ProvideAWrittenStatement: |
| AuthorizedRepresentative: |
| Title: |
| PrintedName: |
| Date: |
File details come from the government source that posted it. Updated .