D-136(5)_RFP_Attachments_FINAL.pdf

Rev. July 2023

ATTACHMENT A: RESPONDER DECLARATIONS

The undersigned certifies, to the best of his or her knowledge and belief, that:

A. Response Contents. The information provided is true, correct, and reliable for purposes of evaluation for potential contract award. The submission of inaccurate or misleading information may be grounds for disqualification from the award as well as subject the Responder to suspension or debarment proceedings as well as other remedies available by law

B. Authorized Signature. This Declaration is signed by the appropriate person(s), with the authority to contractually bind the Responder, as required by applicable articles, bylaws, resolutions, minutes, and ordinances.

C. Non-Collusion Certification.

1. The Proposal has been arrived at by the Responder independently and has been submitted without collusion and without any agreement, understanding or planned common course of action with any other vendor designed to limit fair or open competition; and

2. The contents of the Response have not been communicated by the Responder or its employees or agents to any person not an employee or agent of the Responder and will not be communicated to any other individual prior to the due date and time of this Solicitation. Any evidence of collusion among Responders in any form designed to defeat competitive responses will be reported to the Minnesota Attorney General for investigation and appropriate action.

D. Organizational Conflicts of Interest. To the best of Responder’s knowledge and belief, and except as otherwise disclosed, there are no relevant facts or circumstances which could give rise to an organizational conflict of interest.

An organizational conflict of interest exists when, because of existing or planned activities or because of relationships with other persons,

1. a vendor is unable or potentially unable to render impartial assistance or advice to the State;

2. the vendor’s objectivity in performing the contract work is or might be otherwise impaired; or

3. the vendor has an unfair competitive advantage.

If after award, an organizational conflict of interest is discovered, an immediate and full disclosure in writing must be made to the State’s Chief Procurement Officer which must include a description of the action which the contractor has taken or proposes to take to avoid or mitigate such conflicts. If an organizational conflict of interest is determined to exist, the State may, at its discretion, cancel the contract. In the event the Contractor was aware of an organizational conflict of interest prior to the award of the contract and did not disclose the conflict to OSP, the State may terminate the contract for default. Organizational conflicts of interest terms apply to any subcontractors for this work.

E. Certification Regarding Lobbying. For State of Minnesota Contracts and Grants over $100,000, the undersigned certifies, to the best of his or her knowledge and belief that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, Disclosure Form to Report Lobbying in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into and is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. 1352.

Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

F. Copyrighted Material Waiver. By signing its Response, the Responder certifies that it has obtained all necessary approvals for the reproduction and distribution of the contents of its response.

G. Diverse Spend Reporting. The Sample Contract contains a clause for Diverse Spend Reporting. When this clause applies, Contractor will be required to register in a free portal to report diverse spend.

Please see Diverse Spend Reporting Frequently Asked Questions for additional information.

By signing this form, Responder acknowledges and certifies compliance with all applicable requirements indicated above.

Company Name:

Signature:

Printed Name:

Title:

Date:

Phone Number:

Email Address:

https://osp.admin.mn.gov/sites/osp/files/2022-11/viva_diverse_spend_reporting_faq.pdf

ATTACHMENT B: EXCEPTIONS TO STATE’S TERMS AND CONDITIONS

The State presumes a responder agrees to the terms and conditions of this solicitation unless a responder takes specific exception to one or more of the conditions on this form.

The State reserves the right to reject, negotiate, or accept any exception listed to the State’s terms and conditions (including those found in the attached Sample Contract).

INSTRUCTIONS: A responder must explicitly list all exceptions to State’s terms and conditions, if any (including those found in the attached Sample Contract). Reference the clause number and page number of the State's term and condition for each of a responder’s exceptions. If no exceptions exist, state "NONE" specifically on the form below.

Whether or not exceptions are taken, the Responder must sign and date this form and submit it as part of their response. (Add additional pages if necessary.)

Clause and Page Number Suggested Change to Clause Explanation or Justification

By signing this form, I acknowledge that the above-named responder accepts, without qualification, all terms and conditions stated in this solicitation (including the sample contract) except those clearly outlined as exceptions above.

This acknowledgement includes acceptance of the section of the Sample Contract, Exhibit A, titled “Contractor’s Documents.”

Signature:

Printed Name:

Title:

Date:

ATTACHMENT C: COST DETAIL

1. Cost Proposal. Responders should review Exhibit D of the Sample Contract for additional pricing terms related to the Cost Proposal.

1.1 Responders must download and use the Exhibit D Price Schedule attached to this Solicitation. The Price Schedule must be completed by the Responder and uploaded with the response. If pricing is not returned with your solicitation response, your response may be rejected. Failure to use the Price Schedule may be cause for rejection. Responders are highly encouraged to submit pricing for all relevant line items for each product and/or service being proposed. The State reserves the right to reject responses that do not supply sufficient line items.

1.2. For the purposes of evaluation, if a responder leaves blank or enters "No Bid" into a line item blank the State may enter the highest price received from all responders for that line item. If responder is entering a no cost that will be considered as a zero cost, $0.00 and will not be considered a “No Bid”.

1.3. Responders may offer dental laboratory services for one location, multiple, or all locations. There is no requirement to provide Statewide services. If a responder chooses to submit an offer for a particular location, they must enter for all applicable items. For locations the responder does not want to provide services for, the responder should enter no bid or N/B.

1.4. If additional related services are available through the responder, the responder shall provide those items on Exhibit D Price Schedule. The additional related services must be in accordance with all terms, conditions, and specifications contained in this solicitation. If approved by the State, the related services will be added to final contract.

1.5. Responder must complete the turn around time section within Exhibit D Price Schedule.

2. Installation Services. Installation services are NOT included in this contract.

3. Alterations or Erasures. The State reserves the right to reject a response containing an alteration or erasure of any price used to determine the lowest responsible responder unless the alteration or erasure is done in a manner that is clear and authenticated by an authorized representative of the Responder. An acceptable way to make an alteration or erasure is to cross out the price, print the correction in ink adjacent to it, and have an authorized representative of the Responder initial and date that correction.

ATTACHMENT D: RESPONDER FORMS

STATE OF MINNESOTA

VETERAN-OWNED PREFERENCE FORM

Unless a greater preference is applicable and allowed by law, in accordance with Minn. Stat. §16C.16, subd. 6a, the Commissioner of Administration will award up to a 12% preference on state procurement to certified small businesses that are majority owned and operated by veterans.

Veteran-Owned Preference Requirements - See Minn. Stat. § 16C.19(d):

1) The business has been certified by the Office of Equity in Procurement (OEP) as being a veteran-owned or service-disabled veteran-owned small business.

or

2) The principal place of business is in Minnesota AND the US Small Business Administration verifies the business as being a veteran-owned or service-disabled veteran-owned small business under Public Law 109- 461 and Code of Federal Regulations, title 13, part 128.

Statutory requirements and appropriate documentation must be met by the solicitation response due date and time to be awarded the veteran-owned preference. For Bids, the preference applies only to the first $2,000,000.

Claim the Preference

By signing below I confirm that:

My company is claiming the veteran-owned preference afforded by Minn. Stat. § 16C.16, subd. 6a. By making this claim, I verify that:

• The business has been certified by the Office of Equity in Procurement (OEP) as being a veteran-owned or service-disabled veteran-owned small business.

or

• My company’s principal place of business is in Minnesota and the US Small Business Administration verifies my company as being a veteran-owned or service-disabled veteran-owned small business.

Name of Company: _____________________________ Date: ________________________________

Authorized Signature: _____________________________ Telephone: ________________________________

Printed Name: _____________________________ Title: ______________________________________

Sign and return this form with your solicitation response to claim the veteran-owned preference.

Workforce and Equal Pay Declaration Page

This form is required for all businesses executing government contracts under the following:

Select one:

☐ Businesses executing a contract with State or Metropolitan agencies in excess of $100,000 (Workforce Certificate) and if applicable $500,000 (Equal Pay Certificate)

☐ Businesses executing a contract with University of Minnesota for general obligation bond funded capital projects in excess of $100,000 (Workforce Certificate) and if applicable $500,000 (Equal Pay Certificate)

☐ Businesses executing a contract with Political Subdivisions for general obligation bond funded capital projects in excess of $250,000 (Workforce Certificate) and if applicable $1,000,000 (Equal Pay Certificate)

Select all that apply:

We are a Certificate holder:

☐ Workforce Certificate under the name: _________________________________________________________ ☐ Equal Pay Certificate under the name: __________________________________________________________

We are applying/have applied for the following certificate(s):

☐ Workforce Certificate Application date (MM/DD/YYYY): ____________________ ☐ Equal Pay Certificate Application date (MM/DD/YYYY): ____________________

We have not applied for one or both certificates:

☐ Our Company does not yet have a Workforce Certificate or Equal Pay Certificate. We acknowledge that a

Workforce and, if applicable, Equal Pay Certificate, or approved exemption by MDHR is required before a contract can be executed.

We are Exempt:

☐ We attest to MDHR that we have not employed 40 or more employees on a single day during the prior 12 months in Minnesota or the state in where we have our primary place of business. MDHR may request the names of our employees during the previous 12 months, the date of separation, if applicable, and the current employment status and count.

Business Information

Vendor/Supplier ID Business Name Name of Contracting Agency

Authorized Signatory Name Title Date

Signature Email Phone

For assistance with this form, email the Minnesota Department of Human Rights Compliance.MDHR@state.mn.us https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/

ATTACHMENT E: ADDITIONAL INFORMATION

1. Contractor’s Contact Information. Provide the contact information for the representative responsible for the management of the contract and the representative receiving purchase orders.

Vendor’s Legal Name

Address

Contact Person and Title (Contract)

Email Address

Telephone Number

Contact Person and Title (PO Order)

Email Address

Telephone Number

Designated Customer Contact Responsible for Casework Follow-up & General Questions

Email Address

Telephone Number

2. Prompt Pay Discount. What prompt pay discounts do you offer? Select all that apply, if “other,” specify terms in the comment section below:

□ 1% in 30

□ 2% in 30

□ 3% in 30

□ 1% in 10, Net 30

□ 2% in 10, Net 30

□ 3% in 10, Net 30

□ 5% in 10, Net 30

□ Other

□ 1% in 15, Net 30

□ 2% in 15, Net 30

□ 3% in 15, Net 30

□ 1% in 20, Net 30

□ 2% in 20, Net 30

□ 3% in 20, Net 30

□ Net 30

3. Sample Invoice and Quote. Did you submit a sample invoice and quote with your response that complies with the requirements listed in Exhibit D, Supplement 1?

Yes ______ No ______

4. Subcontracting. Will you be subcontracting any of the services? Mark either yes or no below. If yes, indicate what services.

Yes____ , the following services will be subcontracted: _________________

No _ ___

Rev. 9.01.2021

5. Experience. Responders must provide the number of consecutive years they have been in business and have a minimum of at least (3) three years’ experience providing similar requirements as those referenced in Exhibit C:

Specifications, Duties, and Scope of Work under the Sample Contract and Exhibits.

5.1 Does your business have at least 3 years of providing product with similar requirements as found in Exhibit C:

Specifications, Duties and Scope of Work?

Yes ______ No ______

5.2 Indicate your company’s years of experience. ____________Years.

6. Certification Verification. If you lab is registered and has a license, upload a copy with your response in SWIFT.

6.1 Is your dental lab listed and registered with the Minnesota Board of Dentistry? Mark either yes or no below.

Yes ______ No ______

6.2 Provide the following information to verify your license:

6.2.1 License/Registration Type___ ___

6.2.2 Dental Lab Name__ _

6.2.3 License/Registration Number __ _

6.2.4 City _ _

6.3 Products. Are all products offered under your response American Dental Association (ADA) certified? Mark either yes or no below.

Yes ______ No ______

7. Shipping. Is your dental lab capable of shipping and providing related shipping materials to safely and accurately deliver ordered products found under the Sample Contract and Exhibits, Exhibit C: Specifications, Duties and Scope of Work? Mark either yes or no below.

Yes ______ No ______ https://bodgl.hlb.state.mn.us/GLSuite_MNBOD_PROD/GLSuiteWeb/Clients/mnbod/Public/Licensee/LicenseeSearch.aspx

6. Business Information