D140228SB Attachment B- Price Form.docx
DOCX document 24 KB Posted
- Solicitation number
- BPM055102
- Issued by
- Maryland
About this file
This is a Price Form and Small Business Reserve Affidavit for IFB D140228SB issued by the Maryland Department of Transportation State Highway Administration (MDOT SHA) for District 1 mill and pave patching services. The solicitation requests bids for permanent patching work using Hot Mix Asphalt at various locations in Dorchester and Wicomico Counties. Two line items are specified: 50 tons of 9.5 MM Hot Mix Asphalt patching and 50 tons of 12.5 MM Hot Mix Asphalt patching, for a total estimated quantity of 100 tons. Bidders must provide unit prices per ton for each line item, with the total cost calculated by multiplying the vendor's price per ton by the estimated quantity. The bid price must include all costs associated with the work, including mobilization, removal of existing material, Hot Mix Asphalt placement, overhead, tools, transportation, equipment, materials disposal, tax, labor, fuel, and profits.
The price form explicitly states that MDOT SHA is exempt from Maryland Sales and Use Taxes and Federal Excise Taxes, and bidders must not include sales tax in their bid prices. This is a Small Business Reserve procurement designated for certified small businesses in Maryland. Bidders must complete the Small Business Qualification Affidavit, affirming under penalty of perjury that their firm meets the qualifications for small business certification as of the bid submission date and committing to notify the Procurement Officer within 30 days if circumstances change during contract performance. False information or failure to maintain small business status may result in bid rejection, contract termination, suspension and debarment, or criminal prosecution.
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| File | Type | Posted |
|---|---|---|
| D140228SB IFB Patching.docx | DOCX document |
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Text version
PRICE FORM
& SBR AFFIDAVIT– ATTACHMENT-B D140228SB Pg 1
This form is to be completed in its entirety, is not to be altered in any way and is to contain only the price or prices stipulated on the form.
SHA IFB No.: D140228SB
| Column A |
| Column B |
| Column C |
| Column D |
(Column B x Column C)
| Item / Description |
| Estimated Quantity |
| Vendor’s Price per Ton |
| Vendor’s Total Cost |
| Line #1- Permanent Patching with 9.5 MM Hot Mix Asphalt at various locations in Dorchester and Wicomico Counties. Total bid cost per ton based on the specification and scope of work and includes mobilization, removal of existing material, Hot Mix Asphalt Placement, overhead, tools, transportation, equipment cost, materials disposal cost, tax, labor, fuel, profits etc.) |
| 50 Ton |
| $ /per Ton |
| $_____________ |
| Line #1- Permanent Patching with 12.5 MM Hot Mix Asphalt at various locations in Dorchester and Wicomico Counties. Total bid cost per ton based on the specification and scope of work and includes mobilization, removal of existing material, Hot Mix Asphalt Placement, overhead, tools, transportation, equipment cost, materials, disposal cost, tax, labor, fuel, profits etc.) |
| 50 Ton |
| $ / per Ton |
| $______________ |
TOTAL SUM AMOUNT (Sum of Column D items)
NOTE:
MDOT SHA, is exempt from Maryland Sales and Use Taxes by Exemption Certificate Number 3000256-3 and from Federal Excise Taxes by Exemption Number 52-73-0358K. Do not include sales tax in bid prices.
PRICE FORM
& SBR AFFIDAVIT– ATTACHMENT-B D140228SB Pg 2
For the Contractor:
Company Name & Address
City State Zip
Phone _____________________ Fax ______________________Email _____________________________________
Representing the above Company _______________________________
SIGNATURE
Print Name & Title
SOCIAL SECURITY NO. OR
FEDERAL TAX ID NO. _________________________ DATE: ___________________
Maryland Department of Transportation
SMALL BUSINESS CONTRACT AFFIDAVIT
********** PROVIDING FALSE INFORMATION **********
Anyone providing false information to the State of Maryland in connection with obtaining or attempting to obtain a contract under Small Business Reserve or Preference procurement may be subject to the following:
1. A determination by a Procurement Officer that a bidder/offeror is not responsible;
2. A determination that a contract entered into is void or voidable under § 11-204 of the State Finance and Procurement Article of the Annotated Code of Maryland;
3. Suspension and debarment under Title 16 of the State Finance and Procurement Article;
4. Criminal prosecution for procurement fraud (§ 11-205.1 of the State Finance and Procurement Article), perjury, or other crimes; and
5. Other actions permitted by law.
********** FAILURE TO MEET MINIMUM QUALIFICATIONS **********
Any Bidder or potential bidder failing to meet the qualifications of a "small business" specified in § 14-501(c) of the State Finance and Procurement Article will be ineligible to participate in a procurement designated for a Small Business Reserve under § 14-504 or Small Business Preference under § 14-206 - 207. Any person or company bidding on Small Business Reserve or Preference procurement and not qualifying as a small business under § 14-501(c) will have its bid or offer rejected on the ground that the bidder is not responsible.
I AFFIRM THAT:
| To the best of my knowledge, information, and belief, as of the date of submission of this Bid/Proposal, | ||
| (name of firm) meets the qualifications for certification as a Small Business in Maryland. I further affirm that, if for any reason during the term of the contract | (name of firm) no longer meets the qualifications of certification as a Small Business in Maryland, I will notify the Procurement Officer within 30 days. I agree that a failure to so notify the Procurement Officer of this change in circumstances may result in this contract being terminated for default. |
I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE CONTENTS OF THIS AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF.
SMALL BUSINESS QUALIFICATION NUMBER ___________________
Date of Most Recent Qualification__________________________________
DATE:_____________
BY:_____________________________________________________________
Signature (Authorized Representative and Affidavit)
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