DCKA-2021-B-0053_Att2.pdf

DCKA – 2021-B-0053

Thermoplastic Pavement Marking Citywide Project

SECTION K (ATTACHMENTS)

K.1

BID BOND

Office of Administrative Services Department of Public Works

BID BOND

(CONSTRUCTION)

Date Bond Executed (Must Not be later Than Bid Opening Date)

Bid Bond Period Ninety (90) Calendar Days TYPE OF ORGANIZATION (“X”) After Bid Opening

□ INDIVIDUAL

□ PARTNERSHIP

PRINCIPAL Name(s) and Address(es) □ JOINT VENTURE □ CORPORATION

STATE OF INCORPORATION

1. PENAL SUM OF BID

AMOUNT NOT TO EXCEED

SURETY (IES) Name(s) and Address(es) MILLION(S) THOUSAND(S) HUNDRED(S) CENT(S)

5%

OF BID

2. BID IDENTIFICATION

BID OPENING DATE INVITATION NO.:

KNOW ALL MEN BY THE PRESENTS. That we, the Principal and Surety(ies) hereto, are firmly bound to the District of Columbia Government, a municipal corporation, hereinafter called the District, in above penal sum for the payment of which we bind ourselves, our heirs, executors and successors, jointly and severally Provided, That, where the Sureties are corporations acting as co-sureties, we, the Sureties, bind ourselves in such sum “jointly and severally” only for the purpose of allowing a joint action or actions against any or all of us, and for all other purposes each Surety binds itself, jointly and severally with the Principal, for the payment of such sum only as is set forth opposite the name of such Surety, but if no limit of liability is indicated, the limit of liability shall be the full amount of the penal sum.

THE CONDITION OF THIS OBLIGATION IS SUCH, that whereas the Principal has submitted the bid identified above.

NOW, THEREFORE, if the Principal shall not withdraw said bid within the period specified therein after the opening of the same, or, if no period be specified, within ninety (90) calendar days after said opening, and shall within the period specified therefore, or, if no period be specified, within ten (10) days after being called upon to do so, furnish Performance & Payment bonds with good and sufficient surety, as may be required, for the faithful performance and proper fulfillment of the Contract, and for the protection of all persons supplying labor specified, or the failure to furnish such bond within the time specified, if the Principal shall pay the District the difference between the amount specified in said bid and the amount for which the District may procure the required work and/or supplies, if the latter amount be in excess of the former, then the above obligations shall be void and of no effect, otherwise to remain in full force and virtue.

Each Surety executing this bond hereby agrees that its obligation shall not be impaired by extension(s) of time for acceptance of the bid that the Principal may grant to the District, notice of which extension(s) to the Surety(ies) being hereby waived; provided that such waiver of notice shall apply only with respect to extensions aggregating not more than ninety calendar days in addition to the period originally allowed for acceptance of the bid.

IN WITNESS WHEREOF, the Principal and Surety(ies) have executed this bid bond and have affixed their seals on the date set forth above.

PRINCIPAL

3. Signature 1. Attest

Seal

Corporate

Name & Title (Typed) Name & Title (Typed) Seal

2. Signature 2. Attest

Name & Title (Typed) Name & Title (Typed) Seal

Form No. DC 2640-5

PRINCIPAL (Continued)

CERTIFICATE AS TO CORPORATION

I, certify that I am Secretary of the Corporation named as Principal herein, that who signed this bond on behalf of the Principal was then

Of said corporation; that I know this signature, and his signature thereto is genuine; that said bond was duly signed and sealed for and on behalf of said corporation by authority of its governing body, and is within the scope of its corporate powers.

Secretary of Corporation

SURETY(IES)

1. Name & Address (typed) State of

Inc.

Liability Limit

Signature of Attorney-In-Fact Attest (Signature)

Name & Address (typed) Name & Address (Typed)

2. Name & Addressed (typed) State of Inc.

Liability Limit

Signature of Attorney-In-Fact Attest (Signature)

Name & Address (typed) Name & Address (typed)

4. INSTRUCTIONS

1. This form shall be used whenever a bid guaranty is required in connection with construction, alteration and repair work.

2. Corporation’s name should appear exactly as it does on Corporate Seal and inserted in the space designated “Principal” on the face of this form. If practicable, bond should be signed by President or Vice President; if signed by other official, evident of authority must be furnished. Such evidence should be in the form of an Extract of Minutes of a Meeting of the Board of Directors, or Extract of Bylaws, certified by the Corporate Secretary, or Assistant Secretary and Corporate Seal affixed thereto. CERTIFICATE AS TO CORPORATION must be executed by Corporate Secretary, or Assistant Secretary.

3. Corporations executing the bond as sureties must be among those appearing on the US Treasury Department’s list of approved sureties and must be acting within the limitations set forth therein, and shall also be listed with the “Insurance Administration, Department of Consumer and Regulatory Affairs”, to do business in the District of Columbia. The surety shall attach hereto an adequate Power-of-Attorney for each representative signing the bond.

4. Corporations executing the bond shall affix their Corporate Seals. Individuals shall sign full first name, middle initial and last name opposite the work “seal”, two witnesses must be supplied, and their addresses, under the word “attest”.

If executed in Maine or New Hampshire, an adhesive shall be affixed.

5. Names of partners must be set out in body or bond form, with the recital that they are partners composing a firm, naming it, and all members of the firm shall execute the bond as individuals. Each signature must be witnessed by two persons and addresses supplied.

K.2

BID FORM

Undersigned acknowledges receipt of the following addenda. Failure to acknowledge receipt of all addenda may result in rejection of bid.

BID FORM

(CONSTRUCTION CONTRACT)

Read Instructions to Bidders (See Standard Contract Provisions as amended)

Invitation No.:

Issue Date:

TO: CONTRACTING OFFICER, GOVERNMENT OF THE DISTRICT OF COLUMBIA

In compliance with above Invitation, the undersigned proposes to furnish all plant, labor and materials and perform required work per provisions as set forth in the Standard Contract Provisions, as amended, specifications, addenda, drawings, and at the prices named in the Schedule of Prices for:

PROJECT TITLE: Thermoplastic Pavement Marking Citywide Project

The undersigned agrees that if he is awarded the Contract within 90 calendar days after bid opening date and he is notified thereof, he will within 10 days after the prescribed forms are forwarded for execution, or within any authorized extension of time, execute and deliver a Contract on Form No. DC 2640-6 and furnish performance and payment bonds on Form No. DC 2640-7 and Form No. DC 2640-8 with good and sufficient survey; and that if he falls or refuses, required bid guaranty shall be applied as specified in Instructions to Bidders.

Addendum No. 1 2 3 4 5 6 7

Received

Enclosed is bid guaranty consisting of 5% of the total bid Bid Bond Certified Check Other Name of bidder must be shown in full if an individual; and if a partnership, full names of all partners must be shown. If bidder is a corporation, impress corporate seal and furnish name of State where incorporated. If joint venture, all parties must sign.

Bidder represents that he operates as an individual, joint venture, corporation Incorporated in State of Telephone No.

Name of Bidder (Type or print) Corporate Seal

DUNS or RUBS NO Business Address (Type or print)

By (Signature in ink) Attest

Title of Person Signing Title of Person Attesting

Bid, guaranty, etc., must be marked and addressed as follows:

Invitation No.:

To be opened (date): At

Address as follows:

Office of Contracting and Procurement Bid Room 55 M Street SE 4th Floor Washington, DC 20003

Form No. DC 2640-13 P-4745 J-3617-74 Oct. 1973

K.3

TAX CERTIFICATE AFFIDAVIT

GOVERNMENT OF THE DISTRICT OF COLUMBIA

Office of the Chief Financial Officer

Office of Tax and Revenue

TAX CERTIFICATION AFFIDAVIT

THIS AFFIDAVIT IS TO BE COMPLETED ONLY BY THOSE WHO ARE REGISTERED TO CONDUCT BUSINESS IN

THE DISTRICT OF COLUMBIA.

Date

Name of Organization/Entity Business Address (include zip code) Business Phone Number(s)

Principal Officer Name and Title Square and Lot Information Federal Identification Number Contract Number Unemployment Insurance Account No.

"I hereby authorize the District of Columbia, Office of the Chief Financial Officer, Office of Tax and Revenue;

consent to release my tax information to an authorized representative of the District of Columbia agency from which I am seeking to enter into a contractual relationship. I understand that the information released under this consent will be limited to whether or not I am in compliance with the District of Columbia tax laws and regulations as of the date found on the government request. I understand that this information is to be used solely for the purpose of determining my eligibility to enter into a contractual relationship with a District of Columbia agency. I further authorize that this consent be valid for one year from the date of this authorization."

I hereby certify that I am in compliance with the applicable tax filing and payment requirements of the District of Columbia.

The Office of Tax and Revenue is hereby authorized to verify the above information with the appropriate government authorities. The penalty for making false statements is a fine not to exceed $5,000.00, imprisonment for not more than 180 days, or both, as prescribed by D.C. Official Code § 47-4106.

Signature of Authorizing Agent Title

Office of Tax and Revenue, PO Box 37559, Washington, DC 20013

K.4

FHWA BUY AMERICAN CERTIFICATION

INVITATION NO.:

PROJECT NAME: Thermoplastic Pavement Marking Citywide Project

FHWA BUY AMERICA

23 CFR.635.410(b)

Certification of Compliance with FHWA Buy America Requirements

In accordance with 23 CRF 635.410(b), the Contractor agrees that only steel or iron materials manufactured in the United States will be used for permanent incorporation on the Project.

To be considered domestic, all steel and iron used and all products manufactured from steel and iron must be produced in the United States and all manufacturing processes, including application of a coating, for these materials must occur in the United States. Coating includes all processes, which protect or enhance the value of the material to which the coating is applied. This requirement does not preclude a minimal use of foreign steel and iron materials, provided the cost of such materials does not exceed 0.1 percent of the Contract Price.

Company Name Title Signature Date

FHWA Buy America Certification 2017

K.5

PAST PERFORMANCE FORM

District of Columbia Department of Transportation

PAST PERFORMANCE FORM

Solicitation:

Project Description: Thermoplastic Pavement Marking Citywide Project

Name of Bidder:

Identify your 3 most recent projects of similar scope and size and include a reference with personal knowledge of your performance on the project and contact information. By submitting this form, you acknowledge and agree that the Contracting Officer may contact the references directly to discuss past performance.

Project Description Dates of Performance

Contract Amount

Name of Reference:

Title:

Company:

Email Address:

Phone Number:

Company:

Company:

DDOT Past Performance Form 06.14.17

K.6

BIDDER OFFEROR CERTIFICATE

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BIDDER/OFFEROR CERTIFICATION FORM

COMPLETION

The person(s) completing this form must be knowledgeable about the bidder's/offeror's business and operations.

RESPONSES

Every question must be answered. Each response must provide all relevant information that can be obtained within the limits of the law. Individuals and sole proprietors may use a Social Security number but are encouraged to obtain and use a federal Employer Identification Number (EIN). Provide any explanation at the end of the section or attach additional sheets with numbered responses. Include the bidder's/offeror's name at the top of each attached page.

GENERAL INSTRUCTIONS

This form contains four (4) sections. Section I concerns the bidder's/offeror's responsibility; Section II includes additional required certifications; Section III relates to Domestic Preferences (if applicable); and Section IV requires the bidder's/offeror's signature.

SECTION I. BIDDER/OFFEROR RESPONSIBILITY CERTIFICATIONS

Instructions for Section I: Section I contains seven (7) parts. Part 1 requests information concerning the bidder's/offeror's business entity. Part 2 inquires about current or former owners, partners, directors, officers or principals. Part 3 relates to the responsibility of the bidder's/offeror's business. Part 4 concerns the bidder's/offeror's business certificates and licenses. Part 5 inquires about legal proceedings. Part 6 relates to the bidder's/offeror's financial and organizational status. Part 7 relates to disclosures under the District of Columbia Freedom of Information Act (FOIA).

PART 1: BIDDER/OFFEROR INFORMATION

Legal Business Entity Name: Solicitation #:

Address of the Principal Place of Business (street, city, state, zip code): Telephone # and ext.: Fax #:

Email Address: Website:

Additional Legal Business Entity Identities: If applicable, list any other DBA, Trade Name, Former Name, Other Identity and EIN used in the last five (5) years and the status (active or inactive).

Type: Name: EIN: Status:

1.1 Business Type (Please check the appropriate box and provide additional information if necessary.):

Corporation (including PC) Date of Incorporation:

Joint Venture Date of Organization:

Limited Liability Company (LLC or PLLC) Date of Organization:

Nonprofit Organization Date of Organization:

Partnership (including LLP, LP or General) Date of Registration or Establishment:

Sole Proprietor How many years in business?:

Other Date established?:

If "Other," please explain:

1.2 Was the bidder's/offeror's business formed or incorporated in the District of Columbia?

Yes No

If "No" to Subpart 1.2, provide the jurisdiction where the bidder's/offeror's business was formed or incorporated. Attach a Certificate or Letter of Good Standing from the applicable jurisdiction and a certified Application for Authority from the District, or provide an explanation if the documents are not available.

State

Country

1.3 Please provide a copy of each District of Columbia license, registration or certification that the bidder/offeror is required by law to obtain (other than those provided in Subpart 1.2). If the bidder/offeror is not providing a copy of its license, registration or certification to transact business in the District of Columbia, it shall either:

(a) Certify its intent to obtain the necessary license, registration or certification prior to contract award; or

(b) Explain its exemption from the requirement.

PART 2: INDIVIDUAL RESPONSIBILITY

Additional Instructions for Section I, Parts 2 through 8: Provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s).

Within the past five (5) years, has any current or former owner, partner, director, officer, principal or any person in a position involved in the administration of funds, or currently or formerly having the authority to sign, execute or approve bids, proposals, contracts or supporting documentation on behalf of the bidder/offeror with any government entity:

2.1 Been sanctioned or proposed for sanction relative to any business or professional permit or license? Yes No

2.2 Been under suspension, debarment, voluntary exclusion or determined ineligible under any federal, District or state statutes?

Yes No

2.3 Been proposed for suspension or debarment? Yes No

2.4 Been the subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation for any business-related conduct?

Yes No

2.5 Been charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime, or subject to a judgment or a plea bargain for:

Yes No

(a) Any business-related activity; or

(b) Any crime the underlying conduct of which was related to truthfulness?

2.6 Been suspended, cancelled, terminated or found non-responsible on any government contract, or had a surety called upon to complete an awarded contract?

Yes No

Please provide an explanation for each "Yes" in Part 2.

PART 3: BUSINESS RESPONSIBILITY

Within the past five (5) years, has the bidder/offeror:

3.1 Been under suspension, debarment, voluntary exclusion or determined ineligible under any federal, District or state statutes?

Yes No

3.2 Been proposed for suspension or debarment?

Yes No

3.3 Been the subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation for any business-related conduct?

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3.4 Been charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime, or subject to a judgment or plea bargain for:

(a) Any business-related activity; or

(b) Any crime the underlying conduct of which was related to truthfulness?

3.5 Been disqualified or proposed for disqualification on any government permit or license?

Yes No

3.6 Been denied a contract award or had a bid or proposal rejected based upon a non-responsibility finding by a government entity?

Yes No

3.7 Had a low bid or proposal rejected on a government contract for failing to make good faith efforts on any Certified Business Enterprise goal or statutory affirmative action requirements on a previously held contract?

3.8 Been suspended, cancelled, terminated or found non-responsible on any government contract, or had a surety called upon to complete an awarded contract?

Yes No

Please provide an explanation for each "Yes" in Part 3.

PART 4: CERTIFICATES AND LICENSES

Within the past five (5) years, has the bidder/offeror:

4.1 Had a denial, decertification, revocation or forfeiture of District of Columbia certification of any Certified Business Enterprise or federal certification of Disadvantaged Business Enterprise status for other than a change of ownership?

Please provide an explanation for "Yes" in Subpart 4.1.

4.2 Please provide a copy of the bidder's/offeror's District of Columbia Office of Tax and Revenue Tax Certification Affidavit.

PART 5: LEGAL PROCEEDINGS

Within the past five (5) years, has the bidder/offeror:

5.1 Had any liens or judgments (not including UCC filings) over $25,000 filed against it which remain undischarged?

Yes No

If "Yes" to Subpart 5.1, provide an explanation of the issue(s), relevant dates, the Lien Holder or Claimant's name, the amount of the lien(s) and the current status of the issue(s).

5.2 Had a government entity find a willful violation of District of Columbia compensation or prevailing wage laws, the Service Contract Act or the Davis-Bacon Act?

Yes No

5.3 Received any OSHA citation and Notification of Penalty containing a violation classified as serious or willful?

Yes No

Please provide an explanation for each "Yes" in Part 5.

PART 6: FINANCIAL AND ORGANIZATIONAL INFORMATION

6.1 Within the past five (5) years, has the bidder/offeror received any formal unsatisfactory performance assessment(s) from any government entity on any contract?

Yes No

If "Yes" to Subpart 6.1, provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s).

6.2 Within the past five (5) years, has the bidder/offeror had any liquidated damages assessed by a government entity over $25,000?

Yes No

If "Yes" to Subpart 6.2, provide an explanation of the issue(s), relevant dates, the government entity involved, the amount assessed and the current status of the issue(s).

6.3 Within the last seven (7) years, has the bidder/offeror initiated or been the subject of any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?

Yes No

If "Yes" to Subpart 6.3, provide the bankruptcy chapter number, the court name and the docket number. Indicate the current status of the proceedings as "initiated," "pending" or "closed".

6.4 During the past three (3) years, has the bidder/offeror failed to file a tax return or pay taxes required by federal, state, District of Columbia or local laws?

Yes No

If "Yes" to Subpart 6.4, provide the taxing jurisdiction, the type of tax, the liability year(s), the tax liability amount the bidder/offeror failed to file/pay and the current status of the tax liability.

6.5 During the past three (3) years, has the bidder/offeror failed to file a District of Columbia unemployment insurance return or failed to pay District of Columbia unemployment insurance?

Yes No

If "Yes" to Subpart 6.5, provide the years the bidder/offeror failed to file the return or pay the insurance, explain the situation and any remedial or corrective action(s) taken and the current status of the issue(s).

6.6 During the past three (3) years, has the bidder/offeror failed to comply with any payment agreement with the Internal Revenue Service, the District of Columbia Office of Tax and Revenue and the Department of Employment Services?

If "Yes" to Subpart 6.6, provide the years the bidder/offeror failed to comply with the payment agreement, explain the situation and any remedial or corrective action(s) taken and the current status of the issue(s).

6.7 Indicate whether the bidder/offeror owes any outstanding debt to any state, federal or District of Columbia government.

Yes No

If "Yes" to Subpart 6.7, provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s).

6.8 During the past three (3) years, has the bidder/offeror been audited by any government entity?

Yes No

(a) If "Yes" to Subpart 6.8, did any audit of the bidder/offeror identify any significant deficiencies in internal controls, fraud or illegal acts; significant violations of provisions of contract or grant agreements;

significant abuse; or any material disallowance?

(b) If "Yes" to Subpart 6.8(a), provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s).

PART 7: FREEDOM OF INFORMATION ACT (FOIA)

7.1 Indicate whether the bidder/offeror asserts that any information provided in response to a question in Section I is exempt from disclosure under the District of Columbia Freedom of Information Act (FOIA), effective March 25, 1977 (D.C. Law 1-96; D.C. Official Code §§ 2-531, et seq.). Include the question number(s) and explain the basis for the claim. (The District will determine whether such information is, in fact, exempt from FOIA at the time of request for disclosure under FOIA.)

SECTION II. ADDITIONAL REQUIRED BIDDER/OFFEROR CERTIFICATIONS

Instructions for Section II: Section II contains seven (7) parts. Part 1 requests information concerning District of Columbia employees. Part 2 applies to the bidder/offeror's pricing. Part 3 relates to equal employment opportunity and human rights requirements. Part 4 relates to First Source Act requirements. Part 5 relates to employment eligibility requirements. Part 6 relates to Language Access Act requirements. Part 7 relates to conflicts of interest.

PART 1. DISTRICT EMPLOYEES NOT TO BENEFIT

1.1 The bidder/offeror certifies that no officer or employee of the District of Columbia will benefit from this contract. List the name(s) of any officer or employee of the District of Columbia that may benefit from this contract in section 1.2 below.

1.2 The following officer or employee of the District of Columbia may benefit from this contract.

(a)

(b)

PART 2: INDEPENDENT PRICE DETERMINATION REQUIREMENTS

The bidder/offeror certifies that:

2.1 The signature of the bidder/offeror is considered to be a certification by the signatory that:

(a) The contract prices have been arrived at independently without, for the purpose of restricting competition, any consultation, communication or agreement with any bidder/offeror or competitor related to:

(i) Those prices;

(ii) The intention to submit a bid/proposal; or

(iii) The methods or factors used to calculate the prices in the contract.

(b) The prices in this contract have not been and will not be knowingly disclosed by the bidder/offeror, directly or indirectly, to any other bidder/offeror or competitor before bid/proposal opening unless otherwise required by law; and

(c) No attempt has been made or will be made by the bidder/offeror to induce any other concern to submit or not to submit a contract for the purpose of restricting competition.

2.2 The signature on the bid/proposal is considered to be a certification by the signatory that the signatory:

(a) Is the person in the bidder's/offeror’s organization responsible for determining the prices being offered in this contract, and that the signatory has not participated and will not participate in any action contrary to subparagraphs 2.1(a)(i) through (a)(iii) above; or

(b) Has been authorized, in writing, to act as an agent for the following principal in certifying that the principal has not participated, and will not participate, in any action contrary to subparagraphs 2.1(a)(i) through (a)(iii) above:

[Insert full name of person(s) in the organization responsible for determining the prices offered in this contract and the title of his or her position in the bidder's/offeror’s organization]

(i) As an authorized agent, certifies that the principals named in subparagraph 2.2(b) above have not participated, and will not participate, in any action contrary to subparagraphs 2.1(a)(i) through (a)(iii) above; and

(ii) As an agent, has not participated and will not participate in any action contrary to subparagraphs 2.1(a)(i) through (a)(iii) above.

2.3 If the bidder/offeror deletes or modifies subparagraph 2.1(b) above, the bidder/offeror must furnish with its bid a signed statement setting forth in detail the circumstances of the disclosure.

PART 3: EQUAL OPPORTUNITY AND HUMAN RIGHTS OBLIGATIONS

3.1 The bidder/offeror certifies that it is fully aware of the contents of Mayor's Order 85-85, Mayor's Order 2017-313, and the Office of Human Rights' regulations in Chapter 11 of title 4 of the DCMR, and agrees to comply with them while performing this contract.

PART 4: FIRST SOURCE OBLIGATIONS

4.1 The bidder/offeror certifies that it is fully aware of the requirements of the First Source Employment Agreement Act of 1984, as amended, D.C. Official Code § 2-219.01 et seq ., and agrees to enter into a First Source Employment Agreement with the Department of Employment Services if awarded any contract valued at $300,000 or more which receives funds or resources from the District, or funds or resources which, in accordance with a federal grant or otherwise, is administered by the District government.

4.2 I certify that the Initial Employment Plan submitted with my bid or proposal is true and accurate.

PART 5: EMPLOYMENT ELIGIBILITY OBLIGATIONS

5.1 The bidder/offeror certifies that it has verified the identity and employment eligibility of all of its employees.

PART 6: LANGUAGE ACCESS OBLIGATIONS

6.1 For contracts where the contracting agency is a “covered entity” or “covered entity with major public contact” as defined in Sections 2(2) and 2(3) of the Language Access Act of 2004 (D.C. Official Code § 2-1931(2) and § 2-1931(3)), the bidder/offeror certifies that it will comply with Language Access compliance requirements of the contracting agency while performing this contract.

PART 7: CONFLICTS OF INTEREST

7.1 The bidder/offeror certifies that it presently has no interest and shall not acquire any interest, direct or indirect, which would conflict in any manner or degree with the performance of its obligations under the contract.

SECTION III. DOMESTIC PREFERENCE CERTIFICATIONS

Instructions for Section III: Section III contains three (3) parts which should only be completed only as applicable.

PART 1: BUY AMERICAN ACT COMPLIANCE (Applies if the bidder/offeror will provide goods to the District that are subject to the requirements of the Buy American Act)

1.1 In accordance with 41 USC 8301 et. seq . and implementing regulations, the bidder/offeror certifies that each end product, except the end products listed below, is a domestic end product.

EXCLUDED END PRODUCTS

COUNTRY OF ORIGIN

PART 2: FHWA BUY AMERICA ACT COMPLIANCE (Applies to FHWA-funded construction contracts)

2.1 In accordance with 23 CFR 635.410(b), the bidder/offeror certifies that only steel or iron materials manufactured in the United States will be used for permanent incorporation on the project.

Yes No

PART 3: BUY AMERICAN ACT COMPLIANCE (Applies to locally-funded construction contracts)

3.1 In accordance with 41 USC 8301 et. seq . and implementing regulations, the bidder/offeror certifies that only construction materials manufactured in the United States will be used on the project.

Yes No

SECTION IV. CERTIFICATION

Instruction for Section IV: This section must be completed by all bidder/offerors.

I, [ ], as the person authorized to sign these certifications, hereby certify that the information provided in this form is true and accurate. In accordance with the requirements of section 302(c) of the Procurement Practices Reform Act of 2010 (D.C. Official Code § 2-353.02(c)), I shall update any response provided in this form within 60 days of a material change to a response and prior to the exercise of an option period.

Name [Print and sign]: Telephone #: Fax #:

Title: Email Address:

Date: Contract No:

The District of Columbia is authorized to verify the above information with appropriate government authorities. Penalty for making false statements is a fine of not more than $1,000.00, imprisonment for not more than 180 days, or both, as prescribed in D.C. Official Code § 22-2405. Penalty for false swearing is a fine of not more than $2,500.00, imprisonment for not more than three (3) years, or both, as prescribed in D.C. Official Code § 22-2404.

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K.7

NON-COLLUSION AFFIDAVIT STATEMENT

NON-COLLUSION AFFIDAVIT

I, the undersigned depose and certify that I am the Title of the Company that I am authorized to make this affidavit on behalf of said company; and that said company has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive proposal submittal in connection with proposed contract and pursuant to 23 CFR 635.112 (f).

Signature of Official

K.8

CERTIFICATION OF ELIGIBILITY

CERTIFICATION OF ELIGIBILITY

INVITATION NO.

, being

(President or Authorized Official of Bidder) duly sworn (or under penalty of perjury under the laws of the United States), certifies that, except as noted below, (the Company) or any person associated therewith in the capacity of (owner, partner, director, officer, principal investigator, project director, manager, auditor, or nay position involving the administration of federal funds):

is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility under any Federal, District or State statutes;

has not been suspended, debarred, voluntarily excluded or determined ineligible by any Federal, District or State agency within the past three (3) years;

does not have a proposed debarment pending; and has not been indicted, convicted, or had a civil judgment rendered against (it) by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past three (3) years.

Exceptions will not necessarily result in denial of award, but will be considered in determining acceptability of offeror. For any exception noted, indicate below to who it applies, initiating agency, and dates of action. Providing false information may result in criminal prosecution or administrative sanctions.

Contractor

President or Authorized Official

Title The penalties for making false statements are prescribed in the Program Fraud Civil Remedies Act of 1986 (public Law 99- 509, 31 U.S.C. 3801-3812).

Subscribed and sworn before me this day at

City and State

Notary Seal Notary Public

K.9

CERTIFICATION REGARDING DEBARMENT

CERTIFICATION REGARDING DEBARMENT

SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

LOWER TIER COVERED TRANSACTION

, being

(President or Authorized Official of Bidder) duly sworn (or under penalty of perjury under the laws of the United States), certifies that, except as noted below, (the Company) or any person associated therewith in the capacity of (owner, partner, director, officer, principal investigator, project director, manager, auditor, or any position involving the administration of federal funds):

is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility under any Federal, District or State statutes;

has not been suspended, debarred, voluntarily excluded or determined ineligible by any Federal, District or State agency within the past three (3) years;

does not have a proposed debarment pending; and has not been indicted, convicted, or had a civil judgment rendered against (it) by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past three (3) years.

Exceptions will not necessarily result in denial of award, but will be considered in determining bidder responsibility. For any exception noted, indicate below to who it applies, initiating agency, and dates of action. Providing false information may result in criminal prosecution or administrative sanctions.

Contractor

President or Authorized Official

Date Title

The penalties for making false statements are prescribed in the Program Fraud Civil Remedies Act of 1986 (public Law 99- 509, 31 U.S.C. 3801-3812).

Subscribed and sworn before me this day at

City and State

Notary Seal Notary Public

K.10

DISCLOSURE OF LOBBYING AFFIDAVIT

DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0346-0046

(See reverse for public burden disclosure)

1. Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

2. Status of Federal Action:

a. bid/offer/application

b. initial award

c. post-award

3. Report Type:

a. initial filing

b. material change

For Material Change Only:

Year quarter date of last report

4. Name and Address of Reporting Entity:

Prime Subawardee Tier , if known:

Congressional District, if known:

5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime:

Congressional District, if known:

6. Federal Department/Agency: 7. Federal Program Name/Description:

CFDA Number, if applicable:

8. a. Name and Address of Lobbing Entity (if individual, last name, first name, MI):

(attach Continuation Sheet(s)

b. Individuals Performing Services (including address if different from No. 10a) (last name, first name, MI):

SF-LLL-A, if necessary)

8. Federal Action Number, if known: 9. Award Amount, if known:

11. Amount of Payment (check all that apply):

$ actual planned

13. Type of Payment (check all that apply):

a. retainer

b. one-time fee

c. commission

d. contingent fee

e. deferred

f. other; specify:

12. Form of Payment (check all that apply):

a. cash

b. in-kind; specify: nature _ value

14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment indicated in Item 11:

(attach Continuation Sheet(s) SF-LLL-A, if necessary)

15. Continuation Sheet(s) SF-LLL-A attached: Yes No

16. Information requested through the form is authorized by order 31 U.S.C., section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when the transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C., 1352. This information will be reported to the Congress semi-annually and will b available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than

$100,000 for each such failure.

Signature:

Print Name: _ Title: _ Telephone No.: _ Date: _

Federal Use Only

Authorized for Local Reproduction Standard Form – LLL

DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB

CONTINUATION SHEET 0346-0046

Reporting Entity: Page of

Authorized for Local Reproduction

Standard Form - LLL-A

K.11

CERTIFICATE FOR GRANTS, LOANS AND COOPERATIVE

AGREEMENT

CERTIFICATION

FOR GRANTS, LOANS

AND COOPERATIVE AGREEMENTS

DISTRICT OF COLUMBIA DEPARTMENT OF TRANSPORTATION

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

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 Federal 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.

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 Federal 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.

The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subgrants, and contracts and subcontracts under grants, subgrants, loans, and cooperative agreements) which exceed $100,000, and that all such subrecipients shall certify and disclose accordingly.

This certification is material representation of fact upon which reliance was placed when this award was made. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file that 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.

Title of Official Company

Date Signature of Official

A bidder's failure to submit this certification or submission of a false certification may render his/her bid non-responsive.

(FAP)

K.12

DBE SOLICITATION CERTIFICATION

DISTRICT DEPARTMENT OF TRANSPORTATION

DISADVANTAGED BUSINESS ENTERPRISE CERTIFICATION

SUBCONTRACTOR (DBE & Non-DBE) INFORMATION

49 CFR PART 26

INVITATION No.:

The contractor or subcontractor shall not discriminate on the basis of race, color, national origin, or sex in the performance of this contract. The contractor shall carry out applicable requirements of 49 CFR Part 26 in the award and administration of DOT-assisted contracts. Failure by the contractor to carry out these requirements is a material breach of this contract, which may result in the termination of this contract or such other remedy, as the recipient deems appropriate.

I hereby submit the names of any firm, both DBE and Non-DBE from which quotations were received or discussions were held in conjunction with this project. The following information is being provided: name, address of firm, proposed area of work, and proposed dollar amount.

Name Address Area of work Proposed $ amount

Additionally, I certify that, I will submit a complete DBE Plan in accordance with the Special Provisions entitled “Participation by Disadvantaged and Non-Disadvantaged Business Enterprise Firms” within five

(5) days subsequent to the bid opening. Said plan will contain the name, address of DBE firm, amount of award and area of work. A bidder’s/offeror’s failure to submit this certification or submission of a false certification may render his/her bid non-responsive.

Title of Official Company

Signature of Official Date

Revised 11/04

K.13

EEO CERTIFICATE/ NON-SEGREGATED FACILITIES

CERTIFICATE

EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATE

Bidder represents that he [] has [] has not participated in a contract or subcontract subject to in substance either the equal opportunity provisions in Article 6 of LABOR PROVISIONS, STANDARD CONTRACT PROVISIONS, 1973, or Section 202 of Executive Order 11246 of 3 CFR; that he [] has [] has not filed all required compliance reports under any such contract or subcontract; and that representations indicating submission of required compliance reports signed by proposed subcontractors will be obtained prior to subcontract awards.

NONSEGREGATED FACILITIES CERTIFICATE

Bidder represents that he does not and will not maintain or provide for his employees any segregated facility at any of his establishments; that he does not and will not permit his employees to perform their services at any location under his control where segregated facilities are maintained; and that he will obtain and retain identical certifications from proposed subcontractors prior to award of subcontracting exceeding $10,000.00.

"Segregated facilities" shall mean any waiting room, work area, wash and rest room, eating area, time clock, locker room and other storage or dressing area, parking lot drinking fountain, recreation or entertainment area, transportation and housing facility, provided for employees which is segregated by explicit directive or is segregated on the basis of race, creed, color, or national origin, because of habit, local custom or otherwise.

Penalty for violations or making false statements is prescribed in 18 USC 1001.

Company

Signature of Official

Date Title