Document_2_of_3_Declarations_.pdf

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. 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.

SIGNATURE PAGE TO FOLLOW

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:

ATTACHMENT B: PRICING

1. Pricing.

A 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 the response, your response will be rejected. Failure to use the Price Schedule may be cause for rejection. Responders are strongly encouraged to provide a price for all line items. The State reserves the right to reject responses that do not supply sufficient line items.

2. Installation Services.

A responder must not charge a separate fee for an installation or mounting service. The price for equipment, attachments, or options includes all installation and mounting costs. The price offered must include everything needed so the unit is complete and ready for immediate use.

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 C: 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 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/

For assistance with this form, email the Minnesota Department of Human Rights Compliance.MDHR@state.mn.us

ATTACHMENT D: 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 (Contract)

Email Address

Telephone Number

Contact Person (PO Order)

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 1% in 15, Net 30

2% in 30 2% in 15, Net 30

3% in 30 3% in 15, Net 30

1% in 10, Net 30 1% in 20, Net 30

2% in 10, Net 30 2% in 20, Net 30

3% in 10, Net 30 3% in 20, Net 30

5% in 10, Net 30 Net 30

Other None

Comments:

3. Delivery Time Frame: Responder must enter a delivery time frame after receipt of order (ARO) (Note repairs must be completed 120 days)

4. Warranty Information: What warranty are you offering with this product? If applicable, please include any warranty on materials AND labor/workmanship.

6. Business Information