DOHVAC30SB PRICE FORM ATTACHMENT B.docx

DOHVAC30SB

PRICE FORM

& SBR AFFIDAVIT– ATTACHMENT-B PAGE 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.

Line 6- Materials at MSRP/Retail

$ 4,500.00

NOTE:

a) Quantities are estimated and used for bid evaluation only. They may not represent the actual quantities experienced once the contract is awarded.

b) 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 tax in bid prices

DOHVAC30SB

PRICE FORM

& SBR AFFIDAVIT– ATTACHMENT-B PAGE 2

Bid via eMMA

For the Contractor:

Company/Bidder Entity 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:

SMALL BUSINESS QUALIFICATION NUMBER ___________________

Date of Most Recent Qualification__________________________________

DATE:_____________

BY:_____________________________________________________________

Signature (Authorized Representative and Affidavit)