DOTOW29SB Attachment B- Price Form Final.docx

PRICE FORM

CONTRACT BID FORM & SBR AFFIDAVIT– ATTACHMENT-B

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.: DOTOW29SB

Vendor Bid Form – Solicitation : DOTOW29SB

Item / Description Estimated Quantity Over Contract Duration

Vendor’s Bid per unit

Total Cost ($) (column B X C)

Line item 1) Light Duty Hook Up Rate (this is the price of each response to the site with the appropriate equipment and operator to tow or winch)

Line Item 2) Light Duty Mileage Rate per Towed Mile (this is the price per mile of towing from the hook up until drop site or MDOT/SHA determined destination).

Line Item 3) Light Duty Onsite winching rate per hour

Line item 4) Medium Duty Hook Up Rate (this is the price of each response to the site with the appropriate equipment and operator to tow or winch)

Line Item 5) Medium Duty Mileage Rate per Towed Mile (this is the price per mile of towing from the hook up until drop site or MDOT/SHA determined destination).

Line Item 6) Medium Duty Onsite winching rate per hour

Line item 7) Heavy Duty Hook Up Rate (this is the price of each response to the site with the appropriate equipment and operator to tow or winch)

Line Item 8) Heavy Duty Mileage Rate per Towed Mile (this is the price per mile of towing from the hook up until drop site or MDOT/SHA determined destination).

Line Item 9) Heavy Duty Onsite winching rate per hour

TOTAL BID AMOUNT (Sum of Column D for line items 1 through 9)

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.

DOTOW29SB Price Form (Page 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:

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)