DQ08-2016-008 Auto Tech Hydr. Simulator.docx
DOCX document 53 KB Posted
- Attached to
- Double sided Hydraulics Simulator
- Solicitation number
- DQ1 GJTA 2016000942 1
- Issued by
- Pueblo County, Colorado
About this file
This is a documented quote solicitation issued by Colorado Northwestern Community College (CNCC) for the purchase of a Double sided troubleshooting Hydraulic Simulator (model NFT100D-TS) for the Auto Technician Program. The solicitation was posted on January 21, 2016, with quotes due by January 26, 2016, at 5:00 p.m. (MDT). Quotes were to be submitted via email to Amy Griffin at amy.griffin@cncc.edu, by fax at (970) 675-5046, or delivered to the Purchasing Department. Award will be made to a single vendor. All price quotes must be submitted on the college's provided quote form with no substitute forms acceptable. Quotes must include all materials, labor, permits, shipping, and packing charges, with pricing based on the specified objectives of delivering the NFT100D-TS Hydraulic Simulator.
Evaluation of bids will be based primarily on the vendor's ability to meet the stated objectives and requirements, with consideration given to proposed total project cost, payment terms, projected delivery dates, reference checks, and other pertinent factors. CNCC reserves the right to purchase additional goods and services at the same bid prices or lower within a reasonable period of time. Vendors must be registered on the Colorado Vendor Self Service (VSS) system to be considered responsive, though non-registered vendors may be considered if adequate competition is not demonstrated by registered vendors. Responsive submissions must include the response sheet, narrative submission, references, key personnel resumes, W-9 form, unauthorized immigrant certification, and SDVOSB certification if applicable. The purchase order includes standard Colorado state terms and conditions, FOB destination, net 45 payment terms, and requires vendors to obtain and maintain specified insurance with the Colorado Community College System listed as certificate holder and additional insured.
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DOCUMENTED QUOTE
Colorado Northwestern Community College CNCC DQ08-2016-008 500 Kennedy Drive
| Rangely, CO 81648 | Post Date: January 21st, 2016 | |
| Amy Griffin, Purchasing | Submission Due Date: January 26th, 2016 |
Phone: (970) 675-3212 Fax: (970) 675-5046
Quotes referencing the Documented Quote #. in the subject line will be accepted via e-mail (preferred) to amy.griffin@cncc.edu, by Fax at (970) 675-5046, or delivery to the Purchasing Department prior to opening date of January 26th, 2015 at 5:00 p.m. (MDT). Award will only be made to one vendor. Acceptable quotes must include pricing for all products and services listed.
The Colorado Northwestern Community College Auto Technician Program is accepting bids for the purchase of a Double sided troubleshooting Hydraulic Simulator.
Specifications: All price quotes must be submitted on the quote form provided. NO SUBSTITUTE FORMS ARE ACCEPTABLE. Quotes shall include all materials, labor, permits, and all other necessary fees. CNCC reserves the right to purchase additional goods and services at the same bid prices or lower within a reasonable period of time.
Objectives: NFT100D-TS Hydraulic Simulator, price should include shipping and packing charges.
Any questions should be submitted in writing to Amy Griffin at amy.griffin@cncc.edu prior to January 26th, 2016 at 5:00 PM (MDT).
Evaluation:
CNCC will be the sole judge in determining the acceptability of an offer and in determining the most beneficial offer(s) for the State. Bid evaluation will consist primarily of determining vendor’s ability to meet the Objectives and the Vendor Requirements and comparing the Proposed Total Cost of Project for each submission. Evaluation terms may also take into account payment terms, projected delivery dates, reference checks, and any other pertinent factors.
For questions contact Amy Griffin at (970) 675-3212 or email to amy.griffin@cncc.edu.
Colorado Vendor Self Service (VSS) and Registration This solicitation is published using the Colorado Vendor Self Service (VSS). Vendors must be registered on ColoradoVSS in order to download solicitation documents and information (including any amendments or modifications) and to be considered responsive at the time of submission of the response. ColoradoVSS and its registration information may be linked through the State Purchasing Office link at www.colorado.gov/VSS. All respondents will be responsible to check the ColoradoVSS system for awarding of quote. No other notifications will be given.
Limited Competition Because of the limited competition expected from registered ColoradoVSS vendors on this solicitation, the procuring agency intends to use both ColoradoVSS and additional methods of vendor notification and may make the specifications available to non-registered vendors through additional means. However, quotes, bids or offers submitted by non-registered vendors will not be opened or considered (except as necessary to determine ColoradoVSS registration status) unless, after examination of quotes/bids/offers submitted by ColoradoVSS registered vendors, it is determined that there is not adequate competition among ColoradoVSS registered vendors. A vendor is considered registered if its registration and payment is received in the State Purchasing Office prior to the bid opening time or the due date for receipt of quotes.
General Conditions Financial obligations of the State, payable after the current fiscal year, are contingent upon funds for that purpose being appropriated, budgeted and otherwise made available.
The awarded vendor shall submit a certificate of insurance in the minimum state-prescribed limits no later than five days prior to beginning work. Specific requirements may be obtained through the Purchasing Department. The certificate shall list the Colorado Community College System as both Certificate Holder and Additional Insured.
MWBE - It is the State’s goal to achieve maximum participation of minorities and women owned businesses in the procurement process. Accordingly, minority and women owned business enterprises are to be utilized whenever possible.
SDVOSB - In accordance with House Bill 14-224, CNCC reports on contracts with Service Disabled Veteran Owned Small Businesses (SDVOSB). Bidders who qualify as SDVOSB are requested to submit proof of certification with their response.
Environmentally Preferable Products - In accordance with Procurement Code, CRS 24-103-207.5 titled -Purchasing Preference for Environmentally Preferable Products; bidders responding to this solicitation may seek to qualify for the preference and governmental bodies conducting this solicitation shall award a contract to a bidder who offers environmentally preferable products subject to the conditions in the Code and Procurement Rules.
Employment Eligibility - CNCC hereby notifies all bidders that the State requires that Contractor certify, warrant, and agree that it will not knowingly employ or contract with an illegal alien who will perform work under this contract and will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this contract, through participation in the E-Verify Program or the Department program established pursuant to CRS §8-17.5-102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work under this contract or enter into a contract with a subcontractor that fails to certify to Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this contract.
A Contractor that operates as a sole proprietor hereby swears or affirms under penalty of perjury that the Contractor (i) is a citizen of the United States or otherwise lawfully present in the United States pursuant to federal law, (ii) shall comply with the provisions of CRS 24-76.5-101 et seq, and (iii) shall produce one of the forms of identification required by CRS 24-76.5-103 prior to the effective date of this Contract. Except where exempted by federal law and except as provided in CRS 24-76.5-103(3), a Contractor that receives federal or state funds under this contract must confirm that any individual natural person eighteen years of age or older is lawfully present in the United States pursuant to CRS 24-76.5-103(4) if such individual applies for public benefits provided under this contract.
Contract Performance for Services Outside US or Colorado - After award of the contract, Contractor shall provide written notice to the State within 20 days of the earlier to occur of Contractor’s decision to perform, or its execution of an agreement with a Subcontractor to perform, Services outside the State of Colorado and/or the United States. Such notice shall specify the type of Services to be performed outside the State of Colorado and/or the United States and the reason why it is necessary or advantageous to perform such Services at such location or locations. All notices received by the State pursuant to this requirement shall be posted on the Colorado Department of Personnel & Administration’s website. Knowing failure by Contractor to provide notice to the State under this requirement shall constitute a material breach of this Contract.
Quotes must be in accordance with specifications set forth by the State of Colorado’s Terms and Conditions and subject to conditions herein and/or attached. CNCC will use the State of Colorado Purchase Order Terms & Conditions and the special provisions with any purchase or lease.
FOB: Destination
RESPONSE SHEET
DOCUMENTED QUOTE CNCC DQ 08-2016-008
**THIS SHEET MUST BE RETURNED WITH YOUR QUOTED PRICES**
Quotes will be accepted via e-mail at amy.griffin@cncc.edu (preferred) or fax at (970) 675-5046.
Proposed total cost of project: ________________________
By signature below, vendor certifies its ability to complete the project by: ________________________
THE FOLLOWING MUST BE COMPLETED:
Vendor Name
Vendor Address
Vendor Phone / Fax
E-Mail Address
Printed Name, Title
Signature
Assured Delivery Date
| Payment Terms |
| FOB Destination / Net 45 |
Using the Federal Government definition, does your company qualify as:
| A Small Business |
| Yes____ No____ |
| A Woman Owned Business |
| Yes____ No____ |
| A Minority Business |
| Yes____ No____ |
| If Yes, State Ethnicity |
| A Service Disabled Veteran Owned Small Business (SDVOSB) (If yes, provide certification) |
| Yes____ No____ |
Federal ID Number
| Are you a member of the ColoradoVSS System? Yes____ No____ |
| VSS # ______________________ |
Responsive bids must include Response Sheet, Narrative Submission, References, Key Personnel Bio/Resume, W-9, Unauthorized Immigrant Certification, SDVOSB certification (if applicable).
Attachment A Purchase Order Terms and Conditions
1. Offer/Acceptance. If this purchase order (“PO”) refers to vendor’s bid or proposal, this PO is an ACCEPTANCE of vendor’s OFFER TO SELL in accordance with the terms and conditions of the “solicitation” identified in vendor’s bid or proposal. The solicitation includes an RFP, IFB, or any other form of order by buyer. If a bid or proposal is not referenced, this PO is an OFFER TO BUY, subject to vendor’s acceptance, demonstrated by vendor’s performance or written acceptance of this PO. Any COUNTER-OFFER TO SELL automatically CANCELS this PO, unless a change order is issued by buyer accepting a counter-offer. This PO shall supersede and control over any vendor form(s) or part(s) thereof included in or attached to any bid, proposal, offer, acknowledgment, or otherwise, in the event of inconsistencies or contradictions, regardless of any statement to the contrary in such form(s) or parts thereof. 2. Safety Information. All chemicals, equipment and materials proposed and/or used in the performance of this PO shall conform to the requirements of the Occupational Safety and Health Act of 1970. Vendor shall furnish all Material Safety Data Sheets (MSDS) for any regulated chemicals, equipment or hazardous materials at the time of delivery.
3. Changes. Vendor shall furnish products and/or services strictly in accordance with the specifications and price set forth for each item. This PO shall not be modified, superseded or otherwise altered, except in writing signed by purchasing agent and accepted by vendor. Each shipment received or service performed shall comply with the terms of this PO, notwithstanding invoice terms or acts of vendor to the contrary, unless this PO has been modified, superseded or otherwise altered in accordance with this section.
4. Delivery. Unless otherwise specified in the solicitation or this PO, delivery shall be FOB destination. Buyer is relying on the promised delivery date, installation, and/or service performance set forth in vendor’s bid or proposal as material and basic to buyer’s acceptance. If vendor fails to deliver or perform as and when promised, buyer, in its sole discretion, may cancel its order, or any part thereof, without prejudice to its other rights, return all or part of any shipment so made, and charge vendor with any loss or expense sustained as a result of such failure to deliver or perform as promised. Time is of the essence.
5. Intellectual Property. Any software, research, reports, studies, data, photographs, negatives or other documents, drawings or materials (collectively “materials”) delivered by vendor in performance of its obligations under this PO shall be the exclusive property of buyer. Ownership rights shall include, but not be limited to, the right to copy, publish, display, transfer, prepare derivative works, or otherwise use the materials. Vendor shall comply with all applicable Cyber Security Policies of the State of Colorado (the “State”), or buyer, as applicable, and all confidentiality and non-disclosure agreements, security controls, and reporting requirements.
6. Quality. Buyer shall be the sole judge in determining “equals” with regard to quality, price and performance. All products delivered shall be newly manufactured and the current model, unless otherwise specified.
7. Warranties. All provisions and remedies of the Colorado Uniform Commercial Code, CRS, Title 4 (“CUCC”), relating to implied and/or express warranties are incorporated herein, in addition to any warranties contained in this PO or the specifications.
8. Inspection and Acceptance. Final acceptance is contingent upon completion of all applicable inspection procedures. If products or services fail to meet any inspection requirements, buyer may exercise all of its rights, including those provided in the CUCC. Buyer shall have the right to inspect services provided under this PO at all reasonable times and places. "Services" as used in this section includes services performed or tangible material produced or delivered in the performance of services. If any of the services do not conform to PO requirements, buyer may require vendor to perform the services again in conformity with PO requirements, without additional payment. When defects in the quality or quantity of service cannot be corrected by re-performance, buyer may (a) require vendor to take necessary action to ensure that future performance conforms to PO requirements and (b) equitably reduce the payment due vendor to reflect the reduced value of the services performed. These remedies do not limit the remedies otherwise available in this PO, at law, or in equity.
9. Cash Discount. The cash discount period will start from the later of the date of receipt of acceptable invoice, or from date of receipt of acceptable products/services at the specified destination by an authorized buyer representative.
10. Taxes. Buyer and the State are exempt from all federal excise taxes under Chapter 32 of the Internal Revenue Code [No. 84-730123K] and from all State and local government sales and use taxes [CRS, Title 39, Article 26, Parts I and II]. Such exemptions apply when materials are purchased for the benefit of State, except that in certain political subdivisions (e.g., City of Denver) vendor may be required to pay sales or use taxes even though the ultimate product or service is provided to buyer. Buyer shall not reimburse such sales or use taxes.
11. Payment. Buyer shall pay vendor for all amounts due within 45 days after receipt of products or services and a correct notice of amount due. Interest on the unpaid balance shall begin to accrue on the 46th day at the rate set forth in CRS §24-30-202(24) until paid in full. Interest shall not accrue if a good faith dispute exists as to buyer’s obligation to pay all or a portion of the amount due. Vendor shall invoice buyer separately for interest on delinquent amounts due, referencing the delinquent payment, number of day’s interest to be paid, and applicable interest rate.
12. Vendor Offset. [Not Applicable to Inter-governmental POs] Under CRS §24-30-202.4 (3.5), the State Controller may withhold payment under the State’s vendor offset intercept system for debts owed to State agencies for: (a) unpaid child support debts or arrearages; (b) unpaid balances of tax, accrued interest, or other charges specified in CRS §39-21-101, et seq.; (c) unpaid loans due to the Student Loan Division of the Department of Higher Education; (d) amounts required to be paid to the Unemployment Compensation Fund; and (e) other unpaid debts owing to the State as a result of final agency determination or judicial action.
13. Assignment and Successors. Vendor shall not assign rights or delegate duties under this PO, or subcontract any part of the performance required under this PO, without the express, written consent of buyer. This PO shall inure to the benefit of and be binding upon vendor and buyer and their respective successors and assigns. Assignment of accounts receivable may be made only upon written notice furnished to buyer.
14. Indemnification. If any article sold or delivered under this PO is covered by a patent, copyright, trademark, or application therefore, vendor shall indemnify and hold harmless buyer from any and all loss, liability, cost, expenses and legal fees incurred on account of any claims, legal actions or judgments arising out of manufacture, sale or use of such article in violation or infringement of rights under such patent, copyright, trademark or application. If this PO is for services, vendor shall indemnify, save, and hold harmless buyer, its employees and agents, against any and all claims, damages, liability and court awards including costs, expenses, and attorney fees and related expenses, incurred as a result of any act or omission by vendor, or its employees, agents, subcontractors or assignees, arising out of or in connection with performance of services under this PO.
15. Independent Contractor. Vendor shall perform its duties hereunder as an independent contractor and not as an employee. Neither vendor nor any agent or employee of vendor shall be deemed to be an agent or employee of buyer. Vendor and its employees and agents are not entitled to unemployment insurance or workers compensation benefits through buyer and buyer shall not pay for or otherwise provide such coverage for vendor or any of its agents or employees. Unemployment insurance benefits will be available to vendor and its employees and agents only if coverage is made available by vendor or a third party. Vendor shall pay when due all applicable employment, income, and local head taxes incurred pursuant to this PO. Vendor shall not have authorization, express or implied, to bind buyer to any agreement, liability or understanding, except as expressly set forth herein. Vendor shall (a) provide and keep in force workers' compensation and unemployment compensation insurance in the amounts required by law, (b) provide proof thereof when requested by buyer, and (c) be solely responsible for its acts and those of its employees and agents.
16. Communication. All communication concerning administration of this PO, prepared by vendor for buyer’s use, shall be furnished solely to purchasing agent.
17. Compliance. Vendor shall strictly comply with all applicable federal and state laws, rules, and regulations in effect or hereafter established, including, without limitation, laws applicable to discrimination and unfair employment practices.
18. Insurance. Vendor shall obtain, and maintain, at all times during the term of this PO, insurance as specified in the solicitation, and provide proof of such coverage as requested by purchasing agent.
19. Termination Prior to Shipment. If vendor has not accepted this PO in writing, buyer may cancel this PO by written or oral notice to vendor prior to shipment of goods or commencement of services.
20. Termination for Cause. (a) If vendor refuses or fails to timely and properly perform any of its obligations under this PO with such diligence as will ensure its completion within the time specified herein, buyer may notify vendor in writing of non-performance and, if not corrected by vendor within the time specified in the notice, terminate vendor's right to proceed with the PO or such part thereof as to which there has been delay or a failure. Vendor shall continue performance of this PO to the extent not terminated and be liable for excess costs incurred by buyer in procuring similar goods or services elsewhere. Payment for completed services performed and accepted shall be at the price set forth in this PO. (b) Buyer may withhold amounts due to vendor as buyer deems necessary to reimburse buyer for excess costs incurred in curing, completing or procuring similar goods and services.(c) If after rejection, revocation, or other termination of vendor's right to proceed under the CUCC or this clause, buyer determines for any reason that vendor was not in default or the delay was excusable, the rights and obligations of buyer and vendor shall be the same as if the notice of termination had been issued pursuant to termination under §21.
21. Termination in Public Interest. Buyer is entering into this PO for the purpose of carrying out the public policy of the State, as determined by its Governor, General Assembly, and Courts. If this PO ceases to further the public policy of the State, buyer, in its sole discretion, may terminate this PO in whole or in part and such termination shall not be deemed to be a breach of buyer’s obligations hereunder. This section shall not apply to a termination for vendor’s breach, which shall be governed by §20. Buyer shall give written notice of termination to vendor specifying the part of the PO terminated and when termination becomes effective. Upon receipt of notice of termination, vendor shall not incur further obligations except as necessary to mitigate costs of performance. For services or specially manufactured goods, buyer shall pay (a) reasonable settlement expenses, (b) the PO price or rate for supplies and services delivered and accepted, (c) reasonable costs of performance on unaccepted supplies and services, and (d) a reasonable profit for the unaccepted work. For existing goods, buyer shall pay (e) reasonable settlement expenses, (f) the PO price for goods delivered and accepted, (g) reasonable costs incurred in preparation for delivery of the undelivered goods, and (h) a reasonable profit for the preparatory work. Buyer’s termination liability under this section shall not exceed the total PO price plus a reasonable cost for settlement expenses. Vendor shall submit a termination proposal and reasonable supporting documentation, and cost and pricing data as required by CRS §24-106-101, upon request of buyer.
22. PO Approval. This PO shall not be valid unless it is executed by purchasing agent. Buyer shall not be responsible or liable for products or services delivered or performed prior to proper execution hereof.
23. Fund Availability. Financial obligations of buyer payable after the current fiscal year are contingent upon funds for that purpose being appropriated, budgeted and otherwise made available. If this PO is funded in whole or in part with federal funds, this PO is subject to and contingent upon the continuing availability of federal funds for the purposes hereof. Buyer represents that it has set aside sufficient funds to make payment for goods delivered in a single installment, in accordance with the terms of this PO.
24. Choice of Law. State laws, rules and regulations shall be applied in the interpretation, execution, and enforcement of this PO. The CUCC shall govern this PO in the case of goods unless otherwise agreed in this PO. Any provision included or incorporated herein by reference which conflicts with such laws, rules, and regulations is null and void. Any provision incorporated herein by reference which purports to negate this or any other provision in this PO in whole or in part shall not be valid or enforceable or available in any action at law, whether by way of complaint, defense, or otherwise. Unless otherwise specified in the solicitation or this PO, venue for any judicial or administrative action arising out of or in connection with this PO shall be in Denver, Colorado. Vendor shall exhaust administrative remedies in CRS §24-109-106, prior to commencing any judicial action against buyer.
25. Public Contracts for Services. [Not Applicable to offer, issuance, or sale of securities, investment advisory services, fund management services, sponsored projects, intergovernmental POs, or information technology services or products and services] Vendor certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien who will perform work under this PO and will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this PO, through participation in the E-Verify Program or the Department program established pursuant to CRS §8-17.5-102(5)(c), Vendor shall not knowingly employ or contract with an illegal alien to perform work under this PO or enter into a contract or PO with a subcontractor that fails to certify to vendor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this PO. Vendor shall (a) not use E-Verify Program or Department program procedures to undertake pre-employment screening of job applicants during performance of this PO, (b) notify subcontractor and buyer within three days if vendor has actual knowledge that subcontractor is employing or contracting with an illegal alien for work under this PO, (c) terminate the subcontract if subcontractor does not stop employing or contracting with the illegal alien within three days of receiving notice, and (d) comply with reasonable requests made in the course of an investigation, undertaken pursuant to CRS §8-17.5-102(5), by the Colorado Department of Labor and Employment. If vendor participates in the Department program, vendor shall deliver to the buyer a written, notarized affirmation that vendor has examined the legal work status of such employee, and shall comply with all of the other requirements of the Department program. If vendor fails to comply with any requirement of this provision or CRS §8-17.5-101 et seq., buyer may terminate this PO for breach and, if so terminated, vendor shall be liable for damages.
26. Public Contracts with Natural Persons. Vendor, if a natural person eighteen (18) years of age or older, hereby swears and affirms under penalty of perjury that he or she (a) is a citizen or otherwise lawfully present in the United States pursuant to federal law, (b) shall comply with the provisions of CRS §24-76.5-101 et seq., and (c) has produced a form of identification required by CRS §24-76.5-103 prior to the date vendor delivers goods or begins performing services under terms of the PO.
Effective Date 01/01/09
Attachment B
HOUSE BILL 1023 IDENTIFICATION REQUIREMENT
As required by C.R.S. 24-76.5-103
NOTE: REQUIRED FOR SOLE PROPRIETORS ONLY (see General Conditions)
PLEASE PLACE AN ENLARGED COPY OF ONE OF THE FOLLOWING IN THIS SPACE:
· A valid state issued Driver’s License that is considered to be an official form of identification by the issuing state; or
· A United States military card or a military dependents identification card; or
· A United States Coast Guard Merchant Mariner Card; or
· A Native American Tribal Document
| _______________________________________________________ | __________________________________________ | |
| Signature of Document Holder | Date |
| _______________________________________________________ | __________________________________________ | |
| Printed Name of Document Holder | Social Security Number |
Place Notary Stamp or Seal above
| _________________________________________________________ | ____________________________________________ | |
| Signature of Authorized Notary | Date |
| _________________________________________________________ |
| Printed Name of Authorized Notary |
| (Faxed copies must be notarized in order to be considered acceptable) |
Attachment C
STATE OF COLORADO
CERTIFICATION AND AFFIDAVIT
REGARDING UNAUTHORIZED IMMIGRANTS
(Ref General Conditions)
CERTIFICATION STATEMENT CRS 8-17.5-101 & 102 (HB 06-1343, SB 08-193)
The Vendor, whose name and signature appear below, certifies and agrees as follows:
1. The Vendor shall comply with the provision of CRS 8.17.5-101 et seq. The Vendor shall not knowingly employ or contract with an unauthorized immigrant to perform work for the State or enter into a contract with a subcontractor that knowingly employs or contracts with an unauthorized immigrant.
2. The Vendor certifies that it does not now knowingly employ or contract with an unauthorized immigrant who will perform work under this contract, and that it will participate in either (i) the “E-verify Program” jointly administered by the United States Department of Homeland Security and the Social Security Administration, or (ii) the “Department Program” administered by the Colorado Department of Labor and Employment, in order to confirm the employment eligibility of all employees who are newly hired to perform work under this contract.
3. The Vendor shall comply with all reasonable requests made in the course of an investigation under CRS 8-17.5-102 by the Colorado Department of Labor and Employment. If the Vendor fails to comply with any requirement of this provision or CRS 8-17.5-101 et seq., the State may terminate work for breach and the Vendor shall be liable for damages to the State.
AFFIDAVIT CRS 24-76.5-101 (HB 06S-1023)
If the Vendor is a sole proprietor, the undersigned hereby swears or affirms under penalty of perjury under the laws of the State of Colorado that (check one):
______ I am a United States citizen, or
______ I am a Permanent Resident of the United States, or
______ I am lawfully present in the United States pursuant to Federal law.
I understand that this sworn statement is required by law because I am a sole proprietor entering into a contract to perform work for the State of Colorado. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to starting work for the State. I further acknowledge that I will comply with the requirements of CRS 24-76.5-101 et seq. and will produce the required form of identification prior to starting work. I acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under CRS 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
CERTIFIED and AGREED to this ______ day of ___________________, 20_______.
| VENDOR : | ________________________________________________________________ | |
| Vendor Full Legal Name |
| BY: | ________________________________________________________________ | ______________________ | |
| Signature of Authorized Representation | Title |
ATTACHMENT D
(For Use with Service Contracts)
VENDOR DISCLOSURE STATEMENT
Contract Performance Outside the United States or Colorado Colorado Revised Statute 24-102-206
To the extent the vendor has not disclosed the following information in the Statement of Work, this form shall be completed and returned to the contracting agency. This applies to all state contracts and solicitation for services executed after August 3, 2007.
Vendor Name: _____________________________________
Are any services under the contract or any subcontracts anticipated to be performed outside the United States or Colorado?
Yes ____ No ____
If “Yes”, please complete the following three questions:
1. Where will the services be performed under the contract, including any subcontracts? (List country(ies) and/or state(s).)
2. What is the total percentage of contract performance outside US or Colorado?
3. Explain why it is necessary or advantageous to go outside of the United States or the State of Colorado to perform the contract or any subcontracts.
Not required for contracts to which the State is a party under:
· Medicare
· The “Colorado Medical Assistance Act”, Articles 4 to 6 of Title 25.5 CRS
· The “Children/s Basic Health Plan Act”, Article 8 of Title 25.5, CRS
· The “Colorado Indigent Care Program”, Part I of Article 4 of Title 25.5, CRS
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