Contractor Affidavit under O.C.G.A. § 13-10-91(b)(1)

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of Board of Regents of the University System of Georgia for the use and benefit of Institution, Using Agency (name of public employer) has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number

Date of Authorization

Name of Contractor

FY2026-2027 Task Order Contracting Services Name of Project

Board of Regents of the University System of Georgia for the use and benefit of Institution, Using Agency Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , , 20 in (city), (state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE DAY OF ,20 .

NOTARY PUBLIC

My Commission Expires:

Exhibit I

Company Name:

Physical Address:

Authorized person handling company tax issues:

Telephone and Email Address:

Federal Identification Number (FEI):

Selling any tangible property or goods? Y / N

What type of service will your company perform?

Ever been registered with Georgia Dept. of Revenue? Y / N

If yes, please provide the following information:

State Taxpayer ID (STI):

Sales and Use Tax No:

Withholding Tax No:

Company Affiliate's Name, if applicable:

Federal Identification (FEI):

State Taxpayer ID (STI):

Sales & Use Tax Number:

Withholding Tax Number:

If there is more than one affiliate, please attach a separate sheet listing the information above.

State Entity: Please submit this page via email to DOR at compliance-state-con@dor.ga.gov for processing in accordance with the Georgia Procurement Manual.

TAX COMPLIANCE

In the event the professional services / contractor is considered for contract award ($100K+), the information provided in the form below will be submitted by the State Entity to the Georgia Department of Revenue (DOR) for a determination as to whether the company is a "prohibited source" as defined by O.C.G.A. 50-5-82 or whether there are any other oustanding tax issues. MISSING, INCOMPLETE, OR ERRONEOUS DATA may delay or prohibit verification of company eligibility for contract award. No prohibited source may receive contract awards.

Therefore, you are strongly encourged to check your tax stsatus now or resolve any outstanding tax liabilities and/or missing tax returns.

Exhibit J

SCRUTINIZED COMPANY

___________________________________ located at ___________________________________

A scrutinized company as defined by…

1. …O.C.G.A. Section 50-5-84?

SUDAN: Any Supplier that currently and/or previously, within the last three years, has had business activities or other operations outside of the United States, must certify that it is not a “scrutinized company.” A scrutinized company is a company conducting business operations in Sudan that is involved in power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, but excludes a company which can demonstrate any of the following exceptions noted in O.C.G.A. Section 50-5-84. False certification hereunder may result in civil penalties, contract termination, ineligibility to bid on state contractors for three or more years, and/or any other available remedy. If the Supplier is a scrutinized company, the Supplier shall not be eligible to bid on or submit a proposal for a contract with the State Entity unless DOAS makes a determination in accordance with O.C.G.A. Section 50-5-84 that it is in the best interests of the State to permit the scrutinized company to submit a bid or proposal. Any scrutinized company desiring DOAS to make such a determination should contact both DOAS and the Issuing Officer immediately.

☐ I certify my company is NOT a “scrutinized company.”

☐ I certify my company is a “scrutinized company.”

☐ I certify I have requested & received written permission from DOAS to submit a response to this Event in accordance with Section 50-5-84.

2. …O.C.G.A. Section 50-5-84.1?

RUSSIA/BELARUS: A scrutinized company is any sole proprietorship, organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, limited liability company, or other entity or business association, including all wholly owned subsidiaries, majority owned subsidiaries, parent companies, or affiliates of such entities or business associations, that exists for the purpose of making profit owned or operated by the Government of Belarus or the Government of Russia. The Government of Belarus means the Republic of Belarus, and the Government of Russia means the Russian Federation. A scrutinized company is ineligible to submit a response to this solicitation. False certification hereunder may result in a civil penalty in an amount that is equal to the greater of $250,000 or twice the amount of the contract for which a bid or proposal was submitted, contract termination, and any other penalties available under law, rule or policy.

☐ I certify my company is NOT a “scrutinized company.”

☐ I certify my company is a “scrutinized company.”

Exhibit K dvongsouvan Typewritten Text Legal Firm Name dvongsouvan Typewritten Text Physical Address/Location

3. …O.C.G.A. Section 50-5-84.2?

CHINA: A scrutinized company is any sole proprietorship, organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, limited liability company, or other entity or business association, including all wholly owned subsidiaries, majority owned subsidiaries, parent companies, or affiliates of such entities or business associations, that exists for the purpose of making profit owned or operated by the Government of China. The Government of China means the People’s Republic of China led by the Chinese Communist Party. A scrutinized company is ineligible to submit a bid or proposal in response to this solicitation. False certification hereunder may result in a civil penalty in an amount that is equal to the greater of $250,000 or twice the amount of the contract for which a bid or proposal was submitted, contract termination, and any other penalties available under law, rule, regulation or policy.

☐ I certify my company is NOT a “scrutinized company.”

☐ I certify my company is a “scrutinized company.”

Signature:____________________________________ _______________________

State Entity: Please keep this completed document with the company contract documents. If you are posting and collecting documents via JAGGAER, this form is NOT required as these questions are included.

Exhibit K dvongsouvan Typewritten Text Date dvongsouvan Typewritten Text Print Name/Title of Authorized Signer dvongsouvan Typewritten Text Authorized Signer

Exhibit L

Insurance Requirements

Sample Certificate of Insurance (COI)

(CONTRACTOR – PLEASE ATTACH)

1. Copy of your Firm’s current Certificate of Insurance (COI) that meets or exceeds Board of Regents minimum requirements as outlined in the attached sample certificate. *** Builders Risk coverage or equivalent (when applicable) must be indicated.***

Version 03/01/2024

CERTIFICATE HOLDER

ACORD 25 (2010/05)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE

PRO-

GEN'L AGGREGATE LIMIT APPLIES PER:

GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

WC STATU-

TORY LIMITS

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

© 1988-2010 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

POLICY LOCJECT

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

Policy must contain the following Builder's Risk Endorsement: The following may occur without diminishing, changing, altering or otherwise affecting the coverage and protection afforded the insured under this policy:(i) Furniture and equipment may be delivered to the insured premises and installed in place ready for use; and (ii) Partial or complete occupancy by Owner; and (iii) Performance of work in connection with construction operations insured by the Owner, by agents or lessees or other Contractors of the Owner or Using Agency

Umbrella Liability: Contracts Amounts Less than $5M obtain $2M per occurrence/$4M aggregate; Contract Amounts Equal to or Greater than $5M obtain $2M per occurrence/$10M aggregate When using subcontractors, Contractor must comply with Section 1.5.3.3.1 (Worker's Compensation Insurance) and 1.5.3.3.2 (Employers' Liability Insurance)

AUTHORIZED REPRESENTATIVE

1,000,000

Current Date must list must list must list must list must list must list

Policy Number

Policy Number

Effective Date

Effective Date

Expiration Date

Expiration DateSAMPLE smorgan63 Highlight smorgan63 Highlight smorgan63 Highlight

SPECIMEN CERTIFICATE OF MANUFACTURER

SECTION 7 – FORMS

SPECIMEN CERTIFICATE OF MANUFACTURER

SECTION 7 – FORMS

SPECIMEN CERTIFICATE OF MANUFACTURER