Attach_2_-_Contractor_Submittal_Form.pdf

FA2517-17-Q-5072

Attachment 2 Contractor Submittal Form

RFQ# FA2517-17-Q-5072

Please complete the following:

1 Contractor Name

2 DUNS Number

3 CAGE Code

4 NAICS Code (Must match para. 1 of the RFQ and offeror must be registered in SAM under this NAICS in order to be considered responsive)

333415

5 Point of Contact

6 Address

7 Phone Number

8 Email address

9 Payment Terms (Net 30 unless any discount terms are offered)

10 [Contractor Name]:

CLIN Information

CLIN Supplies Extended Item Description Qty Unit Unit Price ($) Total Amount ($)

0001 New 12.5 Ton Condensing Unit

New 12.5 Ton Condensing Unit IAW SOW Section 2.2. Includes removal & installation.

1 EA

0002 New 4 Ton Condensing Unit

New 4 Ton Condensing Unit IAW SOW Section 2.2. Includes removal & installation.

1 EA

0003 New Evaporator Coil for 12.5 Ton Condensing Unit

New Evaporator Coil for 12.5 Ton Condensing Unit IAW SOW Section 2.3. Includes removal & installation.

1 EA

0004 New Evaporator Coil for 4 Ton Condensing Unit

New Evaporator Coil for 4 Ton Condensing Unit IAW SOW Section 2.3. Includes removal & installation.

1 EA

Total Price

** Delivery & Installation shall be made 45 days after contract award. Peterson Air Force Base (PAFB), Colorado. All information described in Statement of Work, dated 24 Aug 2017. Include all shipping costs (if applicable) in the total amount quoted.

Offeror to complete the following:

DFARS 252.209-7999, Representation by Corporations Regarding an Unpaid Delinquent Tax Liability or a Felony Conviction under any Federal Law (Class Deviation 2012-O0004) (January 23, 2012)

(a) In accordance with sections 8124 and 8125 of Division A of the Consolidated Appropriations Act, 2012, (Pub. L. 112-74), none of the funds made available by this or any other Act may be used to enter into a contract with any corporation that-

(1) Has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability, where the awarding agency is aware of the unpaid tax liability, unless the agency has considered suspension or debarment of the corporation and made a determination that this further action is not necessary to protect the interests of the Government; or

(2) Was convicted of a felony criminal violation under any Federal law within the preceding 24 months, where the awarding agency is aware of the conviction, unless the agency has considered suspension or debarment of the corporation and made a determination that this action is not necessary to protect the interests of the Government.

(b) The Offeror represents that-

(1) It is [ ] is not [ ] a corporation that has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability,

(2) It is [ ] is not [ ] a corporation that was convicted of a felony criminal violation under a Federal law within the preceding 24 months.

(End of provision)

Company Name

Name

Title