FINAL_NEW_ROAD_BID FORMS_ Packet_DJH.pdf

BID FORMS REQUIRED FORMS PACKET

The bidder must include the following items or their bid proposal may be deemed non responsive.

The County reserves the right to accept or reject any and all bids, in whole or in part, that are deemed to be in the best interest of the County at its sole discretion.

CHECKLIST

• Electronic Bid Submittal Item Pricing (to be completed within the ebidding software)

• Signed and Completed Bid Proposal Sheet

• Signed Bid Bond with Power of Attorney

• A copy of All applicable, professional license(s) and business license(s)

• Sample Certificate of Insurance

• Signed and Completed Local Vendor Preference Package (if applicable)

• Signed and Completed Acknowledgement of Addenda Form

• IRS W-9 Form Signed Additional Required Forms

• Signed and completed Legal Statement

• Signed Anti-Lobbying Form

• Signed and Completed Form of NonCollusion Affidavit

• Signed Debarment, Suspension and Other Responsibility Matters Form

• Signed South Carolina Drug Free Workplace Form

• Signed/Completed NonResident TaxPayer Registration Form

• Signed/Completed Responsibility Statement Form

Required Form

Bid Proposal Sheet

BID PROPOSAL OF:

(hereinafter called "BIDDER"), organized and existing under the laws of the State of SouthCarolina).

TO: Horry County (hereinafter called"OWNER")

In compliance with your request for Bids, BIDDER hereby proposes to perform all WORK for the construction of the improvements as shown and called for in the CONSTRUCTION DOCUMENTS in strict accordance with the CONTRACT DOCUMENTS, within the time set forth and for the TOTAL BID AMOUNT stated in Electronic Bid proposal Item Pricing.

By submission of this BID, each BIDDER certifies that this BID has been arrived at independently, without consultation, communication, or agreement as to any matter relating to the BID with any other BIDDER or with any competitor.

BIDDER hereby agrees, if awarded this contract, to commence WORK under the contract on or before a date specified in the NOTICE TO PROCEED.

BIDDER agrees to provide faithful performance of all work described in the CONTRACT DOCUMENTS and proper fulfillment of such Contract for the TOTAL BID AMOUNT as presented in electronic bidsubmittal.

Bidder hereby acknowledges receipt of all Addenda published in Horry County’s ebidding software.

NOTE: Bids shall include sales tax and all other applicable taxes and fees. Any work required as identified in the requirements / specifications not specifically listed below shall be included in the most closely related work item listed.

It is the responsibility of the Contractor to verify all quantity take-offs, and to bid the work appropriately. Any discrepancy and resulting cost adjustments should be noted in comments section when entering the unit price into the ebidding software.

By the act of submitting a bid for the proposed contract, the Bidder represents that:

1. The Bidder and all subcontractors the Bidder intends to use have carefully and thoroughly reviewed the drawings(if applicable), specifications and other construction contract documents and have found them complete and free from ambiguities and sufficient for the purpose intended; furtherthat,

2. The bidder and all workmen, employees and subcontractors the Bidder intends to use are skilled and experienced in the type of construction represented by the construction contract documents bid upon; furtherthat,

3. Neither the Bidder not any of the Bidder’s employees, agents, intended suppliers or subcontractors have relied upon any verbal representations, allegedly authorized or unauthorized from the Owner, or the Owner’s employees or agents including architects, engineers or consultants, in assembling the bid figure; and further that,

4. The Bid figure is based solely upon the construction contract documents and properly issued written addenda and not upon any other written representation.

BID ITEM PRICING PROVIDED IN EBIDDING SOFTWARE

Signature Line:

Authorized Signing Officer (Printed Name) Authorized Signing Officer Signature

Title Email address

Address

License Number Date

COMPANY

Phone # FAX #

BID BOND

KNOW ALL MEN BY THESE PRESENTS, that we the undersigned, as PRINCIPLE, and as SURETY are held and firmly bound unto , hereinafter called the “OWNER”, inthe penal sum of

Dollars ($ ), lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents.

THE CONDITION OF THIS OBLIGATION IS SUCH, that Whereas the Principal has submitted the Accompanying Bid, dated , 20 , for

NOW, THEREFORE, if the Principle shall not withdraw said Bid within the period specified therein after the opening of the same, or, if no period be specified, within thirty (30) days after the said opening, and shall within the period specified therefore, or if no period be specified, within ten (10) days after the prescribed forms are presented to him for signature, enter into a written Contract with the Owner in accordance with the Bid as accepted, and give bond with good and sufficient surety or sureties, as may be required, for the faithful performance and proper fulfillment of such Contract; or in the event of the withdrawal of said Bid within the period specified, or the failure to enter into such Contract and give such bond within the time specified, if the Principal shall pay the Owner the difference between the amount specified in said Bid and the amount for which the Owner may procure the required work or supplies or both, if the latter be in excess of the former, then the above obligation shall be void and of no effect, otherwise to remain in full force and virtue.

IN WITNESS WHEREOF, the above-bounded parties have executed this instrument under their several seals this day of , 20 , the name and corporate seal of each corporate party being hereto affixed and these presentssigned by its undersigned representative, pursuant to authority of its governing body.

(SEAL)

(SEAL)

Attest: By:

Affix

By: Corporate Seal

Non-Required Form

Local Vendor Preference Procedures and Affidavit of Eligibility

The Local Vendor Preference Affidavit of Eligibility form and other required documentation as described on the following pages MUST be submitted WITH a vendor’s SEALED BID to be considered, per Horry County Council Resolution # 116 - 13.

By submitting a completed local vendor preference affidavit, the “local bidder” is acknowledging and accepting the application of local vendor preference if their “local bid” total is the second lowest price within five percent (5%) – or two percent (2%), as applicable – of the lowest price if lowest price is submitted by a non-local vendor.

After bids are opened and it is determined that the above criteria apply to an eligible “local bid”, the “local bidder” will then be required to proceed with the contract award process with reduced line item totals for each item in the original bid schedule such that the revised total bid price will then equal the original lowest price of the non-local vendor. Effective unit prices for each line item will be calculated after the line item adjustments are made, as appropriate. Those vendors not seeking to have their bids considered under the provisions of the “Local Vendor Preference” resolution (116-13) do not need to submit any documentation.

Procurement Department 3230 Hwy 319 E, Conway, SC 29526 Phone: 843.915.5380

LOCAL VENDOR PREFERENCE

AFFIDAVIT OF ELIGIBILITY

IMPORTANT: Local Vendor Preference affidavit and required documentation MUST be submitted WITH a vendor’s SEALED BID to be considered, per Horry County Council Resolution # 116 - 13.

This form is to be completed in its entirety by the local vendor requesting consideration for the preference and submitted along with your Sealed Bid. Incomplete forms may be rejected for local vendor preference evaluation.

Attach required documentation to sealed bid.

1. LEGAL NAME OF FIRM:

Mailing Address: Physical Address (if different)

2. Year your business was established in Horry County:

(attach documentation, as indicated in the instructions below)

3. Business License Number issued by Horry County or applicable municipality:

Yes No Date Issued:

(attach documentation, as indicated in the instructions below)

4. Current Horry County Taxes paid? Yes No

Paid Tax Receipt Number Date Taxes Paid

5. For transactions which require sales tax, provide the following Reseller information:

Reseller Permit Number:

Enter the Company Name and Address as it appears on permit:

6. The business will attribute any sales tax from the contract with Horry County.

Does your business have more than one office in the State of South Carolina? Yes No

If Yes, specify the office location considered as the point-or-sale for sales tax purposes

7. Are a majority of employees (on payroll of local vendor requesting preference) Horry County residents? Yes No

Horry County Local Vendor Preference Package - Page 1 of 4

Publication effective date: October 15, 2013

8. Are a majority of independent contractors (engaged by local vendor requesting preference) Horry County residents? Yes No

8. Has the vendor applying for the local vendor preference in this affidavit been in default or terminated from any Horry County contract within the last five (5) years? Yes No (A condition of default includes notices from sub-contractors and suppliers who have contracted the local vendor’s surety, or Horry County, without successful resolution for contract payment disputes.)

If “Yes”, explain:

Note: Horry County reserves right to demand proof or documentation of any certification or claim contained herein, at any time during resultant contract period. Failure to provide requested information may result in contract termination. Section 13-3-3 of the Horry County Procurement Regulation outlines Horry County’s Audit authority.

By signing below, it is understood that all terms and conditions and instructions have been carefully examined before deciding to submit this local vendor preference affidavit. Under the penalty of perjury, the undersigned states that the foregoing statements are true and correct. The undersigned also acknowledges that any person, firm, corporation or entity intentionally submitting false information to the County in an attempt to qualify for local preference may be suspended from bidding on Horry County products and services for a period of at least ninety

(90) calendar days, per Chapter 15 of the Horry County Procurement Regulation.

Company Legal Name (Printed) Date

Authorized Person’s Signature

Printed Name & Title

Email Address Phone ( )

On this day of , , before me, the under-signed officer, personally appeared

[name(s) of person(s) who made acknowledgment on behalf of the corporation], a corporation/partnership/sole proprietor, and that he/she/they, as such [title of corporate officer or other description of legal capacity], being authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself/herself/themselves as [title of corporate officer or other description of legal capacity].

In witness whereof I hereunto set my hand and official seal.

Notary Public

My Commission Expires:

Horry County Local Vendor Preference Package - Page 2 of 4

HORRY COUNTY, SOUTH CAROLINA LOCAL VENDOR PREFERENCE

INSTRUCTIONS FOR APPLICATION

1. Background and Legal Authority

1.1. On October 15, 2013, Horry County Council passed Resolution # 116-13 creating a local vendor preference for qualified Horry County businesses. – This Resolution is attached in its entirety.

1.2. In 2010, Horry County Council passed ordinance # 02-10, Horry County

Procurement Code and Regulation effective May 1, 2010 – This Code and Regulation is available on the Horry County web site at:

http://www.horrycounty.org/Departments/Procurement.aspx.

2. Definitions, based on legislation referenced above

2.1. “Principle place of business” – Physical location (street address) of Horry County business.

2.2. “Horry County resident employee” – Employee of local vendor that permanently and legally resides in Horry County.

2.3. “Horry County resident sub-contractor” – Subcontractor of local vendor that also has a “principle place of business” in Horry County.

2.4. “Proof” (#2.c of Resolution) – Documentation, as determined by Horry County Chief Procurement Official or County Attorney, required to substantiate local vendor status.

2.5. “Default” – Local vendor who has been terminated or defaulted on a previous Horry County contract. A condition of default also includes notices from sub-contractors and suppliers who have contracted the local vendor’s surety, or Horry County, without successful resolution for contract payment disputes.

3. Terms, Conditions and Instructions, based on legislation referenced above

3.1. Applicability

3.1.1. As required in the attached Horry County Council Resolution # 116-13, the second apparent low total bid must be within the percentage, based on the threshold bid amount, and will be applied across-the-board. If local vendor preference is activated, the actual percentage used to match the apparent low total bid will be applied to each line item. The reduced line item amounts will be incorporated into the resultant contract and may be used for change order calculations, as necessary.

3.1.2. Applicability of local vendor preference will apply to only the sealed bid under consideration and be applicable only to its resultant contract.

3.1.3. Apparent low bidder, with or without application of local vendor preference, will be required to be a responsive and responsible bidder.

3.1.4. All bidders of record will be notified when local vendor preference has been properly requested. Such notification will set a deadline for submitting a bid protest based on local vendor preference only. All other objections for

Horry County Local Vendor Preference Package - Page 3 of 4 http://www.horrycounty.org/Departments/Procurement.aspx bid protests shall follow Subchapter 15-3 of the Horry County Procurement Regulation.

3.2. Submission of local vendor preference affidavit

3.2.1. Must submit local vendor preference affidavit and required documentation

(see below) as part of your sealed bid proposal

3.2.2. By submitting a completed local vendor preference affidavit, you are acknowledging and accepting the application of local vendor preference if your total bid is second lowest price within five percent (5%) – or two percent (2%), as applicable – of the lowest price if lowest price is submitted by non-local vendor

3.2.3. By submitting a completed local vendor affidavit with your sealed bid as required will bind your company to meet the “lowest price” bid amount as applicable in 4.2.2 above.

3.2.4. Mistakes in bids are covered by section 11-2-10 of the Horry County Procurement Code and Regulation which is identified as “Code of Ordinances” on this page of the Horry County web site:

http://www.horrycounty.org/Departments/Procurement.aspx.

3.3. Documentation to submit with affidavit as part of sealed bid

3.3.1. Principle place of business

3.3.1.1. Lease or purchase agreement that shows location and date acquired. Vendor may redact confidential information such as monthly payment amount.

3.3.2. Majority of employees are Horry County residents – certification is part of local vendor preference affidavit.

3.3.3. Majority of independent contractors are Horry County residents – certification is part of local vendor preference affidavit.

3.3.4. All fees and taxes paid in full – certification is part of local vendor preference affidavit.

3.3.5. Applicable business license

3.3.5.1. Photocopy of current Horry County business license or business license from applicable municipality.

3.3.6. All other relevant licenses, permits, and authorizations – these items may be requested, as deemed relevant by Horry County Chief Procurement Official

3.3.6.1. Examples of potentially relevant documentation:

3.3.6.1.1. State of SC general contractor license

3.3.6.1.2. Permits for current projects

3.3.7. Default information – certification is part of local vendor preference affidavit.

Horry County Local Vendor Preference Package - Page 4 of 4 http://www.horrycounty.org/Departments/Procurement.aspx

COUNTY OF HORRY )

STATE OF SOUTH CAROLINA )

RESOLUTION R-116-13

A RESOLUTION AUTHORIZING AND DIRECTING THE AMENDMENT OF HORRY

COUNTY'S PROCUREMENT REGULATIONS TO INCLUDE A LOCAL VENDOR

PREFERENCE PROVISION.

WHEREAS, Appendix E of the Horry County Code of Ordinances (Procurement Code) provides in Section 103 that amendments to the County's regulations governing procurement, management, control, and disposal of supplies, services, and/or construction to be procured by the County, once approved by way ofresolution of Horry County Council, shall be binding in all procurements made by the County, absent existing contract without consent of the parties to be so bound; and

WHEREAS, Horry County desires to further its support of local businesses when awarding contracts for the provision of goods and services to the County by providing for a local vendor preference in its procurement regulations, in an effort to promote local economic activity and stimulus, job creation, and fairness.

NOW, THEREFORE, BE IT RESOLVED that the Horry County Procurement Regulations are hereby amended to include the following provision:

A. Local Vendor Preference

1. A responsive and responsible local bidder who is within a certain percentage of the lowest non-local bidder, may be given the opportunity to match the bid submitted by the non-local bidder and thereby be awarded a contract, if the following conditions are met.

a. The apparent low bidder on a formal sealed bidding procurement (commodity value over $25,000, but not exceeding $100,000, as a Tier 4 process, Horry County Procurement Regulation section 11-2) is NOT a local vendor (see below for definition of "local vendor") and the next apparent low bidder is local and the local bid is within 5% of apparent non-local low bid, then the local vendor has the opportunity to meet the apparent low non-local bid. The local vendor must perform as specified in the invitation to bid at the price bid by a non-local vendor assuming the difference is 5% or less. Consideration for an award will include the willingness and ability of the local bidder to perform fully at the reduced bid amount.

b. The apparent low bidder on a formal sealed bidding procurement (commodity value over $100,000, but not exceeding $10,000,000 as a Tier 4 process, Horry County Procurement Regulation section 11-2) is NOT a local vendor (see below for definition of " local vendor") and the next apparent low bidder is local and the local bid is within 2% of apparent non-local low bid, then the local vendor has the opportunity to meet the apparent low non-local bid. The local vendor must perform as specified in the invitation to bid at the price bid by a non-local vendor assuming the difference is 2% or less. Consideration for an award will include the willingness and ability of the local bidder to perform fully at the reduced bid amount.

c. Contracts awarded using a local vendor preference must still comply with all the same terms and conditions of the bid documents . The same due diligence will be performed regardless if the apparent low bidder is local or non-local. Horry County will not award a contract to a non-responsive or non-responsible bidder.

d. Bidders must include an executed " local vendor preference" affidavit form and submit it with their sealed bid. All items declared in the local vendor preference affidavit must be current at the time the form is submitted. Bidders will not be permitted to submit the local vendor preference affidavit after the sealed bids have been publically opened. If the local vendor preference affidavit is not included as part of the local vendor' s sealed bid, the bidder will not be permitted to request the preference.

e. Preference will be applied on the total bid amount, including sales/use tax, shipping, handling, and any other fees.

f. Local vendor preference cannot be applied to any sealed bid process that has any federal or state grant dollars attached to it, or otherwise if prohibited by law.

g. Should the lowest responsive and responsible local bidder not exercise its right to match the bid as granted herein , the next lowest qualified local bidder shall have that right and so on.

h. The right to exercise the right to match a non-local bidder' s bid shall be exercised within 24 hours of notification of the right to match that bid.

1. Local preference shall not apply to goods or services provided under a cooperative purchasing agreement or similar "piggyback" contract, or any bid announcement which specifically provides that the general local preference policies set forth herein are suspended due to unique or extraordinary circumstances or where such suspension is required by law or determined to be in the best interests of the County as determined by the Chief Procurement Officials.

2. To qualify as a "local vendor", the following must be met:

a. Vendor must have a current physical business address (as a principal place of business), located and in operation (regularly conducting business) in Horry County for the last three (3) years, and maintain such throughout the term of any contract with the County.

b. The majority of employees/independent contractors of the vendor must be " legal" and "permanent" full-time Horry County residents.

c. Vendor is in good standing with the State of South Carolina and Horry County Government. Proof shall be submitted as part of sealed bid, and shall include:

• All fees, taxes, etc. must be paid in full prior to due date of sealed bid and submittal of affidavit.

• Horry County (or applicable municipality) business license must be obtained in advance of requesting local vendor preference. Copy shall be submitted as part of the local vendor preference affidavit.

• All other relevant licenses , permits, and authorizations are in hand.

d. Vendor has not defaulted or been terminated from a previous Horry County contract within the last five (5) years. A condition of default includes notices from sub-contractors and suppliers who have contacted the local vendor' s surety, or Horry County, without successful resolution for contract payment disputes .

B. Review by Council

To enable it to appropriately monitor the effect of such regulation on the procurement of goods and services by the County, Council will conduct a review of such regulation on an annual basis.

AND IT IS SO RESOLVED.

Dated this 15th day of October, 2013.

Mark Lazarus, Chairman

Harold G. Worley , District 1 Brent J. Schulz, District 2

Marion D. Foxworth, III, District 3 Gary Loftus, District 4

Paul D. Price, Jr., District 5 Robert P. Grabowski, District 6

James R. Frazier, District 7 Carl H. Schwartzkopf, District 8

W. Paul Prince, District 9 Jody Prince, District 10

Al Allen, District 11

Required Form ACKNOWLEDGEMENT OF ADDENDA

Offeror hereby acknowledges receipt of all Addenda through and including:

Addendum No. , dated .

Company

Authorized Signature

Print Name

Legal / Litigation Statement Form

Disclose any litigation within the last five (5) years in which a claim has been made against any team member (individual or company) asserting a cause of action other than Employment issues or Contracts not related to your professional work. Explain the issues in these cases (or the fact there are none) as part of your submittal:

ANTI-LOBBYING FORM

CERTIFICATION OF RESTRICTIONS ON LOBBYING

I, , hereby certify on

(name and title of bidder's official) behalf of that:

(name of bidder)

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit standard Form-LLL, "Disclosure Form to Report Lobbying, " in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all sub awards at all tiers (including subcontracts, sub grants, and contracts under grants, loans, and cooperative agreements) and that all sub recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance is placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Executed this day of , .

By (signature of authorized official)

(title of authorized official)

Bid Submittal Required Form

FORM OF NONCOLLUSION AFFIDAVIT

(This Affidavit is Part of the Bid Submittal)

STATE OF

) COUNTY OF

being first duly sworn, deposes and says that he/she is

(Sole owner, a partner, president, secretary, etc.)

of the party making the foregoing Bid Proposal that such Bid Proposal is genuine and not collusive or sham; that said Bidder has not colluded, conspired, connived, or agreed directly or indirectly, with any Bidder or person to put in a sham Bid Proposal, or that such other person shall refrain from offering and has not in any manner, directly or indirectly sought by agreement or collusion, or communication of conference, with any person, to fix the bid proposal price of affiant or any other Bidder, or to fix any overhead, profit or cost element of said bid proposal price, or that of any other Bidder to secure any advantage against OWNER any person interested in the proposed Contract; and that all statements in said Bid Proposal are true; and further, that such Bidder has not, directly or indirectly submitted this bid proposal, or the contents thereof, or divulged information or date relative thereto to any association or to any member or agent thereof.

(Bidder)

Sworn to and subscribed before me this day of , 20 .

State County Notary Public in and for

My commission expires , 20 .

CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER

RESPONSIBILITY MATTERS

As required by Executive Order 12549, Debarment and Suspension, and implemented under the applicable CFR, for prospective participants in covered transactions, as defined in the applicable CFR

A. The applicant certifies that it and its principals:

(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, sentenced to a denial of Federal benefits by a State or Federal court, or voluntarily excluded from covered transactions by any Federal department or agency;

(b) Have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity

(Federal State or local) with commission of any of these offenses enumerated in paragraph (1) (b) of this certification; and

(d) Have not within a three-year period preceding this application had one or more public transactions

(Federal, State or local) terminated for cause or default; and

B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this application.

Address:

Contractor’s Signature

Printed or Typed Name

Title

Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should also review the instructions for certification included in the regulations before completing this form. Signature of this form provides for compliance with certification requirements under the applicable CFR covering New Restrictions on Government-wide Debarment and Suspension (Non- procurement). The certification shall be treated as a material representation of fact upon which reliance will be placed when the Agency determines to award the covered transaction or cooperative agreement.

BB. S.C. DRUG-FREE WORKPLACE (CONTRACTORS OTHER THAN INDIVIDUALS) -

APPLICABLE TO CONTRACTORS RECEIVING $50,000 OR MORE FROM A STATE

AGENCY AND ALL STATE AGENCIES REGARDLESS OF CONTRACT AMOUNT.

As required by the S.C. Drug-Free Workplace Act #593 of 1990 and the Federal Drug-Free Workplace Act of 1988 and implemented under the applicable CFR –

A. The applicant certifies that it will or will continue to provide a drug-free workplaceby:

(a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the contractor’s workplace and specifying the actions that will be taken against employees for violation of such prohibition;

(b) Establishing an on-going drug-free awareness program to inform employeesabout-

(1) The dangers of drug abuse in the workplace;

(2) The contractor’s policy of maintaining a drug-free workplace;

(3) Any available drug counseling, rehabilitation and employee assistance programs;

and,

(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

(c) Making it a requirement that each employee to be engaged in the performance of the contract be given a copy of the statement required by paragraph(a);

(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the contract, the employee will –

(1) Abide by the terms of the statement; and

(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction;

(d) Notifying the agency, in writing, within 10 calendar days after receiving notice under subparagraph (d) (2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to the State Funding Agency. Notice shall include the identification number(s) of each affected contract;

(f) Taking one of the following actions, within 30 calendar days of receiving noticeunder subparagraph (d) (2), with respect to any employee who is soconvicted-

(1) Taking appropriate personnel action against such an employee up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or

(2) Requiring such employees to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;

(g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f).

B. DRUG-FREE WORKPLACE (CONTRACTORS WHO ARE INDIVIDUALS) -APPLICABLE

TO CONTRACTORS RECEIVING $50,000 or MORE FROM A STATE AGENCY.

As required by the S.C. Drug-Free Workplace #593 of 1990 –

(a) As a condition of the contract I certify that I will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the contract; and

(b) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any contract activity, I will report the conviction, in writing, within 10 calendar days of the conviction to the State Funding Agency.

Signature of Contractor Typed Name and Title

Responsibility Form Page 1 of 1

Responsibility Statement Form

By signing this form, the bidder/proposer/offeror:

1. Has, or has the ability to obtain, the resources, financial and otherwise, to satisfy all of the contract’s requirements; and

2. Is legally qualified to contract with Horry County (or provide sub-contract services);

and

3. Does not have a record of consistent unsatisfactory performance in previous contracts with Horry County or any other public or private entity; and

4. Has proposed, bid, or quoted a price pursuant to which the bidder, quoter, or offeror can successfully meet the requirements of the procurement; and

5. Has no unresolved surety claims; and

6. Has not been party to a contract which was terminated for cause for alleged conduct on its part.

Bidder/Proposer/Offeror Name: ___________________________________________________

Authorized Signature: __________________________________________________________

Authorized Signer’s Printed Name: ________________________________________________

Authorized Signer’s Title: ________________________________________________________

Date:_____________________________________

Required Form (if applicable)

Mail to: The company or individual you are contracting with.

The undersigned nonresident taxpayer on oath, being first duly sworn, hereby certifies as follows:

1. Name of Nonresident Taxpayer:

2. Trade Name, if applicable (doing business as):

3. Mailing Address:

4. Federal Employer Identification Number (FEIN):

5. Hiring or Contracting with:

Name:

Address:

Receiving Rentals or Royalties From:

Name:

Address:

6. I hereby certify that the above named nonresident taxpayer is currently registered with (check the appropriate box):

The South Carolina Secretary of State or The South Carolina Department of Revenue:

Date of Registration:

7. I understand that by this registration, the above named nonresident taxpayer has agreed to be subject to the jurisdiction of the South Carolina Department of Revenue and the courts of South Carolina to determine its South Carolina tax liability, including estimated taxes, together with any related interest and penalties.

8. I understand the South Carolina Department of Revenue may revoke the withholding exemption granted under Code

Section 12-8-550 (temporarily doing business or professional services in South Carolina) or Code Section 12-8-540 (rentals) at any time it determines that the above named nonresident taxpayer is not cooperating with the Department in the determination of its correct South Carolina tax liability.

The undersigned understands that any false statement contained herein could be punished by fine, imprisonment or both.

Recognizing that I am subject to the criminal penalties under Code Section 12-54-44(B)(6)(a)(i), I declare that I have examined this affidavit and to the best of my knowledge and belief, it is true, correct and complete.

(Seal) Signature of Nonresident Taxpayer (Owner, Partner or Corporate Officer, when relevant) Date

If Corporate officer, state title:

(Name - Please Print)

33231028

1350 STATE OF SOUTH CAROLINA

DEPARTMENT OF REVENUE I-312

NONRESIDENT TAXPAYER REGISTRATION (Rev. 5/18/15)

AFFIDAVIT INCOME TAX WITHHOLDING 3323

INFORMATION

NONRESIDENT TAXPAYER REGISTRATION AFFIDAVIT

Submit this form to the company or individual you are contracting with.

Do not submit this form to South Carolina Department of Revenue.

PURPOSE OF AFFIDAVIT

A person is not required to withhold taxes for a nonresident taxpayer who submits an affidavit certifying that they are registered with either the South Carolina Secretary of State or the South Carolina Department of Revenue.

REQUIREMENTS TO MAKE WITHHOLDING PAYMENTS

Code Section 12-8-550 requires persons hiring or contracting with a nonresident taxpayer to withhold 2% of each payment made to the nonresident where the payments under the contract exceed $10,000. However, this section does not apply to payments on purchase orders for tangible personal property when those payments are not accompanied by services to be performed in this state.

Code Section 12-8-540 requires persons making payment to a nonresident taxpayer of rentals or royalties at a rate of $1,200 or more a year for the use of or for the privilege of using property in South Carolina to withhold 7% of the total of each payment made to a nonresident taxpayer who is not a corporation and 5% if the payment is made to a corporation.

Our Internet address is: www.dor.sc.gov

33232026 http://www.dor.sc.gov/