Final RFP Road Patching.pdf

REQUEST FOR BID PROPOSAL FOR 2024 ROAD PATCHING AND

REPAIR - MERIWETHER COUNTY

Meriwether County is accepting bids for per square yard cost of patching various roads in Meriwether County Georgia.

You may pick up a copy of the Bid Package at Meriwether County Administration Office located at 17234 Roosevelt Highway, Building B. Greenville, GA 30222, or the bid package is available online at www.meriwethercountyga.gov.

Meriwether County will accept sealed bids until 2:00 p.m., on Friday, May 17, 2024. Bids are to be sealed and delivered to the Meriwether County Administration Office, 17234 Roosevelt Highway, Building B, Greenville, GA 30222. All Bids are to be clearly marked on exterior of Bid as outlined in the bid documents.

http://www.meriwethercountyga.gov/

2024 MC Road Patching and Repair Page 1 of 20

MERIWETHER COUNTY 2024 ROAD PATCHING AND REPAIR

BIDDERS ARE ADVISED TO THOROUGHLY UNDERSTAND THE GENERAL CONDITIONS

AND SPECIAL PROVISIONS, PRIOR TO SUBMITTING THEIR BID.

I. GENERAL CONDITIONS

A. QUALIFICATIONS

1. Bids will be considered only from experienced and well-equipped Contractor engaged in work of this type and magnitude.

2. Bidders may be required to submit evidence setting forth qualifications, which entitle him to consideration as a responsible Contractor. A list of work of similar character successfully completed within the last two years may be required giving the location, size and listing equipment available for use on this work. Before accepting any bid, the County may require evidence of the Contractor's financial ability to successfully perform the work to be accomplished under the contract.

3. All questions concerning the project shall be addressed in writing to Theron Gay, at t.gay@meriwethercountyga.gov no later than 5:00 p.m. on Thursday, May 9, 2024.

B. GUARANTEE TO ACCOMPANY BID

1. A Bid Bond is not Required for this project.

C. SUBMITTING BIDS

Bids will be accepted by the Meriwether County Board of Commissioners, at 17234 Roosevelt Hwy, Bldg. B, Greenville, GA 30222, until 2:00 p.m., Friday, May 17th, 2024. Bids received after the designated time will not be considered.

1. Bids should be submitted in a sealed envelope with the following information clearly typed or printed on the outside:

Meriwether County Board of Commissioners Your Company Name 2024 Road Patching

D. AUTHORITY TO SIGN

The Bidder should ensure that the legal and proper name of his proprietorship, firm, partnership or corporation is printed or typed in the space provided on the Schedule of Items.

E. RIGHTS RESERVED

1. Meriwether County reserves the right to reject any or all Bids, to waive informalities and to re-advertise. It is understood that all Bids are made subject to this agreement, that Meriwether County reserves the right to decide which Bid it deems lowest and best, and in arriving at this decision, full consideration will be given to the reputation of the Bidder, his financial responsibility, and work of this type successfully completed.

2. Bidders are advised to examine any Plans and Specifications carefully and to make examinations of the site of the proposed work as necessary to familiarize themselves with local conditions, mailto:t.gay@meriwethercountyga.gov

2024 MC Road Patching and Repair Page 2 of 20 which may affect the proposed work. Bidders are also advised to inform themselves fully in regard to conditions under which the work will be performed. Meriwether County will not be responsible for Bidder’s errors or misjudgment, nor for any information on local conditions or general laws and regulations.

3. Any unauthorized additions, conditions, limitations, or provisions attached to the Bid shall render it informal and may be cause for rejection.

4. No Bids may be withdrawn after submission for a period of 60 days after the date set for opening thereof.

5. Meriwether County reserves the right to reject any and all bids from any person, firm, or corporation who is in arrears in any department or obligation to Meriwether County, Georgia.

6. Individuals, firms, and businesses seeking an award of a Meriwether County contract may not initiate or continue any verbal or written communications regarding a solicitation with any County officer, elected official, employee or other County representative without permission of the County Administrator between the date of the issuance of the solicitation and the date of the final contract award by the Board of Commissioners. The County Administrator will review violations.

If determined that such communication has compromised the competitive process, the offer submitted by the individual, firm or business may be disqualified from consideration for award.

F. AWARD OF CONTRACT

1. The contract will be awarded to the lowest responsive and responsible bidder whose bid will be most advantageous to Meriwether County with price and other factors considered.

2. Prior to award of the contract, the successful bidder may be required to submit documentation demonstrating the bidder’s ability to commence, proceed, and complete in a timely manner. A bidder’s failure to demonstrate the ability to proceed as required may result in the award to the next low, responsive and responsible bidder, as deemed in the County's best interest.

G. RETAINAGE

1. Retainage on work completed will be withheld by Meriwether County as follows:

A. The county shall retain 5% of the gross value of the completed work, indicated by current estimates, until all pay items are substantially completed.

2024 MC Road Patching and Repair Page 3 of 20

MERIWETHER COUNTY PROJECT DESCRIPTION

Meriwether County, Georgia is seeking bids from qualified contractors to assist the County with patching and repair of various roads to be determined by the Meriwether County Board of Commissioners. Once a road or roads are selected, County staff will paint mark the areas on the roadway to be patched. As no two roads are the same, this Proposal is asking for a per square yard price for patching based on the following specifications. Once the repair is complete, the square yard quantities will be calculated and will be the basis for the invoice for payment.

Patching proposals must meet the following specifications and procedures:

• Area to be patched must be cleaned of any loose material, dirt, or debris. Material removed must be hauled away by Contractor and disposed of in a proper manner.

• Area to be repaired must include tack coat application prior to patching.

• Patching material shall be recycled asphalt concrete 9.5MM or 12MM, including bituminous material and H-Lime, including tack, 220lbs per square yard.

• Repairs shall be compacted using a vibratory Asphalt Tamp Plate once all repair materials are in place.

Application of patching material shall conform to GDOT specifications for temperature and inclement weather conditions as outlined in Section 400 – Hot Mix Asphaltic Concrete Construction.

2024 MC Road Patching and Repair Page 4 of 20

H. LOCATION, WORK AND SITE

This bid request is for a unit price based on one square yard of patching material as specified in this document.

The actual site location of the work to be performed will be determined at a future date by Meriwether County.

2. The Contractor shall accept the site in its present condition and carry out all work in accordance with the requirements of the specifications as directed by the County.

3. The Contract Documents contain the provisions required for the work to be performed pursuant to this Contract. Information obtained from an Officer, agent, or employee of Meriwether County or any other person shall not affect the risks or obligations assumed by the Contractor or relieve him from fulfilling any of the conditions of the Contract. Each Bidder is responsible for for reading and being thoroughly familiar with the Contract Documents. The failure or omission of any Bidder to so familiarize himself shall in no way relieve any Bidder from any obligation in respect to his Bid.

4. The Contractor is responsible for the location of above and below ground utilities and structures, which may be affected by the work.

I. COMPLIANCE WITH OSHA STANDARDS AND REGULATIONS

The work connected with this Contract shall be performed in accordance with all applicable OSHA regulations and standards including any additions or revisions thereto until the job is completed and accepted by Meriwether County.

J. INSPECTION

Meriwether County does not commit to have a full-time inspection or testing of work while in progress or at sources of materials furnished. Any lack of inspection and/or testing will in no way relieve the Contractor of his responsibility to provide quality workmanship in accordance with the Specifications.

Any test ordered under the supervision of the County that fails to meet standards and retesting required, will be at the contractor’s expense.

K. GENERAL BOND REQUIREMENTS

1. Bid Bonds – Not required for this Proposal

2. Performance Bond - (Supplied by successful vendor) – Not required for this Proposal.

3. Payment, Labor and Materials Bonds - Not required for this Proposal.

L. CONTRACT REQUIREMENTS

1. Successful vendor is required to do the following within ten (10) days of Notice of Award:

A. Return to County Administrator contract documents executed by the authorized representative and attested by the corporate secretary treasurer.

B. Provide Insurance certificates as specified in the bid documents.

C. Provide bonding as required by the bid documents. – Not required for this proposal.

2024 MC Road Patching and Repair Page 5 of 20

2. Failure to execute the Contract or furnish satisfactory proof of carriage of the insurance required within ten days after the date of Notice of Award of the Contract may be just cause for the annulment of the award. At the discretion of the County, the award may then be made to the next lowest, responsible bidder, or the work may be re-advertised or constructed by County forces.

3. The contractor shall furnish, install, maintain and remove all necessary traffic signs, barricades, lights, signals, cones and other traffic control devices, and all flagging and other means of traffic protection and guidance as required by the Standard Specifications of the Georgia Department of Transportation and Special Provision 150. Such work shall be considered incidental to the overall contract, and no additional compensation will be made.

3. Statutory Workers' Compensation Insurance A. Employers Liability:

a) Bodily Injury by Accident - $500,000 each accident

b) Bodily Injury by Disease - $500,000 policy limit

c) Bodily Injury by Disease - $500,000 each employee

4. Commercial General Liability Insurance

A. $1,000,000 limit of liability per occurrence for bodily injury and property damage and $2,000,000 annual aggregate.

B. Separate $1,000,000 Owner's and Contractor's Protective policy with Meriwether County Board of Commissioners as Named Insured

C. The following additional coverage must apply:

a) 1986 (or later) ISO Commercial General Liability Form

b) Dedicated Limits per Project Site or Location (CG 25 03 or CG 25 04)

c) Additional Insured Endorsement (Form B CG 20 10 with a modification for completed operations or a separate endorsement covering Completed Operations)

d) Blanket Contractual Liability

e) Broad Form Property Damage

f) Severability of Interest

g) Underground, explosion, and collapse coverage.

h) Personal Injury (deleting both contractual and employee exclusions)

i) Incidental Medical Malpractice

j) Hostile Fire Pollution Wording

6. Auto Liability Insurance A. $1,000,000 limit of liability per occurrence for bodily injury and property damage B. Comprehensive form covering all owned, non-owned, leased, hired, and borrowed vehicles.

C. Additional Insured Endorsement D. Contractual Liability

7. Umbrella Liability Insurance - Minimum $5,000,000 limit of liability

(Higher limit may be required depending on the extent of contract) A. The following additional coverage must apply

a) Additional Insured Endorsement

b) Concurrency of Effective Dates with Primary

c) Blanket Contractual Liability

d) Drop Down Feature

2024 MC Road Patching and Repair Page 6 of 20

e) Care, Custody, and Control - Follow Form Primary

f) Aggregates: Apply Where Applicable in Primary

g) Umbrella Policy must be as broad as the primary policy

8. Builder's Risk Insurance or Installation Floater Insurance required on all new structures, bridges, overpasses, tunnels, culverts and railroad crossings - limit at least as broad as contract amount

9. Meriwether County Board of Commissioners should be shown as an additional insured on General Liability, Auto Liability and Umbrella Liability policies.

10. The cancellation should provide 10-day notice for nonpayment and 30 day notice of cancellation.

11. Certificate Holder should read:

Meriwether County Board of Commissioners 17234 Roosevelt Hwy, Bldg. B Greenville, GA 30222

12. Insurance Company, except Worker' Compensation carrier, must have an A.M. Best Rating of

A-10 or higher. Certain Workers' Comp funds may be acceptable by the approval of the Insurance Unit. European markets including those based in London and domestic surplus lines markets that operate on a non-admitted basis are exempt from this requirement provided that the contractor’s broker/agent can provide financial data to establish that a market is equal to or exceeds the financial strengths associated with the A.M. Best’s rating of A-10 or better.

13. Insurance Company should be licensed to do business by the Office of Georgia Insurance and

Safety Fire Commissioner.

14. Certificates of Insurance, and any subsequent renewals, must reference specific bid/contract by project name and project/bid number.

15. The Contractor shall agree to provide complete certified copies of current insurance policy(ies) or a certified letter from the insurance company(ies) if requested by the County to verify the compliance with these insurance requirements.

16. All insurance coverages required to be provided by the Contractor will be primary over any insurance program carried by the County.

17. Contractor shall incorporate a copy of the insurance requirements as herein provided in each and every subcontract with each and every Subcontractor in any tier, and shall require each and every Subcontractor of any tier to comply with all such requirements. Contractor agrees that if for any reason Subcontractor fails to procure and maintain insurance as required, all such required Insurance shall be procured and maintained by Contractor at Contractor's expense.

18. No Contractor or Subcontractor shall commence any work of any kind under this Contract until all insurance requirements contained in this Contract have been complied with and until evidence of such compliance satisfactory to Meriwether County as to form and content has been filed with Meriwether County. The Acord Certificate of Insurance or a preapproved substitute is the required form in all cases where reference is made to a Certificate of Insurance or an approved substitute.

19. The Contractor shall agree to waive all rights of subrogation against the County, the Board of

2024 MC Road Patching and Repair Page 7 of 20

Commissioners, its officers, officials, employees, and volunteers from losses arising from work performed by the contractor for the County.

20. Special Form Contractors’ Equipment and Contents Insurance covering owned, used, and leased equipment, tools, supplies, and contents required to perform the services called for in the Contract. The coverage must be on a replacement cost basis. The County will be included as a Loss Payee in this coverage for County owned equipment, tools, supplies, and contents.

21. The Contractor shall make available to the County, through its records or records of their insurer, information regarding a specific claim related to any County project. Any loss run information available from the contractor or their insurer relating to a County project will be made available to the county upon their request.

22. Compliance by the Contractor and all subcontractors with the foregoing requirements as to carrying insurance shall not relieve the Contractor and all Subcontractors of their liability provisions of the Contract.

23. The Contractor and all Subcontractors are to comply with the Occupational Safety and Health

Act of 1970, Public Law 91-956, and any other laws that may apply to this Contract.

24. The Contractor shall at a minimum apply risk management practices accepted by the contractors’ industry.

2024 MC Road Patching and Repair Page 8 of 20

The County requires that all who enter into a contract for the physical performance of services with the County must satisfy O.C.G.A. § 13-10-91 and Rule 300-10-1-.02, in all manner, and such are conditions of the contract.

In compliance with the attached specifications, the undersigned offers and agrees, if this bid is accepted by the Board of Commissioners within ninety (90) days of the date of bid opening, to furnish any or all of the items upon which prices are quoted within the time specified in the Bid Schedule.

Legal Business Name (If your company is an LLC, you must identify all principals to include addresses and phone numbers in your submittal)

Federal Tax ID

Address

Does your company currently have a location within Meriwether County? Yes No

Representative Signature

Print Authorized Representative's Name

Telephone Number Fax Number

E-Mail Address

2024 MC Road Patching and Repair Page 9 of 20

LIST OF SUBCONTRACTORS

I do , do not , propose to subcontract some of the work on this project.

I propose to Subcontract work to the following subcontractors:

NAME AND ADDRESS

TYPE OF WORK

Company Name

2024 MC Road Patching and Repair Page 10 of 20

REFERENCES

MERIWETHER County requests a minimum of three, (3) references where work of a similar size and scope has been completed.

1. Company Name

Brief Description of Project

Completion Date

Contact Person

Telephone Facsimile

2. Company Name

3. Company Name

Company Name

2024 MC Road Patching and Repair Page 11 of 20

CONTRACT

This CONTRACT made and entered into this day of , 2024 by and between Meriwether County, Georgia (Party of the First Part, hereinafter called the "County"), and, (Party of the Second Part, hereinafter called the "Contractor").

NOW THEREFORE, for and in consideration of the mutual promises and obligations contained herein and under the conditions hereinafter set forth, the parties do hereby agree as follows:

1. TERM:

This contract shall commence upon Acceptance by Meriwether County Board of Commissioners and extend until December 31, 2024.

2. ATTACHMENTS:

Copies of the Contractor's proposal, including all drawings, specifications, price lists, Instructions to Bidders, General Conditions, Special Provisions, and Detailed Specifications submitted to the County during the Bid process (hereinafter collectively referred to as the "Bid ") are attached hereto (Exhibit A) and are specifically incorporated herein by reference. The E-Verify Affidavit form is included as Exhibit “B” and must be completed and returned. The SAVE Affidavit is attached as Exhibit “C”, and must be completed and returned. In the event of a conflict between the County's contract documents and the Bid, the County's contract documents shall control.

3. PERFORMANCE:

Contractor agrees to furnish all skill and labor of every description necessary to carry out and complete in good, firm and substantial, workmanlike manner, the work specified, in strict conformity with the Bid.

4. PRICE:

As full compensation for the performance of this Contract, the County shall pay the Contractor for the actual quantity of work performed. The fees for the work to be performed under this Contract shall be charged to the County in accordance with the per square yard rate referenced in the Bid (Exhibit A). The County agrees to pay the Contractor following receipt by the County of a detailed invoice, reflecting the quantity of materials used and the actual work performed by the Contractor.

5. INDEMNIFICATION AND HOLD HARMLESS:

Contractor agrees to protect, defend, indemnify, and hold harmless the COUNTY, its commissioners, officers, agents and employees from and against any and all liability, damages, claims, suits, liens, and judgments, for whatever nature, including claims for contribution and/or indemnification, for injuries to or death of any person or persons, or damage to the property or other rights of any person or persons to the extent arising out of and attributed to the negligent errors, acts, or omissions of the Contractor. Contractor's obligation to protect, defend, indemnify, and hold harmless, as set forth hereinabove shall include any matter arising out of any patent, trademark, copyright, or service mark, or any actual or alleged unfair competition disparagement of product or service, or other business tort of any type whatsoever, or any actual or alleged violation of trade regulations.

Contractor further agrees to protect, defend, indemnify, and hold harmless the COUNTY, its commissioners, officers, agents, and employees from and against any and all claims or liability for compensation under the Worker's Compensation Act arising out of injuries sustained by any employee of the Contractor.

6. TERMINATION FOR CAUSE:

2024 MC Road Patching and Repair Page 12 of 20

The County may terminate this Contract for cause upon ten (10) days prior written notice to the Contractor of the Contractor's default in the performance of any term of this Contract. Such termination shall be without prejudice to any of the County's rights or remedies provided by law.

7. TERMINATION FOR CONVENIENCE:

The County may terminate this Contract for its convenience at any time upon 30 days written notice to the Contractor. In the event of the County's termination of this Contract for convenience, the Contractor will be paid for those services actually performed. Partially completed performance of the Contract will be compensated based upon a signed statement of completion to be submitted by the Contractor who shall itemize each element of performance.

8. CONTRACT NOT TO DISCRIMINATE:

During the performance of this Contract, the Contractor will not discriminate against any employee or applicant for employment because of race, creed, color, sex, national origin, age, or disability which does not preclude the applicant or employee from performing the essential functions of the position. The Contractor will also, in all solicitations or advertisements for employees placed by qualified applicants, consider the same without regard to race, creed, color, sex, national origin, age, or disability which does not preclude the applicant from performing the essential functions of the job. The Contractor will cause the foregoing provisions to be inserted in all subcontracts for any work covered by this Contract so that such provision will be binding upon each subcontractor, providing that the foregoing provisions shall not apply to contracts or subcontractors for standard commercial supplies of raw materials.

9. ASSIGNMENT:

The Contractor shall not sublet, assign, transfer, pledge, convey, sell or otherwise dispose of the whole or any part of this Contract or his right, title, or interest therein to any person, firm, or corporation without the previous consent of the County in writing.

10. WAIVER:

A waiver by either party of any breach of any provision, term, covenant, or condition of this Contract shall not be deemed a waiver of any subsequent breach of the same or any other provision, term, covenant, or condition.

11 SEVERABILITY:

The parties agree that this Contract shall be governed and construed in accordance with the laws of the State of Georgia. This Contract has been signed in Meriwether County, Georgia. This Contract has been signed in Meriwether County, Georgia. Any dispute related to this Contract shall be submitted to the exclusive jurisdiction and venue of the Superior Court of Meriwether County.

12. GOVERNING LAW:

The parties agree that this Contract shall be governed and construed in accordance with the laws of the State of Georgia. This Contract has been signed in Meriwether County, Georgia.

13. MERGER CLAUSE:

The parties agree that the terms of this Contract include the entire Contract between the parties, and as such, shall exclusively bind the parties. No other representations, either oral or written, may be used to contradict the terms of this Contract.

14. VENUE:

The parties agree that the venue of any dispute arising from this Contract shall be resolved in the Superior Court of Meriwether County, Georgia and the parties submit the jurisdiction of said Court and waive any objection to said venue based on jurisdiction or otherwise.

2024 MC Road Patching and Repair Page 13 of 20

(Signatures Next Page)

2024 MC Road Patching and Repair Page 14 of 20

IN WITNESS WHEREOF, the parties hereto, acting through their duly authorized agents, have caused this CONTRACT to be signed, sealed, and delivered.

MERIWETHER COUNTY, GEORGIA

By:

Gene King, Chairman Meriwether Co Board of Commissioners

ATTEST:

Allyson Stephens, County Clerk Meriwether Co Board of Commissioners

APPROVED AS TO FORM:

Meriwether County Attorney

CONTRACTOR:

BY:

(Signature)

(Print Name)

(Title)

ATTEST:

(Signature)

(Print Name)

Corporate Secretary (Seal)

2024 MC Road Patching and Repair Page 15 of 20

***ATTENTION***

FAILURE TO RETURN THE FOLLOWING DOCUMENTS MAY RESULT IN BID BEING

DEEMED NON-RESPONSIVE AND AUTOMATIC REJECTION:

1. FAILURE TO USE COUNTY BID SCHEDULE.

2. FAILURE TO RETURN APPLICABLE COMPLIANCE

SHEETS/SPECIFICATION SHEETS.

3. FAILURE TO RETURN APPLICABLE ADDENDA.

4. FAILURE TO PROVIDE INFORMATION ON ALTERNATES OR

EQUIVALENTS.

5. THE COUNTY SHALL BE THE SOLE DETERMINANT OF TECHNICALITY

VS. NON-RESPONSIVE BID.

6. FAILURE TO PROVIDE BID BOND, WHEN REQUIRED, WILL RESULT IN

BID BEING DEEMED NON-RESPONSIVE AND AUTOMATIC REJECTION.

BID BONDS ARE NOT REQUIRED ON ALL BIDS. BOND REQUIREMENTS

ARE CLEARLY STATED ON THE INVITATION TO BID. IF YOU NEED

CLARIFICATION, CONTACT THE COUNTY ADMINISTRATOR.

7. FAILURE TO PROVIDE CONTRACTOR AFFIDAVIT AND AGREEMENT,

WHEN REQUIRED, MAY RESULT IN BID BEING DEEMED NON-

RESPONSIVE AND AUTOMATIC REJECTION. CONTRACTOR AFFIDAVIT

AND AGREEMENT IS NOT REQUIRED ON ALL BIDS. IF YOU NEED

CLARIFICATION, CONTACT THE COUNTY ADMINISTRATOR.

2024 MC Road Patching and Repair Page 16 of 20

Bid Tabulation Sheet

Patching: per square yd...…………………………….…………… $_________________ based on specifications included in proposal.

TOTAL ………………………………….…………… $_________________

Bidder: ____________________________________________

Signature: __________________________________________

Date: ______________________________________________

2024 MC Road Patching and Repair Page 17 of 20

EXHIBIT "B"'

E-VERIFY AFFIDAVIT

Contractor Affidavit under O.C.G.A. § 13-10-91(b )(I) The undersigned contractor ("Contractor") executes this Affidavit to comply with O.C.G.A § 13- 10-91 related to any contract to which Contractor is a party that is subject to O.C.G.A. § 13-10-91 and hereby verifies its compliance with O.C.G.A. § 13-10-91, attesting as follows:

a) The Contractor has registered with, is authorized to use, and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program;

b) The Contractor will continue to use the federal work authorization program throughout the contract period, including any renewal or extension thereof;

c) The Contractor will notify the public employer in the event the Contractor ceases to utilize the federal work authorization program during the contract period, including renewals or extensions thereof;

d) The Contractor understands that ceasing to utilize the federal work authorization program constitutes a material breach of Contract;

e) The Contractor will contract for the 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. § 13-10-9l(a), (b), and (c);

f) The Contractor acknowledges and agrees that this Affidavit shall be incorporated into any contract(s) subject to the provisions of O.C.G.A. § 13-10-91 for the project listed below to which Contractor is a party after the date hereof without further action or consent by Contractor; and

g) Contractor acknowledges its responsibility to submit copies of any affidavits, drivers' licenses, and identification cards required pursuant to O.C.G.A. § 13-10-91 to the public employer within five business days of receipt.

Federal Work Authorization User Identification Number Date of Authorization

_____________________________________________ 2024 Road Patching and Repair Name of Contractor

MERIWETHER COUNTY, GEORGIA

Name of Public Employer

2024 MC Road Patching and Repair Page 18 of 20

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

Executed on ____________, ___________, 2024, 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 _____ DAY OF ____________, 2024.

NOTARY PUBLIC

My Commission Expires: _______________________

2024 MC Road Patching and Repair Page 19 of 20

EXHIBIT "C"

SAVE Affidavit Verifying Status for Meriwether County Public Benefit Application

By executing this affidavit under oath, as a bidder for a REQUEST FOR PROPOSAL or other public benefit as referenced in O.C.G.A. O.C.G.A. § from MERIWETHER COUNTY, GEORGIA, the undersigned applicant verifies one of the following with request to my application for public benefit for ______________________. [Name of natural person applying on behalf of individual, business, corporation, partnership, or other private entity]

1) __________ I am a United States citizen

2) __________ I am a legal permanent resident of the United States

3) __________ I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other Federal immigration agency.

My alien number issued by the Department of Homeland Security or other Federal immigration agency is:

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A § 50-36-1 (f) (1), with this affidavit.

The secure and verifiable document provided with this affidavit can best be classified as:

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of violation of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute.

2024 MC Road Patching and Repair Page 20 of 20

Executed in _______________________ (city), _______________________________ (state)

Signature of Applicant:

Printed Name of Applicant

SUBSRIBED AND SWORN

BEFORE ME ON THIS THE

_______ DAY OF ___________, 2024.

Notary Public

My Commission Expires: ___________