FORM OF PROPOSAL.pdf

RFB-237-19

OFFICIAL BID DOCUMENT

FOR

MIKE MAY SLIDE & RICK EDMISTON SLIDE

HIGH PRIORITY

AML PROJECT

PIKE COUNTY, KENTUCKY

This Official Bid Document consisting of Page’s 1 through 21, shall be used in submitting a bid document for the work. Copies will be furnished upon request by the authority issuing the Contract Documents.

THIS BID DOCUMENT SUBMITTED BY________________________________________________________________________

(Name and Address of Bidder)

DATE:_________________________________________ TELEPHONE:________________________________________________

TO: SEALED BID CLERK

403 WAPPING STREET, 2nd FLOOR

ENGINEERING AND CONTRACT ADMINISTRATION

COMMONWEALTH OF KENTUCKY

FRANKFORT, KY 40601-2638

PHONE: (502) 564-3050

GENTLEMEN:

This Bidder, in compliance with your Request for Bid No. RFB-237-19, and having carefully examined the Drawings and complete

Contract Documents as defined in Article 1 of the General Conditions as well as the Specifications for the work as prepared by John

Mark Clements, Division of Abandoned Mine Lands, 300 Sower Blvd, Frankfort, KY 40601, Phone No. (502) 892-3423; hereby proposes to furnish all labor, materials, supplies and services required to perform the specifics of the Contract Documents, within the time set forth therein and for the stated Lump Sum Bid Amount.

The Bidder, hereby acknowledges receipt of the following Addenda:

ADDENDUM NO._____________ DATED______________ ADDENDUM NO._____________ DATED______________

(IF NONE HAVE BEEN ISSUED AND RECEIVED, INSERT THE WORD NONE.)

FOR

MIKE MAY SLIDE & RICK EDMISTON SLIDE

HIGH PRIORITY

AML PROJECT

PIKE COUNTY, KENTUCKY

NOTE FOR BID SCHEDULE:

A. The quantities of each item on the bid, as finally ascertained at the close of the contract, will determine the total payments to accrue under the contract.

B. No bid will be considered unless all items in the Bid Schedule are priced, and only one contract will be awarded.

C. The bid will be awarded in the aggregate total of the Bid Schedule.

D. Unbalanced bidding and front loading of bid will be grounds for rejection of bids.

E. Unit Prices shall include the furnishing of labor, materials complete and in place, overhead profit, insurance, etc., to cover the furnished work of the several classifications listed and shall be based on the same type and/or similar work included in the contract specifications.

F. The Unit Price shall govern. The Owner will make corrections in extensions and additions. Unit Prices do not change during the time of this contract. Any Additions or Deductions for Estimated Qualities are paid on Unit Price Bid.

THE CONTRACTOR THAT WILL BE AWARDED PROJECT MUST SUBMIT THEIR

PAYMENT AND PERFORMANCE BONDS WITHIN FIVE (5) CALENDAR DAYS

FROM RECEIPT OF THE INTENT TO AWARD. THEY CAN ME EMAILED OR

FAXED AND ORIGINALS MAILED. FAILURE TO PROVIDE THE INFORMATION

AS REQUESTED WILL RESULT IN ANOTHER CONTRACTOR BEING SELECTED.

1 MOBILIZATION L.S. L.S. 1.0 X NA ≤ NA = 25,000.00$

2 UTILITY RELOCATION/REPLACEMENT A.C.U. A.C.U. 1.0 X NA ≤ 1.00$ = 2,000.00$

3 LANDSCAPE ALLOWANCE A.C.U. A.C.U. 500.0 X NA ≤ 1.00$ = 500.00$

4 STRUCTURE REMOVAL/REPLACEMENT A.C.U. A.C.U. 1,500.0 X NA ≤ 1.00$ = 2,000.00$

5 SITE PREPARATION U.P. ACRE 1.0 X $750.00 ≤ $ = $

6 SITE PREPARATION- WASTE AREAS U.P. ACRE 1.0 X $750.00 ≤ $ = $

7 TREE CHIPPING U.P. ACRE 1.0 X $1,000.00 ≤ $ = $

8 FILTER FABRIC U.P. SY 200.0 X $0.50 ≤ $ = $

9 SILT BARRIER - BALES & FENCE U.P. LF 500.0 X $1.00 ≤ $ = $

10 HOE RAM U.P. HOUR 20.0 X $50.00 ≤ $ = $

11 EARTHWORK (PLAN QUANTITY) P.Q. CY 10,000.0 X $1.00 ≤ $ = $

12 CLASS II / III U.P. TON 50.0 X $15.00 ≤ $ = $

13 SUBDRAIN U.P. LF 540.0 X $14.00 ≤ $ = $

14 SEEDBED PREPARATION U.P. ACRE 1.0 X $75.00 ≤ $ = $

15 AGRICULTURAL LIMESTONE U.P. TON 25.0 X $15.00 ≤ $ = $

16 FERTILIZER U.P. TON 1.0 X $600.00 ≤ $ = $

17 SEED U.P. LBS 40.0 X $4.00 ≤ $ = $

18 HYDROMULCH & HYDROSEEDING U.P. ACRE 0.5 X $500.00 ≤ $ = $

19 RESIDENTIAL SEEDING U.P. ACRE 1.0 X $500.00 ≤ $ = $

DENSE GRADE AGGREGATE FOR

ROADWAYS

U.P. TON 50.0 X $15.00 ≤ $ = $

21 ROADWAY STONE U.P. TON 50.0 X $15.00 ≤ $ = $

22 BITUMINOUS REPAIR U.P. TON 100.0 X $75.00 ≤ $ = $

BID TOTAL = $

MIKE MAY HP PHASE II (AML) RECLAMATION PROJECT

PIKE COUNTY, KENTUCKY

BID SCHEDULE

NOTE: THE AUTHENTICATION OF BID AND STATEMENT OF NON-COLLUSION AND NON-CONFLICT OF INTEREST PAGE MUST BE PROPERLY

EXECUTED FOR THE TOTAL BID AMOUNT TO BE VALID.

* Any Unit Price outside the Allowable Price Limit (APL) range may be considered an unbalanced bid and may have to be justified in writing if such bid is deemed the low responsive bid.

NO. ITEM M.O.P. UNIT QUANTITY * Low APL UNIT PRICE TOTAL

1 MOBILIZATION L.S. L.S. 1.0 X NA ≤ NA ≤ = 5,000.00$

2 UTILITY RELOCATION/REPLACEMENT A.C.U. A.C.U. 5,000.0 X NA ≤ 1.00$ ≤ = 5,000.00$

3 LANDSCAPE ALLOWANCE A.C.U. A.C.U. 1,000.0 X NA ≤ 1.00$ ≤ = 1,000.00$

4 STRUCTURE REMOVAL/REPLACEMENT A.C.U. A.C.U. 8,000.0 X NA ≤ 1.00$ ≤ = 8,000.00$

5 SITE PREPARATION U.P. ACRE 1.5 X $750.00 ≤ ≤ = $

6 SITE PREPARATION- WASTE AREAS U.P. ACRE 1.0 X $750.00 ≤ ≤ = $

7 TREE CHIPPING U.P. ACRE 1.0 X $1,000.00 ≤ ≤ = $

8 CONCRETE- FORMED & FINISHED U.P. CY 5.0 X $150.00 ≤ ≤ = $

9 FILTER FABRIC U.P. SY 275.0 X $0.50 ≤ ≤ = $

10 SILT BARRIER - BALES & FENCE U.P. LF 600.0 X $1.00 ≤ ≤ = $

11 HOE RAM U.P. HOUR 20.0 X $50.00 ≤ ≤ = $

12 EARTHWORK (PLAN QUANTITY) P.Q. CY 2,600.0 X $1.00 ≤ ≤ = $

13 EARTHWORK - GRADEWORK U.P. ACRE 1.5 X $2,500.00 ≤ ≤ = $

14 EROSION CONTROL BLANKET- ECB U.P. SY 280.0 X $0.75 ≤ ≤ = $

15 CLASS II / III U.P. TON 275.0 X $15.00 ≤ ≤ = $

16 CONCRETE BLOCK- TIED MAT U.P. SF 240.0 X $4.50 ≤ ≤ = $

17 SUBDRAIN U.P. LF 275.0 X $14.00 ≤ ≤ = $

18 18" DIA. HDPE PIPE- STANDARD U.P. LF 80.0 X $10.00 ≤ ≤ = $

19 CONCRETE HEADWALL- PIPES ≤36" DIA. U.P. EACH 2.0 X $750.00 ≤ ≤ = $

20 POLYURETEHANE FOAM U.P. CY 5.0 X $200.00 ≤ ≤ = $

21 SEEDBED PREPARATION U.P. ACRE 1.0 X $75.00 ≤ ≤ = $

22 AGRICULTURAL LIMESTONE U.P. TON 25.0 X $15.00 ≤ ≤ = $

23 FERTILIZER U.P. TON 1.0 X $600.00 ≤ ≤ = $

24 SEED U.P. LBS 120.0 X $4.00 ≤ ≤ = $

25 MULCH- STRAW & HAY U.P. ACRE 2.0 X $100.00 ≤ ≤ = $

26 RESIDENTIAL SEEDING U.P. ACRE 1.0 X $500.00 ≤ ≤ = $

DENSE GRADE AGGREGATE FOR

ROADWAYS

U.P. TON 50.0 X $15.00 ≤ ≤ = $

RICK EDMISTON HP (AML) RECLAMATION PROJECT

PIKE COUNTY, KENTUCKY

BID SCHEDULE

28 BITUMINOUS REPAIR U.P. TON 75.0 X $75.00 ≤ ≤ = $

29 DEBRIS BARRIER WALL- BALE & PLYWOOD U.P. LF 225.0 X $20.00 ≤ ≤ = $

BID TOTAL = $

NOTE: THE AUTHENTICATION OF BID AND STATEMENT OF NON-COLLUSION AND NON-CONFLICT OF INTEREST PAGE MUST BE PROPERLY

EXECUTED FOR THE TOTAL BID AMOUNT TO BE VALID.

* Any Unit Price outside the Allowable Price Limit (APL) range may be considered an unbalanced bid and may have to be justified in writing if such bid is deemed the low responsive bid.

MIKE MAY HP PHASE ll(AMl) RECLAMATION PROJECT

RICK EDMISTON (AML) RECLAMATION PROJECT

PIKE COUNTY, KENTUCKY

COMBINE BID SHEET

MIKE MAY HP PHASE II BIO SCHEDULE TOTAL ::

RICK EDMISTON BID SCHEDULE TOTAi. ::::

COMBINED TOTAL BID :::

NOTE: THE AUTHENTICATION OF BID AND STATEMENT OF NON-COLLUSION AND NON-CONFLICT OF INTEREST PAGE

MUST BE PROPERLY EXECUTED FOR THE TOTAL BID AMOUNT TO BE VALID,

* Any Unit Price outside the Allowable Price Limit (APL) range may be considered an unbalanced bid and may have to be justified in writing if such bid is deemed the low responsive bid.

AUTHENTICATION OF BID AND STATEMENT OF NON-COLLUSION AND NON-CONFLICT OF INTEREST

I, HEREBY CERTIFY:

1. That I am the bidder (if the bidder is an individual), a partner in the bidder (if the bidder is a partnership), or an officer and employee of the bidding corporation having authority to sign on it’s behalf (if the bidder is a corporation);

2. That the submitted bid or bids covering Division of Engineering and Contract Administration Request for Bid No. RFB-237-

19 have been arrived at by the bidder independently and have been submitted without collusion with, and without any agreement, understanding or planned common course of action with any other contractor, vendor of materials, supplies, equipment or services described in the Request for Bid, designed to limit independent bidding or competition; as prohibited by provision KRS 45A.325;

3. That the contents of the bid or bids have not been communicated by the bidder or its employees or agents to any person not an employee or agent of the bidder, its surety on any bond furnished with the bid or bids and will not be communicated to any such person prior to the official opening of the bid or bids.

4. That the bidder is legally entitled to enter into the contract with the Commonwealth of Kentucky and is not in violation of any prohibited conflict of interest, including those prohibited by the provisions of KRS 164.390; and 45A.330 to 45A.340 and

45A.455;

5. This offer is for thirty (30) calendar days from the date this bid is opened. In submitting the above it is expressly agreed that upon proper acceptance by the Division of Engineering and Contract Administration of any or all items bid above, a contract shall thereby be created with respect to the items accepted;

6. That I have fully informed myself regarding and affirm the accuracy of all statements made in this Official Bid Document including Bid Amount.

7. Unless otherwise exempted by KRS 45.590, the bidder intends to comply in full with all requirements of the Kentucky Civil

Rights Act and to submit data required by the Kentucky Equal Employment Act upon being designated the successful bidder.

8. That the bidder, if awarded a contract, would not be in violation of the Executive Branch Code of Ethics established by KRS

11A.001 through KRS 11A.990.

9. That the bidder is not debarred from doing business with federal agencies and that, if debarred during the life of the contract, the bidder will notify the Commonwealth buyer of record within seventy-two (72) hours of the federal debarment.

READ CAREFULLY – SIGN IN SPACE BELOW – FAILURE TO SIGN INVALIDATES BID

SIGNED BY:________________________________________ FIRM:______________________________________________

PRINT NAME:______________________________________ ADDRESS:__________________________________________

TITLE:_____________________________________________ ____________________________________________________

CITY STATE ZIP CODE

DATE:______________________________________________

TELEPHONE NO:___________________________________

FEDERAL ID. NO. OR SOCIAL SECURITY NO. EMAIL: ____________________________________________

*Minority Contractors, check type of certification:

WBE MBE DBE VETERAN

*Minority Contractors attach a copy of certification.

OFFICIAL BID DOCUMENT – SUBMITTAL DATA

THE FOLLOWING ITEMS ARE HEREWITH ENCLOSED AS REQUIRED:

Sworn Required Affidavit For Bidders, Offerors And Contractors

Sworn Affidavit for Claiming Resident Bidder Status

Vendor Report of Prior Violations of KRS Chapters, 136, 139, 141, 337, 338, 341 and 342.

Bidder’s Qualifications.

Disadvantaged Business Enterprises (DBE) Participation.

The utilization of minority/disadvantaged vendors and subcontractors is encouraged, whenever possible, on public projects.

The bidder and contractor should make full efforts to locate disadvantaged business persons.

Bidders may use the following resources:

Commonwealth of Kentucky's SMALL BUSINESS CONNECTION website: https://secure.kentucky.gov/sbc/default.aspx

Kentucky Minority and Women Business Enterprise website: https://mwbe.ky.gov/Pages/default.aspx

Kentucky Service-Disabled Veteran-Owned Small Business website:

https://finance.ky.gov/initiatives/sdvosb/Pages/default.aspx

Kentucky Transportation Cabinet Disadvantaged Business Enterprise directories: http://transportation.ky.gov/Civil-Rights-and-Small-Business-Development/Pages/Certified-DBE-Directory.aspx

Finance and Administration Cabinet, Office of EEO/Contract Compliance: email Finance.ContractCompliance@ky.gov or call 502-564-2874

U.S. Small Business Administration, Dynamic Small Business Search website: http://dsbs.sba.gov/dsbs/search/dsp_dsbs.cfm

Louisville/ Jefferson County Metropolitan Sewer District website: http://www.msdlouky.org/insidemsd/diverse/find.html

A bidder must include a list of all disadvantaged vendors and/or subcontractors contacted in order to prepare a bid (ATTACH

TO OFFICIAL BID DOCUMENT).

If the bidder fails to utilize any disadvantaged vendors and/or subcontractors, a statement must be included to describe actions to include disadvantaged vendors and/or subcontractors (ATTACH TO OFFICIAL BID DOCUMENT).

The Finance and Administration Cabinet will review all submissions by bidders to determine compliance with this provision.

List of Unit Prices, if applicable.

List of Proposed Subcontractors, if applicable.

List of Materials and Equipment, if applicable.

Bid Guaranty in the amount of no less than five percent (5%) of the TOTAL BID AMOUNT.

Roofing Certifications, if applicable.

INSURANCE CERTICATES REQUIRED.

CONTRACTOR’S INFORMATION SHEET The Contractor’s Information sheet must be filled out and submitted with the bid.

Failure to submit the Contractor’s Information sheet with the bid will be the basis for declaring the bid “unresponsive.”

COMMONWEALTH OF KENTUCKY

FINANCE AND ADMINISTRATION CABINET

SWORN STATEMENT REGARDING CAMPAIGN FINANCE LAWS

PURSUANT TO KRS 45A.110 AND KRS 45A.115

The following form (page 5) relative to Campaign Finance Laws shall be completed in total, notarized and returned with your bid.

Responsibility of a bidder or offeror for a contract award shall not be made until the bidder or offeror provides this sworn statement.

https://secure.kentucky.gov/sbc/default.aspx https://mwbe.ky.gov/Pages/default.aspx https://finance.ky.gov/initiatives/sdvosb/Pages/default.aspx http://transportation.ky.gov/Civil-Rights-and-Small-Business-Development/Pages/Certified-DBE-Directory.aspx http://transportation.ky.gov/Civil-Rights-and-Small-Business-Development/Pages/Certified-DBE-Directory.aspx mailto:Finance.ContractCompliance@ky.gov http://dsbs.sba.gov/dsbs/search/dsp_dsbs.cfm http://www.msdlouky.org/insidemsd/diverse/find.html

AML

CONTRACTOR/SUBCONTRACTOR

INFORMATION FORM

The requested information is necessary to obtain an AVS data evaluation to determine eligibility to work on AML-funded projects. Provide the requested information for the prime contractor and for each subcontractor.

Project Name:

Part A:

General Information

Contractor Name:

Federal ID Number:

Business Address:

City:

State:

Zip Code:

Phone :

B:

Legal Structure

( ) Corporation ( ) Sole Proprietorship ( ) Partnership ( ) LLC

( ) Other ________________________________________________________________

C:

Ownership/Control Information

Provide information for the following relationships: officers/directors; persons/companies owning greater than 10% of the voting stock; partners; members; person(s) who commit the financial, real estate or working assets;

and person(s) who have the authority to determine the manner in which the AML work is conducted.

(First Middle Last)

Position/Title:

Phone:

% of Ownership:

(First Middle Last)

Position/Title:

Phone:

% of Ownership:

Attach additional pages as needed.

Signature:

Date:

CONTRACTOR’S INFORMATION SHEET

The Contractor’s Information sheet must be filled out and submitted with the bid. Failure to submit the

Contractor’s Information sheet with the bid will be the basis for declaring the bid “unresponsive.”

REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS

FOR BIDS AND CONTRACTS IN GENERAL:

I. Each bidder or offeror swears and affirms under penalty of perjury, that:

a. In accordance with KRS 45A.110 and KRS 45A.115, neither the bidder or offeror as defined in KRS 45A.070(6), nor the entity which he/she represents, has knowingly violated any provisions of the campaign finance laws of the Commonwealth of Kentucky; and the award of a contract to the bidder or offeror or the entity which he/she represents will not violate any provisions of the campaign finance laws of the Commonwealth.

b. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and all subcontractors therein, are aware of the requirements and penalties outlined in KRS 45A.485; have properly disclosed all information required by this statute; and will continue to comply with such requirements for the duration of any contract awarded.

c. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and its affiliates, are duly registered with the Kentucky Department of Revenue to collect and remit the sales and use tax imposed by KRS Chapter 139, and will remain registered for the duration of any contract awarded.

d. The bidder or offeror swears and affirms under penalty of perjury that the entity bidding is not delinquent on any state taxes or fees owed to the Commonwealth of Kentucky and will remain in good standing for the duration of any contract awarded.

e. Pursuant to KRS 45A.480 the bidder or offeror swears and affirms under penalty of perjury, that all contractors and subcontractors employed, or that will be employed, under the provisions of this contract shall be in compliance with the requirements for worker’s compensation insurance according to KRS Chapter 342 and unemployment insurance according to KRS Chapter 341.

f. The bidder or offeror swears and affirms under penalty of perjury that the entity bidding is properly authorized under the laws of the Commonwealth of Kentucky to conduct business in this state; is duly registered with the Kentucky Secretary of

State to the extent required by Kentucky law; and will remain in good standing to do business in the Commonwealth of

Kentucky for the duration of any contract awarded.

g. By his signature, the offeror certifies that he is legally entitled to enter into this contract with the Commonwealth of

Kentucky, and by holding and performing this contract will not be violating any conflict-of-interest statue (KRS 45A.330, KRS 45A.335, KRS 45.340, KRS 45A.990, KRS 164.390) or KRS 11A.040 of the Executive Branch Code of Ethics, relating to employment of former public servants.

FOR “NON-BID” CONTRACTS (I.E. SOLE-SOURCE; NOT-PRACTICAL OR FEASIBLE TO BID; OR EMERGENCY

CONTRACTS, ETC):

II. Each contractor further swears and affirms under penalty of perjury, that:

a. In accordance with KRS 121.056, and if this is a non-bid contract, neither the contractor, nor any member of his/her immediate family having an interest of 10% or more in any business entity involved in the performance of any contract awarded, have contributed more than the amount specified in KRS 121.150 to the campaign of the gubernatorial slate elected in the election last preceding the date of contract award.

b. In accordance with KRS 121.330(1) and (2), and if this is a non-bid contract, neither the contractor, nor officers or employees of the contractor or any entity affiliated with the contractor, nor the spouses of officers or employees of the contractor or any entity affiliated with the contractor, have knowingly contributed more than $5,000 in aggregate to the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract award.

c. In accordance with KRS 121.330(3) and (4), and if this is a non-bid contract, to the best of his/her knowledge, neither the contractor, nor any member of his/her immediate family, his/her employer, or his/her employees, or any entity affiliated with any of these entities or individuals, have directly solicited contributions in excess of $30,000 in the aggregate for the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract.

http://www.lrc.state.ky.us/KRS/045A00/110.PDF http://www.lrc.state.ky.us/KRS/045A00/115.PDF http://www.lrc.state.ky.us/KRS/045A00/070.PDF http://www.lrc.state.ky.us/KRS/045A00/485.PDF http://www.lrc.ky.gov/KRS/139-00/CHAPTER.HTM http://www.lrc.state.ky.us/KRS/045A00/480.PDF http://www.lrc.ky.gov/KRS/342-00/CHAPTER.HTM http://www.lrc.ky.gov/KRS/341-00/CHAPTER.HTM http://162.114.4.13/KRS/045A00/330.PDF http://162.114.4.13/KRS/045A00/335.PDF http://162.114.4.13/KRS/045A00/340.PDF http://162.114.4.13/KRS/045A00/990.PDF http://162.114.4.13/KRS/164-00/390.PDF http://162.114.4.13/KRS/011A00/040.PDF http://www.lrc.ky.gov/KRS/121-00/056.PDF http://www.lrc.ky.gov/KRS/121-00/150.PDF http://www.lrc.ky.gov/KRS/121-00/330.PDF http://www.lrc.ky.gov/KRS/121-00/330.PDF

REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS

As a duly authorized representative for the bidder, offeror, or contractor, I have fully informed myself regarding the accuracy of all statements made in this affidavit, and acknowledge that the Commonwealth is reasonably relying upon these statements, in making a decision for contract award and any failure to accurately disclose such information may result in contract termination, repayment of funds and other available remedies under law.

Signature Printed Name

Title Date

Company Name

Address

Subscribed and sworn to before me by

(Affiant) (Title) of this _____day of ____________,20___.

(Company Name)

Notary Public

[seal of notary] My commission expires:

REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS CLAIMING RESIDENT BIDDER STATUS

FOR BIDS AND CONTRACTS IN GENERAL:

The bidder or offeror hereby swears and affirms under penalty of perjury that, in accordance with KRS 45A.494(2), the entity bidding is an individual, partnership, association, corporation, or other business entity that, on the date the contract is first advertised or announced as available for bidding:

1. Is authorized to transact business in the Commonwealth;

2. Has for one year prior to and through the date of advertisement

a. Filed Kentucky income taxes;

b. Made payments to the Kentucky unemployment insurance fund established in KRS 341.49; and

c. Maintained a Kentucky workers’ compensation policy in effect.

The BIDDING AGENCY reserves the right to request documentation supporting a bidder’s claim of resident bidder status. Failure to provide such documentation upon request shall result in disqualification of the bidder or contract termination.

Signature Printed Name

Title Date

Company Name

Address

Subscribed and sworn to before me by

(Affiant) (Title) of this _____day of ____________,20___.

(Company Name)

Notary Public

[seal of notary] My commission expires:

VENDOR REPORT OF PRIOR VIOLATIONS

ON CONSTRUCTION SEALED BIDS

This form is applicable to all sealed bids for construction projects issued by the Finance and Administration Cabinet, Division of

Engineering and Contract Administration (DECA) in accordance with KRS 45A.080.

The Prime Bidder on any construction sealed bid shall provide the required information attached, for the Prime Bidder, as an attachment to the bid.

The information required is specifically - any violations issued within the last five (5) calendar years of the following:

1. Violations of KRS Chapter 136 (Corporation and Utility Taxes);

1. Violations of KRS Chapter 139 (Sales and Use Taxes);

2. Violations of KRS Chapter 141 (Income Taxes);

3. Violations of KRS Chapter 337 (Wages and Hours);

4. Violations of KRS Chapter 338 (Occupational Safety and Health of Employees);

5. Violations of KRS Chapter 341 (Unemployment Insurance);

6. Violations of KRS Chapter 342 (Workers Compensation); and

7. Violations of Occupational Safety and Health Laws in any other states and at the federal level.

If there are no violations for a particular category, vendor should attach a statement to that effect.

If there are violations for a particular category, the vendor should list them and provide the following information for each: the date of the violation, a short description of the violation (including statutory citation), the name of the governmental enforcement agency involved, and the amount of any penalties imposed as a result of the final determination.

Please note that this information may be provided to other governmental agencies, such as the Kentucky Labor Cabinet, as part of the bid process. DECA reserves the unqualified right to disqualify any vendors from participating further in this bid process.

In addition, the successful prime bidder and subcontractors shall remain in continuous compliance with KRS 45A.485 during the life of any contract awarded, and shall notify DECA of any new final determinations of violations in any of the above-mentioned categories, which occur after contract award, and during the life of any contract awarded. Failure to comply with these requirements may result in the bidder and subcontractors being disqualified from participating in future bid opportunities for the Commonwealth.

COMPANY NAME: ____________________________________________

TAX PAYER ID #: ____________________________________________

THIS VENDOR VIOLATION FORM MAY BE SENT TO THE LABOR CABINET FOR VERIFICATION. PLEASE MAKE SURE

ALL YOUR VIOLATIONS ISSUED WITHIN THE LAST FIVE (5) YEARS ARE LISTED. IF YOU LIST “NONE” BUT THE

LABOR CABINET’S RECORDS SHOW OTHERWISE, YOUR BID MAY BE REJECTED. FOR A LIST OF YOUR VENDOR

VIOLATIONS, YOU CAN FAX OR EMAIL THE LABOR CABINET WITH YOUR REQUEST.

FAX NUMBER IS (502) 696-1984 OR EMAIL: wages@ky.gov.

Violation Category Date Description Govt. Enforcement

Agency

Amount of Penalties mailto:labor.desam@ky.gov

U.S. Department of the Interior

Certification Regarding

Debarment, Suspension, Ineligibility and

Voluntary Exclusion

Lower Tier Covered Transactions

This certification is required by the regulations implementing Executive Order 12549, Debarment and suspension, 43 CFR

Part 12, Section 12.510, Participants’ responsibilities. The regulations were published as Part VII of the May 26, 1988 Federal

Register (pages 19160-19211). Copies of the regulations are included in the bid document package. For further assistance in obtaining a copy of the regulations, contact the U.S. Department of the Interior, Acquisition and Assistance Division, Office of

Acquisition and Property Management, 18th and C Streets, N.W., Washington, D.C. 20240.

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)

(1) The prospective lower tier participant certifies, by submission of this bid document, that neither it not its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(2) Whether the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this bid document.

(Signature)

(Title)

(Name of Company)

Instruction for Certification

1. By signing and submitting this bid document, the prospective lower tier participant is providing the certification set out below.

2. The certification is this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier participant shall provide immediate written notice to the person to which this bid document is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms “covered transaction,” “debarred,” “suspended,” “ineligible,” “lower tier covered transaction,” “participant,”

“person,” “primary covered transaction,” “principal,” “bid document,” and “voluntarily excluded,” as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this bid document is submitted for assistance in obtaining a copy of those regulations.

5. The prospective lower tier participant agrees by submitting this bid document that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.

6. The prospective lower tier participant further agrees by submitting this bid document that it will include this clause titles

“Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,” without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Non-procurement List.

8. Nothing contained in the foregoing, shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with this transaction originated may pursue available remedies, including suspension and/or debarment.

BIDDER’S QUALIFICATIONS

The Bidder’s Qualifications are required by the owner to be submitted as set forth herewith:

1. This firm is a Corp.________, Partnership________, or Proprietorship________.

2. A permanent place of business is maintained at:

STREET CITY STATE ZIP CODE

TELEPHONE NUMBER

3. The following construction plant and equipment will be made available for use on this contract:

4. In the event the contract is awarded the undersigned, surety bonds will be furnished by:

5. Experience of Contractor on other similar work:

6. We now have the following jobs under contract and bonded:

JOB TOTAL CONTRACT PERCENT COMPLETED

P-2

MINORITY BUSINESS ENTERPRISE (MBE) PARTICIPATION

1.01 CERTIFICATION OF MBE: Any DBE utilized pursuant to this Section shall be certified as a DBE by one of the following: Kentucky Finance and Administration Cabinet, Kentucky Transportation Cabinet or other state

Transportation agencies, the Louisville/Jefferson County Metropolitan Sewer District, the Tri-State Minority

Supplier Development Council or other state Minority Supplier Development Councils, the Ohio River Valley

Women’s Business Council, the Women’s Business Enterprise National Council, the National Women Business

Owners Council, or the Small Business Administration.

1.02 OBLIGATION OF BIDDER/CONTRACTOR: Bidder/Contractor shall make a good faith effort to meet the

MBE contract goal set by the Commonwealth by including MBE’s as subcontractors and/or material suppliers on

5% of the total estimated cost of the Contract. The failure to meet the foregoing goal shall not result in disqualification from bidding or being awarded a contract. However, Bidders/Contractors not meeting the MBE goal shall be expected to provide written proof of their good faith efforts. Award of the contract shall be conditioned upon satisfaction of the requirements established by this section. The Bidder/Contractor shall attempt to divide the work in the contract to facilitate use of MBE’s (however, there is no requirement that the work be artificially divided or divided in a way that raises the bid price of the Bidder/Contractor).

1.03 PROOF REQUIRED: Each bidder shall furnish written proof in their bid package that they reached the MBE participation goal for this Contract, or of their good faith efforts to meet the MBE participation goal. A copy of each participating MBE’s certification shall accompany the required forms. All submissions shall be subject to verification of the Commonwealth.

A. Proof that the apparent successful bidder reached the MBE goal shall consist of the following and shall be made on form MB-2-A, attached hereto:

1. The names and addresses of MBE firms that will participate in the contract;

2. A description of the work each named MBE firm will perform;

3. The dollar amount of participation by each named MBE firm;

4. The percentage amount of participation by each named MBE firm;

B. Proof that the apparent successful bidder made a good faith efforts to meet the MBE participation goal may include the following:

1. Advertisement by the Bidder/Contractor of MBE contracting opportunities associated with this contract in at least one of each of the following periodicals: a periodical in general circulation throughout the Commonwealth, a trade periodical focused on MBE contractors/suppliers in general circulation throughout the Commonwealth, and a minority-focused periodical in general circulation throughout the Commonwealth. The Bidder/Contractor shall include copies of the dated advertisements in his bid package;

2. Written notice of MBE opportunities in this contract to at least five pertinent MBE’s at least seven days prior to the bid opening date. Copies of the written notices shall be included in the bid package;

3. The Bidder/Contractor’s response(s) to those MBE’s who requested plans, specifications and/or contracting requirements. Copies of said responses shall be included in the bid package;

4. Documentation on form MB-2-B of good faith negotiations with at least three MBE’s, with no rejection of a qualified MBE without sound reason, including price quotes that are above other subcontractor’s price quotes;

5. Utilization of the Finance and Administration Cabinet’s Office of Equal Employment Opportunity and Contract Compliance for referrals to organizations that assist in locating MBE'’s. Proof of use of such referrals and contacts made as a result thereof shall be included in the bid package.

MB-2-A

DISADVANTAGED BUSINESS AVAILABILITY VERIFICATION

____________________________________________________________ does commit itself that on the following project:

NAME OF COMPANY

PROJECT NAME REQUEST FOR BID NUMBER

The Bidder agrees to furnish information required by the Commonwealth of Kentucky to indicate the Disadvantaged Business which it intends to utilize. Breach of this commitment constitutes breach of the Bidder’s contract if awarded.

NAME OF DISADVANTAGED BUSINESS TELEPHONE TYPE OF WORK

DOLLAR VALUE PERCENT DISADVANTAGED CLASSIFICATION

The undersigned shall enter into a formal agreement with the Disadvantaged business firms for work listed in this schedule conditioned upon execution of a contract with the Commonwealth of Kentucky.

Disadvantaged business firms listed above by the Bidder and accepted by the Owner and the Architect/Engineer shall be used on the work for which they were proposed and accepted and shall not be changed except with the written approval of the Owner and the

Architect/Engineer. The undersigned hereby certifies that he or she has read the terms of this commitment and is authorized to bind the Bidder to the commitment herein set forth.

Signature and title of authorized official of the company and the data shall be properly executed on this document or the bid will be deemed nonresponsive.

NAME OF AUTHORIZED OFFICER TITLE

SIGNATURE DATE

If you are bidding as a General Contractor on this project i.e. direct bidding and a Disadvantaged as defined herein, please provide a copy of your DBE Certification.

Submit with Bid.

(Please copy additional Disadvantaged Business Availability Forms as necessary.)

MB-2-B

DISADVANTAGED BUSINESS UNAVAILABILITY VERIFICATION

I, ________________________________________________________________________, _______________________________

(TITLE)

of _______________________________________________________________________________________________________

(PRIME BIDDER)

certify that on ______________________ I contacted the following minority owned business by: (circle one) Certified Mail, Phone, In Person to obtain a bid for work items to be performed on the Contract.

DISADVANTAGED

FORM OF BID SUPPORT

CLASSIFICATION WORK ITEMS (I.E., UNIT PRICE, MATERIALS

(IE. WBE, MBE, DBE, SDVOSB) CONTRACTOR SOUGHT LABOR & LABOR ONLY)

To the best of my knowledge and belief, said Disadvantaged owned business was unavailable (exclusive of unavailability due to lack of agreement on price) for work on this project, or unable to prepare a bid, for the following reason(s):

SIGNATURE ______________________________________

DATE ____________________________________________

______________________________________________________________________________________________ was offered an

(NAME OF DISADVANTAGED BUSINESS)

opportunity to bid on the above-identified work on _______________________________________________________________by

(SOURCE)

The above statement is a true and accurate account of why I did not submit a bid on this project.

(SIGNATURE OF DISADVANTAGED BUSINESS)

(TITLE) (DATE)

Submit with Bid if Applicable.

(Please copy additional Disadvantaged Business Unavailability Forms as needed.)

INTENDED SUBCONTRACTING SCHEDULE:

The bidder shall indicate in the space below, the type of work that is intended to be subcontracted.

In designating the work to be subcontracted, be specific. If the space is left blank, this will be construed to imply that no subcontracting is intended.

*NAME OF SUBCONTRACTOR: TYPE OF WORK

*SUBCONTRACTING:

A. Prime Contractors are to list on the Official Bid Document and submit with the bid (subcontractor list must be completed before bid is submitted) a listing of subcontractor.

B. Any contractor who has listed a proposed subcontractor who is found not to be in good standing with the Natural Resources and Environmental Protection Cabinet, Department of Surface Mining Reclamation and Enforcement, and the federal Office of Surface Mining after a check with the Applicant Violator System (AVS) must substitute a new subcontractor that is eligible without changes in any of the unit prices or bid amounts.

C. No subcontractor may be added to the project of substituted for a previously approved subcontractor without prior written permission form the Director of the Division of Abandoned Lands, Natural Resources and Environmental Protection Cabinet and then only after a completed and acceptable AVS check.

“NOTE”

Contractors are to list subcontractor and submit with bid. Failure to list subcontractor may be cause for the bid to be rejected.