Forms_for_Solicitation.pdf

RESPONDENT AND TEAM SUMMARY FORM

RESPONDENT:

SOLICITATION NUMBER: DATE:

PROJECT TITLE:

Complete the following Table identifying your firm or company and ALL subcontractors or subconsultants you anticipate utilizing for purposes of responding to this solicitation.

Both sections of this form must be completed. Use additional pages if needed.

Section A RESPONDENT IDENTIFICATION

Respondent intends to utilize the following Vendors in connection with this project. In the spaces provided below, list the firms and corresponding information.

Firm Name (Prime and Subcontractor(s) or Subconsultant(s))

Vendor Phone & Email

Total Dollar Amount of Services

Scope of Work

Indicate the Category that Best Describes Each Organization Listed

Non-

MWBE

Certified MWBE Non-Certified

MWBE

N o n -M in o rity

C e rtifie d S m a ll B u s in e s s

A fric a n A m e ric a n

A s ia n A m e ric a n

H is p a n ic

A m e ric a n

N a tiv e A m e ric a n

N o n -M in o rity

F e m a le

A fric a n A m e ric a n

A s ia n A m e ric a n

H is p a n ic

A m e ric a n

N a tiv e A m e ric a n

N o n -M in o rity

F e m a le

TOTAL

Section B ACKNOWLEDGEMENT (to be completed by the Respondent)

I hereby certify that, as Respondent to this Solicitation, that the information provided herein is true and correct.

Name of Bidder/Respondent

Signature Date

Print Name Title

AFFIDAVIT CERTIFICATION

IMMIGRATION LAWS

Leon County will not intentionally award County contracts to any contractor who knowingly employs unauthorized alien workers, constituting a violation of the employment provisions contained in 8 U.S.C. Section 1324 A(e) {Section 274a(e) of the Immigration and Nationality Act (“INA”).

Leon County may consider the employment by any Contractor of Unauthorized Aliens a violation of Section 274A(e) of the INA. Such violation by the Recipient of the employment provision contained in Section 274A(e) of the INA shall be ground for unilateral cancellation of the contract by Leon County.

BIDDER ATTESTS THAT THEY ARE FULLY COMPLIANT WITH ALL APPLICABLE IMMIGRATION LAWS (SPECIFICALLY

TO THE 1986 IMMIGRATION ACT AND SUBSEQUENT AMENDMENTS).

Company Name:

Signature: Title:

STATE OF

COUNTY OF

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

Personally known

NOTARY PUBLIC

OR Produced identification Notary Public ‐ State of

(Type of identification)

My commission expires:

Printed, typed, or stamped commissioned name of notary

The signee of this Affidavit guarantees, as evidenced by the sworn affidavit required herein, the truth and accuracy of this affidavit to interrogatories hereinafter made.

LEON COUNTY RESERVES THE RIGHT TO REQUEST SUPPORTING DOCUMENTATION,

AS EVIDENCE OF SERVICES PROVIDED, AT ANY TIME.

EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT

1. The contractors and all subcontractors hereby agree to a commitment to the principles and practices of equal opportunity in employment and to comply with the letter and spirit of federal, state, and local laws and regulations prohibiting discrimination based on race, color, religion, national region, sex, age, handicap, marital status, and political affiliation or belief.

2. The contractor agrees to comply with Executive Order 11246, as amended, and to comply with specific affirmative action obligations contained therein.

Signed:

Title:

Firm:

Address:

IDENTICAL TIE BIDS

Preference shall be given to businesses with drug‐free workplace programs. Whenever two or more bids which are equal with respect to price, quality, and service are received by the State or by any political subdivision for the procurement of commodities or contractual services, a bid received from a business that certifies that it has implemented a drug‐free workplace program shall be given preference in the award process. Established procedures for processing tie bids will be followed if none of the tied vendors have a drug‐free workplace program. In order to have a drug‐free workplace program, a business shall:

1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

2) Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug‐free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

3) Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1).

4) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employees will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction.

5) Impose a sanction on, or require the satisfactory participation in a drug assistance or rehabilitation program if such is available in the employee's community, by any employee who is so convicted.

6) Make a good faith effort to continue to maintain a drug‐free workplace through implementation of this section.

As the person authorized to sign the statement, I certify the following: (Check one and sign in the space provided.)

This firm complies fully with the above requirements.

This firm does not have a drug free work place program at this time.

Bidder’s Signature

Title

Date

CONTRACTOR’S BUSINESS INFORMATION

COMPANY INFORMATION

Name:

Street Address:

City, State, Zip:

Taxpayer ID Number:

Telephone: Fax:

Trade Style Name:

TYPE OF BUSINESS ORGANIZATION (check one)

Sole Proprietorship

Limited Liability Company

General Partnership

Joint Venture

Limited Partnership

Trust

Corporation

Other (specify )

Sub‐chapter S Corporation

State of Incorporation: Date Established:

AUTHORIZED SIGNATORIES/NEGOTIATORS

The Bidder represents that the following persons are authorized to sign and/or negotiate contracts and related documents to which the bidder will be duly bound:

Name

Title Telephone E‐Mail

Company Name

Contact=s Name

Telephone

Fax

Address

FLORIDA CONSTRUCTION INDUSTRIES LICENSING BOARD

Please provide the following information for all licenses required by Florida Statutes of the Prime Contractor for the performance of the work in this project.

Primary Licensee:

License Type:

License Number: Expiration Date:

Qualified Business License (certificate of authority) number:

Alternate Licensee:

License Type:

License Number: Expiration Date:

Bidder may use additional sheets to provide information for all applicable licenses and shall provide copies of each license as a part of the bid submittal.

LIST COMPANIES FROM WHOM YOU OBTAIN SURETY

BONDS Surety Company 1

Surety Company 2

Company Name

Contact’s Name

Telephone

Fax

Present Amount of Bonding Coverage

Has your application for surety bond ever been declined?

□ Yes □ No

(If yes, please provided detailed information on reverse)

During the past 2 years, have you been charged with a failure to meet the claims of your subcontractors or suppliers?

□ Yes □ No

(If yes, please provided detailed information on reverse)

THE UNDERSIGNED, A DULY AUTHORIZED OFFICER OR EMPLOYEE, HEREBY CERTIFIES THAT THE ABOVE

INFORMATION IS TRUE AND CORRECT AND HAS HEREUNTO SET HIS SIGNATURE

THIS DAY OF , 20 .

By:_ Title:

Printed Name and Title:

NON‐COLLUSION AFFIDAVIT

The undersigned being first duly sworn as provided by law, deposes and says:

1. This Affidavit is made with the knowledge and intent that it is to be filed with Leon County Government, Leon County, Florida and that it will be relied upon by said County, in any consideration which may give to and any action it may take with respect to this Proposal.

2. The undersigned is authorized to make this Affidavit on behalf of, (Name of Corporation, Partnership, Individual, etc.)

a , formed under the laws of

(Type of Business) (State or Province) of which he/she is .

(Sole Owner, partner, president, etc.)

3. Neither the undersigned nor any other person, firm or corporation named in above Paragraph 2, nor anyone else to the knowledge of the undersigned, have themselves solicited or employed anyone else to solicit favorable action for this Proposal by the County, also that no head of any department or employee therein, or any officer of Leon County, Florida is directly interested therein.

4. This Proposal is genuine and not collusive or a sham; the person, firm or corporation named above in

Paragraph 2 has not colluded, conspired, connived or agreed directly or indirectly with any bidder or person, firm or corporation, to put in a sham Proposal, or that such other person, firm or corporation, shall refrain from bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference with any person, firm or corporation, to fix the prices of said proposal or proposals of any other bidder; and all statements contained in the proposal or proposals described above are true; and further, neither the undersigned, nor the person, firm or corporation named above in Paragraph 3, has directly or indirectly submitted said proposal or the contents thereof, or divulged information or data relative thereto, to any association or to any member or agent thereof.

AFFIANT’S NAME AFFIANT’S TITLE

TAKEN, SWORN AND SUBSCRIBED TO BEFORE ME this Day of ,20 .

Personally Known Or Produced Identification

Type of Identification

NOTARY PUBLIC

(Print, Type or Stamp Commissioned Name of Notary Public)

My Commission Expires:

INSURANCE CERTIFICATION FORM

To indicate that Bidder/Respondent understands and is able to comply with the required insurance, as stated in the bid/RFP document, Bidder/Respondent shall submit this insurances sign‐off form, signed by the company Risk Manager or authorized manager with risk authority.

A. Is/are the insurer(s) to be used for all required insurance (except Workers= Compensation) listed by Best with a rating of no less than A:VII?

□ YES □ NO

Commercial General Indicate Best Rating:

Liability: Indicate Best Financial Classification:

Business Auto: Indicate Best Rating:

Indicate Best Financial Classification:

Professional Liability: Indicate Best Rating:

Indicate Best Financial Classification: _________

1. Is the insurer to be used for Workers= Compensation insurance listed by Best with a rating of no less than

A:VII?

□ YES □ NO

Indicate Best Rating:

Indicate Best Financial Classification:

If answer is NO, provide name and address of insurer:

2. Is the Respondent able to obtain insurance in the following limits (next page) as required for the services agreement?

□ YES □ NO

Insurance will be placed with Florida admitted insurers unless otherwise accepted by Leon County. Insurers will have A.M. Best ratings of no less than A:VII unless otherwise accepted by Leon County.

Required Coverage and Limits

The required types and limits of coverage for this bid/request for proposals are contained within the solicitation package. Be sure to carefully review and ascertain that bidder/proposer either has coverage or will place coverage at these or higher levels.

Required Policy Endorsements and Documentation

Certificate of Insurance will be provided evidencing placement of each insurance policy responding to requirements of the contract.

Deductibles and Self‐Insured Retentions

Any deductibles or self‐insured retentions must be declared to and approved by the County. At the option of the County, either: the insurer shall reduce or eliminate such deductibles or self‐insured retentions as respects the County, its officers, officials, employees and volunteers; or the Contractor shall procure a bond guaranteeing payment of losses and related investigations, claim administration and defense expenses.

Endorsements to insurance policies will be provided as follows:

Additional insured (Leon County, Florida, its Officers, employees and volunteers) ‐ General Liability & Automobile Liability

Primary and not contributing coverage‐ General Liability & Automobile Liability

Waiver of Subrogation (Leon County, Florida, its officers, employees and volunteers)‐ General Liability, Automobile Liability, Workers= Compensation and Employer’s Liability

Thirty days advance written notice of cancellation to County ‐ General Liability, Automobile Liability, Worker’s Compensation & Employer’s Liability.

Professional Liability Policy Declaration sheet as well as claims procedures for each applicable policy to be provided

Please mark the appropriate box:

Coverage is in place □ Coverage will be placed, without exception □

The undersigned declares under penalty of perjury that all of the above insurer information is true and correct.

Name Signature .

Typed or Printed

Date Title .

(Company Risk Manager or Manager with Risk Authority)

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, And OTHER

RESPONSIBILITY MATTERS PRIMARY COVERED TRANSACTIONS

1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:

a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

b) Have not within a three‐year period preceding this been convicted of or had a civil judgement 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 statues 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 governmental 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/proposal had one or more public transactions (Federal, State or local) terminated for cause or default.

2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

3) No subcontract will be issued for this project to any party which is debarred or suspended from eligibility to receive federally funded contracts.

Signature

Title

Contractor/Firm

LOCAL VENDOR CERTIFICATION

The undersigned, as a duly authorized representative of the vendor listed herein, certifies to the best of his/her knowledge and belief, that the vendor meets the definition of a “Local Business.” For purposes of this section, "local business" shall mean a business which:

a) Has had a fixed office or distribution point located in and having a street address within Leon, Gadsden, Wakulla, or

Jefferson County for at least six (6) months immediately prior to the issuance of the request for competitive bids or request for proposals by the County; and

b) Holds any business license required by Leon County (or one of the other local counties), and, if applicable, the City of Tallahassee;

and

c) Is the principal offeror who is a single offeror; a business which is the prime contractor and not a subcontractor; or a partner or joint venturer submitting an offer in conjunction with other businesses.

Please complete the following in support of the self‐certification and submit copies of your County and City business licenses.

Failure to provide the information requested will result in denial of certification as a local business.

Business Name:

Current Local Address: Phone:

Fax:

If the above address has been for less than six months, please provide the prior address.

Length of time at this address:

Home Office Address: Phone:

Fax:

Signature of Authorized Representative Date

STATE OF

COUNTY OF

The foregoing instrument was acknowledged before me this day of ,20

By of , (Name of officer or agent, title of officer or agent) (Name of corporation acknowledging) a Corporation, on behalf of the corporation. He/she is personally known to me (State or place of incorporation) or has produced as identification.

Return Completed form with supporting documents to:

Leon County Purchasing Division 1800‐3 N. Blair Stone Road Tallahassee, Florida 32308

Signature of Notary

Print, Type or Stamp Name of Notary

Title or Rank

Serial Number, If Any

Employment Eligibility Verification

1. Contractor agrees that it will enroll and participate in the federal E‐Verify Program for Employment Verification under the terms provided in the “Memorandum of Understanding” governing the program. Contractor further agrees to provide to the County, within thirty days of the effective date of this contract/amendment/extension, documentation of such enrollment in the form of a copy of the E‐Verify “‘Edit Company Profile’ screen”, which contains proof of enrollment in the E‐Verify Program (this page can be accessed from the “Edit Company Profile” link on the left navigation menu of the E‐Verify employer’s homepage).

2. Contractor further agrees that it will require each subcontractor that performs work under this contract to enroll and participate in the E‐Verify Program within sixty days of the effective date of this contract/amendment/extension or within sixty days of the effective date of the contract between the Contractor and the subcontractor, whichever is later. The Contractor shall obtain from the subcontractor(s) a copy of the “Edit Company Profile” screen indicating enrollment in the E‐Verify Program and make such record(s) available to the Agency upon request.

3. Contractor will utilize the U.S. Department of Homeland Security’s E‐Verify system to verify the employment eligibility of: (a) all persons employed during the term of the Agreement by Contractor to perform employment duties within Florida; and (b) all persons (including subcontractors) assigned by Contractor to perform work pursuant to the Agreement.

a. Contractor must use E‐Verify to initiate verification of employment eligibility for all persons employed during the term of the Agreement by Contractor to perform employment duties within Florida within 3 business days after the date of hire.

b. Contractor must initiate verification of each person (including subcontractors) assigned by Contractor to perform work pursuant to the Agreement within 60 calendar days after the date of execution of this contract or within 30 days after assignment to perform work pursuant to the Agreement, whichever is later.

4. Contractor further agrees to maintain records of its participation and compliance with the provisions of the E‐

Verify program, including participation by its subcontractors as provided above, and to make such records available to the County or other authorized state entity consistent with the terms of the Memorandum of Understanding.

5. Compliance with the terms of this Employment Eligibility Verification provision is made an express condition of this contract and the County may treat a failure to comply as a material breach of the contract.

Signature Date

3. Entity Type (Check only one), Individual / Sole Proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Government (Local, State, Federal)

Tax-Exempt organization under IRC Section 501 C _________________

Limited liability company. Enter tax classification (C=Corporation, S=S corporation, P=partnership

4. 1099 Reporting: Services provided to the Board of County Commissioners Leon County by vendor, if not applicable skip:

Health care or medical service

Legal or attorney services

Rental of Real Property

Royalties

Other ____________

1. Enter your TIN here (DO NOT USE DASHES)

2. Taxpayer Identification Type (check appropriate box):

Employer ID No. (EIN) Social Security No. (SSN)

1. Address: 2. Remittance Address, IF DIFFERENT:

Address Line #1 Address Line #1

Address Line #2 Address Line #2

Address Line #3 Address Line #3

City State Zip + 4 Code City State Zip + 4 Code

Under penalties of perjury, I certify that:

1.

2.

3.

Printed Name Printed Title Telephone Number

Signature Email Date (mm/dd/yyyy)

Include a voided check or letter from financial institution if requesting ACH payments Type of Account Checking Savings

Signature Printed Name

CLERK OF COURT FINANCE DEPARTMENT USE ONLYOFFICIAL / POC USE ONLY

DATE (mm/dd/yyyy)

POC (Print name)

DO NOT SEND TO

IRS - SUBMIT

FORM TO

REQUESTING

AGENCY

FCD 04/2016

PART III: ADDRESS

BOARD OF COUNTY COMMISSIONERS LEON COUNTY

SUBSTITUTE FORM W-9

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION

MAIL COMPLETED FORM AND DOCUMENTS TO:

CLERK OF CIRCUIT COURT & COMPTROLLER LEON COUNTY 301 S. Monroe Street #100 Tallahassee FL32301

PLEASE REFER TO FORM W9 INSTRUCTIONS FOR MORE INFORMATION

1 . Legal Business Name: (As it appears on the IRS Income Tax return IRS EIN records, CP575, 147C - or - Social Security Administration records, Social Security Card, certified Form SSA7028)

2 . If you use a DBA/Trade Name, please list below:

PART I: VENDOR INFORMATION

PART II: TAXPAYER IDENTIFICATION NUMBER (TIN) & TAXPAYER IDENTIFICATION TYPE

I am a U.S. Citizen or other U.S. person.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding

PART IV: CERTIFICATION

The number shown on this form is my correct tax payer identification number (or I am waiting for a number to be issued to me), AND I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, AND

PART VI: OFFICE USE ONLY

I acknowledge the IAT warning and authorize the Board of County Commissioners Leon County to initiate direct deposit of funds to the account and financial institution indicated, and to recover funds deposited in error if necessary in compliance with NACHA regulations.

PART V: DIRECT DEPOSIT (ACH) This is the County's preferred payment method Warning: The Board of County Commissioners Leon County will not process International ACH Transactions (IAT). If any payment to you from the County will ever result in an IAT under National Automated Clearing House Association (NACHA) operating rules or if you are not sure if the rules apply to you DO NOT FILL OUT THIS SECTION OF THE FORM. Please provide a copy of a voided check or letter from bank confirming information indicated above.

BUSINESS UNIT PHONE NO.

POC Initials

N/A (Non United States Business Entity)

KirklandR Highlight

KirklandR Highlight

Instructions for Completing this Form This form substitutes for the IRS W-9 form. Complete this form if you will receive payment from the Board of County Commissioners Leon County for goods and services. To comply with the Internal Revenue Service (IRS) regulations regarding 1099 reporting, the Board of County Commissioners Leon County is required to collect the following information to be completed on the Substitute W-9 form. The information collected on this form will allow the Board of County Commissioners Leon Count to confirm that our records contain the official name of your business, the Tax Identification Number (TIN) that the IRS has on file for your business and business type.

Check the appropriate box(s) that this form is to be utilized and fill in the corresponding section(s) indicated next to the box(s) checked.

PART I: VENDOR INFORMATION

1. Legal Business Name Enter the legal name as registered with the IRS or Social Security Administration.

2. DBA/Trade Name Individuals leave blank. Sole Proprietorships: Enter DBA (doing business as) name. All Others:

Complete only if business name is different than Legal Name.

3. Entity Type Check ONE box which describes business entity.

4. 1099 Reporting Check the appropriate box that applies to the type of services being provided to the Board of County Commissioners Leon County. If the type of service is not specifically stated, then leave blank.

PART II: TAXPAYER IDENTIFICATION NUMBER (TIN) & TAXPAYER IDENTIFICATION TYPE

1. Taxpayer Identification Number Enter TIN with no dashes in the boxes provided

a. TIN is always a 9-digit number. Provide the Social Security Number (SSN) assigned by the Social Security

Administration (SSA) or the Federal Employer Identification Number (FEIN) assigned to the business or other entity by the Internal Revenue Service (IRS).

2. TIN Identification Type Mark the appropriate box for the TIN provided above.

PART III: ADDRESS

1. Address Where correspondence, payment(s), purchase order(s) or 1099s should be sent.

2. Remittance Address If different than Address

3. Zip Code and Phone Number The 5 + 4 code will be required to be entered for all zip codes. If the last 4 digits are unknown, then 4 zeros (0) can be entered. Do not enter the “-“ as part of the zip code. When entering the phone number, only enter the 10 digit number. Do not enter the “( )” or “-“ as part of the phone number.

PART IV: CERTIFICATION

By signing this document you are certifying that all information provided is accurate and complete. The person signing this document should be the partner in the partnership, an officer of the corporation, the individual or sole proprietor noted under legal name above, or the government official for which the vendor account is established.

Identifying information is required of the person signing the form.

PART V: DIRECT DEPOSIT (ACH) We request that you elect to receive payments from the Board of County Commissioners Leon County through Automated Clearing House (ACH) direct deposit. Please provide a copy of a voided check or letter from financial institution with the banking information. Without one of the two items, ACH information WILL NOT be entered and you will need to resend the requested documents. Select the type of account being provided.

I Acknowledge Print name and sign to acknowledge the IAT warning and to authorize the Board of County Commissioners Leon County to initiate direct deposit of funds to your financial institution provided.

Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to furnish your correct TIN to persons who must file information returns with the Internal Revenue Service.

KirklandR Highlight

KirklandR Highlight