General Information Sheet

Supplier General Information Worksheet

Revised 12/22/2010 Page 1 SPD-SP042

Question #

Description Company Name (Provide full legal name) Address 1

Address 2

City

State

Zip Code

Authorized Person’s Name

Telephone Number eMail Address

2 Supplier's Domicile (State)

3 Response

Minority Group Percentage of Ownership

African American %

Hispanic / Latino %

Native American %

Asian American %

This spreadsheet requests basic information concerning the Supplier and may establish other requirements the Supplier must meet to be considered eligible for award. Read each question carefully and provide all requested answers.

Supplier General Information

A Minority Business enterprise means a small business concern which is at least 51% owned and controlled by one or more minorities and is authorized to do and is doing business under the laws of the State of Georgia, paying all taxes duly accessed and domiciled within this state (Official Code of Georgia Annotated §50-5-131).

For the purposes of evaluation only, Suppliers resident in the State of Georgia will be granted the same preference over Suppliers resident in another state in the same manner, on the same basis, and to the same extent that preference is granted in awarding bids for the same goods or services by such other state to Suppliers resident therein over Suppliers resident in the State of Georgia. NOTE:

For the purposes of this law, the definition of a resident Supplier is a Supplier who is domiciled in the State of Georgia.

Georgia Based Business/Reciprocal Preference Law O.C.G.A. §50-5-60(b) In which state is your company domiciled?

Description

Minority Business: Can your company be classified as a Minority Owned Business? Indicate below the percentage of company ownership/control attributable to each of the minority groups listed:

Provide Company Information:

Response

Small Business: Can your company be classified as a Small Business?

A Small Business is defined as an independently owned and operated entity that has either fewer than one hundred (100) employees or less than one million dollars ($1,000,000) in gross receipts per year. (Official Code of Georgia Annotated §50-5-121).

Also, the State encourages all companies to sub-contract portions of any state contract to small and minority business enterprises. Suppliers interested in taking advantage of the Georgia income tax incentives provided for by the Official Code of Georgia Annotated Section 48-7-38, relative to the use of minority subcontractors in the performance of contracts awarded by the State of Georgia, should contact the Vendor Relations Administrator:

Vendor Relations Administrator Department of Administrative Services 200 Piedmont Avenue, S.E.

Suite 1308, West Tower Atlanta, Georgia 30334 9010 Telephone: (404) 657-6000 Fax: (404) 657-8444

Revised 12/22/2010 Page 2 SPD-SP042

This spreadsheet requests basic information concerning the Supplier and may establish other requirements the Supplier must meet to be considered eligible for award. Read each question carefully and provide all requested answers.

Supplier General Information

Pacific Islander %

Revised 12/22/2010 Page 3 SPD-SP042

This spreadsheet requests basic information concerning the Supplier and may establish other requirements the Supplier must meet to be considered eligible for award. Read each question carefully and provide all requested answers.

Supplier General Information

5 Response

6 ResponseHave you submitted a completed Tax Compliance form?

Is your company a scrutinized company? Please answer either a, b, or c as described Any Supplier that currently and/or previously, within the last three years, has had business activities or other operations outside of the United States, must certify that it is not a “scrutinized company.” A scrutinized company is a company conducting business operations in Sudan that is involved in power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, but excludes a company which can demonstrate any of the following exceptions noted in O.C.G.A. Section 50-5-84. False certification hereunder may result in civil penalties, contract termination, ineligibility to bid on state contractors for three or more years, and/or any other available remedy. If the Supplier is a scrutinized company, the Supplier shall not be eligible to bid on or submit a proposal for a contract with the State Entity unless DOAS makes a determination in accordance with O.C.G.A. Section 50-5-84 that it is in the best interests of the State to permit the scrutinized company to submit a bid or proposal. Any scrutinized company desiring DOAS to make such a determination should contact both DOAS and the Issuing Officer immediately.

Please answer either a, b or c in the response column of this worksheet to indicate your answer:

a. I certify my company is NOT a “scrutinized company.”

b. I certify my company is a “scrutinized company.”

c. I certify I have requested and received written permission from DOAS to submit a response to this Event in accordance with O.C.G.A. Section 50-5-84.

Any Offeror identified as a prohibited source will be ineligible for award. Accordingly, the Offeror is strongly encouraged to check its tax status now and resolve any outstanding tax liabilities prior to submitting this response. Department of Revenue has identified the following source to allow Offerors to check current tax status:

http://www.etax.dor.ga.gov/ http://doas.ga.gov/StateLocal/SPD/Seven/Pages/Home.aspx

To be eligible for contract award, the supplier must not owe taxes to the State of Georgia. Also, in accordance with Official Code of Georgia Annotated §50-5-82, the State Entity is prohibited from awarding any contract valued at more than $100,000.00 to a nongovernmental vendor if that vendor or an affiliate of the vendor is a “dealer” failing or refusing to collect sales or use taxes on its sales delivered to Georgia. Each Supplier must submit a completed Tax Compliance Form (SPD-SP045), which has been provided as a downloadable document by accessing the link below. In the event the Supplier is being considered for contract award (and the contract is valued at more than $100,000.00), the information provided in the Tax Compliance Form will be submitted by the State Entity to the Georgia Department of Revenue (“DOR”) for a determination as to whether the Supplier is a “prohibited source” or has other tax deficiencies. The State Entity reserves the right to submit the Supplier’s completed form to DOR for review even if the contract is valued at less than $100,000.00.

Download the Tax Compliance form using the link below and upload the completed form as part of your response:

http://www.etax.dor.ga.gov/ http://doas.ga.gov/StateLocal/SPD/Seven/Pages/Home.aspx

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