IFB_25CS0003_Dental_Laboratory_Services.pdf

State of California Solicitation Number: 25CS0003 Department of Veterans Affairs

INVITATION FOR BID

Notice to Prospective Bidders

February 6, 2025

The California Department of Veterans Affairs, hereafter referred to as “CalVet”, is inviting you to participate in this Invitation for Bid (IFB) No. 25CS0003, entitled Dental Laboratory Services.

This IFB contains a list of Key Action Dates in Section C, and Bid Requirements and Information (see Page 3, Table of Contents).

While a Disabled Veteran Enterprise (DVBE) goal is not required for this IFB, DVBE participation is encouraged; and, the DVBE Incentive and Small Business Preferences do apply. See Section D, Special Programs, in this IFB for requirements.

In submitting your bid, you must comply with all instructions and requirements contained herein.

This IFB package includes the following documents. For additional information on documents required to be included in the bid submission, please see the Bidder’s Checklist.

1. Notice to Prospective Bidders

2. Bidder’s Checklist

3. Bid/Bidder Certification Sheet

4. Bid Rate Sheet

5. Payee Data Record - STD 204 (and STD 205, if applicable)

6. Bidder Declaration - GSPD-05-105

7. Commercially Useful Function Certification Form

8. California Disabled Veteran Business Enterprise Program Requirements

9. Darfur Contracting Act

10. Disabled Veteran Business Enterprise (DVBE) Declarations – DGS PD 843

11. Contractor Certification Clauses (CCC 4/2017)

12. STD 1000 – GenAI Disclosure and Factsheet

13. Sample Standard Agreement (STD 213):

a. Exhibit A – Scope of Work

b. Exhibit B – Budget Detail and Payment Provisions

c. Sample Exhibit B-1 – Rate Sheet

d. Exhibit D – Special Terms and Conditions & Additional Provisions

e. Exhibit E - Business Associates Agreement (HIPAA)

The following documents are incorporated by reference and are available on the internet at https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard- Contract-Language. Bidder may request an electronic copy of these documents by contacting the assigned contract analyst listed below.

1. Exhibit C - General Terms and Conditions for Private Contractors (GTC 04/2017).

2. Standard Contractor Certification Clauses (CCC 04/2017)

Upon award, the Contractor shall be required to provide the following Insurance Requirements as listed in Exhibit D

It is the opinion of CalVet that this IFB is complete and without need of explanation. This IFB can be made available in a text-only format as a disability-related reasonable accommodation compliant with the California Government Code and Americans with Disabilities Act (ADA).

Please note that no verbal information given will be binding upon CalVet unless such information is issued in writing as an official addendum. If you have questions or should you need any clarifying information, the contact person for this IFB is:

Keith Wynkoop, Contract Analyst California Department of Veterans Affairs

1227 O Street Sacramento, CA 95814 Phone: (916) 653-2621

Email: keith.wynkoop@calvet.ca.gov

Table of Contents Section Page

A) Purpose and Description of Services

B) Bidder Minimum Qualifications

C) Bid Requirements and Information

1) Key Action Dates

2) Question and Answer Period

3) Package and Submittal Instructions

4) Evaluation and Selection

5) Awards

6) Protests

7) Disposition of Bid

8) Agreement Execution and Performance

D) Special Programs

1) Disabled Veterans Business Enterprise Program

2) Small Business Preferences

E) Required Disclosures

1) Commercially Useful Function

2) Darfur Contracting Act

3) Contractor Certification Clauses

4) Executive Order N-6-22 – Russia Sanctions

5) Generative Artificial Intelligence (GenAI) Disclosure Notification

F) Required Attachments

A) PURPOSE AND DESCRIPTION OF SERVICES

The California Department of Veterans Affairs is seeking qualified vendors to contract for Dental Laboratory services. The contractor is responsible for meeting all of the licenses and certifications required to perform the scope of services set forth in this solicitation.

B) BIDDER MINIMUM QUALIFICATIONS

Bidder qualifications and licensing requirements (if any) are specified below and/or in Exhibit A. Unless otherwise stated, Bidder shall meet all qualifications and licensing requirements at the time of the public bid opening.

C) BID REQUIREMENTS AND INFORMATION

1) Key Action Dates

The following dates are set forth for informational and planning purposes only and are subject to change:

2) Question and Answer Period

Any questions regarding this IFB must be submitted in writing by, via email to the Contract Analyst listed on page 2 of this IFB. All questions must be received prior to the deadline for questions. Emails should include the individual's name, firm name, address, and must reference IFB #25CS0003. All answers will be posted on the Cal eProcure website. It is the responsibility of the Bidder to check the California State Contract Register at https://caleprocure.ca.gov/pages/index.aspx when inquiring about an addendum, questions, answers, and any other posts related to this IFB.

3) Packaging and Submittal Instructions

a) All proposals and cost information must be submitted and received by the CalVet by the Final Date for Submission of Bid as identified in Section C)1) – Key Action Dates.

b) Bids must be submitted via e-mail to: keith.wynkoop@calvet.ca.gov

c) The e-mail submittal format is the following:

1. The subject line of the submittal e-mail must read, “Response to CalVet Solicitation: 25CS0003”

2. The body of the e-mail must read:

IFB Available to Prospective Bidders Date: February 6, 2025

Deadline for Questions Date: February 12, 2025 Time: 11:59 p.m.

Deadline for Responses to Questions Date: February 14, 2025 Time: 3:30 p.m.

Final Date for Submission of Bid Date: February 20, 2025 Time: 11:29 p.m.

Bid Opening Date: February 21, 2025 Time: 10:00 a.m.

Notice of Intent to Award Date: February 25, 2025

Proposed Award Date Date: March 17, 2025

Term Start Date Date: July 1, 2025 or upon approval whichever is later

Term End Date of Agreement Date: June 30, 2028

DO NOT OPEN

Solicitation #23CS0003 CalVet Central Business Office ATTENTION: Keith Wynkoop

Bidders are ultimately responsible for ensuring timely receipt of their bid. Bidders may verify receipt of a bid by contacting the CalVet Contract Analyst identified in the cover letter of this IFB.

d) Bidders are solely responsible for understanding the scope of work and all requirements, terms, conditions, evaluation criteria, etc., before submitting a bid. If the language is unclear or ambiguous, it is Bidder’s responsibility to request clarification or assistance before submitting a bid. Please note that no verbal information shall be binding upon the State unless the State issues such information in writing as an official addendum. If the IFB is modified prior to the final bid submission date, the State shall issue an addendum to all bidders that received a bid package. By virtue of submitting a bid, Bidder is accepting the terms and conditions expressed herein. Costs incurred for developing bids and in anticipation of award of the Agreement are the responsibility of Bidder and shall not be charged to the State.

e) Bidder may modify a bid after its submission by withdrawing the original bid and resubmitting a new bid prior to the bid submission deadline. Bidder modifications offered in any other manner, oral or written, shall not be considered.

f) Bidder’s bid may be withdrawn from consideration by submitting a written withdrawal request to the State, signed by Bidder or an authorized agent prior to the public bid opening. The bid is binding once it is opened by the State and may not be withdrawn without cause.

4) Evaluation and Selection

a) All bid packages properly received according to the IFB Instructions on or before the bid due date and time shall be publicly opened and the rates read on the date and time specified in Section C)1), Key Action Dates.

Bidders who plan to attend the virtual public bid opening must notify the CalVet Contract Analyst listed in the cover letter of this IFB at least three (3) business days before the date of the public bid opening Section C.1, Key Action Dates, Bid Opening. If Bidder and/or Bidder’s representative require reasonable accommodation to participate in the Public Bid Opening, Bidder must contact the CalVet Contract Analyst identified in this package and identify what reasonable accommodation(s) is required for Bidder to participate

b) CalVet will evaluate each bid to determine compliance and adherence to all IFB requirements, as well as verification of calculations. CalVet reserves the right to request clarification of any documents submitted with this bid regarding any and/or all sections of the IFB.

c) In the event of a precise tie between the lowest responsible bid of a certified small business and a certified disabled veteran owned small business, the contract must be awarded to the disabled veteran owned business per the Department of General Services (DGS) State Contracting Manual (SCM), Section 8.21C. If a tie persists between any Bidders after the small business preference is applied, a coin toss or lot drawing shall be used to determine the contract award. The coin toss or lot drawing shall be officially witnessed and all affected bidders shall be advised of the tiebreaker method and invited to attend.

d) Bids that contain false or misleading statements, or which provide references that do not support an attribute condition claimed by the bidder, may be rejected.

e) No bid shall be considered unless the rate is submitted on the designated Rate Sheet and Bidder Certification form is in conformance with the submission requirements of this IFB.

f) The bid must be submitted for the entire activity described herein. CalVet does not accept alternate contract language from a prospective contractor. A bid with such language shall be considered a counter proposal and shall be rejected. Additionally, bids may be rejected if the bid proposal shows any alterations of form, additions not called for, a conditioned or incomplete bid, or erasures and/or irregularities of any kind. Any bid amounts changed after the amounts are originally inserted MUST be initialed in original ink by Bidder.

g) CalVet reserves the right to reject any and all bid submittal packages and/or waive any immaterial deviations in a bid submittal package and/or allow a Bidder to remedy any immaterial deviations in their bid submittal package. CalVet reserves the right to determine what constitutes an immaterial deviation in Bidder’s bid submittal package. The State’s waiver of an immaterial deviation shall in no way modify the IFB document or excuse Bidder from full compliance with all requirements if awarded an Agreement.

h) CalVet is not required to award an Agreement resulting from this IFB.

i) If a previous Agreement with a prospective bidder was terminated for cause, CalVet reserves the right to hold a responsibility hearing before awarding the Agreement to determine if the bidder is responsible.

The bid may be rejected if CalVet deems, at the conclusion of the responsibility hearing, that the bidder is not responsible.

5) Awards

a) The award of an Agreement, if it is to be awarded, shall be made to the lowest responsible Bidder whose bid complies with all requirements prescribed herein. In the event Bidder submits more than one (1) bid under this bid process, CalVet shall select the lowest bid and reject all other bids from this Bidder.

b) Whenever an Agreement is awarded under a procedure which provides for competitive bidding, but the

Agreement is not to be awarded to the low bidder, the low bidder shall be notified by electronic mail, facsimile transmission, overnight courier, or personal delivery five (5) working days prior to the award of the Agreement.

c) Notice of the Intent to Award shall be posted in a public place in the office of the awarding agency at least five (5) working days prior to awarding the Agreement, if requested in writing by any bidder who submitted a bid.

d) Upon receipt of a tentative award, the apparent winning Bidder must return all required documents to the contract analyst within thirty (30) days of receipt. Failure to do so will result in the disqualification of the bidder’s submission. A tentative award will then be issued to the next lowest responsive responsible bidder.

6) Protests

a) If any bidder, prior to the award of Agreement, files a written protest with the Department of General

Services, Office of Legal Services (DGS/OLS), 707 Third Street, 7th Floor, Suite 7-330, West Sacramento, CA 95605 or Email at OLSProtests@dgs.ca.gov and the California Department of Veterans Affairs on the grounds that the (protesting) bidder is the lowest responsive responsible bidder, the Agreement shall not be awarded until either the protest has been withdrawn or the Department of General Services has decided the matter.

b) Within five (5) days after filing the initial protest, the protesting bidder shall file with the DGS and the awarding agency, a detailed written statement specifying the grounds for the protest. The written protest must be sent to the Department of General Services, Office of Legal Services, 707 Third Street, 7th Floor, Suite #7-330, West Sacramento, CA 95605 and Email at OLSProtests@dgs.ca.gov. A copy of the detailed written statement should be mailed to the awarding agency. It is suggested that you submit any protest by certified or registered mail.

7) Disposition of Bids

a) Upon bid opening, all documents submitted in response to this IFB will become the property of the State of California, and will be regarded as public records under the California Public Records Act (Government Code Section 6250 et seq.) and subject to review by the public.

b) Bid packages may be returned only at the bidder's expense, unless such expense is waived by the awarding agency.

8) Agreement Execution and Performance

a) The successful bidder(s) shall enter into an Agreement with CalVet prepared on a State of California

Standard Agreement (STD 213 form, sample attached) and shall include Exhibits A Scope of Work, B Budget Detail and Payment Provisions, B-1 Rate Sheet, Exhibit C General Terms and Conditions (GTC

– 04/2017), and Exhibit D Special Terms and Conditions. The approval of an Agreement is contingent upon timely receipt and the State's acceptance of the Contractor's certificates of insurance, bonds, licenses, permits and other required documents.

b) This Agreement is not valid unless and until approved by DGS or, under its delegated authority, CalVet.

CalVet has no legal obligation unless and until the Agreement is approved. Any work commenced by the Contractor prior to approval may be considered voluntary and the Contractor may have to pursue claim for payment by filing with the California Victim Compensation and Government Claims Board.

When the Agreement is fully approved, a copy shall be forwarded to Contractor.

c) In the event the Bidder is party to an Agreement awarded in a prior CalVet bid for the same services and a contract award is made to Bidder as a result of this IFB, CalVet shall pay for services using rate(s) in the prior Agreement for the period of time up to and including the term end date of that Agreement. The only exception to this provision occurs when the rate(s) in a subsequent agreement is lower than those of the primary agreement; CalVet then has the sole right to determine which rate(s) will be applied.

d) In the event an awarded Contractor fails to commence work at the agreed upon time, CalVet, upon five

(5) days written notice to the Contractor, reserves the right to terminate the agreement. In addition, the Contractor shall be liable to CalVet for the difference between Contractor's bid price and the actual cost of performing work by the second lowest bidder or by another contractor.

e) All performance under the agreement shall be completed on or before the termination date of the Agreement.

D) SPECIAL PROGRAMS

1) Disabled Veteran Business Enterprise Program

a) DVBE Participation Program with No Goal

While a DVBE goal is not required, DVBE participation is encouraged, and the DVBE Incentive will apply to this IFB as described below.

b) It is the intent of the California Legislature that every State procurement authority honor California’s disabled veterans by taking all practical actions necessary to meet or exceed the Disabled Veteran Business Enterprise participation goal of a minimum of three percent (3%) of total contract value. The Disabled Veteran Business Enterprise (DVBE) Certification and Outreach Branch program was created for this purpose. Under Senate Bill 115, Section 999.5, an incentive program was established.

c) For instructions on how to document DVBE Program Requirements, please see Attachment entitled California Disabled Veteran Business Enterprise Program Requirements.

d) DVBE Incentive: The DVBE Incentive Program applies to this solicitation. It is separate from the DVBE Participation Program and was established in Military and Veterans Code Sections 999 et seq., and Title

2, California of Regulations, Sections 1896.99 (2 CCR Section1896.99) et seq., to encourage bidders to partner with DVBE subcontractors.

The incentive is used only for evaluation purposes to arrive at the successful bidder and does not alter the amounts of the actual bid. CalVet shall apply a DVBE Bid incentive to bids that propose California certified DVBE participation as identified on the Bidder Declaration, GSPD-05-105, and confirmed by the State. The DVBE incentive amount for awards based on low price will vary in conjunction with the percentage of DVBE participation.

Any responsive and responsible bidder with the confirmed DVBE participation per the Table below is eligible to receive the incentive. Bidders who are not responsive and responsible regardless of the amount of DVBE participation are not eligible to receive the incentive.

The following percentages will apply for awards based on low price:

Confirmed DVBE Participation of: DVBE Incentive Percentage:

5% or over 5%

4% to 4.99% inclusive 4% 3% to 3.99% inclusive 3% 2% to 2.99% inclusive 2% 1% to 1.99% inclusive 1%

Application of the DVBE incentive CANNOT displace a California Certified Small Business.

e) Contractor understands and agrees that should award of this contract be based in part on their commitment to use the DVBE subcontractor(s) identified in their bid or offer, per Military and Veterans Code 999.5 (e), a DVBE subcontractor may only be replaced by another DVBE subcontractor and must be approved by the Department of General Services (DGS). Changes to the scope of work that impact the DVBE subcontractor(s) identified in the bid or offer and approved DVBE substitutions will be documented by contract amendment.

f) Failure of Contractor to seek substitution and adhere to the DVBE participation level identified in the bid or offer may be cause for contract termination, recovery of damages under rights and remedies due to the State, and penalties as outlined in M&VC § 999.9; Public Contract Code (PCC) § 10115.10, or PCC § 4110 (applies to public works only).

g) Pursuant to Government Code 14841, upon completion of the contract for which a commitment to achieve small business (SB) or DVBE participation was made, the contractor shall report to the awarding department the actual percentage of SB/DVBE participation that was achieved.

h) Withhold: Prime contractors (prime) must submit a complete and accurate Prime Contractor’s

Certification – DVBE Subcontracting Report (STD 817) – upon contract completion. Ten thousand dollars ($10,000) shall be withheld from the final payment, or full payment if less than $10,000, until contract manager(CM) receives an accurate and complete STD 817. (MVC §999.7)If prime fails to provide an accurate and complete STD 817, CM notifies prime and allows up to 30 calendar days for prime to remedy the situation. The withhold becomes permanent if the prime:

• Refuses to submit the STD 817;

• Fails to correct or complete the STD 817 within the 30-day deadline; or,

• Fails to make all payments due to the listed DVBE sub [MVC §999.5(d)(4)]

2) Small Business Preferences

a) Current law encourages state departments to first consider a Small Business Enterprise (Small)/ Micro-business Enterprise (Micro) for contracting opportunities. CalVet is committed to supporting Small/Micro business participation in state contracting and seeks to use certified Small/Micro businesses whenever possible. A Small/Micro business enterprise is defined as a business certified by the Office of Small Business and DVBE Services (OSDS) in which:

I) The principal office is located in California

II) The officers are domiciled in California III) The business is independently owned and operated IV) The business, with any affiliates, is not dominant in its field of operation and:

(a) For Small Business, either:

(i) The business, together with any affiliates, has 100 or fewer employees and averaged annual gross receipts of $15,000,000 or less over the previous three years, or

(ii) The business is a manufacturer with 100 or fewer employees.

(b) For Micro Business, either:

(i) The business, together with any affiliates, has 25 or fewer employees and averaged annual gross receipts of $5,000,000 or less over the previous three years, or

(ii) The business is a manufacturer with 25 or fewer employees.

b) Section 14835, et seq., of the California Government Code requires that a five percent (5%) preference be given to bidders who qualify as a Small/Micro business enterprise. The rules and regulations of this law are contained in Title 2, California Code of Regulations Section 1896, et seq. A copy of the regulation is available upon request.

c) To claim the Small/Micro business preference, which may not exceed $50,000 for any bid, Bidder’s firm must have a completed application (including proof of annual receipts) on file with the DGS, Procurement Division, OSDS, by 5:00 p.m. on the date bids are opened, and receipt verified by such office. Therefore, if Bidder is a Small/Micro business, but is not certified, it is to Bidder’s advantage to become certified. For certification and preference approval process information, contact the OSDS by telephone at (916) 375-4940 or access the OSDS Internet website at https://www.dgs.ca.gov/PD/About/Page-Content/PD-Branch-Intro-Accordion-List/Office-of-Small- Business-and-Disabled-Veteran-Business-Enterprise/Certification-Program

d) If upon verification of Bidder’s Small/Micro business status it is determined Bidder is not a certified Small/Micro business enterprise, Bidder’s business shall be classified as a large business which shall preclude Bidder’s bid from receiving the five percent (5%) Small/Micro business preference.

e) Pursuant to Title 2, California Code of Regulations Section 1896, et seq., and Government Code Section

14838, et seq., a bid preference of five percent (5%) is available to a responsive non-small business claiming no less than twenty-five percent (25%) Small/Micro business subcontractor participation with one or more Small/Micro businesses. This preference is considered only if the tentative low bidder is not a certified Small/Micro business. In granting the Non-Small Business Subcontractor (NSBS) preference, no bid price shall be reduced by more than $50,000. This preference cost adjustment is for computation purposes only and does not alter the actual cost offered by Bidder. To be eligible for the NSBS preference, the business must complete the following forms:

I) Non-Small Business Subcontractor Preference Request

II) Small Business Subcontractor/Supplier Acknowledgement

f) Pursuant to Military and Veteran Code Section 999.50 et seq., Nonprofit Veteran Service Agencies

(NVSAs) claiming Small/Micro business preference and verified as such in the relevant category or business type, shall be granted a preference of five percent (5%) of the lowest responsive bid, if the lowest responsive bid is submitted by a bidder not certified as a Small/Micro business. In granting Small/Micro business preference to NVSAs, no bid shall be reduced by more than $50,000. The preference cost adjustment is for computation purposes only and does not alter the actual cost offered by Bidder. To be eligible for the NVSA Small/Micro business preference, the business concern must:

I) Request preference at the time of bid submission; and

II) Have a completed application on file with DGS, OSDS by 5:00 p.m. on the date bids are due.

E) REQUIRED DISCLOSURES

1) Commercially Useful Function

If Bidder is a California certified small business in accordance with Government Code Sections 14837(d)(1)(2), Bidder must address specific aspects of the legislation that requires certified small businesses to perform a commercially useful function as defined in Government Code Sections 14837(d)(4)(A)(B). A Commercially Useful Function Certification (CUF) form is attached to this solicitation.

2) Darfur Contracting Act

Effective January 1, 2009, contracts for Non-Information Technology (Non-IT) goods or services must address the requirements of the Act. The Act was passed to preclude State agencies generally from contracting with “SCRUTINIZED” companies that do business in the African nation of Sudan (of which the Darfur region is a part), for the reasons described in PCC Section 10475.

A SCRUTINIZED company is a company doing business in Sudan as defined in PCC Section 10476.

SCRUTINIZED companies are ineligible to, and cannot, bid on or submit a proposal for a contract with a State agency for Non-IT goods or services (PCC Section 10477(a)). PCC Section 10478(a) requires a company that currently has (or within the previous three years has had) business activities or other operations outside of the United States to certify that it is not a SCRUTINIZED company in order to submit a bid or proposal to a State agency. A SCRUTINIZED company may still, however, submit a bid or proposal for a contract with a State agency for goods or services if the company first obtains permission from the DGS according to the criteria set forth in PCC Section 10477(b).

3) Contractor Certification Clauses

The Contractor Certification Clauses (CCC) may be downloaded from the Internet at https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List- Folder/Standard-Contract-Language An original, signed copy of page 1 must be submitted with the bid.

Failure to submit a signed CCC shall delay approval of this Agreement.

4) Executive Order N-6-22 – Russia Sanctions

On March 4, 2022, Governor Gavin Newsom issued Executive Order N-6-22 (the EO) regarding Economic Sanctions against Russia and Russian entities and individuals. “Economic Sanctions” refers to sanctions imposed by the U.S. government in response to Russia’s actions in Ukraine, as well as any sanctions imposed under state law. By submitting a bid or proposal, Contractor represents that it is not a target of Economic Sanctions. Should the State determine Contractor is a target of Economic Sanctions or is conducting prohibited transactions with sanctioned individuals or entities, that shall be grounds for rejection of the Contractor’s bid/proposal any time prior to contract execution, or, if determined after contract execution, shall be grounds for termination by the State

5) Generative Artificial Intelligence (GenAI) Disclosure Notification

The State of California seeks to realize the potential benefits of GenAI, through the development and deployment of GenAI tools, while balancing the risks of these new technologies.

Bidder / Offeror / Contractor must notify the State in writing if their solution or service includes, or makes available, any GenAI, including GenAI from third parties or subcontractors.

The State has developed a GenAI Reporting and Factsheet (STD 1000) to be completed by the Bidder / Offeror / Contractor .

Failure to submit the GenAI Reporting and Factsheet (STD 1000) will result in disqualification of the Bidder / Offeror / Contractor.

Failure to report GenAI to the State may void any resulting contract. The State reserves its right to seek any and all relief it may be entitled to as a result of such non-disclosure.

Upon receipt of a Bidder / Offeror / Contractor GenAI Reporting and Factsheet (STD 1000), the state reserves the right to incorporate GenAI Special Provisions into the final contract or reject bids/offers that present an unacceptable level of risk to the state.

F) REQUIRED ATTACHMENTS

All required documents are listed on Attachment 1, Bidder’s Checklist, and must be included when submitting a bid.

BIDDER’S CHECKLIST

Dental Laboratory Services

The checklist below is a summary of documents to be submitted based on requirements in the Invitation for Bid.

This checklist should be returned with your bid. Place a check-mark or “X” next to each document being submitted.

Signatures are required on the documents where specified.

The company name listed on all documents submitted (ex. licenses, permits, certifications, and insurance) must be identical to the company name on the Payee Data Record (STD 204). Failure to submit these documents in the manner prescribed may delay award of Agreements.

Bidder’s Checklist

Bidder Certification

Bid Rate Sheet

Signed Payee Data Record - STD 204

Bidder Declaration - GSPD-05-105

Commercially Useful Function (CUF) Certification, if applicable

Disabled Veteran Business Enterprise (DVBE) Declarations – DGS PD 843, if applicable

Darfur Contracting Act

Contractor Certification Clauses (CCC-4/2017) - The CCC-4/2017 can be found on the Internet at https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List- Folder/Standard-Contract-Language

Valid California city or county business license; or, if a corporation located within the State of California, incorporation documents or letter from the Secretary of State; or, if not a California business, an affidavit that business is in good standing with the State, Province, or Country in which business is headquartered.

STD 1000 Generative Artificial Intelligence (GenAI) Disclosure and Factsheet

Sample Invoice

BID/BIDDER CERTIFICATION SHEET

This Bid/Bidder Certification Sheet must be signed and returned along with all the "required attachments" as an entire package. The bid must be transmitted in accordance with IFB instructions.

A. I have read and understand the DVBE participation requirements and have included documentation demonstrating that I have met the participation goals, if goals are included.

B. The undersigned signature certifies under penalty of perjury that they are a duly authorized representative and in compliance with all the requirements of this bid document. The signature below authorizes the verification of this certification.

An Unsigned Bid/Bidder Certification Sheet May Be Cause For Rejection.

1. Company Name 2. Telephone Number 2a. Fax Number

2c. E-MAIL

3. Address

Indicate your organization type:

4. Sole Proprietorship 5. Partnership 6. Corporation

Indicate the applicable employee and/or corporation number:

7. Federal Employee ID No. (FEIN) 8. California Corporation No.

9. Bidder’s Name (Print) 10. Title

11. Signature 12. Date

13. Are you certified with the Department of General Services, Office of Small Business and Disabled Veteran Business Enterprise Services (OSDS) as:

a. California Small Business Yes No

If yes, enter certification number:

b. Disabled Veteran Business Enterprise Yes No If yes, enter your service code below:

NOTE: A copy of your Certification should be included if either of the above items is checked “Yes”.

Date application was submitted to OSDS, if an application is pending:

Completion Instructions for Bid/Bidder Certification Sheet

Complete the numbered items on the Bid/Bidder Certification Sheet by following the instructions below.

Item

Numbers

Instructions

1, 2, 2a, 3 Must be completed. These items are self-explanatory.

Check if your firm is a sole proprietorship. A sole proprietorship is a form of business in which one person owns all the assets of the business in contrast to a partnership and corporation. The sole proprietor is solely liable for all the debts of the business.

Check if your firm is a partnership. A partnership is a voluntary agreement between two or more competent persons to place their money, effects, labor, and skill, or some or all of them in lawful commerce or business, with the understanding that there shall be a proportional sharing of the profits and losses between them. An association of two or more persons to carry on, as co-owners, a business for profit.

Check if your firm is a corporation. A corporation is an artificial person or legal entity created by or under the authority of the laws of a state or nation, composed, in some rare instances, of a single person and his successors, being the incumbents of a particular office, but ordinarily consisting of an association of numerous individuals.

7 Enter your federal employee tax identification number.

Enter your corporation number assigned by the California Secretary of State’s Office. This information is used for checking if a corporation is in good standing and qualified to conduct business in California.

9, 10, 11, 12

Must be completed. These items are self-explanatory.

If certified as a California Small Business, place a check in the "Yes" box, and enter your certification number on the line. If certified as a Disabled Veterans Business Enterprise, place a check in the "Yes" box and enter your service code on the line. If you are not certified to one or both, place a check in the "No" box. If your certification is pending, enter the date your application was submitted to OSDS.

California Department of Veterans Affairs Solicitation Number: 25CS0003

Description of Service

Number Estimated for Term of Agreement

Unit Cost Totals

A.

PFM WITH NON-PRECIOUS METAL- START TO

FINISH (SINGLE UNIT OR EACH UNIT FOR

BRIDGE), PVS IMPRESSION

10 x =

B. PFM WITH DIGITAL SCAN, START TO FINISH 40 x =

C. CAST POST 5 x =

D. ZIRCONIA- START TO FINISH WITH PVS

IMPRESSION

200 x =

E.

ZIRCONIA- START TO FINISH WITH DIGITAL

SCAN

200 x =

F.

PARTIAL METAL WITH ACRYLIC (START TO

FINISH) INCLUDE PATIENT NAME

12 x =

G.

COMPLETE UPPER OR LOWER DENTURE

(START TO FINISH, INCLUDE PATIENT'S NAME,

EXCLUDE CUSTOM TRAY)

12 x =

H.

IMMEDIATE DENTURE (START TO FINISH,

INCLUDE PATIENT'S NAME)

12 x =

I.

VALPLAST (START TO FINISH, INCLUDE

PATIENT'S NAME) 12 x =

J.

STAYPLATE (UP TO 2 CLASPS AND 4 TEETH,

INCLUDE PATIENT'S NAME) 12 x =

K.

EACH ADDITIONAL CLASP OR TEETH FOR

STAYPLATE OR REPAIR SERVICES 12 x =

L. CUSTOM TRAY 10 x =

M.

REDO DENTURE CASE WITH TEETH

RESETTING 5 x =

N. METAL / WIRE MESH 10 x =

O. RELINE PER ARCH 36 x =

P. REBASE 4 x =

Q.

ACRYLIC REPAIR PLUS ADD / REPAIR 1 TOOTH

SERVICES 150 x =

R.

ACRYLIC REPAIR EXTENSIVE (2 OR MORE

TEETH) 150 x =

RATE SHEET

Submission of this attachment is MANDATORY. Upon award, bid below will become part of the Agreement in Exhibit B-1, Rate Sheet. The Bidder shall set forth the rates in the space provided. Failure to indicate a dollar amount for any item will be understood by the State that the Proposer will provide the item at no cost.

The Basis of Award shall be used to determine the lowest responsible bid. The State makes no guarantee, expressed or implied, on the actual amount of services that shall be required for this Agreement and is subject to change based on needs of the Home. However, the rates quoted by Bidder shall be binding for the term of the Agreement.

S.

FRAMEWORK PARTIAL REPAIR (WELDING,

SOLDERING) 24 x =

T. RUSH CASE CHARGE 36 x =

U. EXTRA CHARGE FOR MONOPLANE TEETH 5 x =

V. HARD NIGHT GUARD 12 x =

W. HARD / SOFT COMBO NIGHT GUARD 12 x =

X. SHIPPING / PICK UP COST 700 x =

Y. HANDLING / DELIVER COST 700 x =

Basis of Award and Total Contract Amount

Company Name:

Company Representative Signature:

This Rate Sheet MUST be signed and returned. The quote must be transmitted via email in accordance with solicitation instructions.

Sum of A through Y:

Company Representative's Name (Printed):

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

California Department of Veterans Affairs Central Business Office

1227 O Street (916) 653-2421 (916) 653-2621

Sacramento CA 95814 keith.wynkoop@calvet.ca.gov

Print Form Reset Form

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.

Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification Number The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Section 4 – Payee Residency Status Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at time of death.

A trust is a resident if at least one trustee is a California resident.

o For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

Section 5 – Certification Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signee can provide a power of attorney documented for the individual.

Section 6 – Paying State Agency This section must be completed by the state agency/department requesting the STD 204.

Privacy Statement Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of this form.

STATE OF CALIFORNIA – STATE CONTROLLERS OFFICE

PAYEE DATA RECORD SUPPLEMENT

(This form is optional. Form is used to provide remittance address information if different than the mailing address on the STD 204 – Payee Data Record.

Use this form to provide additional remittance addresses and additional Authorized Representatives of the Payee not identified on the STD 204.)

Payee Information (must match the STD 204) NAME (Required. Do not leave blank.)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

TAX ID NUMBER (Required)

SSN, ITIN, or FEIN that matches Tax ID number provided on STD 204

Additional Remittance Address Information Use the fields below to provide remittance addresses for payee if different from the mailing address on the STD 204.

The addresses provided below are for remittance purposes only. 1099 information returns will be sent to the mailing address specified on the STD 204.

REMITTANCE ADDRESS (number, street, apt or suite no.)

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

Additional Contact Information Use the fields below to provide additional Authorized Representatives for the Payee if applicable.

CONTACT NAME

TELEPHONE (Include area code) EMAIL

CONTACT NAME

TELEPHONE EMAIL

CONTACT NAME

TELEPHONE EMAIL

Certification I hereby certify under penalty of perjury that the information provided on this supplemental document is true and correct.

By signing this document, I authorize the State of California to remit payment to the addresses specified on this supplemental form (STD 205) and certify that all persons identified on this form are authorized representatives of this payee. Payments remitted to any of the listed addresses may be reported on 1099 information returns to the tax liable entity identified on the accompanying Payee Data Record - STD 204.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE

(Print or Type name)

TITLE E-MAIL ADDRESS

SIGNATURE

X___________________________________________

DATE TELEPHONE (Include area code)

Print Form Reset Form

STATE OF CALIFORNIA – STATE CONTROLLERS OFFICE

PAYEE DATA RECORD SUPPLEMENT

(This form is optional. Form is used to provide remittance address information if different than the mailing address on the STD 204 – Payee Data Record.

Use this form to provide additional remittance addresses and additional Authorized Representatives of the Payee not identified on the STD 204.)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record Supplement, STD 205. Sign, date, and return to the state agency/department with a completed STD 204. Prompt return of the fully completed forms will prevent delays when processing payments.

Purpose – Completion of this form (STD 205) is optional. Payees may use this form to provide remittance addresses or contact information in addition to the 1099 information return mailing address provided on the STD 204. This form shall only be used in conjunction with the STD 204, and will not be accepted without a STD 204.

Please note: The State of California Government will issue 1099 information returns to the mailing address provided on the most recently dated form STD 204 validated by the Payee. Addresses provided on this form (STD 205) will be used for remittance purposes only. If the payee would like to update the address for receiving 1099 information returns, please complete the STD 204.

Payee Information: The Payee’s Tax ID number…