ITB-2026-01_Effluent_Sprayfields_and_Pipeline_Route_Clearing_Grubbing_-_Addendum_4_Contract_Exhibits_B_-_K.pdf

Company Name Page 1 of 2

SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(A).

FLORIDA STATUTES ON PUBLIC ENTITY CRIME

THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL

AUTHORIZED TO ADMINISTER OATHS.

1. This sworn statement is submitted to

By

(print this individual’s name and title) for (print name of entity submitting statements) whose business address is and if applicable whose Federal Employer Identification Number (FEIN) is

If the entity has no FEIN, include the Social Security Number of the individual signing this sworn Statement:

2. I understand that a “public entity crime” as defined in paragraph 287.133(1)(a), Florida Statutes, mean a violation of any state or federal law by a person with respect to and directly related to the transactions of business with any public entity or with an agency or political subdivision of any other state or with the United States including, but not limited to any bid or contract for goods or services to be provided to any public entity or any agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

3. I understand that “convicted” or “convection” as defined in Paragraph 287.133(1)(b), Florida Statutes means a finding of guilt or a conviction of a public entity crime, with or without adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a Jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.

4. I understand that an “affiliate” as defined in paragraph 287.133(1)(a), Florida Statutes, means:

1. A predecessor or successor of a person convicted of public entity crime; or

2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term “affiliate” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm’s length agreement, shall be a prima facie case that one person controls another person.

A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.

5. I understand that a “person” as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term “person” includes those officers, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.

6. Based on information and belief, the statement which I have marked below is true in a relation to the

EXHIBIT B

Company Name entity submitting this sworn statement. (Please indicate which statement applies).

_ Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months.

_ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. AND (Please indicate which additional statement applies).

_ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. However, there has been a subsequent proceeding before a Hearing Officers of the State of Florida, Division of Administrative Hearings and the Final Order by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list.

(Attached is a copy of the final order).

I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE PERIOD OF THE CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO

OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.

(Signature)

City of

STATE OF FLORIDA

Sworn and subscribed before me this day of , 20 by who is Personally known to me

Or who produced identification - (Type of Identification)

(Signature) Notary Public—State of Florida

(Printed, typed or stamped commissioned name of notary public)

My commission expires (SEAL)

City of Milton

NON-COLLUSION AFFIDAVIT

STATE OF

COUNTY OF

Owner, Partner or Officer of Firm Company

Name, Address, City and State

Being of lawful age, being first duly sworn, on oath says that he/she is the agent authorized by the bidder to submit the attached bid. Affidavit further states as proposer, that they have not been a party to any collusion among bidders in restraint of competition by agreement to bid at a fixed price or to refrain from bidding; or with any officer of the City of Milton or any of their employees as to quantity, quality or price in the prospective contract; or any discussion between bidders and any official of the City of Milton or any of their employees concerning exchange of money or other things of value for special consideration in submitting a sealed bid for:

FIRM NAME:

SIGNATURE:

TITLE:

The foregoing instrument was acknowledged before me this day of , 20 by the above signed acting on behalf of the organization/company.

He/she is personally known to me or has produced as identification and did (did not) take an oath.

Signature of Notary

SEAL

EXHIBIT C

City of Milton

CONFLICT OF INTEREST DISCLOSURE FORM

For purposes of determining any possible conflict of interest, all bidders/proposers must disclose if any City of Milton, employee(s), elected officials(s), of if any of its agencies is also an owner, corporate officer, agency, employee, etc., of their business.

Indicate either “yes” (a City employee, elected official, or agency is also associated with your business), or “no”. If yes, give person(s) name(s) and position(s) with your business.

YES NO

NAME(S) POSITION(S)

Firm Name By (Printed):

By (Signature): Title

Address Phone No.

E-Mail:

EXHIBIT D

VENDOR SCRUTINIZED COMPANIES LISTS ATTESTATION

Per section 287.135, Florida Statutes, agencies are prohibited from contracting with Vendors for commodities or contractual services valued at over $1,000,000 that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran

Petroleum Energy Sector List, or been engaged in business operations in Cuba or Syria, pursuant to section 215.473, Florida Statutes.

I, ____________________________________ am the ______________________________ of

(Authorized Representative’s Name) (Title)

_______________________________________, (the “Vendor”), and am authorized to represent and ____________________________ contractually bind Vendor.

(Vendor’s Legal Name)

Having been duly sworn, I do hereby attest, to the best of my knowledge and belief, the following:

The Vendor submitting this Response is not listed on any of the following lists:

• Scrutinized Companies with Activities in Sudan List

• Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List

• Scrutinized Companies that Boycott Israel List

I understand that, pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject Vendor to immediate contract termination, civil penalties, attorney’s fees, and/or other costs.

Company Name Signature

Authorized Representative Date

Name and Title

EXHIBIT E

City of Milton

EXHIBIT F

SCHEDULE OF VALUES

Authority: § 255.02, F.S.; § 255.073–.078, F.S.; § 218.735, F.S.

Template Version: 2026.01.06

Contractor will complete the Work in accordance with the Contract Documents for the following prices:

ITEM DESCRIPTION QTY UNIT UNIT PRICE AMOUNT

1 General Conditions of contact, bonds, insurance, mobilization

(Not more than 10% of total bid)

1 LS $ $

2 Sitework, Clearing, and

Grubbing

+/-350 AC $ $

3 Erosion Control 13,800 LF

DETAIL ANY ADDITIONAL COSTS:

TOTAL BASE BID (Numerical)

(including all work required by the contract documents and the allowances)

TOTAL BASE BID (Written):

Contractor acknowledges that (1) each Unit Price includes an amount considered by

Contractor to be adequate to cover Contractor’s overhead and profit for each separately identified item, and (2) final payment for all unit price items will be based on actual quantities, determined as provided in the Contract Documents.

DRUG-FREE WORKPLACE (F.S. 287.087)

Preference to businesses with drug-free workplace programs.—Whenever two or more bids, proposals, or replies that 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, proposal, or reply received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process.

In order to have a drug-free workplace program, a business shall:

(1) Publish a statement notifying employees that 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 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 employee 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 5 days after such conviction.

(5) Impose a sanction on or require the satisfactory participation in a drug abuse 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.

Vendor Name Date:

We have a drug-free workplace program. □yes; or □no (check one)

Vendor’s Signature

EXHIBIT G

City of Milton

EXHIBIT H

CONTRACTOR APPLICATION FOR PAYMENT AND

INVOICE REQUIREMENTS

Authority: § 255.071, F.S.; § 255.073, F.S.; Ch. 218, Part VII, F.S.

1. PURPOSE AND APPLICABILITY

This Exhibit establishes the content, documentation, and certification requirements for all

Contractor Applications for Payment submitted under this Contract. These requirements are intended to ensure compliance with Florida prompt-payment laws and the City’s Purchasing

Policy.

Receipt by the City of a complete Application for Payment that complies with this Exhibit constitutes submission of a Proper Invoice under § 255.073(2), F.S.

2. DEFINITIONS

For purposes of this Contract:

a) Invoice means the Contractor’s written billing request for payment.

b) Proper Invoice means an invoice that meets the minimum content requirements of §

255.073(2), F.S., Chapter 218, Part VII, F.S., and this Exhibit.

c) Application for Payment or Proper Invoice Package means a complete submission consisting of the invoice, certifications, and all required supporting documentation described herein.

3. SUBMISSION METHOD, SUBJECT LINE, AND RECEIPT OF APPLICATIONS FOR PAYMENT

3.1 Submission Method

All Applications for Payment and Proper Invoice Packages required under this Exhibit shall be submitted electronically by email in searchable PDF or Word format, unless otherwise approved in writing by the City.

3.2 Submission Address

Applications for Payment shall be submitted by email to all of the following recipients:

Assistant City Manager: swoodbery@miltonfl.org

a. City Contract Coordinator: ataylor@miltonfl.org

The City may update submission email addresses by written notice to the Contractor, including by email, without requiring a formal amendment to the Contract.

mailto:swoodbery@miltonfl.org mailto:ataylor@miltonfl.org

3.3 Subject Line Requirement

The subject line of the submission email shall include the City’s Contract number and the phrase

“Application for Payment.”

3.4 Delivery and Read Receipt Requirement

The Contractor shall transmit each Application for Payment with delivery receipt and read receipt functions enabled. Failure to enable delivery and read receipts may result in the submission being returned as non-compliant.

3.5 Time of Receipt

For purposes of §§ 255.071 and 255.073, F.S., an Application for Payment shall be deemed received by the City upon successful electronic delivery to all required submission email addresses, provided the submission is not returned to the sender as undeliverable.

3.6 Acknowledgement and Proper Invoice Determination

Receipt of an Application for Payment does not constitute acceptance or confirmation that the submission is complete. An Application for Payment shall not be deemed a Proper Invoice, and shall not trigger statutory payment timelines, unless and until the City has reviewed the submission and provided written acknowledgment that the submission is complete and compliant with this Exhibit.

4. PROPER INVOICE MINIMUM CONTENT REQUIREMENTS

Each Proper Invoice shall include, at a minimum:

a) Contractor’s legal name, address, and remittance information;

b) City of Milton Contract number;

c) Unique invoice number and invoice date;

d) Project name;

e) Description of work performed and/or materials furnished during the billing period, organized by pay items;

f) Billing period dates;

g) Project location;

h) Quantities completed and percentage of completion measured against Exhibit F –

Schedule of Values;

i) An updated Schedule of Values (Exhibit F) showing:

• Current payment requested;

• Cumulative payments to date;

• Retainage withheld (if applicable); and

• Remaining contract balance.

j) Contractor Certification (Section 5.1)

k) Subcontractor and Supplier Payment Certification (Section 5.2)

l) Engineer Certification (Section 6)

5. CONTRACTOR CERTIFICATION

Each Application for Payment shall include the following certification, executed by an authorized representative of the Contractor:

5.1 Contractor Certification:

The undersigned Contractor hereby certifies, under penalty of perjury under the laws of the State of Florida, that this Application for Payment is true, correct, and complete, and that:

a. All quantities, costs, and amounts requested have been incurred for Work actually performed or materials properly delivered and incorporated into the Project (or stored, if permitted by the Contract), in accordance with the Contract Documents, the approved

Schedule of Values, and any duly executed Change Orders;

b. The amounts requested accurately reflect the progress of the Work completed through the end of the applicable billing period;

c. No costs included in this Application for Payment duplicate amounts previously billed or paid under this Contract or any other agreement; and

d. All amounts requested are supported by contemporaneous records maintained in the ordinary course of business and are available for inspection upon request by the City or its authorized representatives.

5.2 Subcontractor and Supplier Payment Certification

The undersigned further certifies, under penalty of perjury under the laws of the State of Florida, that all subcontractors and suppliers have been paid all undisputed amounts due for Work performed or materials supplied through the end of the prior payment period, in accordance with

§§ 255.071 and 255.073, F.S., except for amounts lawfully withheld. Any such withheld amounts are specifically identified in this Application for Payment together with the basis for withholding.

Submission of this certification is a condition precedent to the City’s obligation to process or release payment for the amounts requested herein.

Contractor Signature: ________________________________

Name: __________________________

Title: ___________________________

Date: ___________________

6. ENGINEER REVIEW AND RECOMMENDATION

The Project Engineer shall review the quantities and values of Work performed and provide the following recommendation:

Engineer’s Certification:

I have reviewed the quantities and values of Work performed and certify that the Work has been performed in accordance with the Contract Documents and recommend payment in the amount shown.

7. REQUIRED SUPPORTING DOCUMENTATION

A complete Application for Payment (Proper Invoice Package) shall include the following items submitted together:

1. A Proper Invoice meeting Section 4 of this Exhibit;

2. Updated Schedule of Values (Exhibit F);

3. Material invoices and delivery documentation for materials billed during the period;

4. Approved Change Orders applicable to the billing period (if any); and

5. Any additional documentation reasonably required by the City to demonstrate compliance with the Contract or the applicable State grant agreement.

An Application for Payment that is missing required documentation shall be returned for correction and shall not constitute a Proper Invoice for purposes of statutory payment timelines.

8. OPTIONAL PROPER INVOICE TEMPLATE (REFERENCE ONLY)

For convenience only, the City may provide an illustrative invoice template. Use of the City’s template is optional. Regardless of format, the Contractor remains responsible for ensuring that each Application for Payment fully satisfies all requirements of this Exhibit and applicable

Florida law.

E-VERIFY STATEMENT OF COMPLIANCE

Contractor hereby certifies compliance with the following:

Pursuant to § 448.095(2) Florida Statutes (2020), Contractor shall register with and use the E-

Verify system operated by the United States Department of Homeland Security to verify the work authorization status of all new employees hired by Contractor while performing work or providing services for the City of Milton. Contractor shall also include in any related subcontracts a requirement that subcontractors performing work or providing services for the City of Milton on its behalf register with and use the E-Verify system to verify the work authorization status of all new employees hired by the subcontractor while performing work or providing services for the City of

Milton. Additionally, Contractor shall include in any related subcontracts a requirement that subcontractors performing work or providing services for the City of Milton on its behalf provide

Contractor with an affidavit stating that the subcontractor does not employ, contract with, or subcontract with any unauthorized alien as defined in 8 U.S.C. § 1324a(h)(3). Contractor shall maintain a copy of such affidavit for the duration of its contract with the City of Milton.

FIRM NAME

SIGNATURE

TITLE

P.0. Box 909 • 6738 Dixon Street • Milton, Florida 32572 Phone (850) 983-5400 • Fax (850)983-5415

Established 1844

EXHIBIT J

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 proposal been convicted of or had a civil judgment 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 statutes 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 the 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.

Name Project Name

Title Project Number

Firm Street Address

City, State, Zip

C:\Users\lmccafferty\Documents\PURCHASING INFORMATION\Forms\Certification Regarding Debarment.docx

EXHIBIT K