LS-3_Sub_Contractors_Certification.docx
DOCX document 29 KB Posted
- Solicitation number
- 2025-IFB-017
- Issued by
- Mohave County, Arizona
About this file
The LS-3 Sub-Contractors Certification is a form related to the Jerry Ambrose Veterans Council Transitional Housing Rehabilitation - Phase II project, issued by the City of Kingman, Arizona, through a Community Development Block Grant from the Arizona Department of Housing. The project solicits sealed bids from qualified vendors with a minimum B-2 commercial license to complete the rehabilitation of the veterans facility. Bids must be submitted through the City of Kingman's OpenGov procurement portal by 3:00 pm Arizona time on Thursday, June 12, 2025, with questions accepted through the portal by 6:00 pm on Monday, June 2, 2025.
The certification form requires detailed contractor information, including demographic data, business structure, ownership details, and compliance with labor standards and prevailing wage regulations. The project is funded through a Community Development Block Grant, with selection criteria focusing on overall cost and the ability to meet delivery dates. The form includes provisions for verifying contractor eligibility, preventing ineligible contractors from participating, and collecting comprehensive information about the business entity, including racial and business classification codes, ownership details, and potential conflicts of interest.
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Text version
FORM LS-3
Sub-Contractors certification concerning labor standards and prevailing wages
Recipient:
Contract No:
Activity Name:
| 1. | I, the undersigned, having submitted a bid or having executed a contract with: | |
| (name of contractor or sub-contractor): | ||
| for (name of project): | ||
| for (nature of work): | ||
| in the amount of $ certify that: | ||
| a. | The Labor Standards Provisions (HUD 4010) are included in the aforementioned contract or bid; | |
| b. | Wage Decision # ; Modification # are included in the aforementioned contract or bid. |
| 2. | I hereby certify that: | |
| a. | To the best of my knowledge, neither I nor any firm, partnership or association in which I have a substantial interest, is designated as an ineligible contractor by the Comptroller General of the United States pursuant to Section 5.6(b) of the Regulations of the Secretary of Labor, Part 5 (29 CFR. Part 5) or pursuant to Section 3(a) of the Davis-Bacon Act, as amended [40 U.S.C. 276a-2(a)]. | |
| b. | No part of the aforementioned contract has been or will be sub-contracted to any sub-contractor, if such sub-contractor or firm, corporation, partnership or association in which such sub-contractor has a substantial interest is, to the best of my knowledge, designated as an ineligible contractor pursuant to any of the aforementioned regulatory or statutory provisions. |
| 3. | Further, I certify that: |
| a. | The demographic and business information of the undersigned are: |
| Contractor Information |
| Amount of Contract |
| Type of Trade Code* |
| Racial Code* |
| Hispanic |
(Y/N)
| Women Owned (Y/N) |
| IRS Tax ID # |
| SAM.gov UEI# |
| Section 3 |
(Y/N) Construction Firm Legal Name Address, City, State, Zip AZ License #
* See Demographic and Trade Code table below for information
Demographic and Trade Codes
| Race |
| Type of Trade Code |
| 11 | White |
| 1 | New Construction |
| 12 | African American |
| 2 | Education/Training |
| 13 | Asian |
| 3 | Other (i.e. rehabilitation, administration, professional, public services) |
14 American Indian or Alaskan Native
15 Native Hawaiian or other Pacific Islander
16 American Indian or Alaskan Native and White
17 Asian and White
18 African American and White
19 American Indian or Alaskan Native and White
20 Other Multi-racial
b. The undersigned is:
|_| a sole proprietorship;
|_| a partnership;
|_| a corporation organized in the State of ; or |_| another organization (describe)
| c. | The name, title and address of the owners, partners or officers of the undersigned are (list any other legal names/doing business as (dba)): | ||
| NAME | TITLE | ADDRESS |
| d. | The names and addresses of all other persons, both natural and corporate, having a substantial interest in the undersigned and the nature of the interest, are: (indicate if NONE) | ||
| NAME | ADDRESS | NATURE OF INTEREST |
| e. | The names, addresses and trade classifications of all other building construction contractors in which the undersigned has a substantial interest are: (indicate if NONE) | ||
| NAME | ADDRESS | TRADE CLASSIFICATION |
| 5. | I hereby certify that I have the legal authority to complete and submit this document on behalf of: | |
| a. | Name of Contractor: | |
| b. | Signature (in ink): __________________________________________________________ | |
| c. | Typed or Printed Name: | |
| d. | Title: | |
| e. | Date: |
WARNING: U.S. Criminal Code, Section 1010, Title 18, U.S.C. provides in part: “Whoever...makes, passes, utters or publishes any statement, knowing the same to be false...shall be fined under this title or imprisoned not more than two (2) years, or both.”
LS-3 (REV. 11/2019)
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