NYSDOT Purchasing IFB & RFQ_EXHIBIT A_1-2025_23.pdf

NYSDOT Purchasing

SUPPORTING FORMS/QUESTIONNAIRES

EXHIBIT A

(Complete and submit forms/questionnaires with Proposal as required)

Includes:

Procurement Lobby Act (PLL) Offer Certification Form

Executive Order 177 Certification Form

Executive Order 16 Certification Form

Vendor Assurance of No Conflict of Interest or Detrimental Effect Form (Complete if a Contract for Services ONLY)

Manufacturer’s Certification Form (Complete if a contract for Commodities)

Affidavit of No Change Form (Complete if a Vendor Responsibility Questionnaire has been submitted within the past six months and no changes to the responses of this questionnaire are required)

NYSDOL Registration for Public Work Projects (Complete if Bid includes Prevailing Wage Requirement. Must be registered prior to submitting a Bid) (see Contractor and Subcontractor Landing | Department of Labor)

NYS Sales and Use Tax ST-220 Forms (ST-220-CA & ST-220-TD) can be obtained at the NYS Department of Taxation and Finance website … http://www.tax.ny.gov/pdf/current_forms/st/st220td_fill_in.pdf http://www.tax.ny.gov/pdf/current_forms/st/st220ca_fill_in.pdf

A hard copy of the ST-220 Forms can be requested through the NYSDOT Purchasing Office.

Vendor Responsibility Questionnaire (VRQ) can be obtained through the Office of the State Comptroller (OSC) website (http://www.osc.state.ny.us/vendrep). To expedite review and approval, bidders are encouraged to enroll and submit VRQ through OSC online Vendor Management System. A hard copy of the VRQ can be requested through the NYSDOT Purchasing Office.

Consultant Form A – Contractor’s Planned Employment (see CONSULTANT REPORTING

REQUIREMENTS)

(Complete if a contract for training or consulting services) https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdol.ny.gov%2Fcontractor-and-subcontractor-landing&data=05%7C02%7CJessica.Owen%40dot.ny.gov%7C15bf842d472f49763bac08dd155ef481%7Cf46cb8ea79004d108ceb80e8c1c81ee7%7C0%7C0%7C638690219751883211%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=P0vZskDq%2FEntqf8m7zhLTZc2vDp1frjrY8hihQSlZRU%3D&reserved=0 http://www.tax.ny.gov/pdf/current_forms/st/st220td_fill_in.pdf http://www.tax.ny.gov/pdf/current_forms/st/st220ca_fill_in.pdf http://www.osc.state.ny.us/vendrep

Executive Order No. 16 provides that “all Affected State Entities are directed to refrain from entering into any new contract or renewing any existing contract with an entity conducting business operations in Russia.” The complete text of Executive Order No. 16 can be found here.

The Executive Order remains in effect while sanctions imposed by the federal government are in effect.

Accordingly, vendors who may be excluded from award because of current business operations in Russia are nevertheless encouraged to respond to solicitations to preserve their contracting opportunities in case the sanctions are lifted during a solicitation or even after award in the case of some solicitations.

As defined in Executive Order No. 16, an “entity conducting business operations in Russia” means an institution or company, wherever located, conducting any commercial activity in Russia or transacting business with the Russian Government or with commercial entities headquartered in Russia or with their principal place of business in Russia in the form of contracting, sales, purchasing, investment, or any business partnership.

Is Vendor an entity conducting business operations in Russia, as defined above? Please answer by checking one of the following boxes:

1. No, Vendor does not conduct business operations in Russia within the meaning of Executive Order No. 16.

2.a. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16 but has taken steps to wind down business operations in Russia or is in the process of winding down business operations in Russia. (Please provide a detailed description of the wind down process and a schedule for completion.)

2.b. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16 but only to the extent necessary to provide vital health and safety services within Russia or to comply with federal law, regulations, executive orders, or directives. (Please provide a detailed description of the services being provided or the relevant laws, regulations, etc.)

3. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16.

The undersigned certifies under penalties of perjury that they are knowledgeable about the Vendor’s business and operations and that the answer provided herein is true to the best of their knowledge and belief.

Vendor Name:

(legal entity)

By:

(signature)

Name:

Title:

Date:

Certification Under Executive Order No. 16 Prohibiting State Agencies and Authorities from Contracting with

Businesses Conducting Business in Russia https://www.governor.ny.gov/executive-order/no-16-prohibiting-state-agencies-and-authorities-contracting-businesses-conducting

Certification: Off

Vendor Name:

Name:

Date:

Title:

Contract/Procurement #

Administrative Services Division – Purchasing

NEW YORK STATE DEPARTMENT of TRANSPORTATION

Executive Order 177 Certification

This certification is required from all proposers/bidders at the time of proposal/bid submittal.

The New York State Human Rights Law, Article 15 of the Executive Law, prohibits discrimination and harassment based on age, race, creed, color, national origin, sex, pregnancy or pregnancy-related conditions, sexual orientation, gender identity, disability, marital status, familial status, domestic violence victim status, prior arrest or conviction record, military status or predisposing genetic characteristics.

The Human Rights Law may also require reasonable accommodation for persons with disabilities and pregnancy-related conditions. A reasonable accommodation is an adjustment to a job or work environment that enables a person with a disability to perform the essential functions of a job in a reasonable manner. The Human Rights Law may also require reasonable accommodation in employment on the basis of Sabbath observance or religious practices.

Generally, the Human Rights Law applies to:

· all employers of four or more people, employment agencies, labor organizations and apprenticeship training programs in all instances of discrimination or harassment;

· employers with fewer than four employees in all cases involving sexual harassment; and,

· any employer of domestic workers in cases involving sexual harassment or harassment based on gender, race, religion or national origin.

In accordance with Executive Order No. 177, the Proposer/Bidder hereby certifies that it does not have institutional policies or practices that fail to address the harassment and discrimination of individuals on the basis of their age, race, creed, color, national origin, sex, sexual orientation, gender identity, disability, marital status, military status, or other protected status under the Human Rights Law.

Executive Order No. 177 and this certification do not affect institutional policies or practices that are protected by existing law, including but not limited to the First Amendment of the United States Constitution, Article 1, Section 3 of the New York State Constitution, and Section 296(11) of the New York State Human Rights Law.

Contractor:

By [signature]: ______________________________________

Name [print]:

Title:

Date: , 20

This form must be signed by an authorized executive or legal representative

(5/18)

Contract/Procurement #

Administrative Services Division - Purchasing Unit

MANUFACTURER’S CERTIFICATION FORM

INSTRUCTIONS TO BIDDERS:

This “Manufacturer’s Certification” is to be forwarded to the manufacturer by the bidder (if required by IFB), completed by the manufacturer and returned to the bidder by the manufacturer, and submitted with the bidder’s offer. (See “QUALIFICATION OF BIDDER” clause).

BIDDER’S COMPANY NAME: ______________________________________________

STREET ADDRESS: _______________________________________________________

CITY, STATE ZIP: ________________________________________________________

List the Products/Components to which this Certificate applies: ___________________________________________

The manufacturer executing this certification by signature below does hereby attest to the accuracy and validity of the responses to the following questions:

1.

Is the bidder listed above an authorized dealer?

No Yes

2.

Do you as a manufacturer agree to supply the bidder/dealer with all quantities of products ordered pursuant to any resulting contract with the State?

No Yes

3.

Do you as a manufacturer certify that product listed above meets the requirements stated in the IFB?

No Yes

MANUFACTURER’S COMPANY NAME:

ADDRESS:

TELEPHONE NUMBER:

FAX NUMBER:

E-MAIL ADDRESS:

PRINTED OR TYPED COPY OF SIGNATURE

SIGNATURE OF AUTHORIZED

DATE

MANUFACTURER’S REPRESENTATIVE

TITLE

(6/14)

Contract/Procurement #

Administrative Services Division - Purchasing

VENDOR ASSURANCE of NO CONFLICT of INTEREST or DETRIMENTAL EFFECT — OFFERER CERTIFICATION FORM

The firm offering to provide services pursuant to this solicitation, as a contractor, subcontractor or consultant, attests that its performance of the services outlined in this solicitation does not and will not create a conflict of interest with nor position the firm to breach any other contract currently in force with the State of New York.

Furthermore, the firm attests that it will not act in any manner that is detrimental to any State project on which the firm is rendering services. Specifically, the firm attests that:

1. The fulfillment of obligations by the firm, as proposed in the response, does not violate any existing contracts or agreements between the firm and the State;

2. The fulfillment of obligations by the firm, as proposed in the response, does not and will not create any conflict of interest, or perception thereof, with any current role or responsibility that the firm has with regard to any existing contracts or agreements between the firm and the State;

3. The fulfillment of obligations by the firm, as proposed in the response, does not and will not compromise the firm’s ability to carry out its obligations under any existing contracts between the firm and the State;

4. The fulfillment of any other contractual obligations that the firm has with the State will not affect or influence its ability to perform under any contract with the State resulting from this solicitation;

5. During the negotiation and execution of any contract resulting from this solicitation, the firm will not knowingly take any action or make any decision which creates a potential for conflict of interest or might cause a detrimental impact to the State as a whole including, but not limited to, any action or decision to divert resources from one State project to another;

6. In fulfilling obligations under each of its State contracts, including any contract which results from this solicitation, the firm will act in accordance with the terms of each of its State contracts and will not knowingly take any action or make any decision which might cause a detrimental impact to the State as a whole including, but not limited to, any action or decision to divert resources from one State project to another;

7. No former officer or employee of the State who is now employed by the firm, nor any former officer or employee of the firm who is now employed by the State, has played a role with regard to the administration of this contract procurement in a manner that may violate section 73(8)(a) of the State Ethics Law; and

8. The firm has not and shall not offer to any employee, member or director of the State any gift, whether in the form of money, service, loan, travel, entertainment, hospitality, thing or promise, or in any other form, under circumstances in which it could reasonably be inferred that the gift was intended to influence said employee, member or director, or could reasonably be expected to influence said employee, member or director, in the performance of the official duty of said employee, member or director or was intended as a reward for any official action on the part of said employee, member or director.

Firms responding to this solicitation should note that the State recognizes that conflicts may occur in the future because a firm may have existing or new relationships. The State will review the nature of any such new relationship and reserves the right to terminate the contract for cause if, in its judgment, a real or potential conflict of interest cannot be cured.

Offerer affirms this Day of , 20 that he/she understands and agrees to comply with the New York State procedures relative to Conflicts of Interest – (entity shall seek written affirmations as to the offerer’s understanding and agreement to comply).

Business Entity Name and Address:

By (Signature) ________________________________________ Print Name and Title

This form must be signed by an authorized executive or legal representative

(10/16)

NEW YORK STATE DEPARTMENT OF TRANSPORTATION

PROCUREMENT LOBBYING ACT CERTIFICATION FORM

Offerer Disclosure of Prior Non-Responsibility Determina�ons and Understanding and Agreement to Comply

PART 1 - NAME AND ADDRESS OF INDIVIDUAL OR ENTITY SEEKING TO ENTER INTO THE PROCUREMENT CONTRACT

ENTITY NAME: ________________________________________

ADDRESS: ________________________________________

Part 2 – DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS

2. Has any government En�ty made a finding of non-responsibility regarding the individual or en�ty seeking to enter into the Procurement Contract in the previous four years?

If YES, please also answer ques�ons 2-4. If NO, skip to ques�on 6. Yes No

3. Was the basis for the finding of non-responsibility due to a viola�on of State Finance Law §139-j? Yes No

4. Was the basis for the finding of non-responsibility due to the inten�onal provision of false or incomplete informa�on to a Government En�ty? Yes No

5. If you answered YES to any of the above ques�ons, please provide details regarding the funding of non-responsibility below:

Government En�ty:

Date of Finding of Non-Responsibility:

Basis of Finding of Non-Responsibility:

(attach additional pages as necessary to provide sufficient detail)

6. Has any Governmental En�ty or other Governmental agency terminated or withheld a

Procurement Contract with the individual or en�ty seeking to enter into the Procurement Contract due to the inten�onal provision of false or incomplete informa�on? Yes No

7. If you answered YES to any of the above ques�ons, please provide details regarding the funding of non-responsibility below:

Government En�ty:

Date of Termina�on or Withholding of Contract::

Basis of Termina�on or Withholding:

(attach additional pages as necessary to provide sufficient detail)

Part 3 – AFFIRMATION of UNDERSTANDING and AGREEMENT TO COMPLY Offerer affirms this _____ day of _________________, 20__ that it understands and agrees to comply with the procedures of the Government En�ty rela�ve to permissible contacts as required by State Finance Law §139-j(3) and §139-j(6)9b).

Business En�ty Name and Address:

By (signature) ______________________________________________ Date: ___________________ Print Name and Title: _________________________________________________________________

Contract/Procurement #

ContractProcurement:

Yes: Off

No: Off

Yes_2: Off

No_2: Off

Yes_3: Off

No_3: Off

Yes_4: Off

No_4: Off day of:

Print Name and Title:

Date:

Text1:

Text2:

Text3:

Contract/Procurement #

Administrative Services Division - Purchasing Unit

Vendor Responsibility Questionnaire

AFFIDAVIT OF NO CHANGE

FEDERAL EMPLOYER IDENTIFICATION No. (FEIN): ______________________________________________

NY VENDOR ID No.: _______________________________________________________

The undersigned, being duly sworn, deposes and says:

1.

I am an owner/officer of

(hereafter “bidder” or “contractor”), which is hereby tendering a bid (or anticipating a contract, subcontract, or supplemental agreement) on a New York State Department of Transportation (NYSDOT) Purchase or Contract;

2.

Bidder/Contractor previously submitted a Standard Vendor Responsibility Questionnaire (SVRQ) within six months immediately preceding the date hereof to NYSDOT (or other State Agency);

3.

Attached is an accurate and true copy of such previously submitted SVRQ; and

4.

I hereby certify that there has been no material change in the information pertaining to the Bidder/Contractor specified on such attached SVRQ, except as follows (enter NONE if no changes):

PRINTED OR TYPED COPY OF SIGNATURE

SIGNATURE OF OWNER/OFFICER

DATE

TITLE of OWNER/OFFICER

Sworn to me this ________ day of ___________________________ , 20 ______

_________________________________________ NOTARY PUBLIC

SEAL_____________________

AC 3271-S (Effective 4/12)

FORM A

New York State Consultant Services

Contractor’s Planned Employment

From Contract Start Date Through the End of the Contract Term

State Agency Name:

State Agency Department ID:

Agency Business Unit:

Contractor Name:

Contract Number:

Contract Start Date: / /

Contract End Date: / /

Employment Category

Number of Employees

Number of Hours to be Worked

Amount Payable Under the Contract

0.00

0.00

$0.00

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$0.00

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$0.00

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$0.00

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$0.00

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$0.00

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$0.00

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$0.00

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$0.00

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$0.00

Total this Page

0.00

0.00

$ 0.00

Grand Total

Name of person who prepared this report:

Title:

Phone #:

Preparer’s Signature: ________________________________

Date Prepared: / /

(Use additional pages, if necessary)

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