Offer Document 16_ Statement of Responsibilit.pdf

OFFER DOCUMENT #16

STATEMENT OF RESPONSIBILITY CERTIFICATION

GTEA Solicitation No. 27-001

A responsible proposer is one that the GTEA believes to be responsible based on responses provided in the Contractor's proposal and/or based on Contractor's responses to the requirements of the solicitation document. Responsibility shall generally be presumed. In order for a Contractor to be deemed non-responsible, the GTEA must make an affirmative determination of non-responsibility. The GTEA reserves the right to conduct additional due diligence into any Contractor's responsibility status. Such due diligence may include investigations into one or more of the following areas:

1. Whether Contractor has adequate financial resources to perform the contract, or the ability to obtain them.

This includes, but is not limited to, the ability to obtain required bonds (if any) and insurance from sureties and insurance companies authorized to do business in Georgia.

2. Whether Contractor is able to comply with the contract requirements, considering the Contractor's other business obligations.

3. Whether Contractor is registered to do business in the State of Georgia and is listed as "ACTIVE/

COMPLIANCE" with the Office of the Georgia Secretary of State.

4. Whether Contractor is not presently debarred or suspended from bidding by any Federal or State governmental entity;

5. Whether Contractor has within a three year period preceding this proposal has 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;

6. Whether Contractor is 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 above.

7. Whether Contractor has had a contract terminated for default in the last 3 years.

8. Whether Contractor is currently under investigation for any possible breach of contract, or fraud or allegations of criminal activity related to the types of Services requested within this solicitation document.

(And if yes, the circumstances, nature and magnitude of such investigation shall be considered in any possible non-responsibility determination).

9. Whether Contractor has a satisfactory performance record.

10. Whether Contractor has a satisfactory record of integrity and business ethics.

11. Whether Contractor has satisfactory organization, experience, accounting and operational controls, and managerial and technical skills.

Statement of Responsibility Certification Continued

Instructions:

THIS FORM MUST BE COMPLETED, SIGNED, NOTARIZED AND SUBMITTED WITH YOUR BID/

PROPOSAL.

Please complete this form, answering every question. A “Yes” answer to any of the subparts of QUESTION NO. 3 requires a written explanation attached to the completed form, submitted on your company letterhead and signed by an authorized representative of the company. A “Yes” answer to any of the subparts of Question No. 3 will not necessarily result in denial of award, but will be considered in determining Contractor responsibility in the event the GTEA undertakes an investigation into

Firm's responsibility status. For any explanation, indicate to whom it applies; identify the initiating agency and the dates of action.

Contractors are responsible for updating any information submitted in their Statement of Responsibility Certification Form if a change occurs prior to the award of the contract.

Questions:

1. Does the Contractor certify that it has, or has the ability to obtain, adequate financial resources to perform the Services identified in the Agreement? This includes, but is not limited to, the ability to obtain required bonds (if applicable) and insurance from sureties and insurance companies authorized to do business in Georgia.

Yes No

2. Does the Contractor certify that it is able to comply with all contractual requirements and fulfill all of its contractual obligations, considering Offeror's other business obligations?

3. Within the past three (3) years, has Contractor, or any principal of the Contractor (e.g., any owner, partner, officer, or major stockholder with 10% or more shares) been the subject of any of the following:

(a) a judgment or conviction for any conduct constituting a felony under local, state or federal law, including, but not limited to, fraud, extortion, bribery, racketeering, labor, anti-trust, price-fixing, or bid collusion?

(b) a criminal investigation or indictment for any conduct constituting a felony under local, state or federal law, including, but not limited to, fraud, extortion, bribery, racketeering, price-fixing, or bid collusion (to the best of Firm's knowledge*)?

(c) an unsatisfied judgment, injunction or lien obtained by a Georgia state government agency including, but not limited to, judgments based on taxes owed and fines and penalties assessed by any Georgia state government agency?

(d) an investigation for a civil violation by any local, state or federal agency (to the best of Offeror's knowledge*)?

(e) a suspension, debarment or termination for cause from any local, state or federal government procurement process?

(f) a suspension or termination for cause prior to the completion of the term of any local, state or federal government contract?

(g) a denial of award for non-responsibility determination made by any local, state or federal government?

(h) an agreement to a voluntary exclusion from bidding/contracting on any local, state or federal procurement?

(i) an administrative proceeding or civil action seeking specific performance or restitution in connection with any local, state or federal procurement (to the best of Firm's knowledge*)?

(j) any bankruptcy proceeding?

The undersigned: (i) recognizes that this questionnaire is submitted for the express purpose of assisting the Georgia Transportation

Efficiency Authority (GTEA) to make a determination regarding the eligibility for award of a contract, or to approve a subcontract; (ii) acknowledges that the GTEA, the State of Georgia, its agencies and political subdivisions may, in their sole discretion, by means which they may choose, verify the truth and accuracy of all statements made herein; (iii) acknowledges that submissions of false or misleading information may constitute fraud, may result in ineligibility for contract award, may be used as grounds for termination for default of any contract awarded in relation to this certification, may be considered by the GTEA, the State of Georgia, its agencies and political subdivisions in making responsibility determinations in other procurements, and may subject the Contractor or its representatives to criminal liability; (iv) as the authorized representative of the Firm, states that the information submitted on this certification form and any attached pages is true, accurate and complete.

The undersigned hereby attests that he/she is duly authorized by the Firm to make the statements and representations contained herein and/or attached hereto, on behalf of such Firm.

Legal Name of Firm/Company

Firm/Company Street Address

City, State, Zip

Signature of Offeror's Authorized Representative

Title

State Of County of

Sworn to and subscribed before me on this:

Date

Notary Public Signature Field

My Commission Expires:

Date

Note: *As used herein, the term “to the best of Contractor's knowledge” shall refer to the current actual knowledge of Contractor and shall be construed, by imputation or otherwise, to refer to the knowledge of any agent, manager, representative or employee of Contractor but does not impose upon Contractor any duty of inquiry or investigation of the matter to which such actual knowledge, or the absence thereof, pertains. The fact that Contractors (or their principals) are under investigation will not necessarily result in a determination of non-responsibility; rather, GTEA will determine if the information and circumstances regarding such investigation are of such a nature or magnitude as to cause the GTEA to deem the Contractor non-responsible in order to protect the interests of the GTEA and/or the State.