Request_for_Quote_Packet_1_PANTHER_Final_06.04.2024_(001).pdf

California Department of Public Health

Request for Quote No. 23-CLS-2913

Award Basis: Lowest Responsive Quote

Instructions to Bidder:

1. Review description of each required item. Provide quote/unit and calculate the extended cost. Unit

Cost quoted is used to calculate extension costs.

2. Review attached Scope of Work (SOW).

3. Review the IT General Provisions and Conditions regarding this RFQ.

4. Vendor must submit a copy of its California Sellers’s Permit with its quote.

5. Vendor must complete and submit attached forms: Bidder Declaration, Commercially Useful Function (CUF), DVBE Declaration (if applicable), Darfur, Cal Recycled Content, Payee Data Record/Payee Data Supplement and Generative Artificial Intelligence (GenAI) Disclosure & Factsheet.

6. Bid only make/model quoted – NO EQUIVALENTS.

7. All items must be in new and unused condition.

8. Acquisitions for the purchase of GenAI technology or that include the purchase of services generated by GenAI, must be conducted using a written solicitation. Use of acquisition methods that do not require a written solicitation (e.g., Fair and Reasonable Acquisition Method) are prohibited for these purchases.

The State of California Department of Public Health (the “Department") is considering the purchase of certain IT goods and services. If the Vendor is interested in selling these goods to the Department, it must complete and sign the quote below and submit it to the Department with the attached bidder forms.

RFQ Issue Date: June 6, 2024

Quote Due Date and Time: No later than 5:00 PM on Thursday, June 13, 2024. Quote must be received before the due date and time.

Submit Quote Via E-Mail: sommer.glynn@cdph.ca.gov

Department Contact: Sommer Glynn at sommer.glynn@cdph.ca.gov Interested bidders must submit any questions regarding this quote or the items listed in writing to the buyer at the email listed above.

Delivery: Goods must be delivered to the Department's within 30 days from receipt of order.

mailto:sommer.glynn@cdph.ca.gov mailto:sommer.glynn@cdph.ca.gov https://www.dgs.ca.gov/media/Divisions/PD/PTCS/OPPL/ModelLanguage/IT/ITGeneralProvisions062122.pdf

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.

List of Goods and Price Quote (not including tax)

Item No. Description Quantity U/M Unit Cost Extension

1 PANTHER INSTRUMENT SYSTEM, DX

CONTINUOUS FLUID AND WASTE (Product #

PRD-06067)

PANTHER FUSION MODULE UPGRADE (Product #

PRD-04173)

3 SERVICE COVERAGE (Warranty Period + Two (2) Years of Post Warranty Coverage**

QUOTE TERMS – TO BE COMPLETED/SIGNED BY VENDOR

COOPERATIVE AGREEMENTS: The Department participates in cooperative agreements such as NASPO-Value Point and CMAS. Please provide the best pricing available to the Department.

FREIGHT/SHIPPING/HANDLING COSTS:

If you are not quoting F.O.B. Destination in the unit cost, please indicate the freight, or a freight not-to-exceed amount. This cost will be considered in the award basis

1 $ $

CALIFORNIA TAXES:

Is this taxable? Yes No Include the current sales tax amount, if applicable at 9.75% for Richmond, CA.

Please note any items that are tax-exempt.

1 $

PAYMENT TERMS:

Please provide your payment terms (i.e.

“Net”, “Net 30”, etc.):

DELIVERY DAYS:

Delivery will be made in days after receipt of purchase order days

VENDOR QUOTE NOTES:

Please provide any notes or details regarding your quote that the Department needs to be aware of.

Warranty:

Please define any warranties that are included with each manufacturer product

If selected by the Department, Vendor agrees (i) to sell the requested goods to the Department at the prices specified above, (ii) to deliver the goods to the Department by the dated specified above, and (iii) that the purchase will be governed solely by the Department Purchase Order Terms and Conditions without regard to any additional or other terms and conditions proposed by Vendor. Vendor acknowledges that this RFQ is governed by the DGS IT General Provisions.

Submitted by: Vendor Name:

Address:

(Print or type name and title)

Signature: Email:

Phone:

Fax:

TAX ID:

23-CLS-2913

Department of Public Health, Center for Laboratory Sciences

STATEMENT OF WORK

Panther Fusion Plus Standard

This Statement of Work (“Agreement”) reflects the services to be provided by the awarded vendor, hereinafter referred to as the “Contractor”, for the Department of Public Health, hereinafter referred to as the “State”.

SCOPE

EQUIPMENT INCLUDED

Equipment Name: PANTHER INSTRUMENT SYSTEM, DX CONTINUOUS FLUID

AND WASTE

Equipment Model: PRD-06067

Equipment Specifications:

Description Continuous fluids/waste module is an upgrade to the lower bay of the Panther® instrument, allowing access to (1) replace a set of universal fluids when depleted and (2) dispose solid and liquid waste containers during processing, increasing flexibility and throughput.

Dimensions Panther System: 48 in (122 cm) W x 32 in (81.5 cm) D x 69 in (175 cm) H UPS (Optional): 8.4 in (21.4 cm) W x 16.1 in (41 cm) D x 12.8 in (32.5 cm) H

Weight 805 lb (365 kg) Electrical Req. Electrical Input: 100 - 240 +/- 10% VAC, 50 - 60 Hz, single phase Current Input: Minimum of 15-amp circuit (dedicated);

20-amp circuit (dedicated) if used with optional UPS Current Draw: Average: 700 W, Peak: 1400 W

• 100 VAC circuit draws 13 amps

• 240 VAC circuit draws 5.4 amps

Equipment Name: PANTHER FUSION MODULE UPGRADE

Equipment Model: PRD-04173

Equipment Specifications:

Description Panther Fusion system: up to 28 cartridges, each with 12 reactions per cartridge for a total of 336 tests. Panther system: up to 4 assay kits, 100 or 250 per kit, for a total of up to 1,000 tests. Ability to load and reload cartridges and kits as needed.

Dimensions Panther Fusion System: 76 in (192 cm) W x 32 in (81.5 cm) D x 69 in (175 cm) H UPS (Optional): 8.4 in (21.4 cm) W x 16.1 in (41 cm) D x 12.8 in (32.5

Weight Panther Fusion System: 1,265 lb (574 kg) UPS (Optional): 76 lb (34.5 kg)

Electrical Req. Electrical Input: 190 - 240 VAC, 50 - 60 Hz, 1800 VA single phase Current Input: 15-amp circuit (dedicated), 20-amp circuit (dedicated if used with optional UPS) Current Draw: Instrument and ancillaries draw 1000 W steady state, 1600 W peak

• 190 VAC circuit draws 8.5 amps peak

• 240 VAC circuit draws 6.7 amps peak

1. Vendor pays for shipping charges of Equipment.

2. Equipment must be installed in the 2024 calendar year.

The Contractor will provide thirty-six (36) months of software support for “Panther Fusion Plus Standard”. Support will include the following services:

SERVICES INCLUDED. During the Warranty Period, the following service will be provided:

1. Labor, necessary replacement parts (excluding disposables which include, but are not limited to, tips, MTU’s, TTU’s, waste bags, and bench covers), and vendor travel expenses.

2. Equipment repair for reasons other than those listed below under Services Excluded.

3. Access to Technical Support telephone support, Monday through Friday, 5:00 AM to 5:00 PM Pacific Standard Time (excluding holidays).

4. Telephone Number for all Technical Support: TBD

5. Factory authorized updates or modifications, including parts.

Service Representative Dispatch and REMOTE DIAGNOSTICS

1. Representative on site within 24 hours (Monday – Friday) if Remote Diagnostics Management is installed.

2. Representative on site within 48 hours (Monday – Friday) if Remote Diagnostics is not installed. Service response times are predicated upon the Equipment operator being willing and able to transfer Equipment log files to TBD when instructed by Technical Support using the protocol described in the Equipment Operator’s Manual.

SATISFACTION GUARANTEE

If, for any reason, the State is not satisfied, the State shall notify Contractor in writing within one month of the time the State first becomes dissatisfied. Contractor will try to resolve the problem to the State’s satisfaction. If Contractor is unable to do so, the State will receive a credit equal to the prorated charge for the service for the period of time the State was dissatisfied.

In the event such credit is not received, Contractor agrees that the State may deduct the amount thereof from any monies due or that may become due said supplier.

PERIOD OF PERFORMANCE

The term of this Agreement will be effective upon the Agreement start date or upon the date the Purchase Order is signed, whichever is later, through 06/30/2027.

SHIP-TO AND BILL-TO INFORMATION

The Contractor shall deliver to the following location:

California Department of Public Health CLS 850 Marina Bay Parkway Richmond, CA, 94804

The Contractor shall submit invoices (including the purchase order number) to the following address:

California Department of Public Health CLS 850 Marina Bay Parkway, Building P Richmond, CA, 94804 Attn: Yvette Urrutia-Giacalone Ph: (510) 620-3148

Contractor Primary Contact:

TBD

State’s Primary Contact:

Bryant Hard, Fiscal and Procurement Manager 850 Marina Bay Parkway, Building P Richmond, CA, 94804 Ph: (916) 363-4109 Fax:

Email: Bryant.Hard@cdph.ca.gov

Please forward renewal notices to the attention of the State’s Primary Contact.

TERMINATION

The State shall have the right to terminate maintenance at no expense to the State upon delivery of written notice at least thirty (30) days prior to any scheduled renewal date.

POINTS OF CONTACT

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION

Public Contract Code Sections 10475 -10481 applies to any company that currently or within the previous three years has had business activities or other operations outside of the United States. For such a company to bid on or submit a proposal for a State of California contract, the company must certify that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit a proposal.

If your company has not, within the previous three years, had any business activities or other operations outside of the United States, you do not need to complete this form.

OPTION #1 - CERTIFICATION

If your company, within the previous three years, has had business activities or other operations outside of the United States, in order to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete the certification below.

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that a) the prospective proposer/bidder named below is not a scrutinized company per Public Contract Code 10476; and b) I am duly authorized to legally bind the prospective proposer/bidder named below. This certification is made under the laws of the State of California.

Company/Vendor Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

OPTION #2 – WRITTEN PERMISSION FROM DGS

Pursuant to Public Contract Code Section 10477(b), the Director of the Department of General Services may permit a scrutinized company, on a case-by-case basis, to bid on or submit a proposal for a contract with a state agency for goods or services, if it is in the best interests of the state. If you are a scrutinized company that has obtained written permission from the DGS to submit a bid or proposal, complete the information below.

We are a scrutinized company as defined in Public Contract Code section 10476, but we have received written permission from the Department of General Services to submit a bid or proposal pursuant to Public Contract Code section 10477(b). A copy of the written permission from DGS is included with our bid or proposal.

Company/Vendor Name (Printed) Federal ID Number

Printed Name and Title of Person

STATE OF CALIFORNIA

Department of Resources Recycling and Recovery (CalRecycle) CalRecycle 74 (Revised 01/23)

Postconsumer Recycled-Content Certification

To be completed by the State agency

State Agency:

Purchasing Agent: PO #:

Phone: E-mail:

The State Agency Buy Recycled Campaign (SABRC) is a state mandated program that requires the reporting of all purchases made within 16 specified product categories. All state agencies are required to verify the recycled-content of all products purchased within each of these categories.

All businesses shall certify the minimum percentage in writing to the contracting officer or his or her representative, if not the exact percentage, of postconsumer recycled-content (PCRC) material in the products, materials, goods, or supplies offered or sold to the State regardless of whether the product meets the minimum content requirements specified in law (see reverse side). The certification shall be furnished under penalty of perjury. The certification shall be provided regardless of content, even if the product contains no recycled material. A State agency may waive the certification requirement if the percentage of postconsumer material in the products, materials, goods, or supplies can be verified in a written advertisement, including, but not limited to, a product label, a catalog, or a manufacturer or vendor Internet website.

Public Contract Code sections 12205(a)(1), (2), (3) and (b)(1), (2), and (3)

Contractor/Company Name_________________________________________________________________________________

Address_____________________________________________________________________Phone_____________________

Purchase Order #

RFQ #

RFP #

IFB #

Cal Card Order #

Item # Product or Services Description 1Percent Postconsumer Recycled- Content Material

2SABRC

Product Category Code

M eets SA

B R

C

Pursuant to Public Contract Code 12205(b)(1), I certify under penalty of perjury under the laws of the State of California that the above information is true and correct.

Print Name Signature Title Date

FOOTNOTES:

1. “Postconsumer recycled-content material” is defined as products that were bought, used, and recycled by consumers. For example, a newspaper that has been purchased, recycled, and used to make another product would be considered postconsumer material.

2. “Product category” refers to one of the categories listed below, into which the reportable purchase is best placed.

3. If the product does not belong in any of the product categories, enter “N/A.” Common “N/A” products include wood products, aggregate, concrete, and electronics such as computers, TV, software on a disk or CD, and telephones.

4. For reused or refurbished products, there is no minimum content requirement. (PCC 12209(l))

California Department of Resources Recycling and Recovery (CalRecycle)

State Agency Buy Recycled Campaign (SABRC) - SABRC@CalRecycle.ca.gov

Code* Product Categories Product Subcategories Product Examples in each SABRC Category (PCC 12207 ) Examples include, but are not limited to, these individual products/materials.

Minimum Post-Consumer Content Requirement per Statute (PCC 12209 )

1A Paper Products Toilet Paper Toilet paper. 45 percent by fiber weight post-consumer fiber.

1B Paper Products Paper Towels Paper towels. 40 percent by fiber weight post-consumer fiber.

1C Paper Products Facial Tissues Facial tissue. 10 percent by fiber weight post-consumer fiber.

1D Paper Products Toilet Seat Covers Toilet seat covers. 20 percent by fiber weight post-consumer fiber.

1E Paper Products General Purpose Paper Wipes General purpose paper wipes. 40 percent by fiber weight post-consumer fiber.

1F Paper Products Food Serviceware Napkins, plates, bowls, food trays, takeout boxes, and placemats. 40 percent by fiber weight post-consumer fiber.

1G Paper Products Miscellaneous Paper Products Cartons, wrapping, packaging, file folders, hanging folders, building insulation and panels, corrugated boxes.

30 percent by fiber weight post-consumer fiber.

2 Printing and Writing Papers

Printing and Writing Papers Copy, xerographic, watermark, cotton fiber, offset, forms, computer printout paper, white wove envelopes, manila envelopes, book paper, note pads, writing tablets, newsprint, and other uncoated writing papers, posters, index cards, calendars, brochures, reports, magazines, and publications.

30 percent by fiber weight post-consumer fiber.

3A Soil Amendments and Toppings

Compost Soil amendments, soil conditioner for potting or plant mix, organic materials used for water conservation; organic materials such as biosolids or other comparable substitutes such as livestock, horse, or other animal manure, food residues or fish processing byproducts; mechanical breakdown of materials.

80 percent recovered material that would otherwise be normally disposed of in a landfill.

3B Soil Amendments and Toppings

Mulch Ground covers, weed suppressants. 80 percent recovered material that would otherwise be normally disposed of in a landfill.

4A Glass Products Glass Products Windows, test tubes, beakers, laboratory or hospital supplies, reflective beads, tiles, construction blocks, desktop accessories, flat glass sheets, loose- grain abrasives, deburring media, liquid filter media, and containers.

25 percent post-consumer, by weight.

4B Glass Products Fiberglass Fiberglass (insulation), 30 percent post-consumer, by weight.

5 Lubricating Oils Intended for use in a crankcase, transmission, engine, power steering, gearbox, differential chainsaw, transformer dielectric, fluid, cutting, hydraulic, industrial, or automobile, bus, truck, vessel, plane, train, heavy equipment, or machinery powered by an internal combustion engine.

70 percent re-refined base oil.

6 Plastic Products Printer or duplication cartridges, diskette, carpet, office products, plastic lumber, buckets, wastebaskets, containers, benches, tables, fencing, clothing, mats, packaging, signs, posts, binders, sheet, buckets, building products, garden hose, and trays.

20 percent postconsumer, by weight, is remanufactured or has a take back program.

7A Paint: Low-VOC: < 50 grams/liter Water-based paint, graffiti abatement, interior and exterior, and maintenance. 50 percent post-consumer paint.

7B Paint: Other VOC: > 50 grams/liter

Water-based paint, graffiti abatement, interior and exterior, and maintenance. 50 percent post-consumer paint.

8 Antifreeze Recycled antifreeze, and antifreeze containing a bittering agent or made from polypropylene or other similar non-toxic substance.

70 percent post-consumer material.

9 Tires (Retreaded tires)

Truck and bus tires, and those used on fleet vehicles (and passenger cars where available).

Retreaded: Must use an existing casing that has undergone retreading or recapping process in accordance with Public Resource Code (commencing with section 42400).

10 Tire- Derived Products

Flooring, mats, wheelchair ramps, playground surfacing, sports surfacing, parking bumpers, bullet traps, hoses, bumpers, truck bedliners, pads, walkways, tree ties, wheel chocks, rollers, traffic-related products, mudflaps, accessibility ramps, paths and sidewalks, animal care products, including, but not limited to, horse arena surfacing, stall mats, cow mats, and equestrian barn and breezeway flooring, artificial turf, landscaping and rubber mulch, outdoor surfacing, pavers and tiles, and posts.

50 percent recycled used tires.

11A Metal Products Metal Products Staplers, paper clips, steel furniture, desks, pedestals, scissors, jacks, rebar, pipe, plumbing fixtures, chairs, ladders, file cabinets, shelving, containers, lockers, sheet metal, girders, building and construction products, bridges, braces, nails, and screws.

10 percent post-consumer material, by weight.

11B Metal Products Vehicles Vehicles. 10 percent post-consumer material, by weight.

12 Building Finishes

Open Office Panel Systems

Open office panel systems. Middle range of state contracts.

13 Carpet Carpet Determined by DGS and Posted in SCM.

14A Erosion Control Products

Compost Filter Socks Compost filter sock. 100 percent post-consumer material.

14B Erosion Control Products

Compost Blanket Compost blanket, layer of compost protecting bare soil surfaces. 100 percent post-consumer material.

14C Erosion Control Products

Hydraulic Mulch Hydraulic mulch or erosion control process that uses fiber slurry and tackifier. 100 percent post-consumer material.

15A Textiles Textiles 0 percent post-consumer material.

15B Textiles General Textile Wipes General purpose wipes. 100 percent post-consumer material.

16A Pavement

Surfacing Rubberized Pavement Surfaces

Rubberized asphalt concrete and chip seal. 15 percent post-consumer material.

16B Pavement Surfacing

Recycled Asphalt Pavement

Recycled Asphalt Pavement 25 percent post-consumer material.

*It is each agency’s prerogative to assign internal codes/object codes for post-consumer recycled content products based on their internal paper or computer tracking systems.

For additional information, please visit www.CalRecycle.ca.gov/BuyRecycled/StateAgency/ mailto:SABRC@CalRecycle.ca.gov http://www.calrecycle.ca.gov/BuyRecycled/StateAgency/

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

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

GENAI DISCLOSURE & FACTSHEET

STD 1000 (NEW 01/2024)

DEPARTMENT OF GENERAL SERVICES

PROCUREMENT DIVISION

Generative Artificial Intelligence (GenAI) Disclosure & Factsheet Bidder/Offer Information

Solicitation Number Bidder ID/Vendor ID (optional)

Business Name Business Telephone Number

Business Address

GenAI Disclosure & F actsheet

City State Zip Code

Will you be using or offering GenAI technology, model, or service (collectively, “system”)? Yes No (If No, skip to Signature section of this form.)

If yes, provide details regarding the GenAI system”). See GenAI Disclosure & Factsheet Definitions at the end of this form for more information.

Failure to disclose GenAI to the State and submit the detailed description may result in disqualification and may void any resulting contract.

1. GenAI Model Name, Version (including number of parameters)

2. Model Owner

3. Overview

4. Purpose

5. Intended Domain

6. Model Training Data

7. Model Information

STD 1000 (NEW 01/2024)

STATE OF CALIFORNIA DEPARTMENT OF GENERAL SERVICES

GENAI DISCLOSURE & FACTSHEET PROCUREMENT DIVISION

8. Input and Outputs

9. Performance Metrics

10. Optimal Conditions

11. Poor Conditions

12. Bias

13. Test Data

Explain below how you are ensuring the GenAI system is not adversely affecting “decisions that materially impact access to, or approval for, housing or accommodations, education, employment, credit, health care, and criminal justice.” (AB 302, Department of Technology: High-Risk automated decision systems: inventory).

Signature

By signing this document, I certify that I have identified and disclosed, if any, all GenAI components in the proposed solution or service.

Signature Date

STD 1000 (NEW 01/2024)

GenAI Disclosure & Factsheet Definitions Please use the following definitions to complete the GenAI Disclosure and Factsheet:

1. Model Name, Version & Number of Parameters:

• Definition: The unique identifier or name assigned to the specific GenAI model or service.

• Purpose: Allows users to refer to and distinguish between different GenAI models.

2. Model Owner

• Definition: The name of the organization or entity responsible for creating or deploying the GenAI model or service.

• Importance: Helps identify the source and accountability for the GenAI system.

3. Overview:

• Definition: A concise summary of the GenAI model’s purpose, functionality, and key characteristics.

• Role: Provides a high-level understanding for users and stakeholders.

4. Purpose:

• Definition: The intended use or goal of the GenAI model (e.g., image recognition, natural language processing, text summarization).

• Significance: Helps users assess whether the GenAI model aligns with their needs.

5. Intended Domain:

• Definition: The context, subject matter or domain for which the GenAI model is designed to operate effectively.

• Importance: Helps users determine if the GenAI model is suitable for their specific use case.

6. Training Data:

• Definition: Information used to train the GenAI model (e.g., labeled images, text corpora).

• Role: Influences the GenAI model’s behavior and performance.

7. Model Information:

• Definition: Details about the architecture, parameters, and configuration of the GenAI model.

• Relevance: Provides insights into how the GenAI model functions.

8. Inputs and Outputs:

• Definition:

o Inputs: The data or features provided to the model for prediction (e.g., images, text).

o Outputs: The GenAI model’s predictions or results (e.g., class labels, probabilities).

• Understanding: Crucial for integrating the GenAI model into applications.

9. Performance Metrics:

• Definition: Quantitative measures (e.g., accuracy, F1-score) used to evaluate the GenAI model’s performance.

• Assessment: Determines how well the GenAI model meets its intended purpose.

• Continuous Monitoring Plan: Establishes a plan for continuous monitoring and evaluation of the GenAI model’s performance.

STD 1000 (NEW 01/2024)

10. Optimal Conditions:

• Definition: The ideal environment or context for the GenAI model to perform optimally.

• Contextual Guidance: Helps users achieve the best results.

11. Poor Conditions:

• Definition: Scenarios or conditions where the GenAI model’s performance may degrade.

• Risk Awareness: Alerts users to potential limitations.

12. Bias:

• Definition: Any systematic error or unfairness in the GenAI model’s predictions due to biased training data or design.

• Mitigation: Addressing bias is crucial for ethical and unbiased GenAI.

13. Test Data:

• Definition: Independent data used to evaluate the GenAI model’s performance after training.

• Validation: Ensures the GenAI model generalizes well to unseen examples.