Required Certifications PMT-58.pdf

REQUIRED CERTIFICATIONS

DCF ITB 2526 010

MILK FOR STATE MENTAL HEALTH TREATMENT FACILITIES

PMT-58 1 Effective June 14, 2024

1. RESPONDENT INFORMATION

1.1. ORGANIZATION

OFFICIAL BUSINESS INFORMATION

Name Click or tap here to enter text.

Address Click or tap here to enter text.

Federal Employer Identification Number

Click or tap here to enter text.

1.2. POINTS OF CONTACT AND SIGNATURE AUTHORITY

Both the Primary Contact Person and the Alternate Contact Person must have the authority to bind the Respondent to a Contract. If an Alternate Contact Person is included, both person’s signatures must be included on the last page of this attachment.

PRIMARY CONTACT PERSON

Name Click or tap here to enter text.

Title Click or tap here to enter text.

Telephone Number Click or tap here to enter text.

Email Address Click or tap here to enter text.

ALTERNATE CONTACT PERSON

Name Click or tap here to enter text.

Title Click or tap here to enter text.

Telephone Number Click or tap here to enter text.

Email Address Click or tap here to enter text.

2. CERTIFICATIONS

2.1. SOLICITATION REQUIREMENTS; CONTRACT TERMS AND CONDITIONS

I certify that I have read, accept, and agree to comply with the terms and conditions of this Solicitation;

the submitted Response and the items in it meet or exceed the requirements and specifications herein;

and that if awarded a Contract, I understand the Contract’s terms are non-negotiable for Invitations to Bids or Requests for Proposals.

2.2. CONFLICT OF INTEREST

I certify that my organization does not have an existing conflict of interest due to gaining an unfair competitive advantage as described in §287.057(19)(b)1., Florida Statutes (F.S.).

2.3. NO INVOLVEMENT

I certify that neither my organization nor any person having interest in my organization, disqualifies my organization from receiving a Contract as required by §287.057(19)(c), F.S.

2.4. NO COLLUSION

PMT-58 2 Effective June 14, 2024

I certify that all persons, companies, or parties interested in the Response as principals are named in Attachment C; the Response is made without collusion with any other person(s), organization(s), or vendor(s) submitting a Response, and that it is in all respects made in good faith.

2.5. PROHIBITION OF GRATUITIES

I certify that no elected official or employee of the State of Florida has or shall benefit financially or materially from this Response or a Contract in violation of the provisions of Chapter 112, F.S. I understand that any Contract issued as a result of this Solicitation may be terminated if it is determined that gratuities of any kind were either offered or received by any of the aforementioned parties.

2.6. COMMON CARRIER

I certify that my organization is not a Common Carrier as defined in §908.111, F.S. However, if my organization is a Common Carrier, I have signed and included Form PUR 1808 with this Response.

2.7. FOREIGN COUNTRIES OF CONCERN

I certify that if the Contract will include access to an individual’s personal identifying information, the Provider has signed and included Form PUR 1355 with this Response.

2.8. VENDOR LISTS

I certify that my organization is not listed on the:

2.8.1. Convicted Vendors List maintained pursuant to §287.133, F.S.

2.8.2. Discriminatory Vendors List maintained pursuant to §287.134, F.S.

2.8.3. Suspended Vendors List maintained pursuant to §287.1351, F.S.

2.8.4. Antitrust Violator Vendor List maintained pursuant to §287.137, F.S.

2.8.5. Scrutinized Companies Lists identified in §287.135, F.S.

2.8.6. Ineligible entities list maintained pursuant to §286.101(7)(c), F.S., regarding foreign gifts.

2.8.7. Governmentwide exclusions in the System for Award Management (SAM), for federally funded Contracts.

2.9. SCRUTINIZED COMPANY COMPLIANCE

I certify that my company is not engaged in a boycott of Israel; or engaged in business operations in Cuba or Syria under circumstances where §287.135, F.S. is applicable.

3. TIEBREAKING CERTIFICATIONS

Various provisions of Chapters 287 and 295, F.S., provide qualifying Respondents the advantage of "tiebreakers" whenever two or more bids, proposals, or replies received by the Department are equal with respect to price, quality, and service. To take advantage of the below "tiebreakers," a Respondent who meets the statutory qualifications for one or more of these "tiebreakers" must certify that it qualifies for the cited preference. Completion of this section is optional for qualifying Respondents; however, a Respondent waives all rights to consideration of a "tiebreaker" if it fails to submit the certification on or before the Response Due Date.

Please check all “tiebreaking” certifications that apply to the Respondent:

3.1. ☐ Check here if none of the tiebreaking certifications apply.

3.2. ☐ Certified Minority Business Enterprise, in accordance with §287.0943, F.S.

3.3. ☐ Certified Veteran Business Enterprise, in accordance with §295.187, F.S.

PMT-58 3 Effective June 14, 2024

3.4. ☐ Florida Business, in accordance with §287.084, F.S.

3.5. ☐ Foreign Manufacturer with a Factory in Florida, in accordance with §287.095, F.S.

3.6. ☐ Drug-Free Workplace, in accordance with §287.087, F.S.

4. ACKNOWLEDGEMENT

Signature(s) included below indicate the Respondent’s full acknowledgement of; understanding of; and agreement with all of the certifications and information collected in this attachment.

Signature of Primary Contact Person Signature of Alternate Contact Person

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