Required Forms_ Attachment K-Q.pdf

State Contract No.

Federal-Aid Project:

CERTIFICATION OF CONTRACTOR / CONSULTANT

I hereby certify that I am the ________________________________ and duly authorized representative of the firm of ______________________________________________________, whose address is ________________________________________________, and that neither I nor the above firm I here represent has:

(a) Employed or retained for a commission, percentage, brokerage, contingent fee, or other consideration, any firm or person (other than a bona fide employee working solely for me or the above consultant) to solicit or secure this contract,

(b) Agreed, as an express or implied condition for obtaining this contract, to employ or retain the services of any firm or person in connection with carrying out the contract, or

(c) Paid, or agreed to pay, to any firm, organization or person (other than a bona fide employee working solely for me or the above consultant) any fee, contribution, donation, or the consideration of any kind for, or in connection with, procuring or carrying out the contract;

except as here expressly stated (if any):

I acknowledge that this certificate is to be furnished to the State Agency of Transportation and the

U. S. Department of Transportation, Federal Highway Administration, in connection with this contract involving participation of Federal-Aid highway funds, and is subject to applicable State and

Federal laws, both criminal and civil.

Signature Date

Attachment K

Attachment L

CERTIFICATION REGARDING LOBBYING

1. The prospective contractor certifies, to the best of his or her knowledge and belief, under the penalties of perjury under the laws of the State of Vermont and the United States that on behalf of the person, firm, association, or corporation he or she represents, that:

a. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

b. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. The form and instructions can be found here: CERTIFICATION REGARDING LOBBYING (state.gov)

2. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. 1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

3. The prospective contractor also agrees that they shall require that the language of this certification be included in all lower tier subcontracts which exceed $100,000 and that all such recipients shall certify and disclose accordingly.

Printed Name of Signatory Organization Name

Title of Signatory Street Address

Signature of Authorized Official City, State, Zip

Date https://www.state.gov/wp-content/uploads/2019/01/Certification-Regarding-Lobbying.pdf

CA-91

STATE OF VERMONT

AGENCY OF TRANSPORTATION

DEBARMENT AND NON-COLLUSION CERTIFICATION

I, , representing (Official Authorized to Sign Contracts) of , (Individual, Partnership or Corporation) (City or State) hereby certify under the penalties of perjury under the laws of the State of Vermont and the United States that on behalf of the person, firm, association, or corporation submitting the bid certifying that such person, firm, association, or corporation has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action, in restraint of free competitive bidding in connection with the submitted bid for the Vermont project:

(Project Name) project located on , (Project Number) (Route or Highway) bids opened at , (Town or City)

Vermont on .

(Date)

I further certify under the penalties of perjury under the laws of the State of Vermont and the United States that except as noted below said individual, partnership or corporation or any person associated therewith in any capacity is not currently, and has not been within the past three (3) years, suspended, debarred, voluntarily excluded or determined ineligible by any Federal or State Agency; does not have a proposed suspension, debarment, voluntary exclusion or ineligibility determination pending; and has not been indicted, convicted, or had a civil judgement rendered against (it, him, her, them) by a court having jurisdiction in any matter involving fraud or official misconduct within the past three (3) years.

Exceptions: No Yes. (If yes complete second page of this form.)

(Name of Individual, Partnership or Corporation)

(Signature of Official Authorized to Sign Contracts)

(Name of Individual Signing Affidavit)

(Title of Individual Signing Affidavit)

Attachment M

Exceptions will not necessarily result in denial of award but will be considered in determining bidder responsibility. For any exception noted, indicate below to whom it applies, initiating agency, and dates of action. Providing false information may result in criminal prosecution or administration sanctions.

EXCEPTIONS:

STATE OF VERMONT November, 1985

AGENCY OF TRANSPORTATION CA-109

CONTRACTOR'S EEO CERTIFICATION FORM

Certification with regard to the Performance of Previous Contracts of Subcontracts subject to the Equal Opportunity Clause and the filing of Required Reports.

The bidder , proposed subcontractor , , hereby certifies that he/she has , has not participated in a previous contract or subcontract subject to the equal opportunity clause, as required by Executive Orders 10925 or 11114, as amended, and that he/she has , has not , filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal Government contracting or administering agency, or the President's Committee on Equal Employment Opportunity, all reports due under the applicable filing requirements.

Company By Title

NOTE: The above certification is required by the Equal Employment Opportunity regulations of the Secretary of Labor (41 CFR 60-1.7(b) (1)), and must be submitted by bidders and proposed subcontractors only in connection with contracts and subcontracts which are subject to the equal opportunity clause. Contracts and subcontracts which are exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5 (Generally only contracts or subcontracts of $10,000 or under are exempt.) Currently, Standard Form 100 (EEO-1) is the only report required by the Executive Orders or their implementing regulations.

Proposed prime contractors and subcontractors who have participated in a previous contract or subcontract subject to the Executive Orders and have not filed the required reports should note that 41 CFR 60-1.7 (b) (1) prevents the award of contracts and subcontracts unless such contractor submits a report covering the delinquent period or such other period specified by the Federal Highway Administration, or by the Director, Office of Federal Contract Compliance, U.S. Department of Labor.

ATTACHMENT N

ATTACHMENT O

RFP/PROJECT NUMBER: ______________

DATE: ______________

WORKER CLASSIFICATION COMPLIANCE REQUIREMENT

Self Reporting Form 1 of 2

This form must be completed in its entirety and submitted as part of the response for the proposal to be considered valid.

The Vermont Agency of Transportation, in accordance with Section 32 of Act 54 (2009), as amended by Section 17 of Act 142 (2010) and further amended by Section 6 of Act 50 (2011), and for total projects costs exceeding $250,000.00, requires bidders comply with the following provisions and requirements.

Bidder is required to self report the following information relating to past violations, convictions, suspensions, and any other information related to past performance and likely compliance with proper coding and classification of employees. The state is requiring information on any violations that occurred in the previous 12 months. Attach additional pages as necessary. If not applicable, so state.

Summary of Detailed Information Date of Notification Outcome

WORKER CLASSIFICATION COMPLIANCE REQUIREMENT: Bidder hereby certifies that the company/individual is in compliance with the requirements as detailed in Section 32 of Act 54 (2009), as amended by Section 17 of Act 142 (2010) and further amended by Section 6 of Act 50 (2011).

Date:

Name of Company:

Contact Name:

Address:

Title:

Phone Number:

E-mail:

Fax Number:

By:

Name:

Signature (Request/Report Not Valid Unless Signed)* Type or Print

*Form must be signed by individual authorized to sign on the bidder’s behalf.

RFP/PROJECT NUMBER: ______________

DATE: ______________

WORKER CLASSIFICATION COMPLIANCE REQUIREMENT

Subcontractor Reporting Form Form 2 of 2

This form must be completed in its entirety and submitted prior to contract execution by the Contractor and included in all requests to sublet or assign work as outlined in Section 108.01 of the Standard Specifications for Construction. This form must be updated as necessary, and provided to the State as additional subcontractors are hired.

The Agency of Transportation in accordance with Act 54, Section 32 of the Acts of 2009 and for total project costs exceeding $250,000.00 requires the Contractor to comply with the following provisions and requirements:

The Contractor is required to provide a list of subcontractors on the job along with lists of subcontractors’ subcontractors and by whom those subcontractors are insured for workers’ compensation purposes. Include additional pages if necessary.

This is not a requirement for subcontractors providing supplies only and no labor to the overall contract or project.

Additionally, the Contractor shall collect and retain evidence of subcontractors’ workers’ compensation insurance, such as the ACORD insurance coverage summary sheet. The Agency of Transportation will periodically verify the Contractors’ compliance.

Subcontractor Insured By Subcontractor’s Sub Insured By

Date:

Name of Company:

Contact Name:

Address:

Title:

Phone Number:

E-mail:

Fax Number:

By:

Name:

Signature Type or Print

Failure to adhere to Act 54, Section 32 of the Acts of 2009 and submit Subcontractor Reporting: Worker Classification Compliance Requirement will constitute non-compliance and may result in cancellation of contract and/or forfeiture of future bidding privileges until resolved.

Attachment Q

Executive Order 05 – 16:

Climate Change Considerations in State Procurements Certification

Bidder certifies to the following (Bidder may attach any desired explanation or substantiation.

Please also note that Bidder may be asked to provide documentation for any applicable claims):

1. Bidder owns, leases or utilizes, for business purposes, space that has received:

Energy Star® Certification

LEED®, Green Globes®, or Living Buildings Challenge℠ Certification

Other Internationally Recognized Building Certification:

2. Bidder has received incentives or rebates from an Energy Efficiency Utility or Energy Efficiency

Program in the last five years for energy efficient improvements made at bidder’s place of business.

Please explain:

3. Please Check all that apply:

Bidder can claim on-site renewable power or anaerobic-digester power (“cow-power”). Or bidder consumes renewable electricity through voluntary purchase or offset, provided no such claimed power can be double-claimed by another party.

Bidder uses renewable biomass or bio-fuel for the purposes of thermal (heat) energy at its place of business.

Bidder’s heating system has modern, high-efficiency units (boilers, furnaces, stoves, etc.), having reduced emissions of particulate matter and other air pollutants.

3. Please Check all that apply (continued):

Bidder tracks its energy consumption and harmful greenhouse gas emissions. What tool is used to do this?

Bidder promotes the use of plug-in electric vehicles by providing electric vehicle charging, electric fleet vehicles, preferred parking, designated parking, purchase or lease incentives, etc..

Bidder offers employees an option for a fossil fuel divestment retirement account.

Bidder offers products or services that reduce waste, conserve water, or promote energy efficiency and conservation. Please explain:

4. Please list any additional practices that promote clean energy and take action to address climate change:

Attachment P

State of Vermont

Executive Order 02-22 Vendor Certification

Contractor:

RFP Name OR Contract Number:

Contract Subject Matter/Description:

On March 3, 2022, Governor Phil Scott issued Executive Order No. 02-22, which in part requires a review of all contracts for Russian-sourced goods and goods produced by Russian entities. The

Executive Order can be found here: https://governor.vermont.gov/content/executive-order-02-22-solidarity-ukrainian-people

The State is required to secure your response to this certification request. You should (1) either check

Box A below, or check Box B and complete the associated table accordingly, and (2) sign below certifying that the form is accurate on behalf of your organization with respect to whether Russian-sourced goods and goods produced by Russian entities are being provided to the State of Vermont under the Contract.

A. Contractor hereby certifies that in connection with the RRP or Contract, none of the applicable goods or services are Russian-sourced goods and/or produced by

Russian entities.

B. If the non-use box is not checked in Section A above, Contractor hereby indicates that certain products provided under this RFP and resulting contract with the Sate of

Vermont are Russian-sourced goods and/or produced by Russian entities, as described in the table below.

In addition, identify where indicated in the table, which goods are Russian-sourced and/or produced by Russian entities. An additional column is provided for any note or comment that you may have.

Equipment, Product or Service Provided Contractor Note of Comment