Required_Forms.pdf

Hillsborough County Public Schools Page 1 of 10 Required Forms: Competitive Solicitations

REQUIRED FORMS

The signer of this proposal to a competitive solicitation guarantees, as evidenced by the affidavit required herein, the truth and accuracy of all statements and all answers to interrogatories hereinafter made. The undersigned hereby authorizes any public official, engineer, architect, surety company, bank depository, material or equipment manufacturer or distributor or any person, firm or corporation to furnish any pertinent information requested by HCPS or its representative, deemed necessary to verify the statements made in this qualification form or regarding the standing and general reputation of the applicant. The signer also states that all the information given accurately represents the office location and resources from which the commodities and contractual services are to be rendered.

THE PROPOSER’S STATEMENT OF QUALIFICATIONS

Please provide written responses to the following questions. If the answer to any of the questions is “Yes”, the Proposer shall fully describe the circumstances, reasons, the status, and ultimate disposition of each matter that is the subject of this inquiry. If additional space is needed for any question, please attach it to this document.

☐ Yes ☐ No: Has the Proposer been declared in default of any contract?

☐ Yes ☐ No: Has the Proposer forfeited any performance bond payment issued by a surety company on any contract?

☐ Yes ☐ No: Has an uncompleted contract been assigned by the Proposer’s surety company on any performance bond payment issued to the Proposer arising from its failure to discharge all contractual obligations thereunder fully?

☐ Yes ☐ No: Within the past three (3) years, has the Proposer filed for reorganization, protection from creditors, or dissolution under the bankruptcy statutes?

☐ Yes ☐ No: Is the Proposer now the subject of any litigation in which an adverse decision might result in a material change in the firm’s financial position or future viability?

☐ Yes ☐ No: Is the Proposer currently involved in any state of fact-finding, negotiations, or resistance to a merger, friendly acquisition, or hostile takeover, either as a target or as a pursuer?

License Sanctions: List any regulatory or license agency sanctions. HCPS may perform a background check of the Proposer with any state and regulatory agencies.

SIGNATURE

X

TITLE

DATE

PRINT NAME

Hillsborough County Public Schools Page 2 of 10

PREFERRED PAYMENT

NET 45 (Standard Payment Terms): HCPS is responsible for paying the Contractor’s fees under the Florida Prompt Payment Act (§§ 218.70-218.80, Florida Statutes). Invoice payment is Due 45 days from the delivery date or receipt of a proper invoice, whichever occurs later, unless the invoice specifies a prompt payment discount. All payments due and not made within the time specified in this section bear interest from 30 days after the due date at the rate of one percent (1%) per month on the unpaid balance.

HCPS may consider alternate payment should the Proposer choose one of the following options.

☐ Net 21 Days (E-Payables Option; Visa Virtual Credit Card): Please get in touch with Procurement Services for specific information on the E-Payables option. This option requires using credit cards through your financial institution and/or credit card processor.

☐ _____ % 21 Days, Net 45: (Discount for early payment, i.e., 2% 21, NET 45). Invoices with less agreed-upon discounts are paid in 21 days. This option requires you to enter a discount percentage.

P-CARD PAYMENT

If your company accepts P-Card payments without additional service fees or handling charges, this section must be filled

in. HCPS reserves the right to reject this option.

☐ P-Card: I accept the Purchasing Card conditions stated in this solicitation. If yes, please check the level of reporting your firm offers its customers who utilize the P-Card:

☐ Level 1: Includes the basic information found on a typical credit card statement.

☐ Level 2: Level 1 information, plus sales tax and transaction data field (usually 16 characters), providing information related to the transaction, such as an order number or an employee name.

☐ Level 3: Level 2 information, plus other valuable data (item product code, item description, quantity, price, and so on). Level 3 reporting provides information usually found on a typical invoice.

Hillsborough County Public Schools Page 3 of 10

DRUG-FREE WORKPLACE CERTIFICATION

Preference must be given to vendors submitting a certification with their proposal certifying they have a drug-free workplace in accordance with § 287.087, Florida Statutes. This requirement affects all Florida public entities. The special condition is as follows:

IDENTICAL TIE BIDS - Preference shall be given to businesses with drug-free workplace programs. Whenever two or more proposals, which are equal with respect to price, quality, and service, are received by any political subdivision for the procurement of commodities or contractual services, a proposal received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. Established procedures for processing tie proposals will be followed if none of the tied vendors have a drug-free workplace program. A business shall:

1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violating such prohibition.

2) Inform employees about the dangers of drug abuse in the workplace- the business's policy of maintaining a drug-free workplace; any available drug counseling, rehabilitation, and employee assistance programs; and the penalties that may be imposed upon employees for drug abuse violations.

3) Give each employee providing the commodities or contractual services under the award a copy of the statement specified in subsection (1).

4) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under the award, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contender to, any violation of § 893, Florida Statutes, or of any controlled substance law of the United States or any state, for a violation occurring in the workplace, no later than five (5) days after such conviction.

5) Impose a sanction on or require the satisfactory participation in a drug-abuse assistance or rehabilitation program if such is available in the employee's community, on any employee who is so convicted. 6) Make a good-faith effort to maintain a drug-free workplace by implementing this section.

As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements.

COMPANY NAME

Hillsborough County Public Schools Page 4 of 10

SCRUTINIZED COMPANY CERTIFICATION

I hereby swear or affirm that as of the date below, this company is not listed on a Scrutinized Companies list created pursuant to §§ 215.4725, 215.473, or 287.135, Florida Statutes. Pursuant to § 287.135, Florida Statutes, I further affirm that:

• This company is not participating in a boycott of Israel, such that it is not refusing to deal, terminating business activities, or taking other actions to limit commercial relations with Israel, or persons or entities doing business in Israel or Israeli-controlled territories, in a discriminatory manner.

• This Company does not appear on the Scrutinized Companies with Activities in Sudan List, where the State Board of Administration has established the following criteria:

o Have a material business relationship with the government of Sudan or a government-created project involving oil-related, mineral extraction, or power generation activities, or o Have a material business relationship involving the supply of military equipment, or o Impart minimal benefit to disadvantaged citizens who are typically located in the geographic periphery of Sudan, or o Have been complicit in the genocidal campaign in Darfur.

• This Company does not appear on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, where the State Board of Administration has established the following criteria:

o Have a material business relationship with the government of Iran or a government-created project involving oil-related or mineral extraction activities, or o Made material investments that significantly enhanced Iran‘s petroleum sector.

• This Company is not engaged in business operations in Cuba or Syria.

Hillsborough County Public Schools Page 5 of 10

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY, AND VOLUNTARY EXCLUSION –

LOWER TIER COVERED TRANSACTIONS

AD-1048 OMB No. 0505-0027

Expiration Date: 09/30/2025

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552a, as amended). This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, and 2 CFR §§ 180.300, 180.335, Participants' responsibilities. The regulations were amended and published on August 31, 2005, in 70 Fed. Reg. 51865-51880. Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the proposed covered transaction. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0505-0027. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The provisions of appropriate criminal or civil fraud, privacy, and other statutes may be applicable to the information provided.

(Read instructions on page two before completing certification.)

A. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency; B. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

ORGANIZATION NAME PR/AWARD NUMBER OR PROJECT NAME

NAME(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/ parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.

mailto:program.intake@usda.gov

Hillsborough County Public Schools Page 6 of 10

INSTRUCTIONS FOR CERTIFICATION

(1) By signing and submitting this form, the prospective lower tier participant is providing the certification set out on page 1 in accordance with these instructions.

(2) The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the Department or agency with which this transaction originated may pursue available remedies, including suspension or debarment.

(3) The prospective lower tier participant must provide immediate written notice to the person(s) to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

(4) The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person, ""primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549, at 2 CFR Parts 180 and 417. You may contact the Department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations.

(5) The prospective lower tier participant agrees by submitting this form that, should the proposed covered transaction be entered into, it may not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department or agency with which this transaction originated.

(6) The prospective lower tier participant further agrees by submitting this form that it will include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

(7) A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the General Services Administration’s System for Award Management Exclusions database.

(8) Nothing contained in the foregoing shall be construed to require establishment of a system of records to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

(9) Except for transactions authorized under paragraph (5) of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the Department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Hillsborough County Public Schools Page 7 of 10

TRUTH AND ACCURACY STATEMENT

The signer of this bid guarantees, as evidenced by the affidavit required herein, the truth and accuracy of all statements and of all answers to interrogatories hereinafter made.

The undersigned hereby:

• authorizes any public official, engineer, architect, surety company, bank depository, material or equipment manufacturer or distributor or any person, firm, or corporation to furnish any HCPS-requested pertinent information, or its representative, deemed necessary to verify the statements made in this qualification form or regarding the standing and general reputation of the organization; and

• states that all information given is an accurate representation of the office location and resources from where the services are to be rendered; and

• certifies that he/she is authorized to sign this bid for the organization and that this bid is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a bid for the same materials, supplies, or equipment and is in all respects fair and without collusion or fraud. The undersigned certifies acceptance of this solicitation’s terms, conditions, exhibits, specifications, attachments, and addenda.

“I certify (or declare) under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct”:

Hillsborough County Public Schools Page 8 of 10

BIDDER’S STATEMENT OF PRINCIPAL PLACE OF BUSINESS

☐ THIS SECTION MUST BE FILLED IN IF BOX IS CHECKED IN THE SOLICITATION.

Name of Vendor: _____________________________________________ whose principal place of business is in the state of: ____________________________________________________________________________

Vendor’s Signature: _______________________________________________________________

INSTRUCTIONS: IF your principal place of business above is located within the State of Florida, provide the information as indicated above and return this form with your bid response. No further action is required. IF your principal place of business is outside of the State of Florida, the following must be completed by an attorney and returned with your bid response. Failure to comply shall be considered to be non-responsive to the terms of this solicitation.

OPINION OF OUT-OF-STATE BIDDER’S ATTORNEY ON BIDDING PREFERENCES

(TO BE COMPLETED BY THE ATTORNEY FOR AN OUT-OF-STATE VENDOR)

NOTICE: Section 287.084(2), Florida Statutes, provides that “a vendor whose principal place of business is outside this state must accompany any written bid, proposal, or reply documents with a written opinion of an attorney at law licensed to practice law in that foreign state, as to the preferences, if any or none, granted by the law of that state [or political subdivision thereof] to its own business entities whose principal places of business are in that foreign state in the letting of any or all public contracts.” See also: Section 287.084(1), Florida Statutes.

LEGAL OPINION ABOUT STATE BIDDING PREFERENCES

(Please Select One)

The Vendor’s principal place of business is in the State of ________________________________________ and it is my legal opinion that the laws of that state do not grant a preference in the letting of any or all public contracts to business entities whose principal places of business are in that state.

The Vendor’s principal place of business is in the State of ________________________________________ and it is my legal opinion that the laws of that state grant the following preference(s) in the letting of any or all public contracts to business entities whose principal places of business are in that state: [Please describe applicable preference(s) and identify applicable state law(s)]: _________________________________________________________.

LEGAL OPINION ABOUT POLITICAL SUBDIVISION BIDDING PREFERENCES

(Please Select One)

The Vendor’s principal place of business is in the political subdivision of _________________________________ and it is my legal opinion that the laws of that political subdivision do not grant a preference in the letting of any or all public contracts to business entities whose principal places of business are in that political subdivision.

The Vendor’s principal place of business is in the political subdivision of _________________________________ and it is my legal opinion that the laws of that political subdivision grant the following preference(s) in the letting of any or all public contracts to business entities whose principal places of business are in that political subdivision: [Please describe applicable preference(s) and identify applicable authority granting the preference(s)]: ___________________

Signature of out-of-state Bidder’s attorney

Printed name of out-of-state Bidder’s attorney Attorney’s state(s) of bar admission.

Telephone number of the out-of-state Bidder’s attorney. Email of the out-of-state Bidders’ attorney

Hillsborough County Public Schools Page 9 of 10

VENDOR AFFIDAVIT REGARDING THE USE OF COERCION FOR LABOR AND SERVICES

HUMAN TRAFFICKING: § 787.06 (13), FLORIDA STATUTES

Section 787.06(13), Florida Statutes, requires all nongovernmental entities (the “Contractor”) executing, renewing, or extending a contract with a governmental entity (such as The School Board of Hillsborough County, Florida, or Hillsborough County Public Schools) to provide an affidavit signed by an officer or representative of the Contractor under penalty of perjury that the Contractor does not use coercion for labor or services as defined in that statute.

As the person authorized to sign on behalf of the Contractor, I certify that the company identified above does not:

• use or threaten to use physical force against any person; or

• restrain, isolate, or confine, or threaten to restrain, isolate, or confine any person without lawful authority and against her or his will; or

• use lending or other credit methods to establish a debt by any person when labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt, the length and nature of the labor or services are not respectively limited and defined; or

• destroy, conceal, remove, confiscate, withhold, or possess any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person; or

• cause or threaten to cause financial harm to any person; or

• entice or lure any person by fraud or deceit; or

• provide a controlled substance as outlined in Schedule I or Schedule II of § 893.03, Florida Statutes, to any person for exploitation of that person.

Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.

By:

Authorized Signature

Name:

Title:

Date:

Hillsborough County Public Schools Page 10 of 10

ADDENDA AND BID FORM

Receipt of the following Addenda is hereby acknowledged: (List all Addenda as follows):

Addendum No.: _____ Dated: _____________________________