RFP 170-4438-25 Attachment G Responsibility Form_FINAL.docx

Attachment G Responsibility Inquiry

Proposer Proposer Legal Business Name:

Responsibility Determination Treasury will determine your Responsibility if you are selected to be awarded a contract under this Request. Prior to the execution of a Contract, you must complete this form. Treasury may require other documentation to determine Responsibility including, but not limited to, recent profit-and-loss history, current balance statements and cash flow information, assets-to-liabilities ratio, including number and amount of secured versus unsecured creditor claims, availability of short and long-term financing, bonding capacity, insurability, credit information, materials and equipment, facility capabilities, personnel information, record of performance under previous contracts, etc. Failure to promptly provide requested information or clearly demonstrate Responsibility may result in a finding of non-responsibility and rejection.

Provide the following information

1. Mark the statement that best describes your company’s ability to fully perform a contract under this Request. My company:

2. Within the last five years and based on the cost and time available under your company’s control, please complete the following statements. My company:

a. Completed contracts of a similar nature within the time and budget allotted.

b. Completed contracts of a similar nature outside the time and budget allotted.

c. Completed contracts that were subject to a contract claim by any party.

Please complete Item 2 under the explanations section if your company had contracts that were outside the time and budget allotted or a party made a contract claim.

3. Within the last three years, my company (including a partner or shareholder owning 10 percent or more of my company or a major subcontractor receiving 10 percent or more of a total contract amount) has been charged, indicted, convicted, or subject to a civil lawsuit or judgement in connection with (check all that apply, if any):

Please complete Item 3 under the explanations section if you marked one or more of the statements above.

4. Within the last three years, my company (check all that apply, if any):

Please complete Item 4 under the explanations section if marked one or more of the statements above.

5. Check if the following statements apply:

If you checked both boxes, attach a copy of a Pay Equity Certificate issued by the Department of Administrative Services. (See Section 1[E] of the Request for more information).

6. Attach copies of all the required licenses and registrations identified in this paragraph:

a.

7. Attach proof of insurance for the following required lines of coverage:

a.

Explanations

[Insert your response here]

[Insert your response here]

[Insert your response here]

Authorized Representative By my signature below and on behalf of my company, I hereby certify that to the best of my knowledge and belief that the responses provided on this form are complete, accurate, and are not misleading.

Authorized Representative Printed Name

Title

Authorized Signature

Date

Attachment G Responsibility Inquiry (DOJ Template Approval: 1/22/19) 170-4438-25 image1.png image2.png