RFP 197F-24 Attachment 3-DBE Certification.docx

Attachment 3: DBE Response Forms & Certification

List of Included Certifications and Affidavits:

Item Certification / Affidavit 1 DBE Letter of Intent 2 Schedule of Participation by Disadvantaged Business Enterprises 3 DBE Affidavit 4 Affidavit of Subcontractor Payment

Instructions:

Bidders: Please complete and submit the list of proposed DBE subcontractors along with your bid response:

Item 1: DBE Letter of Intent Item 2: Schedule of Participation by Disadvantaged Business Enterprises Item 3: DBE Affidavit

Note: When the bidder completes 2: Schedule of Participation by Disadvantaged Business Enterprises the bidder will determine whether or not they need to complete the DBE Joint Check Arrangement Approval Form and / or the Joint Venture Affidavit. If the bidder needs to complete these, the bidder shall contact the MBTA buyer to request the forms.

The successful Bidder(s) must complete and submit Item 5: Affidavit of Subcontractor Payment on a quarterly basis following contract execution.

Item 1: DBE Letter of Intent DOCUMENT 010 (to be submitted by the DBE firm) The DBE firm will also include the latest MassUCP letter with this Letter of Intent.

To:

(Prime Bidder)

From:

(DBE Firm)

Contract No.:

Bid Opening or Due Date:

Project Name:

Project Location:

I, , authorized signatory of the above-reference DBE firm hereby declare:

(a) My company is currently certified as a Disadvantaged Business Enterprise (DBE) by the Massachusetts Supplier Diversity Office (SDO), as a (check all that apply):

[Additional guidance is available at Title 49, Code of Federal Regulations, Part 26.55 (49 CFR Part 26.55)]

(b) My firm has the ability to manage, supervise and perform the activity described on the following page(s) of this Letter of Intent. If you are awarded the contract, my company intends to enter into a contract with your firm to perform the items of work or other activity described on the following sheet for the prices indicated.

(c) There have been no changes affecting the ownership, control or independence of my company since my last certification review on Click or tap to enter a date.. If any such change is planned or occurs prior to my company's completion of this proposed work, I will give prior written notification to your firm and to the Massachusetts Bay Transportation Authority (MBTA) Office of Diversity and Civil Rights and SDO.

(d) I have read the MBTA proposal for the Project, and acknowledge that my company will comply with that document and the requirements of 49 CFR Part 26.

(e) For the purpose of obtaining subcontractor approval from the MBTA, my firm will provide to you:

a. The following construction work:

i. a complete list of contact information for proposed Superintendent, i.e., address, phone number and e-mail address, and;

ii. a list of projects completed in the last 10 years. I shall also include, for each project: the name and telephone number of a contact person for the contracting authority, person, or organization; project title / location (City/State), dollar value of the work; a description of the work; and the date project completed .

b. The following professional services work:

i. resume, stating the qualifications and experience of person responsible for project oversight and contact information, i.e., address, phone number and e-mail address.

ii. proposed team and organization,

iii. resumes of key personnel;

iv. example projects

c. The following services, materials or supplies:

i. a written agreement and invoices for the materials or supplies, and any other documents evidencing the terms of providing such items to be sent to the Office of Diversity and Civil Rights Government Compliance Unit designee;

ii. information concerning brokers fees and commissions for providing services or materials.

DBE Firm Authorized Signature

Date

Item 1: DBE Letter of Intent (continued) Prime Bidder:

DBE Firm:

Contract No.:

Bid Opening or Due Date:

Project Name:

Project Location:

Item number if applicable

with notations such as Services, or Brokerage, Labor Only, Material Only, or Complete

TOTAL AMOUNT:

Please give full explanations, attach additional sheets if necessary.

I HEREBY VERIFY THAT

(DBE Firm)

WILL SOLELY PERFORM THE WORK, OR PROVIDE THE SERVICES OR MATERIALS, AS DESCRIBED ABOVE.

DBE Authorized Signature:

Name (Print):

Title:

Email Address:

Phone Number:

Fax Number:

Attachment 3/ RFP NO. 197F-24 Overhaul of 40 HSP46 Locomotives

Item 2: Schedule of Participation by Disadvantaged Business Enterprises DOCUMENT 020 (to be submitted by bidder) Prime Bidder

Date of Bid Opening:

Contract Number:

Project Location:

DBE Contractor Activity Amount (b)

NAICS

CODE(S)

(c) Total amount eligible for credit under rules in Supplementary Conditions, Appendix 3 of Section 6

Is a Joint Check arrangement needed for any of the above? (see Section 7.1.21.7 (g))

*If yes, contact the MBTA buyer to request and complete Form F: DBE Joint Check Arrangement Approval Form (Document 030).

Are any of the above a joint venture entity?

*If yes, contact the MBTA buyer to request and complete Form G: Joint Venture Affidavit (Document 031).

Will any of the contractors listed above be using a third party (i.e. manufacturer) to deliver materials or perform any portion of work by a third party?

CERTIFICATION: I HEREBY DECLARE, TO THE BEST OF MY KNOWLEDGE, THAT I HAVE READ THE SPECIAL PROVISIONS FOR PARTICIPATION BY DISADVANTAGED BUSINESS ENTERPRISES – SECTION 7.1.21. BOTH THIS SCHEDULE AND THE RELEVANT AND ACCOMPANYING LETTER(S) OF INTENT ARE IN FULL COMPLIANCE WITH THE PROVISIONS OF, AND IN ACCORDANCE WITH, TITLE 49 CODE OF FEDERAL REGULATIONS, PART 26 (49 CFR Part 26).

Signature:

Name (Print):

Date:

Title:

Email:

Telephone:

Item 3: DBE Affidavit

STATE OF ______________________________ Date: _____________________

COUNTY OF ____________________________ S.S.

The undersigned being duly sworn, deposes and says that he/she is the

(sole owner, partner, president, treasurer or other duly authorized official of a corporation) of _______________________________________________________________________ (Name of DBE) and certifies that since the date of its certification by

(SDO)

the certification has not been revoked nor has it expired nor has there been any change in the minority status of

(Name of DBE)

(Signature and Title of Person Making Affidavit)

Sworn to before me this _______day of _________________20 ______

Notary Public: _______________________________________________

My commission expires: _______________________________________

NOTE: The Bidder must attach the DBE's must recent certification letter or document to this affidavit.

Item 4: Affidavit of Subcontractor Payment

Massachusetts Bay Transportation Authority Disadvantaged Business Enterprise (DBE) Program Affidavit of Subcontractor Payment

Code of Federal Regulations 49 §26.37(b) and 26.29 requires the Massachusetts Bay Transportation Authority (MBTA) to monitor the performance of Disadvantaged Business Enterprise (DBE) firms and non-DBE firms on all USDOT assisted transit projects. This affidavit attest that the DBE Firms listed below are performing or have performed a “commercially useful function” (CUF) in accordance with 49 CFR §26.55.

Signing this affidavit hereby certifies that the information provided by Firm acting as Prime Contractor and/or Consultant on said MBTA Project is true and accurate.

Project Name: _________________________________________________________ Prime Contractor/Consultant:_______________ MBTA Contract Number: _________________ DBE Goal:

Payment Request # ________________________ Invoice Amount:______________________________ Payment Period: From to______________________ ☐ Final Payment: Check this box only when submitting final pay request.

SECTION 1: PAYMENT TO SUBCONTRACTORS

Complete the chart below for ALL SUBCONTRACTORS participating on project regardless of dollar amount.

Report payments that have already been made to subcontractors.

Item 4: Affidavit of Subcontractor Payment (continued)

SECTION 2: SIGNATURE AUTHORIZATION AND NOTARIZATION

The undersigned Firm certifies that the preceding chart is a true and accurate statement that all payments that have been distributed to subcontractors and suppliers on said MBTA Project. If no subcontractors or suppliers are listed on the preceding chart, the Firm certifies that no subcontractors or suppliers were used in performing said MBTA Project for the payment period indicated.

Firm Representative Name/Title (print) Signature NOTE: This affidavit must be notarized.

Sworn or affirmed and subscribed before me this day of_______20_____

Notary Signature:

DBE Owner Name/Title (Print) Signature NOTE: This affidavit must be notarized.

Sworn or affirmed and subscribed before me this day of_______20____

Notary Signature:

Non-DBE Subcontractor Owner Name/Title (Print) Signature NOTE: This affidavit must be notarized.

Sworn or affirmed and subscribed before me this day of_______20_____

Notary Signature: _________________________________________________________________

Please mail the original, completed and signed formed to the MBTA Assist Director of Government Compliance:

Massachusetts Department of Transportation/MBTA, Office of Diversity & Civil Rights, 10 Park Plaza, Suite 3800, Boston, MA 02116

Please also send a scanned copy by Email to aflynn@mbta.com image1.jpeg