RFP - Bay Lane Water District # 2 Map Plan and Report.pdf

TOWN OF WILLSBORO

Essex County, New York

REQUEST FOR PROPOSALS

Bay Lane Water District #2 Formation

Map, Plan and Report | Engineering Consultant Services

RFP Information Details Issue Date 11/02/2026 Deadline for Written Questions 11/19/2026

Proposal Due Date Monday, November 30, 2026, at 2:00pm Eastern Time

Submit To

Town of Willsboro Attn: Susan Thompson, Town Clerk Via email to: townclerk@townofwillsborony.gov Or online at: https://www.townofwillsboro.com/submit-documents

Town Contact Hannah Neilly, Director of Community and Economic Development hneilly@townofwillsborony.gov mailto:townclerk@townofwillsborony.gov https://www.townofwillsboro.com/submit-documents mailto:hneilly@townofwillsborony.gov

RFP Contents

1. Notice and Procurement Overview

2. Project Background and Context

3. Project Objectives and Required Outcomes

4. Scope of Services and Deliverables

5. Consultant Qualifications and References

6. Proposal Response Format

7. Evaluation and Selection

8. Fee Proposal and Contract Requirements

9. Procurement Schedule

10. Questions and Proposal Submission

11. Town Reservations and Conditions

12. Appendices and Required Response Forms

1. Notice and Procurement Overview The Town of Willsboro, Essex County, New York (the “Town”), invites proposals from qualified engineering firms licensed to practice in New York State to evaluate the former Willsboro Bay Water Company, which operated the Bay Circle Seasonal Water System, and prepare a Map, Plan and Report for the potential formation of Town of Willsboro Water District #2.

The Town seeks a practical assessment of the existing system, identification of deficiencies and potential improvements, planning-level cost estimates, and recommendations consistent with applicable New York State Department of Health requirements. The Town intends to select a consultant based on demonstrated qualifications, relevant experience, technical approach, proposed project team, and ability to complete the work. The Town will evaluate and rank Technical Proposals separately from Cost Proposals. Following identification of the highest-ranked proposer, the Town will review and negotiate a fair and reasonable fee, subject to applicable law, Town procurement policies, funding requirements, and Town Board authorization.

All costs associated with preparing a proposal, interview, or presentation shall be borne by the proposer unless otherwise agreed to in writing by the Town. The Town encourages participation by qualified MWBE and SDVOB firms.

2. Project Background and Context The Town has been contacted by residents in the Bay Lane area regarding the potential creation of a municipal water district to provide drinking water service to affected properties. The former Willsboro Bay Water Company was a privately owned water system that experienced operational and regulatory issues. In April 2018, the New York State Public Service Commission (PSC) appointed the Town as temporary operator. That appointment authorized temporary operation of the existing system; it did not transfer ownership of the private system to the Town. In 2025, the PSC authorized abandonment of the system and ended the Town’s temporary operator role. The Town is no longer the temporary operator, and a municipal water district has not been formally established.

The Town previously issued an RFP for engineering services in 2025, but the procurement was not awarded and a formal Map, Plan and Report (MPR) has not been completed. The Town is reissuing this RFP to obtain the engineering analysis needed to evaluate options and inform future decisions. The consultant shall review available information and work with the Town to define the appropriate scope of evaluation. The MPR should evaluate the feasibility and relative costs of a stand-alone seasonal district compared with a potential future connection to the Town’s larger municipal water system, to the extent sufficient information is available. The Town currently anticipates that planning for future Phase 2 water infrastructure improvements could begin around 2028, with potential construction around 2030; this timing is subject to funding availability and completion of required planning, environmental review, financing, engineering, and approval processes and is not guaranteed.

3. Project Objectives and Required Outcomes

• Prepare a Map, Plan and Report addressing the potential formation of a municipal water district serving the Bay Lane area, including evaluation of a stand-alone seasonal district and a potential future connection to the Town's larger municipal water system.

• Evaluate the existing water system and document deficiencies, operational limitations, and reliability concerns based on available information and the proposed level of investigation.

• Identify and compare feasible system upgrade or improvement alternatives.

• Prepare planning-level cost estimates for identified improvements and discuss potential costs and implications for the proposed district.

• Provide recommendations consistent with applicable New York State Department of Health rules and regulations.

• Identify additional surveys, investigations, approvals, or specialist services that may be needed, distinguishing them from the base scope.

4. Scope of Services and Deliverables Proposers shall describe their approach, assumptions, level of effort, and deliverables for each task. Any proposed exclusions, deviations, or optional services shall be clearly identified.

Task 1 — Project Initiation and Records Review

• Conduct a kickoff meeting with Town staff to confirm objectives, available records, responsibilities, communication procedures, and schedule.

• Review available system plans, operating information, ownership information, prior studies, water-quality or compliance records, and other relevant materials supplied by the Town or identified by the consultant.

• Identify missing information and recommend any additional fieldwork or investigations needed to complete the assessment.

Task 2 — Existing System Evaluation

• Assess the existing seasonal water system and document known or observed deficiencies, limitations, and operational concerns.

• Describe the existing system and its service area using available records and mapping.

• Identify issues affecting system reliability, capacity, operation, maintenance, and compliance with applicable requirements, within the limits of the proposed investigation.

• Clearly identify assumptions, information gaps, and any work that would require additional authorization.

Task 3 — Alternatives and Upgrade Options Evaluate feasible alternatives for providing service to the affected area. The analysis shall compare, to the extent technically feasible and supported by available information, (1) a stand-alone seasonal municipal water district and (2) a potential future connection to the Town’s larger municipal water system as part of anticipated Phase 2 improvements. Identify differences in required infrastructure, regulatory considerations, capital costs, operation and maintenance responsibilities, financing considerations, schedule dependencies, and information needed for further evaluation. The consultant shall not assume that a future connection, funding, or a particular system configuration will be available or approved.

• Develop and discuss feasible options for system upgrades or improvements, including the no-action or continued-existing-condition alternative where appropriate.

• Compare alternatives based on feasibility, reliability, regulatory considerations, anticipated service implications, and relative cost.

• Identify potential advantages, disadvantages, constraints, and additional information needed to advance each alternative.

Task 4 — Planning-Level Cost Estimates

• Prepare planning-level costs for identified system improvements and upgrades.

• Identify anticipated capital costs and, where sufficient information is available, potential operation and maintenance considerations.

• State the basis, assumptions, exclusions, and level of accuracy of estimates; distinguish construction costs from engineering, legal, administrative, and other soft costs where feasible.

Task 5 — Map, Plan and Report

• Prepare a Map, Plan and Report addressing the potential formation of the Town of Willsboro Water

District #2, serving the Bay Lane area.

• Describe the proposed district area and service area based on available information and the Town’s direction.

• Summarize the existing system, deficiencies, alternatives, estimated costs, operation and maintenance considerations, relevant regulatory requirements, and a comparison of the potential stand-alone seasonal district with a potential future connection to the Town’s larger municipal water system, to the extent supported by the engineering review.

• Evaluate and compare the feasibility, anticipated capital costs, operational considerations, and long-term implications of (1) establishing a stand-alone seasonal municipal water district utilizing existing Bay Circle infrastructure, with necessary improvements, and (2) a potential future connection to the Town's larger municipal water system as part of anticipated Phase 2 improvements. The analysis shall identify the advantages, disadvantages, constraints, and anticipated costs associated with each alternative, to the extent sufficient information is available. No future connection or Phase 2 improvement is guaranteed or assumed.

• Identify next steps, potential approvals, additional studies, and decisions needed by the Town to proceed.

• Provide a draft for Town review, address one consolidated round of Town comments, and submit a final report in PDF and editable electronic format.

5. Consultant Qualifications and References

• Describe the firm, its relevant services, years in business, office locations, and organizational structure.

• Identify the project manager and key staff, qualifications, licenses, anticipated roles, and availability;

include resumes or brief biographies.

• Describe experience with municipal water systems, seasonal water systems, district formation studies, Maps, Plans and Reports (MPRs), alternatives analysis, cost estimating, and applicable New York State requirements.

• Provide at least three comparable projects, including client, services delivered, completion date, and reference contact information.

• Identify subconsultants and technical specialists, their responsibilities, and whether their services are included in the proposed fee.

• Disclose actual or potential conflicts of interest that could affect services to the Town.

6. Proposal Response Format Proposals should be clear, concise, and organized in the order below. The Technical Proposal must not contain any pricing, fee information, hourly rates, or other cost information. The Town may request clarification or deem a materially incomplete proposal nonresponsive.

1. Cover Letter: Identify the proposer, primary contact, and an authorized representative; include a brief statement of interest and confirmation of the proposal’s validity period.

2. Firm Qualifications and Relevant Experience: Provide the information requested in Section 5, including comparable projects and references.

3. Project Understanding and Technical Approach: Describe the firm’s understanding of the project, proposed methodology for each task, assumptions, anticipated level of effort, and approach to evaluating the alternatives.

4. Project Team and Subconsultants: Identify the project manager, key staff, licenses, roles, availability, and proposed subconsultants; include resumes or brief biographies.

5. Project Schedule and Deliverables: Provide a proposed schedule showing major tasks, meetings, draft and final deliverables, Town review periods, and key dependencies.

6. Exceptions, Assumptions, and Conflicts: Identify proposed exclusions or deviations from the RFP, additional services, assumptions, and actual or potential conflicts of interest.

7. Required Forms: Include the applicable completed forms and certifications identified in the appendices, excluding Appendix A, which belongs in the separate Cost Proposal.

Separate Cost Proposal Requirement:

Submit the Cost Proposal as a separate electronic PDF file labeled “COST PROPOSAL – [Firm Name].”

Include Appendix A – Fee Proposal Form and all supporting cost information in that file. Do not include pricing or fee information in the Technical Proposal.

Cost Proposals will not be opened or considered as part of the technical scoring process; they will be reviewed after the technical proposals have been evaluated and ranked, consistent with the Town’s procurement policy and applicable law.

7. Evaluation and Selection The Town intends to evaluate and rank Technical Proposals based on qualifications and technical merit.

The review committee may evaluate proposals, conduct interviews or presentations, contact references, and request clarifications. Only the criteria below will be scored. Cost Proposals must be submitted separately and will not be included in the technical evaluation or scoring.

After the technical evaluation is complete and proposers are ranked, the Town will review the separate Cost Proposal submitted by the highest-ranked proposer and seek to negotiate a mutually acceptable scope and fair and reasonable compensation. If the Town is unable to negotiate an acceptable agreement, it may end negotiations and proceed to the next highest-ranked proposer, consistent with applicable law, funding requirements, and Town procurement policies. Final selection is subject to Town Board authorization and execution of a written agreement.

Technical Evaluation Criteria Points Firm qualifications and relevant municipal engineering experience 25 Understanding of project scope and objectives 20 Proposed technical approach and methodology 25 Qualifications and experience of project team and key personnel 20 Project schedule, availability, and ability to meet deliverables 10

TOTAL 100

8. Fee Proposal and Contract Requirements

8.1 Fee Proposal

The Cost Proposal shall be submitted as a separate electronic PDF file, separate from and not included in the Technical Proposal. Provide a clear fee proposal organized by task and deliverable. Identify the total base fee and any not-to-exceed amount. Separate professional labor, subconsultant costs, and reimbursable expenses. The Town will review the Cost Proposal after technical evaluation and ranking, beginning with the highest-ranked proposer.

8.2 Agreement and General Requirements

• The selected consultant shall enter into a written agreement acceptable to the Town and approved by the Town Board.

• The agreement shall define scope, deliverables, schedule, compensation, invoicing, Town review and acceptance, change authorization, and termination provisions.

• The consultant shall maintain project records and provide copies to the Town upon request, subject to applicable law and contract requirements.

• The consultant shall comply with applicable federal, state, and local laws and maintain appropriate insurance, with proposed coverage reviewed by the Town before contract execution.

• Work outside the authorized scope requires prior written approval.

9. Procurement Schedule Milestone Date / Time RFP issued Monday, November 2, 2026 Deadline for written questions Thursday, November 19, 2026 Proposal submission deadline Monday, November 30, 2026, at 2:00pm Eastern Time Technical evaluation and ranking To be determined by the Town Fee review and negotiations Following technical evaluation and ranking

10. Questions and Proposal Submission

10.1 Questions

All questions concerning this RFP shall be submitted in writing to Hannah Neilly, Director of Community and Economic Development, at hneilly@townofwillsborony.gov by the deadline in the procurement schedule. No oral interpretation or modification shall be binding. Only written addenda issued by the Town may modify this RFP.

10.2 Submission Instructions

Item Requirement

Format

Technical Proposal: Include the required proposal sections and supporting documentation identified in Section 6. Exclude all cost and fee information.

COST PROPOSAL: [Firm Name]: Include Appendix A – Fee Proposal Form and all supporting cost information, including task-based costs, hourly rates, reimbursable expenses, assumptions, exclusions, and total proposed fee.

Submit the Cost Proposal as a separate electronic PDF file from the Technical Proposal. Clearly label it “COST PROPOSAL – [Firm Name].” All cost and fee information must be excluded from the Technical Proposal.

Submit both the Technical Proposal and Cost Proposal by email or through the Town's designated online submission portal. The Technical Proposal and Cost Proposal must be submitted as separate PDF files, regardless of the submission method used.

Submit to Susan Thompson, Town Clerk Via email to: townclerk@townofwillsborony.gov Or online at: https://www.townofwillsboro.com/submit-documents

Subject / file name Bay Lane Water District MPR– [Firm Name] Deadline Monday, November 30, 2026, at 2:00pm Eastern Time

Late proposals Proposals received after the stated deadline will be rejected. Proposers are responsible for ensuring timely delivery.

Proposals shall be signed by a person authorized to bind the proposer. Any confidential or proprietary material shall be clearly identified, recognizing that disclosure is governed by applicable law.

11. Town Reservations and Conditions

• The Town reserves the right to reject any or all proposals, waive nonmaterial irregularities, request clarifications or supplemental information, conduct interviews, verify references, negotiate scope and fee, issue addenda, amend or cancel the RFP, or make no award if determined to be in the Town’s best interest, subject to applicable law.

• The Town is not obligated to award a contract or reimburse proposal preparation, travel, interview, or negotiation costs.

• Issuance of this RFP does not obligate the Town to form a district or undertake any specific improvement or funding commitment.

• Any award is subject to Town Board authorization, required funding approvals, successful negotiation, and execution of a written agreement.

• The procurement and award process shall be conducted in accordance with applicable New York State law, Town policies, and any applicable funding conditions.

mailto:townclerk@townofwillsborony.gov https://www.townofwillsboro.com/submit-documents

12. Appendices and Required Response Forms

Appendix A – Fee Proposal Form

Appendix B – Reference Information

Appendix C – Conflict of Interest Disclosure

Appendix D – Non-Collusion Affidavit

Appendix E – Iran Divestment Act Form

Appendix F – Vendor Responsibility Questionnaire

Appendix G – NYS Sexual Harassment Prevention Certification Form

Appendix A — Fee Proposal Form

Complete the following fee schedule and identify assumptions, exclusions, and the basis for reimbursable expenses. The Cost Proposal, including this form, must be submitted separately from the Technical Proposal.

Identify whether subconsultant costs are included within the task-based fees or are listed separately. All costs shall be accounted for without duplication.

Task / Deliverable Base Fee Task 1 — Project Initiation and Records Review $ Task 2 — Existing System Evaluation $ Task 3 — Alternatives and Upgrade Options $ Task 4 — Planning-Level Cost Estimates $ Task 5 — Map, Plan and Report $ Base Scope Total $ Reimbursable Expenses (identify basis) $ Subconsultant Costs (identify firms/services) $

TOTAL BASE PROPOSAL $

Hourly rates for additional services, if authorized:

Staff Classification Hourly Rate Principal / Project Director $ / hour Project Manager $ / hour Professional Engineer $ / hour Engineer / Designer $ / hour Technician / Field Staff $ / hour Other (identify) $ / hour

Authorized representative: ____________________________________ Title: ______________________________

Firm: ____________________________________ Signature: ____________________________________________

Date: ____________________________________

Appendix B — Reference Information Provide at least three references for comparable municipal water system, seasonal water system, district formation, or Map, Plan and Report projects.

Appendix C — Conflict-of-Interest Disclosure

Firm name: __________________________________________________________________________________

Identify any actual or potential conflict of interest that could affect the firm’s ability to provide services to the Town of Willsboro. Attach additional pages if necessary.

☐ No actual or potential conflicts of interest are known.

☐ The following actual or potential conflict(s) are disclosed:

I certify that the information provided is accurate and complete to the best of my knowledge.

Authorized representative: ____________________________________ Title: ______________________________

Signature: _________________________________________________ Date: ______________________________

Appendix D — Non-Collusion Affidavit

NON-COLLUSION AFFIDAVIT

The undersigned bidder or agent, being duly sworn on oath, says that he/she has not, nor has any other member, representative, or agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to include anyone to refrain from bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or combination with any other person in reference to such bidding.

He/She further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee gift, commission or thing of value on account of such sale.

OATH AND AFFIRMATION

I HEREBY AFFIRM UNDER THE PENALTIES FOR PERJURY THAT THE FACTS

AND INFORMATION CONTAINED IN THE FOREGOING BID FOR PUBLIC

WORKS ARE TRUE AND CORRECT.

Dated this ___ day of ____________________, ________

(Name of Organization)

(Title of Person Signing)

(Signature)

ACKNOWLEDGEMENT

STATE OF _______________________)

) ss

COUNTY OF_____________________)

Before me, a Notary Public, personally appeared the above named and swore that the statements contained in the foregoing document are true and correct.

Subscribed and sworn to me this _______ day of _____________, _______.

Notary Public Signature

My Commission Expires: __________________________________________________

Appendix E — Iran Divestment Act Form

BIDDER’S CERTIFICATION OF COMPLIANCE WITH IRAN DIVESTMENT ACT

The law is known as the "Iran Divestment Act of 2012" (the "Act") and can be found at § 165-a of the NY State Finance Law. The Act became effective on April 12, 2012. The Act imposes limitations on "persons" that are determined to be engaged in investment activities in the Iranian energy sector, as defined in the Act.

[Please Check One]

BIDDER’S CERTIFICATION

By submission of this bid or proposal, each bidder/proposer and each person signing on behalf of any bidder/proposer certifies, and in the case of a joint bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of its knowledge and belief, that each bidder/proposer is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law.

I am unable to certify that my name and the name of the bidder/proposer does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify.

Dated: , New York

, 2026

SIGNATURE

PRINTED NAME

TITLE

Sworn to before me this day of , 2026

Notary Public

Appendix F — Vendor Responsibility Questionnaire

AC 3290-S (Rev. 03/2022) NYS Vendor ID: 000000000

NEW YORK STATE

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

You have selected the For-Profit Non-Construction questionnaire which may be printed and completed in this format or, for your convenience, may be completed online using the New York State VendRep System.

COMPLETION & CERTIFICATION

The person(s) completing the questionnaire must be knowledgeable about the vendor’s business and operations. An owner or owner’s official representative authorized to legally bind the Reporting Entity must certify the truth of the questionnaire answers.

NEW YORK STATE VENDOR IDENTIFICATION NUMBER (VENDOR ID)

The Vendor ID is a ten-digit identifier issued by New York State when the vendor is registered on the Statewide Vendor File. This number must now be included on the questionnaire. If the business entity has not obtained a Vendor ID, contact the IT Service Desk at ITServiceDesk@osc.state.ny.us or call 866-370-4672.

DEFINITIONS

All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” found at https://www.osc.state.ny.us/files/vendors/2017-11/vendor-questionnaire-definitions.pdf. These terms may not have their ordinary, common or traditional meanings. Each vendor must read the respective definitions for any and all underlined terms. By submitting this questionnaire, the vendor agrees to be bound by the terms as defined in the "New York State Vendor Responsibility Definitions List" existing at the time of certification.

RESPONSES

Every question must be answered fully. Each response must provide all relevant information to appropriately explain the answer. If you have concerns as to the legal requirements behind your answers, please seek clarification from your counsel. However, information regarding a determination or finding made in error which was subsequently corrected or overturned, and/or was withdrawn by the issuing government entity is not required to be identified. Individuals and Sole Proprietors may use a Social Security Number but are encouraged to obtain and use a federal Employer Identification Number (EIN).

REPORTING ENTITY

Each vendor must indicate if the questionnaire is filed on behalf of the entire Legal Business Entity or an Organizational Unit within or operating under the authority of the Legal Business Entity and having the same EIN. Generally, the Organizational Unit option may be appropriate for a vendor that meets the definition of “Reporting Entity” but due to the size and complexity of the Legal Business Entity, is best able to provide the required information for the Organizational Unit, while providing more limited information for other parts of the Legal Business Entity and Associated Entities.

ASSOCIATED ENTITY

An Associated Entity is one that owns or controls the Reporting Entity, or any entity owned or controlled by the Reporting Entity.

However, the term Associated Entity does not include “sibling organizations” (i.e., entities owned or controlled by a parent company that owns or controls the Reporting Entity), unless such sibling entity has a direct relationship with or impact on the Reporting Entity. Please refer to the Definitions List for the complete definition.

STRUCTURE OF THE QUESTIONNAIRE

The questionnaire is organized into eleven sections. Section I is to be completed for the Legal Business Entity. Section II requires the vendor to specify the Reporting Entity for the questionnaire. Section III refers to the individuals of the Reporting Entity, while Sections IV-VIII require information about the Reporting Entity. Section IX pertains to any Associated Entities, with one question about their Officials/Owners. Section X relates to disclosure under the Freedom of Information Law (FOIL). Section XI requires an authorized contact for the questionnaire information.

http://www.osc.state.ny.us/vendrep/ mailto:ITServiceDesk@osc.state.ny.us https://www.osc.state.ny.us/files/vendors/2017-11/vendor-questionnaire-definitions.pdf

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

I. LEGAL BUSINESS ENTITY INFORMATION

Legal Business Entity Name* EIN

Address of the Principal Place of Business (street, city, state, zip code) New York State Vendor Identification Number

Telephone Ext.

Fax

Email Website

Additional Legal Business Entity Identities: If applicable, list any other DBA, Trade Name, Former Name, Other Identity, or EIN used in the last five (5) years and the status (active or inactive).

Type Name EIN Status

1.0 Legal Business Entity Type – Check appropriate box and provide additional information:

Corporation (including PC) Date of Incorporation

Limited Liability Company (LLC or PLLC) Date of Organization

Partnership (including LLP, LP or General) Date of Registration or Establishment

Sole Proprietor How many years in business?

Other Date Established

If Other, explain:

1.1 Was the Legal Business Entity formed or incorporated in New York State? Yes No

If ‘No,’ indicate jurisdiction where Legal Business Entity was formed or incorporated and attach a Certificate of Good Standing from the applicable jurisdiction or provide an explanation if a Certificate of Good Standing is not available.

United States State

Other Country

Explain, if not available:

1.2 Is the Legal Business Entity publicly traded? Yes No

If “Yes,” provide CIK Code or Ticker Symbol

1.3 Does the Legal Business Entity have a DUNS Number? Yes No

If “Yes,” Enter DUNS Number

*All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” which can be found at

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

I. LEGAL BUSINESS ENTITY INFORMATION

1.4 If the Legal Business Entity’s Principal Place of Business is not in New York State, does the Legal Business Entity maintain an office in New York State?

(Select “N/A,” if Principal Place of Business is in New York State.)

Yes No N/A

If “Yes,” provide the address and telephone number for one office located in New York State.

1.5 Is the Legal Business Entity a New York State certified Minority-Owned Business Enterprise (MBE), Women-Owned Business Enterprise (WBE), Service-Disabled Veteran-Owned Business (SDVOB), New York State Small Business (SB) or a federally certified Disadvantaged Business Enterprise (DBE)?

If “Yes,” check all that apply:

New York State certified Minority-Owned Business Enterprise (MBE) New York State certified Women-Owned Business Enterprise (WBE) New York State certified Service-Disabled Veteran-Owned Business (SDVOB) New York State Small Business (SB) Federally certified Disadvantaged Business Enterprise (DBE)

Yes No

1.6 Identify Officials and Principal Owners of the Reporting Entity, if applicable. For each person, include name, title, date of birth, and percentage of ownership. For each Business Entity that is a Principal Owner, include name, address, EIN, and percentage ownership. Identify all Business Entities owning 25% or more of the Reporting Entity and include name, address, EIN and percentage of ownership. Attach additional pages if necessary. If applicable, reference to relevant SEC filing(s) containing the required information is optional. Each Business Entity identified as a Principal Owner must also submit a vendor responsibility questionnaire.

If there is no person or Business Entity that owns 25% or more of the Reporting Entity (or 10% or more if the Reporting Entity is publicly traded), check here.

Name of Officials and Principal Owners (for each person, please include a middle initial)

Title

Date of Birth Percentage Ownership (Enter 0% if not applicable)

Name of each Business Entity owning 25% or more of Reporting Entity

Address

EIN

Percentage Ownership

II. REPORTING ENTITY INFORMATION

2.0 The Reporting Entity for this questionnaire is:

Note: Select only one.

Legal Business Entity Note: If selecting this option, “Reporting Entity” refers to the entire Legal Business Entity for the remainder of the questionnaire. (SKIP THE REMAINDER OF SECTION II AND PROCEED WITH SECTION III.)

Organizational Unit within and operating under the authority of the Legal Business Entity

SEE DEFINITIONS OF “REPORTING ENTITY” AND “ORGANIZATIONAL UNIT” FOR ADDITIONAL

INFORMATION ON CRITERIA TO QUALIFY FOR THIS SELECTION.

Note: If selecting this option, “Reporting Entity” refers to the Organizational Unit within the Legal Business Entity for the remainder of the questionnaire. (COMPLETE THE REMAINDER OF SECTION II AND ALL REMAINING

SECTIONS OF THIS QUESTIONNAIRE.)

IDENTIFYING INFORMATION

a) Reporting Entity Name

Address of the Primary Place of Business (street, city, state, zip code) Telephone ext.

b) Describe the relationship of the Reporting Entity to the Legal Business Entity

c) Attach an organizational chart

d) Does the Reporting Entity have a DUNS Number? Yes No

If “Yes,” enter DUNS Number

e) Identify the designated manager(s) responsible for the business of the Reporting Entity.

For each person, include name and title. Attach additional pages if necessary.

Name Title

INSTRUCTIONS FOR SECTIONS III THROUGH VII

For each “Yes,” provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). For each “Other,” provide an explanation which provides the basis for not definitively responding “Yes” or “No.” Provide the explanation at the end of the section or attach additional sheets with numbered responses, including the Reporting Entity name at the top of any attached pages.

III. LEADERSHIP INTEGRITY

Within the past five (5) years, has any current or former reporting entity official or any individual currently or formerly having the authority to sign, execute or approve bids, proposals, contracts or supporting documentation on behalf of the reporting entity with any government entity been:

3.0 Sanctioned relative to any business or professional permit and/or license? Yes No Other

3.1 Suspended, debarred, or disqualified from any government contracting process? Yes No Other

3.2 The subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation for any business-related conduct?

Yes No Other

3.3 Charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime or subject to a judgment for:

a) Any business-related activity; or

b) Any crime, whether or not business-related, the underlying conduct of which was related to truthfulness?

Yes No Other

For each “Yes” or “Other” provide an explanation for the response and attach additional sheets with numbered responses if necessary:

IV. INTEGRITY – CONTRACT BIDDING

Within the past five (5) years, has the reporting entity:

4.0 Been suspended or debarred from any government contracting process or been disqualified on any government procurement, permit, license, concession, franchise or lease, including, but not limited to, debarment for a violation of New York State Workers’ Compensation or Prevailing Wage laws or New York State Procurement Lobbying Law?

Yes No

4.1 Been subject to a denial or revocation of a government prequalification? Yes No

4.2 Been denied a contract award or had a bid rejected based upon a non-responsibility finding by a government entity?

Yes No

4.3 Had a bid rejected on a government contract for failure to make good faith efforts on any Minority- Owned Business Enterprise, Women-Owned Business Enterprise, Service-Disabled Veteran-Owned Business or Disadvantaged Business Enterprise goal or statutory affirmative action requirements on a previously held contract?

Yes No

4.4 Agreed to a voluntary exclusion from bidding/contracting with a government entity? Yes No

4.5 Initiated a request to withdraw a bid submitted to a government entity in lieu of responding to an information request or subsequent to a formal request to appear before the government entity?

Yes No

For each “Yes,” provide an explanation for the response and attach additional sheets with numbered responses if necessary:

V. INTEGRITY – CONTRACT AWARD

5.0 Been suspended, cancelled or terminated for cause on any government contract including, but not limited to, a non-responsibility finding?

Yes No

5.1 Been subject to an administrative proceeding or civil action seeking specific performance or restitution in connection with any government contract?

Yes No

5.2 Entered into a formal monitoring agreement as a condition of a contract award from a government entity? Yes No

For each “Yes,” provide an explanation for the response and attach additional sheets with numbered responses if necessary:

VI. CERTIFICATIONS/LICENSES

6.0 Had a revocation, suspension or disbarment of any business or professional permit and/or license? Yes No

6.1 Had a denial, decertification, revocation or forfeiture of New York State certification of Minority-Owned Business Enterprise, Women-Owned Business Enterprise, Service-Disabled Veteran-Owned Business or federal certification of Disadvantaged Business Enterprise status for other than a change of ownership?

For each “Yes,” provide an explanation for the response and attach additional sheets with numbered responses if necessary:

VII. LEGAL PROCEEDINGS

7.0 Been the subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation?

Yes No

7.1 Been the subject of an indictment, grant of immunity, judgment or conviction (including entering into a plea bargain) for conduct constituting a crime?

Yes No

7.2 Received any OSHA citation and Notification of Penalty containing a violation classified as serious or willful?

Yes No

7.3 Had a government entity find a willful prevailing wage or supplemental payment violation or any other willful violation of New York State Labor Law?

Yes No

7.4 Entered into a consent order with the New York State Department of Environmental Conservation, or received an enforcement determination by any government entity involving a violation of federal, state or local environmental laws?

Yes No

7.5 Other than previously disclosed:

a) Been subject to fines or penalties imposed by government entities which in the aggregate total

$25,000 or more; or

b) Been convicted of a criminal offense pursuant to any administrative and/or regulatory action taken by any government entity?

For each “Yes,” provide an explanation for the response and attach additional sheets with numbered response if necessary:

VIII. FINANCIAL AND ORGANIZATIONAL CAPACITY

8.0 Within the past five (5) years, has the Reporting Entity received any formal unsatisfactory performance assessment(s) from any government entity on any contract?

Yes No

If “Yes,” provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

8.1 Within the past five (5) years, has the Reporting Entity had any liquidated damages assessed over $25,000 for any reason, including failure to meet Minority-Owned Business Enterprise, Women-Owned Business Enterprise, Service-Disabled Veteran-Owned Business, or Disadvantaged Business Enterprise goals?

Yes No

If “Yes,” provide an explanation of the issue(s), relevant dates, contracting party involved, the amount assessed and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

8.2 Within the past five (5) years, have any liens, claims or judgments (not including UCC filings) over $25,000 been filed against the Reporting Entity which remain undischarged?

Yes No

If “Yes,” provide an explanation of the issue(s), relevant dates, the Lien holder or Claimant’s name(s), the amount of the lien(s), the current status of the issue(s), and the balance of the lien or judgment not yet paid. Provide answer below or attach additional sheets with numbered responses.

8.3 In the last seven (7) years, has the Reporting Entity initiated or been the subject of any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?

Yes No

If “Yes,” provide the bankruptcy chapter number, the court name and the docket number. Indicate the current status of the proceedings as “Initiated,” “Pending” or “Closed.” Provide answer below or attach additional sheets with numbered responses.

8.4 During the past three (3) years, has the Reporting Entity failed to file or pay any tax returns required by federal, state or local tax laws?

Yes No

If “Yes,” provide the taxing jurisdiction, the type of tax, the liability year(s), the tax liability amount the Reporting Entity failed to file/pay and the current status of the tax liability. Provide answer below or attach additional sheets with numbered

8.5 During the past three (3) years, has the Reporting Entity failed to file or pay any New York State unemployment insurance returns?

Yes No

If “Yes,” provide the years the Reporting Entity failed to file/pay the insurance, explain the situation and any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

8.6 During the past three (3) years, has the Reporting Entity had any government audit(s) completed? Yes No

a) If “Yes,” did any audit of the Reporting Entity identify any reported significant deficiencies in internal control, fraud, illegal acts, significant violations of provisions of contract or grant agreements, significant abuse or any material disallowance?

Yes No

If “Yes” to 8.6 a), provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

IX. ASSOCIATED ENTITIES

This section pertains to any entity(ies) that either controls or is controlled by the reporting entity.

(See definition of “associated entity” for additional information to complete this section.)

9.0 Does the Reporting Entity have any Associated Entities?

Note: All questions in this section must be answered if the Reporting Entity is either:

− An Organizational Unit; or − The entire Legal Business Entity which controls, or is controlled by, any other entity(ies).

If “No,” SKIP THE REMAINDER OF SECTION IX AND PROCEED WITH SECTION X.

If “Yes,” provide the name, address and EIN of each Associated Entity and its relationship to the Reporting Entity.

Yes No

9.1 Within the past five (5) years, has any Associated Entity Official or Principal Owner been charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime or subject to a judgment for:

a) Any business-related activity; or

b) Any crime, whether or not business-related, the underlying conduct of which was related to truthfulness?

If “Yes,” provide an explanation of the issue(s), the individual involved, their title and role in the Associated Entity, identify the Associated Entity’s name(s), EIN(s), primary business activity, the individual’s relationship to the Reporting Entity, relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s).

9.2 Does any Associated Entity have any currently undischarged federal, New York State, New York City or New York local government liens or judgments (not including UCC filings) over $50,000?

If “Yes,” provide an explanation of the issue(s), identify the Associated Entity’s name(s), EIN(s), primary business activity, relationship to the Reporting Entity, relevant dates, the Lien holder or Claimant’s name(s), the amount of the lien(s) and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

9.3 Within the past five (5) years, has any Associated Entity:

a) Been disqualified, suspended or debarred from any federal, New York State, New York City or other New York local government contracting process?

b) Been denied a contract award or had a bid rejected based upon a non-responsibility finding by any federal, New York State, New York City, or New York local government entity?

c) Been suspended, cancelled or terminated for cause (including for non-responsibility) on any federal, New York State, New York City or New York local government contract?

d) Been the subject of an investigation, whether open or closed, by any federal, New York State, New York City, or New York local government entity for a civil or criminal violation with a penalty in excess of $500,000?

e) Been the subject of an indictment, grant of immunity, judgment, or conviction (including entering into a plea bargain) for conduct constituting a crime?

f) Been convicted of a criminal offense pursuant to any administrative and/or regulatory action taken by any federal, New York State, New York City, or New York local government entity?

g) Initiated or been the subject of any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?

IX. ASSOCIATED ENTITIES

This section pertains to any entity(ies) that either controls or is controlled by the reporting entity.

(See definition of “associated entity” for additional information to complete this section.)

For each “Yes,” provide an explanation of the issue(s), identify the Associated Entity’s name(s), EIN(s), primary business activity, relationship to the Reporting Entity, relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered

X. FREEDOM OF INFORMATION LAW (FOIL)

10. Indicate whether any information supplied herein is believed to be exempt from disclosure under the Freedom of Information Law (FOIL).

Note: A determination of whether such information is exempt from FOIL will be made at the time of any request for disclosure under FOIL.

If “Yes,” indicate the question number(s) and explain the basis for the claim.

XI. AUTHORIZED CONTACT FOR THIS QUESTIONNAIRE

Name

Telephone Fax ext.

Title

Email

Certification

The undersigned: (1) recognizes that this questionnaire is submitted for the express purpose of assisting New York State government entities (including the Office of the State Comptroller (OSC)) in making responsibility determinations regarding award or approval of a contract or subcontract and that such government entities will rely on information disclosed in the questionnaire in making responsibility determinations; (2) acknowledges that the New York State government entities and OSC may, in their discretion, by means which they may choose, verify the truth and accuracy of all statements made herein; and (3) acknowledges that intentional submission of false or misleading information may result in criminal penalties under State and/or federal law, as well as a finding of non-responsibility, contract suspension or contract termination.

It being acknowledged and agreed that all responses included in this questionnaire are to the knowledge, information and belief of the Business Entity, the undersigned certifies under penalties of perjury that they:

The undersigned certifies that he/she:

• are knowledgeable about the submitting Business Entity's business and operations;

• have legal authority to bind the Business Entity;

• have read and understand all of the questions contained in the questionnaire, including all definitions;

• have not altered the content of the questionnaire in any manner;

• have reviewed and/or supplied full and complete responses to each question;

• have provided true, accurate and complete responses, including all attachments, if applicable;

• understand that New York State government entities will rely on the information disclosed in the questionnaire when entering into a contract with the Business Entity; and

• are under an obligation to update the information provided herein to include any material changes to the Business Entity's responses at the time of bid/proposal submission through the contract award notification, and may be required to update the information at the request of the New York State government entities or OSC prior to the award and/or approval of a contract, or during the term of the contract.

Signature of Owner/Official

Printed Name of Signatory

Title

Name of Business

Address

City, State, Zip

Date

Appendix G — NYS Sexual Harassment Prevention Certification Form

Sexual Harassment Prevention Certification Form

By submission of this application, each applicant and each person signing on behalf of any applicant certifies, and in the case of a partnering application each party thereto certifies as to its own organization, under penalty of perjury, that the applicant has and has implemented a written policy addressing sexual harassment prevention in the workplace and provides annual sexual harassment prevention training to all of its employees. Such policy shall, at a minimum, meet the requirements of section two hundred one-g of the labor law.

Applicant :_______________________________________________________________

Signature:_____________________________________________________________________

Print Name and Title:___________________________________________________________

Date:_____________________

If the above certification cannot be made, the applicant must submit a signed statement below detailing the reasons why the the requirements of NYS Labor Law §201-G are not applicable or cannot be met

Applicant :_______________________________________________________________

Signature:_____________________________________________________________________

Print Name and Title:___________________________________________________________

Date:_____________________