RFP Bid Forms- Required forms.pdf

STAFFING PLAN

Submit with Bid or Proposal – Instructions on page 2

Solicitation No.:

Reporting Entity:

Report includes Contractor’s/Subcontractor’s:

□ Work force to be utilized on this contract

□ Total work force

Offeror’s Name:

□ Offeror

□ Subcontractor Subcontractor’s name________________

Offeror’s Address:

Enter the total number of employees for each classification in each of the EEO-Job Categories identified

EEO-Job Category

Total Work force

Work force by Gender

Work force by Race/Ethnic Identification

Male (M)

Total Female

(F)

White

(M) (F)

Black

Hispanic

Asian

Native American

Disabled

Veteran

Officials/Administrators

Professionals

Technicians

Sales Workers

Office/Clerical

Craft Workers

Laborers

Service Workers

Temporary /Apprentices

Totals

PREPARED BY (Signature): TELEPHONE NO.:

EMAIL ADDRESS:

DATE:

NAME AND TITLE OF PREPARER (Print or Type):

Submit completed with bid or proposal M/WBE 101 (Rev 11/08)

General instructions: All Offerors and each subcontractor identified in the bid or proposal must complete an EEO Staffing Plan (M/WBE 101) and submit it as part of the bid or proposal package. Where the work force to be utilized in the performance of the State contract can be separated out from the contractor’s and/or subcontractor’s total work force, the Offeror shall complete this form only for the anticipated work force to be utilized on the State contract. Where the work force to be utilized in the performance of the State contract cannot be separated out from the contractor’s and/or subcontractor’s total work force, the Offeror shall complete this form for the contractor’s and/or subcontractor’s total work force.

Instructions for completing:

1. Enter the Solicitation number that this report applies to along with the name and address of the Offeror.

2. Check off the appropriate box to indicate if the Offeror completing the report is the contractor or a subcontractor.

3. Check off the appropriate box to indicate work force to be utilized on the contract or the Offerors’ total work force.

4. Enter the total work force by EEO job category.

5. Break down the anticipated total work force by gender and enter under the heading ‘Work force by Gender’

6. Break down the anticipated total work force by race/ethnic identification and enter under the heading ‘Work force by Race/Ethnic Identification’. Contact the OM/WBE Permissible contact(s) for the solicitation if you have any questions.

7. Enter information on disabled or veterans included in the anticipated work force under the appropriate headings.

8. Enter the name, title, phone number and email address for the person completing the form. Sign and date the form in the designated boxes.

RACE/ETHNIC IDENTIFICATION

Race/ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. For the purposes of this form, an employee may be included in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. However, no person should be counted in more than one race/ethnic group. The race/ethnic categories for this survey are:

• WHITE (Not of Hispanic origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

• BLACK a person, not of Hispanic origin, who has origins in any of the black racial groups of the original peoples of Africa.

• HISPANIC a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

• ASIAN & PACIFIC a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.

ISLANDER

• NATIVE INDIAN (NATIVE a person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal AMERICAN/ ALASKAN affiliation or community recognition.

NATIVE)

OTHER CATEGORIES

• DISABLED INDIVIDUAL any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies)

- has a record of such an impairment; or

- is regarded as having such an impairment.

• VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975.

• GENDER Male or Female

M/WBE UTILIZATION PLAN

INSTRUCTIONS: This form must be submitted with any bid, proposal, or proposed negotiated contract or within a reasonable time thereafter, but prior to contract award. This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (M/WBE) under the contract. Attach additional sheets if necessary.

Offeror’s Name: Federal Identification No.:

Address: Solicitation No.:

City, State, Zip Code: Project No.:

Telephone No.: M/WBE Goals in the Contract: MBE % WBE % Region/Location of Work:

1. Certified M/WBE Subcontractors/Suppliers Name, Address, Email Address, Telephone No.

2. Classification

3.Federal ID No.

4.Detailed Description of Work (Attach additional sheets, if necessary)

5.Dollar Value of Subcontracts/ Supplies/Services and intended performance dates of each component of the contract.

A.

NYS ESD CERTIFIED

MBE

WBE

B.

NYS ESD CERTIFIED

6. IF UNABLE TO FULLY MEET THE MBE AND WBE GOALS SET FORTH IN THE CONTRACT, OFFEROR MUST SUBMIT A REQUEST FOR WAIVER FORM (M/WBE 104).

TELEPHONE NO.:

FOR M/WBE USE ONLY

REVIEWED BY:

PREPARED BY (Signature):

NAME AND TITLE OF PREPARER (Print or Type):

SUBMISSION OF THIS FORM CONSTITUTES THE OFFEROR’S ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH THE M/WBE REQUIREMENTS SET FORTH UNDER NYS EXECUTIVE LAW, ARTICLE 15-A, 5 NYCRR PART 143, AND THE ABOVE-REFERENCED SOLICITATION. FAILUR E TO SUBMIT COMPLETE AND ACCURATE INFORMATION MAY RESULT IN A FINDING OF NONCOMPLIANCE AND POSSIBLE TERMINATION

OF YOUR CONTRACT.

M/WBE 103 (Revised 11/08)

UTILIZATION PLAN APPROVED: YES NO Date:

Contract No.: Project No. (if applicable):

Contract Award Date:

Estimated Date of Completion:

Amount Obligated Under the Contract:

Description of Work:

NOTICE OF DEFICIENCY ISSUED: YES NO Date:______________

NOTICE OF ACCEPTANCE ISSUED: YES NO Date:_____________

REQUEST FOR WAIVER FORM

INSTRUCTIONS: SEEPAGE 2 OF THIS ATTACHMENT FOR REQUIREMENTS AND DOCUMENT SUBMISSION INSTRUCTIONS.

Offeror/Contractor Name:

Federal Identification No.:

Address:

Solicitation/Contract No.:

City, State, Zip Code:

M/WBE Goals: MBE % WBE %

By submitting this form and the required information, the offeror/contractor certifies that every Good Faith Effort has been taken to promote M/WBE participation pursuant to the M/WBE requirements set forth under the contract.

Contractor is requesting a:

1. MBE Waiver – A waiver of the MBE Goal for this procurement is requested. Total Partial

2. WBE Waiver – A waiver of the WBE Goal for this procurement is requested. Total Partial

3. Waiver Pending ESD Certification – (Check here if subcontractors or suppliers of Contractor are not certified M/WBE, but an application for certification has been filed with EmpireState Development.) Date of such filing with EmpireState Development:_____________________

PREPARED BY (Signature):

SUBMISSION OF THIS FORM CONSTITUTES THE OFFEROR/CONTRACTOR’S

ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH THE M/WBE REQUIREMENTS

SET FORTH UNDER NYS EXECUTIVE LAW, ARTICLE 15-A AND 5 NYCRR PART 143.

FAILURE TO SUBMIT COMPLETE AND ACCURATE INFORMATION MAY RESULT IN A

FINDING OF NONCOMPLIANCE AND/OR TERMINATION OF THE CONTRACT.

Date:

Name and Title of Preparer (Printed or Typed): Telephone Number: Email Address:

******************** FOR M/WBE USE ONLY ********************

DATE: Submit with the bid or proposal or if submitting after award submit to:

Roosevelt Island Operating Corporation Procurement Manager 591 Main Street Roosevelt Island, NY 10044

Waiver Granted: YES MBE: WBE:

Total Waiver Partial Waiver ESD Certification Waiver *Conditional Notice of Deficiency Issued ___________________

*Comments:

M/WBE 104(Revised 11/08)

REQUIREMENTS AND DOCUMENT SUBMISSION INSTRUCTIONS

When completing the Request for Waiver Form please check all boxes that apply. To be considered, the Request for Waiver Form must be accompanied by documentation for items 1 – 11, as listed below. If box # 3 has been checked above, please see item 11. Copies of the following information and all relevant supporting documentation must be submitted along with the request:

1. A statement setting forth your basis for requesting a partial or total waiver.

2. The names of general circulation, trade association, and M/WBE-oriented publications in which you solicited certified M/WBEs for the purposes of complying with your participation goals.

3. A list identifying the date(s) that all solicitations for certified M/WBE participation were published in any of the above publications.

4. A list of all certified M/WBEs appearing in the NYS Directory of Certified Firms that were solicited for purposes of complying with your certified

M/WBE participation levels.

5. Copies of notices, dates of contact, letters, and other correspondence as proof that solicitations were made in writing and copies of such solicitations, or a sample copy of the solicitation if an identical solicitation was made to all certified M/WBEs.

6. Provide copies of responses made by certified M/WBEs to your solicitations.

7. Provide a description of any contract documents, plans, or specifications made available to certified M/WBEs for purposes of soliciting their bids and the date and manner in which these documents were made available.

8. Provide documentation of any negotiations between you, the Offeror/Contractor, and the M/WBEs undertaken for purposes of complying with the certified M/WBE participation goals.

9. Provide any other information you deem relevant which may help us in evaluating your request for a waiver.

10. Provide the name, title, address, telephone number, and email address of offeror/contractor’s representative authorized to discuss and negotiate this waiver request.

11. Copy of notice of application receipt issued by Empire State Development (ESD).

Note:

Unless a Total Waiver has been granted, the Offeror/Contractor will be required to submit all reports and documents pursuant to the provisions set forth in the Contract, as deemed appropriate by Roosevelt Island Operating Corporation, to determine M/WBE compliance.

M/WBE 104 Instructions (11/08)

SERVICE-DISABLED VETERAN-OWNED-BUSINESS UTILIZATION PLAN

INSTRUCTIONS: This form must be submitted with any bid, proposal, or proposed negotiated contract or within a reasonable time thereafter, but prior to contract award. This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Service-Disabled Veteran-Owned Business (SDVOB) under the contract. Attach additional sheets if necessary.

Offeror’s Name: Federal Identification No.:

Address: Solicitation No.:

City, State, Zip Code: Project No.:

Telephone No.: SDVOB Goals in the Contract: % Region/Location of Work:

1. Certified SDVOB Subcontractors/Suppliers Name, Address, Email Address, Telephone No.

2. Classification

3. Federal ID No.

4. Detailed Description of Work (Attach additional sheets, if necessary)

5. Dollar Value of Subcontracts/ Supplies/Services and intended performance dates of each component of the contract.

A.

NYS OGS CERTIFIED

B.

NYS OGS CERTIFIED

6. IF UNABLE TO FULLY MEET THE SDVOB GOALS SET FORTH IN THE CONTRACT, OFFEROR MUST SUBMIT A REQUEST FOR WAIVER FORM (SDVOB 104).

7. UTILIZATION OF CERTIFIED SDVOB ENTERPRISES MAY NOT BE COUNTED TOWARDS UTILIZATION OF MINORITY AND WOMEN-OWNED BUSINESS ENTERPRISES

PREPARED BY (Signature):

DATE:

NAME AND TITLE OF PREPARER (Print or Type):

SUBMISSION OF THIS FORM CONSTITUTES THE OFFEROR’S ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH THE SDVOB REQUIREMENTS SET FORTH IN THE NYS SERVICE-DISABLED VETERAN-OWNED BUSINESS ACT AND ARTICLE 17-B, AND THE ABOVE-REFERENCED SOLICITATION. FAILURE TO SUBMIT COMPLETE AND ACCURATE INFORMATION MAY RESULT IN A FINDING OF NONCOMPLIANCE AND POSSIBLE

TERMINATION OF YOUR CONTRACT.

TELEPHONE NO.:

FOR SDVOB USE ONLY

UTILIZATION PLAN APPROVED: YES NO Date:

Contract No.: Project No. (if applicable):

Contract Award Date:

Estimated Date of Completion:

Amount Obligated Under the Contract:

Description of Work:

NOTICE OF DEFICIENCY ISSUED: YES NO Date:______________

NOTICE OF ACCEPTANCE ISSUED: YES NO Date:_____________

SDVOB 103

REQUEST FOR WAIVER FORM

INSTRUCTIONS: SEE PAGE 2 OF THIS ATTACHMENT FOR REQUIREMENTS AND DOCUMENT SUBMISSION INSTRUCTIONS.

Offeror/Contractor Name: Federal Identification No.:

Address: Solicitation/Contract No.:

City, State, Zip Code: SDVOB Goals: %

By submitting this form and the required information, the offeror/contractor certifies that every Good Faith Effort has been taken to promote SDVOB participation pursuant to the SDVOB requirements set forth under the contract.

Contractor is requesting a:

1. SDVOB Waiver – A waiver of the SDVOB Goal for this procurement is requested. Total Partial

2. Waiver Pending OGS Certification – (Check here if subcontractors or suppliers of Contractor are not certified SDVOB, but an application for certification has been filed with the OGS) Date of such filing with the Office of General Services:_____________________

PREPARED BY (Signature):

SUBMISSION OF THIS FORM CONSTITUTES THE OFFEROR/CONTRACTOR’S

ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH THE SDVOB REQUIREMENTS

SET FORTH UNDER THE NYS SERVICE-DISABLED VETERAN-OWNED BUSINESS ACT AND

ARTICLE 17-B. FAILURE TO SUBMIT COMPLETE AND ACCURATE INFORMATION MAY

RESULT IN A FINDING OF NONCOMPLIANCE AND/OR TERMINATION OF THE CONTRACT.

Date:

Name and Title of Preparer (Printed or Typed): Telephone Number: Email Address:

Submit with the bid or proposal or if submitting after award submit to:

Roosevelt Island Operating Corp Procurement Department Roosevelt Island Operating Corp.

591 Main Street, Roosevelt Island, NY 10044-0002

******************** FOR RIOC USE ONLY ********************

REVIEWED BY: DATE:

Waiver Granted: YES

Total Waiver Partial Waiver OGS Certification Waiver *Conditional Notice of Deficiency Issued ___________________

*Comments:

SDVOB 104

REQUIREMENTS AND DOCUMENT SUBMISSION INSTRUCTIONS

When completing the Request for Waiver Form please check all boxes that apply. To be considered, the Request for Waiver Form must be accompanied by documentation for items 1 – 10, as listed below. If box # 2 has been checked above, please see item 11. Copies of the following information and all relevant supporting documentation must be submitted along with the request:

1. A statement setting forth your basis for requesting a partial or total waiver.

2. The names of any general circulation, trade association, and SDVOB-oriented publications in which you solicited certified SDVOBs for the purposes of complying with your participation goals.

3. A list identifying the date(s) that all solicitations for certified SDVOB participation were published in any of the above publications.

4. A list of all certified SDVOBs appearing in the NYS Directory of Certified Firms that were solicited, in writing, for purposes of complying with your certified SDVOB participation levels.

5. Copies of notices, dates of contact, letters, and other correspondence as proof that solicitations were made in writing and copies of such solicitations, or a sample copy of the solicitation if an identical solicitation was made to all certified SDVOBs.

6. Provide copies of responses made by certified SDVOB to your solicitations.

7. Provide a description of any contract documents, plans, or specifications made available to certified SDVOBs for purposes of soliciting their bids and the date and manner in which these documents were made available.

8. Provide documentation of any negotiations between you, the Offeror/Contractor, and the SDVOBs undertaken for purposes of complying with the certified SDVOB participation goals.

9. Provide any information not satisfied by items 1 – 8, above, that otherwise satisfies Part 252.2(n) of the Rules and Regulations of the SDVOB program (see http://ogs.ny.gov/About/Regs/docs/part252.pdf ) for additional information.

10. Provide any other information you deem relevant which may help us in evaluating your request for a waiver.

11. Provide the name, title, address, telephone number, and email address of offeror/contractor’s representative authorized to discuss and negotiate this waiver request.

12. Copy of notice of application receipt issued by the Office of General Services (OGS).

Note: Unless a Total Waiver has been granted, the Offeror/Contractor will be required to submit all reports and documents pursuant to the provisions set forth in the Contract, as deemed appropriate by RIOC, to determine SDVOB compliance.

SDVOB 104 Instructions http://ogs.ny.gov/About/Regs/docs/part252.pdf

Failure to submit this form will result in non-compliance M/WBE 105

AGENCY M/WBE Program Management Page 14 1/14/2015

M/WBE Quarterly Report of NYS Roosevelt Island Operating Corporation Contract No. ___________________ Project No. _____________________

The following information indicates the payment amounts made by the grantee/contractor to the NYS Certified M/WBE subcontractor on this project.

The payments as shown made are in compliance with contract documents for the above referenced project.

*See Reverse Side for Product Codes

Date_________ Name________________________ Title ____________________ Signature______________________

Federal ID# Goals/$ Amt.

MBE ____%= __________

WBE____%=___________

Contract Type ___________________________

Paid to Contractor This Quarter_____________

Total Paid to Contractor To Date ____________

Contractors Name and Address

Project

Completion Date Work Location Reporting Period:

___ 1st Quarter (4/1-6/30) ____ 3rd Quarter (10/1-12/31)

___ 2nd Quarter (7/1-9/30) ____ 4th Quarter (1/1-3/31)

M/WBE

Subcontractor/Vendor

Product Code*

Work Status This Report

Total Subcontractor Contract Amount

Payments this Quarter Previous Payments

Total Payment Made to Date

MBE WBE MBE WBE

WBE MBE

Name:

FED ID#

___Active ___Inactive ___Complete

___Active

___Active

___Active

Is this a final report? Check One Yes _____ No______

Failure to submit this form will result in non-compliance M/WBE 105

AGENCY M/WBE Program Management Page 15 1/14/2015

PRODUCT KEY CODE

A = Agriculture/ Landscaping (e.g., all forms of landscaping services) B = Mining (e.g., geological investigations) C = Construction C15 = Building Construction – General Contractors C16 = Heavy Construction (e.g., highway, pipe laying) C17 = Special Trade Contractors (e.g., plumbing, heating, electrical, carpentry) D = Manufacturing E = Transportation, Communication and Sanitary Services (e.g., delivery services, warehousing, broadcasting and cable systems) F/G = Wholesale/Retail Goods (e.g. hospital supplies and equipment, food stores, computer stores, office supplies G52 = Construction Materials (e.g., lumber, paint, law supplies) H = Financial, Insurance and Real Estate Services I = Services I73 = Business Services (e.g., copying, advertising, secretarial, janitorial, rental services of equipment, computer programming, security services) I81 = Legal Services I82 = Education Services (e.g., AIDS education, automobile safety, tutoring, public speaking) I83 = Social Services (Counselors, vocational training, child care) I87 = Engineering, architectural, accounting, research, management and related services

New York State Department of Taxation and Finance

ST-220-CA

(12/11)

Contractor name

Contractor’s principal place of business City State ZIP code

Contractor’s mailing address (if different than above)

Contractor’s federal employer identification number (EIN) Contractor’s sales tax ID number (if different from contractor’s EIN)

Contractor’s telephone number Covered agency name

Covered agency address

of the above‑named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that:

(Mark an X in only one box)

G The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete.

and, to the best of the contractor’s knowledge, the information provided on that previously filed Form ST-220-TD, is correct and complete as of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time.

Sworn to this day of , 20

(sign before a notary public) (title)

For covered agency use only

Contract number or description

Estimated contract value over the full term of contract (but not including renewals)

Covered agency telephone number

For information, consult Publication 223, Questions and Answers Concerning Tax Law Section 5-a (see Need Help? on back).

Instructions

General information Tax Law section 5-a was amended, effective April 26, 2006. On or after that date, in all cases where a contract is subject to Tax Law section 5-a, a contractor must file (1) Form ST-220-CA, Contractor Certification to Covered Agency, with a covered agency, and

(2) Form ST-220-TD with the Tax Department before a contract may take effect. The circumstances when a contract is subject to section 5-a are listed in Publication 223, Q&A 3. See Need help?

for more information on how to obtain this publication. In addition, a contractor must file a new Form ST-220-CA with a covered agency before an existing contract with such agency may be renewed.

Note: Form ST-220-CA must be signed by a person authorized to make the certification on behalf of the contractor, and the acknowledgement on page 2 of this form must be completed before a notary public.

When to complete this form As set forth in Publication 223, a contract is subject to section 5-a, and you must make the required certification(s), if:

i. The procuring entity is a covered agency within the meaning of the statute (see Publication 223, Q&A 5);

ii. The contractor is a contractor within the meaning of the statute (see Publication 223, Q&A 6); and

iii. The contract is a contract within the meaning of the statute. This is the case when it (a) has a value in excess of $100,000 and (b) is a contract for commodities or services, as such terms are defined for purposes of the statute (see Publication 223, Q&A 8 and 9).

Furthermore, the procuring entity must have begun the solicitation to purchase on or after January 1, 2005, and the resulting contract must have been awarded, amended, extended, renewed, or assigned on or after April 26, 2006 (the effective date of the section 5-a amendments).

Need help?

Telephone assistance

Sales Tax Information Center: (518) 485-2889

To order forms and publications: (518) 457-5431

Text Telephone (TTY) Hotline (for persons with hearing and speech disabilities using a TTY): (518) 485-5082 accessible to persons with disabilities. If you have questions about special accommodations for persons with disabilities, call the information center.

Persons with disabilities: In compliance with the Americans with Disabilities Act, we will ensure that our lobbies, offices, meeting rooms, and other facilities are

Visit our Web site at www.tax.ny.gov

Individual, Corporation, Partnership, or LLC Acknowledgment

On the day of in the year 20 , before me personally appeared , known to me to be the person who executed the foregoing instrument, who, being duly sworn by me did depose and say that he resides at , Town of , County of , State of ; and further that:

[Mark an X in the appropriate box and complete the accompanying statement.]

G (If an individual): _he executed the foregoing instrument in his/her name and on his/her own behalf.

G (If a corporation): _he is the of , the corporation described in said instrument; that, by authority of the Board of Directors of said corporation, _he is authorized to execute the foregoing instrument on behalf of the corporation for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said corporation as the act and deed of said corporation.

G (If a partnership): _he is a of , the partnership described in said instrument; that, by the terms of said partnership, _he is authorized to execute the foregoing instrument on behalf of the partnership for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said partnership as the act and deed of said partnership.

on behalf of the limited liability company for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said limited liability company as the act and deed of said limited liability company.

Notary Public

Registration No.

Page 2 of 2 ST-220-CA (12/11)

Privacy notification The Commissioner of Taxation and Finance may collect and maintain personal information pursuant to the New York State Tax Law, including but not limited to, sections 5-a, 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 1415 of that Law; and may require disclosure of social security numbers pursuant to 42 USC 405(c)(2)(C)(i).

This information will be used to determine and administer tax liabilities and, when authorized by law, for certain tax offset and exchange of tax information programs as well as for any other lawful purpose.

Information concerning quarterly wages paid to employees is provided to certain state agencies for purposes of fraud prevention, support enforcement, evaluation of the effectiveness of certain employment and training programs and other purposes authorized by law.

Failure to provide the required information may subject you to civil or criminal penalties, or both, under the Tax Law.

This information is maintained by the Manager of Document Management, NYS Tax Department, W A Harriman Campus, Albany NY 12227; telephone

(518) 457-5181.

Need help?

Telephone assistance

Sales Tax Information Center: (518) 485-2889

To order forms and publications: (518) 457-5431

Text Telephone (TTY) Hotline (for persons with hearing and speech disabilities using a TTY): (518) 485-5082 accessible to persons with disabilities. If you have questions about special accommodations for persons with disabilities, call the information center.

Persons with disabilities: In compliance with the Americans with Disabilities Act, we will ensure that our lobbies, offices, meeting rooms, and other facilities are

Visit our Web site at www.tax.ny.gov

Department of Taxation and Finance

Contractor Certification

ST-220-TD

(4/15)

Contractor name

Contractor’s principal place of business City State ZIP code

Contractor’s mailing address (if different than above) City State ZIP code

For information, consult Publication 223, Questions and Answers Concerning Tax Law Section 5-a (see Need help? below).

General information Tax Law section 5-a, as amended, effective April 26, 2006, requires certain contractors awarded certain state contracts valued at more than $100,000 to certify to the Tax Department that they are registered to collect New York State and local sales and compensating use taxes, if they made sales delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000, measured over a specified period. In addition, contractors must certify to the Tax Department that each affiliate and subcontractor exceeding such sales threshold during a specified period is registered to collect New York State and local sales and compensating use taxes. Contractors must also file Form ST-220-CA, Contractor Certification to Covered Agency, certifying to the procuring state entity that they filed Form ST-220-TD with the Tax Department and that the information contained on Form ST-220-TD is correct and complete as of the date they file Form ST-220-CA.

All sections must be completed including all fields on the top of this page, all sections on page 2, Schedule A on page 3, if applicable, and Individual, Corporation, Partnership, or LLC Acknowledgement on page 4. If you do not complete these areas, the form will be returned to you for completion.

For more detailed information regarding this form and Tax Law section 5-a, see Publication 223, Questions and Answers Concerning Tax Law Section 5-a, (as amended, effective April 26, 2006). See Need help? for more information on how to obtain this publication.

Note: Form ST-220-TD must be signed by a person authorized to make the certification on behalf of the contractor, and the acknowledgement on page 4 of this form must be completed before a notary public.

Mail completed form to:

NYS TAX DEPARTMENT

DATA ENTRY SECTION

W A HARRIMAN CAMPUS

ALBANY NY 12227-0826

Privacy notification New York State Law requires all government agencies that maintain a system of records to provide notification of the legal authority for any request, the principal purpose(s) for which the information is to be collected, and where it will be maintained. To view this information, visit our Web site, or, if you do not have Internet access, call and request Publication 54, Privacy Notification. See Need help? for the Web address and telephone number.

Page 2 of 4 ST-220-TD (4/15)

Complete Sections 1, 2, and 3 below. Make only one entry in each section.

Section 1 – Contractor registration status

G The contractor has made sales delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made. The contractor is registered to collect New York State and local sales and compensating use taxes with the Commissioner of Taxation and Finance pursuant to Tax Law sections 1134 and 1253, and is listed on Schedule A of this certification.

G The contractor has not made sales delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made.

Section 2 – Affiliate registration status

G The contractor does not have any affiliates.

G To the best of the contractor’s knowledge, the contractor has one or more affiliates having made sales delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made, and each affiliate exceeding the $300,000 cumulative sales threshold during such quarters is registered to collect New York State and local sales and compensating use taxes with the Commissioner of Taxation and Finance pursuant to Tax Law sections 1134 and 1253. The contractor has listed each affiliate exceeding the $300,000 cumulative sales threshold during such quarters on Schedule A of this certification.

G To the best of the contractor’s knowledge, the contractor has one or more affiliates, and each affiliate has not made sales delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made.

Section 3 – Subcontractor registration status

G The contractor does not have any subcontractors.

G To the best of the contractor’s knowledge, the contractor has one or more subcontractors having made sales delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made, and each subcontractor exceeding the $300,000 cumulative sales threshold during such quarters is registered to collect New York State and local sales and compensating use taxes with the Commissioner of Taxation and Finance pursuant to Tax Law sections 1134 and 1253. The contractor has listed each subcontractor exceeding the $300,000 cumulative sales threshold during such quarters on Schedule A of this certification.

G To the best of the contractor’s knowledge, the contractor has one or more subcontractors, and each subcontractor has not made sales delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made.

Sworn to this day of , 20

(sign before a notary public) (title)

of the above‑named contractor, and that I am authorized to make this certification on behalf of such contractor.

ST-220-TD (4/15) Page 3 of 4

A Relationship to contractor

B Name

C Address

D Federal ID number

E Sales tax ID number

F Registration in progress

Column A – Enter C in column A if the contractor; A if an affiliate of the contractor; or S if a subcontractor.

Column B – Name - If the entity is a corporation or limited liability company, enter the exact legal name as registered with the NY Department of State, if applicable. If the entity is a partnership or sole proprietor, enter the name of the partnership and each partner’s given name, or the given name(s) of the owner(s), as applicable. If the entity has a different DBA (doing business as) name, enter that name as well.

Column C – Address - Enter the street address of the entity’s principal place of business. Do not enter a PO box.

Column D – ID number - Enter the federal employer identification number (EIN) assigned to the entity. If the entity is an individual, enter the social security number of that person.

Column E – Sales tax ID number - Enter only if different from federal EIN in column D.

Column F – If applicable, enter an X if the entity has submitted Form DTF-17 to the Tax Department but has not received its certificate of authority as of the date of this certification.

Schedule A – Listing of each entity (contractor, affiliate, or subcontractor) exceeding $300,000 cumulative sales threshold List the contractor, or affiliate, or subcontractor in Schedule A only if such entity exceeded the $300,000 cumulative sales threshold during the specified sales tax quarters. See directions below. For more information, see Publication 223.

Page 4 of 4 ST-220-TD (4/15)

Individual, Corporation, Partnership, or LLC Acknowledgment

On the day of in the year 20 , before me personally appeared , known to me to be the person who executed the foregoing instrument, who, being duly sworn by me did depose and say that he resides at , Town of , County of , State of ; and further that:

(Mark an X in the appropriate box and complete the accompanying statement.)

G (If an individual): _he executed the foregoing instrument in his/her name and on his/her own behalf.

G (If a corporation): _he is the of , the corporation described in said instrument; that, by authority of the Board of Directors of said corporation, _he is authorized to execute the foregoing instrument on behalf of the corporation for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said corporation as the act and deed of said corporation.

G (If a partnership): _he is a of , the partnership described in said instrument; that, by the terms of said partnership, _he is authorized to execute the foregoing instrument on behalf of the partnership for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said partnership as the act and deed of said partnership.

on behalf of the limited liability company for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said limited liability company as the act and deed of said limited liability company.

Notary Public

Registration No.

P a g e 1 | 2

Offerer Disclosure of Prior Non-Responsibility Determinations

Name of Individual or Entity Seeking to Enter into the Procurement Contract:

Address: _______________________________________________________________

Name and Title of Person Submitting this Form: ________________________________

Contract Procurement Number: _____________________________________________

Date:________________________

1. Has any Governmental Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into the Procurement Contract in the previous four years? (Please circle):

No Yes

If yes, please answer the next questions:

2. Was the basis for the finding of non-responsibility due to a violation of State Finance Law

§139-j (Please circle):

No Yes

3. Was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a Governmental Entity? (Please circle):

4. If you answered yes to any of the above questions, please provide details regarding the finding of non-responsibility below.

Governmental Entity: ___________________________________________________________

Date of Finding of Non-responsibility: ______________________________________________

Basis of Finding of Non-Responsibility: _____________________________________________

(Add additional pages as necessary)

5. Has any Governmental Entity or other governmental agency terminated or withheld a

Procurement Contract with the above-named individual or entity due to the intentional provision of false or incomplete information? (Please circle):

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6. If yes, please provide details below.

Governmental Entity: ______________________________________________

Date of Termination or Withholding of Contract: _______________________________________

Basis of Termination or Withholding: ____________________________________________

(Add additional pages as necessary)

Offerer certifies that all information provided to the Governmental Entity with respect to State

Finance Law §139-k is complete, true and accurate.

By: Date:

Signature

Title:

IRAN DIVESTMENT ACT CERTIFICATION

By submitting a bid in response to this solicitation or by assuming the responsibility of a Contract awarded hereunder, Bidder/Contractor (or any assignee) certifies that it is not on the “Entities Determined To Be Non-Responsive Bidders/Offerers Pursuant to The New York State Iran Divestment Act of 2012” list (“Prohibited Entities List”) posted on the OGS website at:

http://www.ogs.ny.gov/about/regs/docs/ListofEntities.pdf and further certifies that it will not utilize on such Contract any subcontractor that is identified on the Prohibited Entities List.

Additionally, Bidder/Contractor is advised that should it seek to renew or extend a Contract awarded in response to the solicitation, it must provide the same certification at the time the Contract is renewed or extended.

During the term of the Contract, should RIOC receive information that a person (as defined in State Finance Law §165-a) is in violation of the above-referenced certifications, RIOC will review such information and offer the person an opportunity to respond. If the person fails to demonstrate that it has ceased its engagement in the investment activity which is in violation of the Act within 90 days after the determination of such violation, then RIOC shall take such action as may be appropriate and provided for by law, rule, or contract, including, but not limited to, seeking compliance, recovering damages, or declaring the Contractor in default.

RIOC reserves the right to reject any bid, request for assignment, renewal or extension for an entity that appears on the Prohibited Entities List prior to the award, assignment, renewal or extension of a contract, and to pursue a responsibility review with respect to any entity that is awarded a contract and appears on the Prohibited Entities list after contract award.

Signature: __________________________________

Name: _____________________________________

Title: ______________________________________

Company Name: _____________________________

Date:_______________________________________ http://www.ogs.ny.gov/about/regs/docs/ListofEntities.pdf

ENCOURAGING USE OF NEW YORK STATE BUSINESSES IN CONTRACT PERFORMANCE

New York State businesses have a substantial presence in State Contracts and strongly contribute to the economies of the state and the nation. In recognition of their economic activity and leadership in doing business in New York State, Bidders for this contract for commodities, services or technology are strongly encouraged and expected to consider New York State businesses in the fulfillment of the requirements of the Contract. Such partnering may be as subcontractors, suppliers, protégés or other supporting roles.

Bidders need to be aware that all authorized users of this Contract will be strongly encouraged, to the maximum extent practical and consistent with legal requirements, to use responsible and responsive New York State businesses in purchasing commodities that are of equal quality and functionality and in utilizing services and technology. Furthermore, Bidders are reminded that they must continue to utilize small, minority and women-owned businesses, consistent with current State law.

Utilizing New York State businesses in State Contracts will help create more private sector jobs, rebuild New York’s infrastructure, and maximize economic activity to the mutual benefit of the Contractor and its New York State business partners. New York State businesses will promote the Contractor’s optimal performance under the Contract, thereby fully benefiting the public sector programs that are supported by associated procurements.

Public procurements can drive and improve the State’s economic engine through promotion of the use of New York businesses by its Contractors. The State therefore expects Bidders to provide maximum assistance to New York businesses in their use of the Contract. The potential participation by all kinds of New York businesses will deliver great value to the State and its taxpayers.

Bidders can demonstrate their commitment to the use of New York State businesses by responding to the question below:

Will New York State Businesses be used in the performance of this Contract? ______ Yes ______ No

If yes, identify New York State Business(es) that will be used; (Attach identifying information).

Non-Collusive Bidding Certification Roosevelt Island Operating Corporation

NON-COLLUSIVE BIDDING CERTIFICATION REQUIRED BY

SECTION 139-D OF THE STATE FINANCE LAW

SECTION 139-D, Statement of Non-Collusion in bids to the State:

BY SUBMISSION OF THIS BID, BIDDER AND EACH PERSON SIGNING ON

BEHALF OF BIDDER CERTIFIES, AND IN THE CASE OF JOINT BID, EACH PARTY

THERETO CERTIFIES AS TO ITS OWN ORGANIZATION, UNDER PENALTY OF

PERJURY, THAT TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF:

[1] The prices of this bid have been arrived at independently, without collusion, consultation, communication, or agreement, for the purposes of restricting competition, as to any matter relating to such prices with any other Bidder or with any competitor;

[2] Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the Bidder and will not knowingly be disclosed by the Bidder prior to opening, directly or indirectly, to any other Bidder or to any competitor; and

[3] No attempt has been made or will be made by the Bidder to induce any other person, partnership or corporation to submit or not to submit a bid for the purpose of restricting competition.

A BID SHALL NOT BE CONSIDERED FOR AWARD NOR SHALL ANY AWARD

BE MADE WHERE [1], [2], [3] ABOVE HAVE NOT BEEN COMPLIED WITH;

PROVIDED HOWEVER, THAT IF IN ANY CASE THE BIDDER(S) CANNOT MAKE

THE FOREGOING CERTIFICATION, THE BIDDER SHALL SO STATE AND SHALL

FURNISH BELOW A SIGNED STATEMENT WHICH SETS FORTH IN DETAIL THE

REASONS THEREFORE:

Subscribed to under penalty of perjury under the laws of the State of New York, this day of , 20 as the act and deed of said corporation of partnership.

STATE OF NEW YORK }

} SS

COUNTY OF }

On the day of _ in the year of _ , before me personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the foregoing Non-collusive Bidding Certification (instrument) and acknowledged to me that he/she executed the same in his/her capacity, and on his/her own behalf.

Notary Public

Registration No:

Version Date: 1 / 3 / 2017

Non-Collusive Bidding Certification Roosevelt Island Operating Corporation

IF BIDDER(S) (ARE) A PARTNERSHIP, COMPLETE THE FOLLOWING:

NAMES OF PARTNERS OR PRINCIPALS LEGAL RESIDENCE

IF BIDDER(S) (ARE) A CORPORATION, COMPLETE THE FOLLOWING:

NAME LEGAL RESIDENCE

President:

Secretary:

Treasurer:

Identifying Data

Potential Contractor

Address Street

City, Town, etc.

Telephone (If applicable, Responsible Corporate Officer)

Name Title

Signature

Joint or combined bids by companies or firms must be certified on behalf of each participant.

Legal name of person, firm or corporation Legal name of person, firm or corporation

By

Name Name

Title Title

Address Address Street Street

City State City State Version Date: 1 / 3 / 2017

MACBRIDE FAIR EMPLOYMENT PRINCIPLES

STIPULATION

Chapter 807 of the Laws of 1992 prohibits a State department from contracting for the supply of goods and services or construction with any Contractor who does not agree to stipulate that it either has no business operations in Northern Ireland, or if it does have such business operations, it shall take lawful steps in good faith to conduct such operations in accordance with the MacBride Fair Employment Principles.

PLEASE READ AND INITIAL EITHER STATEMENT #1 OR STATEMENT #2. DO NOT

INITIAL BOTH STATEMENTS.

_____ 1. The Contractor, and any individual or legal entity in which the Contractor holds a 10% or greater ownership interest and any individual or legal entity that holds a 10% or greater ownership interest in the Contractor has no business operations in Northern Ireland.

_____ 2. The Contractor, and any individual or legal entity in which the Contractor holds a 10% or greater ownership interest and any individual or legal entity that holds a 10% or greater ownership interest in the Contractor shall take lawful steps in good faith to conduct any business operations they have in Northern Ireland in accordance with the MacBride Fair Employment Principles and shall permit the independent monitoring of their compliance with such principles.

Dated:

2019-07-03 1

Vendor Responsibility Questionnaire

Note that a “yes” answer below will not automatically disqualify a firm from consideration for this project.

1. Bidder Identification

a. Legal Name and Address of Bidder: _________________________________________________

b. Type of Entity (check only one) State and Date of Incorporation ☐ Corporation ____________________________________________ ☐ Sole Proprietor ____________________________________________ ☐ General Partnership ____________________________________________ ☐ Limited Partnership ____________________________________________ ☐ Limited Liability Company (LLC) ____________________________________________ ☐ Other – (please specify) ____________________________________________ ☐ Not-for-Profit Corporation Charities Registration Number: ___________________

2. Major Ownership Interest

List below the names of all major owners of the bidding entity (10% or more for publicly traded companies, 25% or more for all others), home addresses and percentages of ownership:

3. Relationships to Other Organizations

Is the Bidder owned by (an)other corporation(s)? Does the Bidder have ownership interest in any other corporations, partnerships, LLCs that might be providing similar construction or services to this bid?

☐ no ☐ yes; list each such corporation, firm or organization by name and address, specify its relationship to the Bidder, and ownership percentage:

2019-07-03 2

4. Financial and Legal History

a. Has the Bidder, or any of its subsidiaries, ever filed for bankruptcy or reorganization (either voluntary or involuntary) within the last ten years.

☐ no ☐ yes, please explain:

b. Has the Bidder, or any of its subsidiaries, been involved in any of the following within the last ten years (check all that apply):

☐ Contract in default ☐ Outstanding judgment on a mechanic’s…