RFP_HSR15-92_Forms_and_Certifications.pdf

California High-Speed Rail Authority

Request for Proposals for Financial Advisors List of Forms and Certifications

Forms and Certifications

Form A: Bidder Declaration

Form B: Organizational Conflicts of Interest Statement

Form C: DVBE Declaration

Cert. 1: Contractor Certification Clauses (CCC-307)

Cert. 2: Proposer’s Overall Project Small Business Goal Commitment Affidavit

Cert. 3: Iran Contracting Certification

Cert. 4: Darfur Contracting Act Certification

Cert. 5: Major Participant Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Cert. 6: Subcontractor Certification Regarding Debarment, Suspension, Ineligibility, and

Voluntary Exclusion Certification

Cert. 7: Non-Collusion Affidavit

Cert. 8: Equal Employment Opportunity Certification

Cert. 9: Non-Discrimination Certification

Cert. 10: Certification Regarding Lobbying

Request for Proposals for Financial Advisors Form A: Schedule of Subcontractor(s)/ Subconsultant(s)

Form A: Bidder Declaration

This form must be completed by all Proposers. The fill and print form is available at the link below:

http://www.documents.dgs.ca.gov/pd/poliproc/MASTEr-BidDeclar08-09.pdf

If you cannot access this form, please contact the Point of Contact listed in 3.1 of the RFP.

http://www.documents.dgs.ca.gov/pd/poliproc/MASTEr-BidDeclar08-09.pdf

Request for Proposal for Financial Advisors Form B: Organizational Conflicts of Interest Disclosure Statement

Form B: Organizational Conflicts of Interest Disclosure Statement

CALIFORNIA HIGH-SPEED RAIL AUTHORITY

1. Definition

The Authority’s Conflict of Interest Policy defines organizational conflicts of interest as follows:

“Organizational Conflict of Interest” means a circumstance arising out of a Contractor’s existing or past activities, business or financial interests, familial relationships, contractual relationships, and/or organizational structure (i.e., parent entities, subsidiaries, Affiliates, etc.) that results in

(i) impairment or potential impairment of a Consultant’s ability to render impartial assistance or advice to the Authority or of its objectivity in performing work for Authority, (ii) an unfair competitive advantage for any Consultant with respect to an Authority procurement; or (iii) a perception or appearance of impropriety with respect to any of the Authority’s procurements or contracts or a perception or appearance of unfair competitive advantage with respect to a procurement by the Authority (regardless of whether any such perception is accurate).

2. Disclosure

In the space provided below, and on supplemental sheets as necessary, identify all relevant facts relating to past, present or planned interest(s) of the Consultant and its team (including Consultant, Consultant Team members, and all Subcontractors identified at the time of the submittal of its Proposal, and their respective personnel) which may result, or could be viewed as, an organizational conflict of interest in connection with the RFP.

Form B: Organizational Conflicts of Interest Disclosure Statement

3. Explanation

In the space below, and on supplemental sheets as necessary, identify steps that have been or will be taken to avoid or mitigate any organizational conflicts of interest described herein.

4. Certification

The undersigned hereby certifies that, to the best of his or her knowledge and belief, no interest exists that is required to be disclosed in this Organizational Conflicts of Interest Disclosure Statement, other than as disclosed above.

Signature

Printed Name

Printed Title

Consultant

Form B: Organizational Conflicts of Interest Disclosure Statement

Form C: DVBE Declaration (STD. 843)

The DVBE Declaration shall be submitted for each DVBE Proposer team member identified on Form A, Bidder Declaration. This fill and print form and instructions are available at the link below:

The DVBE Declaration shall be submitted for each DVBE that will be a Proposer or subcontractor. This fill and print form and instructions are available at the link below:

http://www.documents.dgs.ca.gov/pd/poliproc/STD-843FillPrintFields.pdf

Cert. 1: Certification Regarding Miscellaneous State Requirements

Cert. 1: Contractor Certification Clauses (CCC-307)

This form must be completed by all Proposers as directed in Section 5.3.1.2 of this RFP. The certification is available at the link below:

www.documents.dgs.ca.gov/ols/CCC-307.doc http://www.documents.dgs.ca.gov/ols/CCC-307.doc

Request for Proposals HSR15-92 Financial Advisor Cert. 2: Consultant’s Overall Contract Small Business Goal Commitment Affidavit

Cert. 2: Consultant’s Overall Contract Small Business Goal Commitment Affidavit

AFFIDAVIT

The Consultant submitting the foregoing Proposal (If the Consultant has not yet been formed, modify this form as appropriate to include the names of all of the Principal Participants and to indicate that the Official Representative is signing the form on behalf of all of the Principal Participants.)

The Consultant has carefully examined all documents that form this Request for Proposals and is aware that California High-Speed Rail Authority (Authority) has established an overall contract Small Business goal of 30 percent, inclusive of Small Businesses, Disadvantaged Business Enterprises, Disabled Veteran Business Enterprises and Microbusinesses, in conformance with Executive Order S-02-06, Title VI of the Civil Rights Act of 1964, and related statutes and Best Practices of 49 C.F.R. Part 26, as set forth in the Authority’s Small and Disadvantaged Business Enterprise Program.

The Consultant will aggressively exercise Good Faith Efforts to the satisfaction of the Authority to meet or exceed the overall contract Small Business goal of 30 percent, consistent with the Consultant’s approved Performance Plan developed in accordance with the Authority’s Small and Disadvantaged Business Enterprise Program.

Executed this day of , 20 .

Company Name:

By:

(Signature of Company Official)

(Title of Company Official)

Cert. 3: Iran Contracting Certification

Cert. 3: Iran Contracting Certification

Section 2200 et seq. of the California Public Contract Code prohibits a person from submitting a proposal for a contract with a public entity for goods and services of $1,000,000 or more if that person is identified on a list created by the Department of General Services (DGS) pursuant to Section 2203(b) of the California Public Contract Code. The list will include persons providing goods or services of $20,000,000 or more in the energy sector of Iran and financial institutions that extend $20,000,000 or more in credit to a person that will use the credit to provide goods or services in the energy sector in Iran. DGS is required to provide notification to each person that it intends to include on the list at least 90 days before adding the person to the list.

In accordance with Section 2204 of the California Public Contract Code, the undersigned hereby certifies that

It is not identified on a list created pursuant to Section 2203(b) of the California Public Contract Code as a person engaging in investment activities in Iran described in Section 2202.5(a), or as a person described in Section 2202.5(b), as applicable; or

It is on such a list but has received permission pursuant to Section 2203(c) or (d) to submit a bid or Proposal in response to this RFP HSR15-92 Financial Advisor Services for the California High- Speed Rail Authority.

Note: Providing a false certification may result in civil penalties and sanctions.

Date:

Entity:

Signature

Title

Note: Duplicate this form so that it is signed by the Consultant and all joint venture members of the Consultant.

Cert. 4: Darfur Contracting Act Certification

Cert. 4: Darfur Contracting Act Certification

Pursuant to Public Contract Code section 10478, if a Consultant currently or within the previous three (3) years has had business activities or other operations outside of the United States, it must certify that it is not a “scrutinized” company as defined in Public Contract Code section 10476.

Therefore, to be eligible to submit a bid or Proposal, please complete only one of the following three paragraphs (via initials for Paragraph No. 1 or Paragraph No. 2, or via initials and certification for Paragraph No. 3):

1. We do not currently have, or we have not had within the previous three years, business activities or other operations outside of the United States.

Initials

OR

2. We are a scrutinized company as defined in Public Contract Code section 10476, but we have received written permission from the Department of General Services (DGS) to submit a bid or Proposal pursuant to Public Contract Code section 10477(b). A copy of the written permission from DGS is included with our bid or Proposal.

Initials

OR

3. We currently have, or we have had within the previous three years, business activities or other operations outside of the United States, but we certify below that we are not a scrutinized company below as defined in Public Contract Code section 10476. Initials

CERTIFICATION for Paragraph No. 3

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the Consultant to the clause listed above in Paragraph No. 3. This certification is made under the laws of the State of California.

Consultant Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County and State of

Cert 5: Major Participant Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Cert. 5: Major Participant Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Primary Covered Transactions

This certification applies to the offer submitted in response to this solicitation, and will be a continuing requirement throughout the term of the contract.

In accordance with the provisions of Appendix A to 49 C.F.R. Part 29, the Consultant certifies to the best of its knowledge and belief, that it and its principals:

a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency.

b) Have not within a 3-year period preceding this offer been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) transaction or contract under a public transaction; violation of Federal or state antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, state, or local) with commission of any of the offenses enumerated in item b of this certification.

d) Have not within a 3-year period preceding this offer had one or more public transactions (Federal, state, or local) terminated for cause or default.

(Mark one, below, with an “x”) Certify to the above Cannot certify to the above.

If the “cannot certify” box is checked, attach an explanation of the reasons.

The Consultant shall require any subcontractor, at any tier, whose contract is equal to or greater than $25,000 to complete this certification form and retain this requirement throughout the term of the contract. A copy of a certification, for subcontractors, shall be furnished by the Contracting Officer upon request (see Cert. 6).

Organization Name, Address, and Telephone

Signature of Person Certifying

Date

Cert 6: Subcontractor Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Cert. 6: Subcontractor Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

Lower Tier Covered Transactions

This certification applies to a subcontract at any tier expected to equal or exceed $25,000, and will be a continuing requirement throughout the term of the contract.

In accordance with the provisions of Appendix B to 49 C.F.R. Part 29, the prospective lower tier participant (subcontractor) certifies to the best of its knowledge and belief, that it and its principals:

a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency.

b) Have not within a 3-year period preceding this offer been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) transaction or contract under a public transaction; violation of Federal or state antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, state, or local) with commission of any of the offenses enumerated in item b of this certification.

d) Have not within a 3-year period preceding this offer had one or more public transactions (Federal, state, or local) terminated for cause or default.

(Mark one, below, with an “x”) Certify to the above Cannot certify to the above.

If the “cannot certify” box is checked, attach an explanation of the reasons.

Organization Name, Address, and Telephone

Cert. 7: Non-Collusion Affidavit

Cert. 7: Non-Collusion Affidavit

The party making the foregoing Proposal, and that the Proposal is:

a) NOT made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation

b) Genuine and NOT collusive or a sham.

That the Consultant has NOT directly or indirectly induced or solicited any other Consultant to:

a) Put in a false or sham Proposal; and

b) Colluded, conspired, connived or agreed with any Consultant or anyone else to put in a sham Proposal or that anyone shall refrain from bidding.

That the Consultant has NOT, in any manner directly or indirectly, sought by agreement, communication or conference with anyone to:

a) Fix the Price Proposal of the Consultant or any other Consultant, or

b) Fix any overhead, profit, or cost element, or that of any other Consultant, or

c) Secure any advantage against the public body awarding the contract or anyone interested in the proposed contract.

That all statements contained in the Proposal are true.

The Consultant has not and will not, directly or indirectly, for the purposes of effectuating a collusive or sham negotiation, submitted his or her schedule of rates or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, for payment to any corporation, partnership, company, association, organization, bid depository, or any member or agent thereof.

Executed this day of , 20 .

Company Name:

Cert. 8: Equal Employment Opportunity Certification

Cert. 8: Equal Employment Opportunity Certification

To be executed by the Consultant, all joint venture members of the Consultant, and all Subcontractors.

The undersigned certifies on behalf of that:

(Name of entity making certification)

Check one of the following boxes:

It has developed and has on file at each establishment affirmative action programs pursuant to 41 C.F.R. Part 60-2 (Affirmative Action Programs).

It is not subject to the requirements to develop an affirmative action program under 41 C.F.R. Part 60-2 (Affirmative Action Programs).

Check one of the following boxes:

It has not participated in a previous contract or subcontract subject to the equal opportunity clause described in Executive Orders 10925, 11114 or 11246.

It has participated in a previous contract or subcontract subject to the equal opportunity clause described in Executive Orders 10925, 11114, or 11246, and, where required, it has filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal Government contracting or administering agency, or the former President’s Committee on Equal Employment Opportunity, all reports due under the applicable filing requirements.

Signature:

Title:

Date:

If not the Consultant, relationship to the Consultant:

Cert. 9: Non-Discrimination Certification

Cert. 9: Non-Discrimination Certification

In accordance with Title VI of the Civil Rights Act, as amended; 42 U.S.C. § 2000d, the Consultant agrees that it will not discriminate against any individual because of race, color, national origin, or sex in any activities leading up to or in performance of the contract for Consultant Services.

Organization Name, Address, and Telephone

Cert. 10: Certification Regarding Lobbying

Cert. 10: Certification Regarding Lobbying

The undersigned certifies, to the best of his or her knowledge and belief, that the following are true:

a) No federal appropriated funds have been or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.

b) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying”, in accordance with its instructions.

c) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements), and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance is placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. § 1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Executed this day of , 20 .

Company Name:

Note: If Joint Venture, each Joint Venture member shall provide the above information and sign the certification.