RFQ_2025-ITO-089141_Kodak_Scanner.pdf

ATTACHMENT 2

Department of Financial Protection and Innovation Revised 09/18/25

STATE OF CALIFORNIA

Department of Financial Protection and Innovation

Request For Quotation # 2025-ITO-089141 Kodak Scanner

QUOTE DUE DATE: 09/25/2025 Thursday

TIME: 4:00 PM Pacific Standard Time

Please note that late responses may not be considered.

Delivery Date

# of Days After Receipt of Order

Supplier name:

Supplier address:

Contact Name (Print):

Title:

**THIS QUOTE IS VALID FOR 45 DAYS FROM THE

QUOTE DUE DATE.**

Return quote to:

Jasmin Buada Department of Financial Protection and Innovation 651 Bannon Street, Suite 300 Sacramento, CA 95811

(213) 505-5596 jasmin.buada@dfpi.ca.gov

ARE YOU CLAIMING PREFERENCE

AS A SMALL BUSINESS:

YES NO

IF YES, MANUFACTURER?

YES NO

ARE YOU A NON-SMALL BUSINESS

CLAIMING AT LEAST 25% SMALL

BUSINESS SUBCONTRACTOR

PREFERENCE?

YES NO

SB Ref. # For certification information, please go to:

http://www.pd.dgs.ca.gov/smbus/default.htm

Signature:

__________________________________________________Date: ______________

Phone:

Fax:

E-mail:

Federal Employer Identification Number:

Seller’s Permit Number:

Ship To:

Attention: Receiving Reference # 2025-ITO-089141 Department of Financial Protection and Innovation 651 Bannon Street, Suite 300 Sacramento, CA 95811

See “Delivery” and “Shipment” under Bid Requirements and see “Shipping” in product description area.

SECTION 14838 ET SEQ. OF THE

CALIFORNIA GOVERNMENT CODE

REQUIRES THAT A 5% PREFERENCE BE

GIVEN TO BIDDERS WHO QUALIFY AS A

SMALL BUSINESS AS A NON-SMALL

BUSINESS CLAIMING AT LEAST 25%

CALIFORNIA CERTIFIED SMALL

BUSINESS PARTICIPATION. FOR

REQUIREMENTS SEE TITLE 2,

CALIFORNIA CODE OF REGULATIONS

SECTION 1896 ET SEQ. THE

REQUIREMENTS FOR NONPROFIT

VETERAN SERVICE AGENCIES

QUALIFYING AS A SMALL BUSINESS

ARE CONTAINED IN SECTION 999.50 ET

SEQ. OF THE MILITARY AND VETERANS

CODE.

**Bidder offers and agrees if this response is accepted within 45 calendar days following the date the response is due to furnish all the items upon which prices are quoted, at the prices set opposite each item, delivered at the designated point(s) by the method of delivery and within the times specified and subject to the attached General Provisions. DECLARATIONS UNDER PENALTY OF PERJURY; By signing above, with inclusion of the date of signature, the above signed bidder DECLARES UNDER PENALTY OF PERJURY under the laws of the State of California as follows: (1) (STATEMENT OF COMPLIANCE). The above signed has complied with the non-discrimination program requirements of Government Code 12990 and Title 2, California Code of Regulations Section 8103, and such declaration is true and correct. (2) The National Labor Relations Board declaration set forth in Paragraph 48 of the General Provisions is true and correct. (3) If a claim is made for the Small Business or Disabled Veterans Business preference, the information set forth within is true and correct.

Bid Requirements

1.Delivery: Final delivery, inspection and acceptance shall be at the location described herein. INSIDE DELIVERY REQUIRED. Please address the packages Attention: Receiving, Reference Number 2025-ITO-089141, Department of Financial Protection and Innovation utilizing the following address. Sacramento address: 651 Bannon Street, Suite 300, Sacramento, CA 95811.

• The Sacramento office has a loading dock access available on the West Side of the complex.

• Sacramento Receiving staff must be notified at least 24 hours prior to Delivery.

• All shipments should be addressed to “DFPI – Receiving.”

• Driver(s) must provide DFPI contact number: +1 279-236-5390 to the dock master.

• Loading Dock hours are 8am-4pm.

• Pallet Jacks are required to have polyurethane wheels.

• Elevator corner trim must be taped.

• Masonite floor protection must be used on all stone tiles and carpet where applicable.

• Walk-off plates must be provided to protect door and elevator thresholds.

Revised 09/18/25

• Elevator blanket/pads must be in place if passenger elevators are reserved for moving. These are available through the building management offices. All elevators are equipped with blanket/pad hooks.

2. Quotation Award: The Department of Financial Protection and Innovation reserves the right to award all or part to one or more vendors if deemed more cost effective.

3. Comparable Items: You may quote prices on comparable items provided the comparable items meet all the specifications, including minimum recycled content, of the products listed in this quote.

4. Cash Discounts: Cash discounts will not be considered when evaluating bid responses for award purposes. However, cash discounts may be offered and taken by departments processing invoices within the timeframe specified.

5. Sales Tax: Sales tax will be added to the total (without shipping cost) once the bid is awarded but is not needed for the bid process.

6. Shipment: For the purposes of this solicitation, only bid responses quoting Free on Board (F.O.B) Destination Freight

Prepaid will be accepted. F.O.B. Destination Freight Prepaid—Title to product remains with vendor until delivered to buyer in original condition. The vendor prepays the shipping charges and those charges are included in the unit price.

7. Loss Leader: It is unlawful for any person engaged in business within the State to sell or use any article or product as a “loss leader” as defined in Section 17030 of the Business and Professions Code.

8. Bidder’s Instructions and General Provisions:

Bidder Instructions rev. 11/09/11 https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf, General Provisions Non-IT rev. 2/20/25 file:///C:/Users/JBuada/Downloads/NonIT-General-ProvisionsGoods-DGS-PD-401NITGP-Revised-02202025%20(5).pdf, General Provisions IT Cloud Computing Services rev. 2/20/25 file:///C:/Users/JBuada/Downloads/IT-General-Provisions-Cloud-DGS-PD-402ITGP-Revised-02202025%20(2).pdf, and General Provisions IT Non-Cloud Goods & Services rev. 2/20/25 file:///C:/Users/JBuada/Downloads/IT-General-Provisions-NonCloud-DGS-PD-403ITGP-Revised-02202025%20(2).pdf are incorporated herein.

9. Declaration Forms: All bidders must complete declaration forms (see explanation and attachments on later pages).

10. Quotation Attachments: Bid responses that reference a supplier’s own terms and conditions or provisions will be considered non-responsive and will be rejected.

11. Important Note: Only bids quoted on the State’s own quotation forms will be considered.

12. Key Action Dates: RFQ Release: 9/19/25 Vendor questions due: 9/23/25 4 pm PST RFQ due: 9/25/25 4 pm PST

13. Attachments: The attached Shipping Instructions and Attachments 1-5 are incorporated as part of this solicitation by reference.

QTY UNIT COMMODITY/PRODUCT

CODE

DESCRIPTION UNIT PRICE EXTENSION

1 1 EA KODAK; I5250; DOCUMENT

SCANNER; 150 PPM DUPLEX;

3 MONTH WARRANTY

2 1 EA KODAK; I52X0; CARE KIT; 9

MONTHS EXT. WARR; SBD

SERVICE WINDOW; 1 PMS

PER YR

3 1 EA TUNGSTEN; VRS; ELITE

PRODUCTION

4 2 EA PROFESSIONAL SERVICES;

DAYS

5 1 EA TRADE IN CREDIT I5200V

Shipping: For the purposes of this solicitation, only bid responses quoting Free on Board (F.O.B) Destination Freight Prepaid will be accepted. F.O.B. Destination Freight Prepaid — Title to product remains with vendor until delivered to buyer in original condition. The vendor prepays the shipping charges and those costs are included in the unit price. See information in #6 above. (Also see “Ship To:” and “Delivery” on page one for additional shipping instructions.) INSIDE DELIVERY

REQUIRED.

Licenses to be (electronic delivery) emailed to software_dfpi@dfpi.ca.gov Total

Revised 09/18/25

Responsible Bidder: The Department of Financial Protection and Innovation may require bidder(s) to submit evidence of their qualifications at such times and under conditions, as it may deem necessary. The question of whether a particular bidder is a responsible bidder may involve an evaluation of the bidder’s experience, type of facility, expertise or financial resources regarding the particular items requested by the pertinent solicitation. If a bidder has been determined to be non-responsible, the bid shall be rejected.

New Equipment: All equipment to be provided in response to a State of California solicitation shall be new and latest model in current production. USED, SHOPWORN, DEMONSTRATOR, PROTOTYPE OR DISCONTINUED

MODELS ARE NOT ACCEPTABLE.

Payee Data Record: The successful bidder will be required to submit a Payee Data Record, STD. Form 204 listing their Taxpayer Identification Number.

Seller’s Permit: If applicable, please note that award will be conditional on providing the following document prior to award: You must provide your company’s California retailer’s seller’s permit or certification of registration and, if applicable, the permit or certification of all participating affiliates, issued by California’s State Board of Equalization (BOE), pursuant to all requirements as set forth in Sections 6487, 7101 and Sections 6452.1, 6487.3, 18510 of the Revenue and Taxation Code, and Section 10295.1 of the Public Contract Code.

California Disabled Veteran Business Enterprise (DVBE) Program Requirements:

DVBE PARTICIPATION REQUIREMENTS

The Department elects to waive the DVBE program requirements in this solicitation, but opts to include the DVBE Incentive. To be considered for the incentive, bidders must complete and return the Bidder Declaration GSPD-05- 105 (03/15), the DVBE Declarations, STD. 843 (5/2006), and signed, written confirmation (described below). The California DVBE Bid Incentive Instructions (09/03/09) include information about the DVBE incentive.

Supplier agrees to provide verification, in a form agreed to by the state, that DVBE subcontractor participation under this agreement is in compliance with the goals specified at the time of award of contract/purchase order, or with any subsequent amendment.

Small Business Regulations: The small business regulations, located in the California Code of Regulations (Title 2, Division 2, Chapter 3, Subchapter 8, Section 1896 et seq.), concerning the application and calculation of the small business preference, small business certification, responsibilities of small businesses, department certification, and appeals are revised, effective 09/09/04. The new regulations can be viewed at http://www.documents.dgs.ca.gov/pd/smallbus/SBRegulations.pdf. Access the regulations by clicking on “Small Business Regulations” in the right sidebar. For those without Internet access, a copy of the regulations can be obtained by calling the Office of Small Business and DVBE Services at (916) 375-4940.

Non-Small Business Subcontractor Preference: A 5% bid preference is now available to a non-small business claiming 25% California certified small business subcontractor participation. If applicable, claim the preference in the box on the right-hand side of the first page of this solicitation.

Declaration Forms: All bidders must complete the Bidder Declaration GSPD-05-106, attached and at Bidder Declaration , and include it with the bid response. When completing the declaration, bidders must identify all subcontractors proposed for participation in the contract. Bidders awarded a contract are contractually obligated to use the subcontractors for the corresponding work identified unless the State agrees to a substitution and it is incorporated by amendment to the contract.

Bidders who have been certified by California as a DVBE (or who are bidding rental equipment and have obtained the participation of subcontractors certified by California as a DVBE) must also submit a completed Disabled Veteran Business Enterprise Declaration form(s) STD. 843, attached and at DVBE Declarations . All disabled veteran owners and disabled veteran managers of the DVBE(s) must sign the form(s). The completed form(s) should be included with the bid response.

At the State’s option prior to award, bidders may be required to submit additional written clarifying information.

Failure to submit the required written information as specified may be grounds for bid rejection.

Shipping Instructions Department of Financial Protection and Innovation- MLSOC Office

651 Bannon Street, Suite #300 Sacramento, California 95811

+1 279-236-5390 (Receiving Staff Phone Number)

Regular Delivery

All deliveries must be made at the loading dock.

Loading dock access is available on the West Side of the complex.

Sacramento Receiving staff must be notified at least 24 hours prior to Delivery.

All shipments should be addressed to “DFPI – Receiving.”

Driver(s) must provide DFPI contact number: +1 279-236-5390 to the dock master.

Loading Dock hours are 8am-4pm.

Set-in-Place Delivery

All deliveries must be made at the loading dock.

Loading dock access is available on the West Side of the complex.

Sacramento Receiving staff must be notified at least 24 hours prior to Delivery.

All shipments should be addressed to “DFPI – Receiving.”

Driver(s) must provide DFPI contact number: +1 279-236-5390 to the dock master.

Loading Dock hours are 8am-4pm.

Pallet Jacks are required to have polyurethane wheels.

Elevator corner trim must be taped.

Masonite floor protection must be used on all stone tiles and carpet where applicable.

Walk-off plates must be provided to protect door and elevator thresholds.

Elevator blanket/pads must be in place if passenger elevators are reserved for moving. These are available through the building management offices. All elevators are equipped with blanket/pad hooks.

It is the Contractor’s responsibility to coordinate delivery with the DFPI regarding building requirements.

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number

Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

Department of Financial Protection and Innovation Business Operations Office

2101 Arena Boulevard (916) 576-3184

Sacramento CA 95834 jasmin.buada@dfpi.ca.gov

Print Form Reset Form

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section

6. Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification Number The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Section 4 – Payee Residency Status Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at time of death.

A trust is a resident if at least one trustee is a California resident.

o For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

Section 5 – Certification Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signee can provide a power of attorney documented for the individual.

Section 6 – Paying State Agency This section must be completed by the state agency/department requesting the STD 204.

Privacy Statement Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of this form.

STATE OF CALIFORNIA – DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

(Rev. /20 )

Instructions: The disabled veteran (DV) owner(s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment [Military and Veterans Code Section 999.2]. Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.

SECTION 1

Name of certified DVBE: DVBE Ref. Number:

Description (materials/supplies/services/equipment proposed):

Solicitation/Contract Number: SCPRS Ref. Number:__________________________

(FOR STATE USE ONLY)

SECTION 2

APPLIES TO ALL DVBEs. Check only one box in Section 2 and provide original signatures.

I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2 (b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.

Pursuant to Military and Veterans Code Section 999.2 (f), I (we) declare that the DVBE is a broker or agent for the principal(s) listed below or on an attached sheet(s). (Pursuant to Military and Veterans Code 999.2 (e), State funds expended for equipment rented from equipment brokers pursuant to contracts awarded under this section shall not be credited toward the 3-percent DVBE participation goal.)

All DV owners and managers of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Owner/Manager) (Signature of DV Owner/ Manager) (Date Signed)

(Printed Name of DV Owner/Manager) (Signature of DV Owner/Manager) (Date Signed)

Firm/Principal for whom the DVBE is acting as a broker or age nt:

(If more than one firm, list on extra sheets.) (Print or Type Name)

Firm/Principal Phone: Address:

SECTION 3

APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AND DECLARE THE DVBE IS NOT A BROKER.

Pursuant to Military and Veterans Code Section 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.

The undersigned owner(s) own(s) at least 51% of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsections (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax return(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections

(c) and (g), will result in the DVBE being deemed an equipment broker.

Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):

(Printed Name) (Signature) (Date Signed)

(Address of Owner) (Telephone) (Tax Identification Number of Owner)

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Manager) (Signature of DV Manager) (Date Signed)

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