RFQ 87470 Spring Mill SP PM HVAC Services.pdf

(rev 01/25)

STATE OF INDIANA

Request for Quotation SOLICITATION NO: 87470______

REQUEST FOR: Preventative Maintenance Services on HVAC Equipment_______________

REQUESTED BY: Spring Mill State Park ________________

REQUESTOR: Jen Reeves_________________________________________

PHONE: 317-232-4088__________________ EMAIL: JReeves@dnr.in.gov_______________

YOUR RESPONSE MUST BE RECEIVED BY: Monday 5/18/2026 at 10AM EDST_______________________________

GENERAL INFORMATION

The information below is provided to assist you in completing this request. Please note that these instructions may not contain all applicable requirements. Careful reading of this request is imperative. Failure to follow these instructions or those printed throughout this package could lead to rejection of your quotation. It is not necessary to return this page with your response.

• Type or print legibly in black ink all requested information, including prices and extensions, as well as accurate vendor information.

• Manually sign the Signature Page and Contract if applicable.

• E-mail your response to the Requestor listed above. (IF THE RESPONSE IS GREATER THAN $75,000, A MANUAL SIGNATURE IS REQUIRED, THEREFORE A

E-MAIL IS NOT ACCEPTABLE) AGENCY PERSONNEL ARE ONLY AUTHORIZED TO CONDUCT PURCHASES OF THIS DOLLAR AMOUNT ON

MAINTENANCE AGREEMENTS AND SOFTWARE LICENSES.

• Do not add any contractual or payment terms and conditions. Terms and conditions of the award will be those listed in this request package and the resulting

Purchase Order only.

• If you are not eligible to claim the Recycled Preference but are offering recycled content products, please list the percentage of content for EACH LINE ITEM and provide manufacturer certification.

• If you are not willing to accept a split award (partial order), your response must include the statement, “Bidding all or none.”

• Your response must be received by the requested date and time indicated.

• If you have questions regarding this request, contact the requestor listed above.

Bidders are not required to be registered with the Procurement Division to respond to a solicitation. If your quotation is recommended for an award, you will be notified of the registration requirements. You will have five (5) days from the date of notification to complete the registration requirements, or the recommended award will be canceled. To register electronically, visit http://www.in.gov/idoa/2464.htm .

https://protect.checkpoint.com/v2/___http:/www.in.gov/idoa/2464.htm___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2Ojk4YTQ6OTI2YTZiYjhkYTFhOTg0YzFlZDVlMjFiNDJlNmE0ZDI5YzU4OWI0ZDU5YzY0ZmI0OGY1ZmFkOTViMmY1YmUyZjpwOlQ6Tg

Event Description

RFQ# 0030087470

Sourcing event 0030087470 is for obtaining bids for Preventative Maintenance Services on HVAC Equipment at Spring Mill State Park.

If you are viewing this event through the Bidder Portal, please be sure to check https://www.in.gov/idoa/procurement/current-business-opportunities/ for additional details and documents related to this event.

Completed bids must be emailed to Jen Reeves at JReeves@dnr.in.gov or faxed to 317-972-3275. Attn: Jen Reeves.

A completed bid package MUST be submitted by the Response Due By date/time.

The bid package is available for download through the Bid Documents link in the Event Name column. This bid is not eligible for electronic bid through the Supplier Portal. To allow for sufficient processing time in compliance with Indiana State law, all quoted prices offered to the State under this Event must be valid for thirty (30) calendar days after the Response Due By date/time. Pricing must include all applicable charges, fees, and shipping. All questions must be submitted to JReeves@dnr.in.gov no less than 7 days before bidding ends.

General Comments

- This is a request to establish a Contractual Agreement for HVAC Equipment Preventative Maintenance Services. Contract commencing 06/01/2026 or from date of last State signature, whichever is later and ending 05/31/2027 or one year after the State's last signature, whichever is later. By mutual consent of both parties, contract may be renewed. The term of the contract, including any renewals, may not exceed four (4) years. Prices may be listed in the unit requested (per Service). Prices listed above and beyond what is requested shall not be considered and shall be reason to reject bid/quote. Prices must be inclusive of all applicable charges.

Event Details

Bidder: INTERNAL EVENT DETAILS

Submit To: Natural Resources Indiana Dept of Natural Resources Purchasing

402 W WASHINGTON ST RM W265

INDIANAPOLIS IN 46204

United States

Contact: Jen Reeves - 00300 Phone: 317/232-4088 Email: JReeves@dnr.IN.gov

State of Indiana Request for Quotation Event ID Format Type Page 00300-0000087470 Buy RFx 1 Event Name 300 SP Spring Mill HVAC Preventative Maintenance Start Time Finish Time

04/14/2026 12:39:23 EDT 05/18/2026 10:00:00 EDT

Line Details No Bid:

Response Comments

Bidder Information Firm Name:

Name: Signature: Date:

Phone #: Fax #:

Street Address:

City & State: Zip Code:

Email:

Exhibit A

** Apply Pricing to Highlighted Sections on Exhibit A Pages 3, 5, and 6 **

***FOR PREVENTATIVE MAINTENANCE SERVICES ONLY-NOT FOR SYSTEM REPAIRS***

2026 HVAC AND PLUMBING EQUIPMENT

INSPECTION AND MAINTENANCE SCOPE OF WORK

Contractor shall provide a monthly inspection and scheduled maintenance; listed in the Scope of Work, to all HVAC and Plumbing equipment; listed in Schedule A, according to the terms and conditions herein to (hereafter refer to as Customer). Technicians used on-site must be certified for service of AAON and Daikin equipment located at Spring Mill Inn, Spring Mill State Park.

**Contractor must have access to the AAON service tool and software first day of contract and maintain access through the length of the contract.

Contractor must have access to a Daikin Service Checker tool and software first day of contract and maintain access through length of the Contract.**

A. Contractor shall:

1. Perform scheduled maintenance and inspection as outlined in this Scope of Work.

2. Scheduled maintenance and inspection shall be on only equipment listed in Schedule A.

3. Furnish Customer with a written report of each inspection and of any conditions which require repairs or corrective action. If authorized by the Customer, contractor will make the needed repairs at the Customer service rate listed in the Scope of Work.

4. Provide filters as listed in Schedule A for a monthly change.

5. Perform scheduled maintenance and inspection functions as a part of the Scope of Work fee to include:

Monthly Inspection Items – 1 On-site visit per month:

Check in with onsite contact Connect software to VRV system, complete visual inspection of all systems checking system for alarms, error codes, and proper system operation Complete visual inspection of all condensers and fluid cooler, check coils for debris, light cleaning as needed Complete visual inspection of Air Handlers, checking coils, replacing filters, and checking operation of heat recovery wheels Complete visual inspection of mechanical room equipment including boilers, hydronic pumps, water heaters, expansion tanks and system gauges Report and provide list of recommended repairs, actions, suggestions for improved equipment operation, efficiency, and dependability

Quarterly Inspection Items– (January, April, July, October) In Conjunction with Monthly Inspection items:

• Daikin VRV System

Collect and record (1) hour of operational data, using Daikin Service Checker software, for monitoring equipment operation and active system errors

Analyze data and confirm proper operation of all systems Confirm that all indoor units and heat recovery boxes are communicating Check high and low refrigerant pressures Check to ensure calibration of all EEV/LEV valves

Exhibit A Page 2

Confirm proper sub cooling and super heat Confirm proper discharge super heat Confirm proper Hex temperatures and refrigeration flow Check that all oil indicators are working Confirm operation of reversing valves Confirm operation of crank case heaters Check range of all thermistors Check unit for voltage and phase imbalance Check all electrical connections Clean Condenser Coils

• AAON Condensers Clean Condenser Coils

• Indoor Units Check pipe in/out temperatures Confirm Sub Cooling/Super heat in correct range on all indoor units

• Controls Connect to BMS system to monitor room set point vs. actual temperatures Retain BMS provider to ensure system will receive updates throughout length of contract.

BMS provider will provide visits to meet with staff and check the BMS system two times per year.

• Air Handler 145 Clean evaporator coil, reheat and aux. heat coil

• Water Softeners Check salt level Check overall condition

*Spring Inspection Items – To be completed in conjunction with April Onsite Visit

• Indoor Cassette, wall mounted, and floor concealed units – A client representative will be required to accompany Contractor personnel in all occupied rooms

Complete a visual inspection of all cassette units Pull and wash indoor cassette and wall mounted unit filters Check Evaporator coil for dust, dirt, and debris All Evaporator Coil cleanings will need to be client approved and billed in addition to this contract at a rate of $__________ per Evaporator Coil X 29 Evaporator Coils

Check condensation drain line on all wall mounted units for proper drainage Remove and clean condensate drain pan on all cassette and ducted units

Exhibit A page 3

Check thermostats for proper operation Check for all electrical connections Test and check all refrigerant monitors for proper operation

• Air Handling Units Check amp draw on all fan motors Check electrical connections on all VFD’s, blow out with compressed air Check operation of dampers, if applicable Check condensation drain piping for proper drainage, add algae tablets Check and adjust, as needed, all safety controls Check and adjust, as needed, all operating controls Check condition of evaporator coils and heat coils and reheat coils as applicable Check electrical connections on AHU integration kits

• AAON Condensing Units Clean condenser coils Check electrical connections Check and adjust, as needed, all safety controls Check and adjust, as needed, all operating controls Lubricate applicable bearings and motors

• Ducted VRV units Check and adjust, as needed, all safety controls Check and adjust, as needed, all operating controls Check all electrical connections

• Gas Water Heaters Check water heater gas connections Check condensate drain, replace condensate neutralizers Check operation Check electrical Check for leaks on tank Check expansion tank pressure

• Exhaust Fans Check belts, if applicable Check balance to avoid vibration Grease and lubricate bearings Clean and check for grease buildup Check amp draw on motors

Exhibit A Page 4

*Fall Inspections – To be completed in conjunction with October Onsite Visit

• Indoor Cassette, wall mounted, and floor concealed units – A client representative will be required to accompany Contractor personnel in all occupied rooms

Complete a visual inspection of all cassette units Pull and wash indoor cassette and wall mounted unit filters Check Evaporator coil for dust, dirt and debris All Evaporator Coil cleanings will need to be client approved and billed in addition to this contract at a rate of $___________ per Evaporator Coil X 29 Evaporator Coils =$__________________ check condensation drain line on all wall mounted units for proper drainage

Remove and clean condensate drain pan on all cassette and ducted units Check thermostats for proper operation Check all electrical connections Test and check all refrigerant monitors for proper operation

• Air Handling Units Check amp draw on all fan motors Check electrical connections on all VFD’s, blow out with compressed air Check operation of dampers, if applicable Check condensation drain piping for proper drainage, add algae tablets Check and adjust, as needed, all safety controls Check and adjust, as needed, all operating controls Check condition of evaporator coils and heat coils and reheat coils as applicable

• Ducted VRV units Check and adjust, as needed, all safety controls Check and adjust, as needed, all operating controls Check all electrical connections

• AAON Condensing Units Clean condenser coils Check electrical connections Check and adjust, as needed, all safety controls Check and adjust, as needed, all operating controls Lubricate applicable bearings and motors

• Boilers Test the low water level cut off Test the manual reset high temperature limit Test the low gas pressure switch Test operating controls Check the combustion chamber Inspect burners for any signs of deterioration or corrosion, inspect combustion chamber Inspect and clean as needed copper finned tube heat exchanger Replace ignition electrode and gasket Inspect venting system Check gas connections and fittings for leaks Perform combustion analysis Blow down stainers including AHU strainers

Exhibit A Page 5

Check expansion tank pressures Check air vent on top of hydraulic separator for proper operation Check glycol levels in loop

• Electric Hanging and Wall Heaters Check amp draw Check electrical connections Check fan operation

• Backflow Preventers Test backflow Update backflow inspection date Provide inspection paperwork to owner and water service provider

• Software Maintenance Quarterly visits to apply updates and perform ongoing staff training and system review Renew Software Maintenance Agreement with Tridium (This grants access to all updates released while SMA is active) Install and verify Niagara software updates

6. PM service activities will be completed according to schedule listed in “Exhibit A”

B. Excluded from this Scope of Work:

1. Parts, Material, glycol, and refrigerant needed for repairs.

2. Altering equipment from manufacturer’s recommendations.

3. Acts of God i.e., lightning, flood, wind, etc.

4. Belts if applicable

C. Customer Shall:

1. Provide access to the building and to the equipment to be serviced, and remove any fixtures, merchandise, walls, etc. necessary for the performance of work under this Scope of Work.

2. Operate covered equipment according to manufacturer’s recommendations.

3. Call only Contracted personnel to perform service on the covered equipment.

4. Make all payments in full when due.

D. Terms of Agreement:

1. Initial terms of this Agreement shall continue in force for a period of one (1) year with either party able to cancel with a thirty (30) day written notice. To not interrupt service, this Contract can be renewed on a year-to-year basis after the original term ends unless customer or Contractor gives the other written notice not to renew at least thirty (30) days prior to the end of the Agreement term. Billed quarterly; paid in arrears.

Quarterly Invoice Amount =$ _________________

TOTAL FOR ALL SERVICES=$_________________________

Exhibit A Page 6

SCHEDULE A - HVAC Contractor:

PeopleSoft Dept ID: 55781/55740 Address:

Property: Spring Mill State Park & Inn Phone/Fax:

Address: 3333 St. Rd. 60 E, PO Box 376, Mitchell, IN 47446 Contact name:

Phone/Fax: 812-849-3534 Email:

Property Mgr.: Mark Young Email: myoung@dnr.in.gov

Contractor Note: Please improve the accuracy of this equipment list as you progress through the year.

Qty of Devices

Location Building or Area

Location Inside Description Manufacturer Other Info

1 HRU 5 Inn Northside of building - Exterior VRV Emerion Daikin

1 HRU 4 Inn Northside of building - Exterior VRV Emerion Daikin

1 HRU 1 Inn Northside of building - Exterior VRV Emerion Daikin

REYQ216AAYDA

a) REYQ216AAYDA

b) REYQ216AAYDA

REYQ360AAYDA

a) REYQ192AAYDA

b) REYQ168AAYDA

RXYQ312XAYDA

a) RXYQ168XAYDA

b) RXYQ144XAYDA

1 Inn 4 port branch box Daikin

2 Inn 6 port branch box Daikin

2 Inn 8 port branch box Daikin

5 Inn 10 port branch box Daikin

3 Inn 12 port branch box Daikin

1 Inn 0.5 Ton wall mounted unit Daikin

36 Inn 0.75 Ton wall mounted unit Daikin

36 Inn 1 Ton wall mounted unit Daikin

5 Inn 1.5 Ton wall mounted unit Daikin

2 Inn 0.5 Ton one way cassette Daikin

7 Inn 1 Ton one way cassette Daikin

1 Inn 0.75 Ton Vista 2x2 cassette Daikin

1 Inn 2.5 Ton Round flow sensing cassette Daikin

1 Inn 1.0 Ton Ceiling suspended unit Daikin

3 Inn 8.0 Ton Concealed Ceiling Unit Daikin

4 Inn 2.0 Ton Concealed Floor Standing Unit Daikin

1 Inn 1.5 Ton MSP Concealed ducted unit Daikin

2 Inn 2.0 Ton MSP Concealed ducted unit Daikin

3 Inn 3.0 Ton MSP Concealed ducted unit Daikin

1 Inn 4.0 Ton MSP Concealed ducted unit Daikin

1 Inn 4.5 Ton MSP Concealed ducted unit Daikin

105 Inn Wall controllers Daikin

1 Inn AHU-245 AHU integration kit Control box Daikin

1 Inn AHU-245 AHU integration kit Expansion valve Daikin

AHU 245

1 Inn Mechanical Room Expansion Tank Grundfos

1 HPU 8 Inn Northside of building - Exterior

VRV 4X Daikin

1 HRU 7 Inn Northside of building -

Exterior VRV Emerion Daikin

Magna3 100-120 GF 230V

Magna3 40-120 GF 230V

FXFQ30TVJU

FXHQ12MVJU

FXMQ96MVJU

FXNQ24MVJU9

FXSQ18TAVJU

FXSQ24TAVJU

2 HRU 2

& 3

Inn Northside of building -

Exterior VRV Emerion Daikin REYQ240AAYDA

1 HRU 6 Inn Northside of building -

Exterior VRV Emerion Daikin

Identification

REYQ144AAYDA

REYQ192AAYDA

REYQ192AAYDA

CAH017GHAC

2 Inn Mechanical Room Gas Fired Boilers

BSF10Q54TAVJ

P-K Thermific

BS4Q4TAVJ

BSF6Q54TVJ

BSF8Q54TVJ

BS12Q54TAVJ

FXAQ07PVJU

FXAQ09PVJU

FXAQ12PVJU

FXAQ18PVJU

FXEQ07PVJU

FXEQ12PVJU

FXZQ09TBVJU

Magna3 32-100 GF 115/230V

1 Inn Mechanical Room Doas 3

Hydronic Pump Grundfos Magna3 32-120 GF 115/230V

FXSQ36TAVJU

FXSQ48TAVJU

FXSQ54TBVJU

MADOKA

EKEQMBA V3-US

EKEXV

Inn Basement NW corner/ Pool Mech.

AHU Daikin

Mechanical Room Doas 1

Hydronic Pump Grundfos

N2500-MFD

Ser. #GY38-23-43435

Ser. #GY38-23-43436

GNLA-300

2 Inn Mechanical Room Boiler Pump 1&2

Hydronic Pump Grundfos

1 Inn

1 Inn Mechanical Room Doas 2

Hydronic Pump Grundfos

Schedule A 779 012907 HVAC Page 1

Exhibit A Page 7

AHU-145

Doas 1 Inn 4th floor East Attic AHU AAON

Doas 2 Inn 5th floor Attic AHU AAON

Doas 3 Inn 4th floor West Attic AHU AAON

Doas 4 Inn Basement SW corner AHU AAON

Doas 4 Inn West side of building-ExteriorCondensing Unit AAON

20 Inn Hight output wall heaters Q Mark

14 Inn Horizontal/Vertical Unit Heaters Q Mark

2 Inn Draft Barrier Convection Heaters Q Mark

2 Inn Draft Barrier Convection Heaters Q Mark

4 Inn Draft Barrier Convection Heaters Q Mark

EF-1

EF-2

EF-3

KEF-1

1 Inn Mechanical Room Mixing Valve Lawler

4 Inn Boiler Room 130 gal. water heaters AO Smith

4 Inn Mechanical Room 4.5 gallon Watts

1 Inn Kitchen 1/2" backflow Zurn/Wilkens

M# 375XL/Ser.AKE8753

Ser. AKE8765

1 Inn 1st floor East Wing 3/4" backflow Zurn/Wilkens

1 Inn Boiler Room Water Softner Aqua Systems, System, Timer, Resin Tanks

Both tanks have same #

1 Inn Dry Goods Room Ptac unit

2 Inn Laundry Room 2" backflow Zurn/Wilkens

PLT-12-M1

M# 375 XL/Ser.AJAI0468

1 Inn 3rd floor East Wing Ice Machine

3/4" backflow Zurn/Wilkens

Inn 4th floor West Attic Mixed Flow Fan Greenheck QEI-22-300-75-G

Inn Mech. Room Boiler Makeup

1" backflow Zurn/Wilkens

Inn 1st Floor Hallway Ceiling

Ceiling Greenheck SP-B200

Inn Laundry Room Mixed Flow Direct Drive Greenheck QEID-12-300-100-M50-X

Inn Laundry Room Direct Drive Centrifugal inline fan Greenheck SQ-90-VG1X-QD

M# 375XL/Ser. AJAV9547

M# 375XL/Ser. AJAE9363

Model 803

M# 375XL/Ser. AJAW8873

Model:2900NT14DXSF1500HL Serial: 180130223369

M# 375XL/Ser. AJAW8859

BTH-199 300 S# 2308132987209, S#

2231130476690, S# 2330135085274, S#2308132975377

V3-ELB-3-0-162C-12H

CFA-050-D-A-3-GJ00L

SSAR1802

Doas 3 Inn Northside of building - Exterior

Condensing Unit AAON CFA-003-A-A-3-DJ00H

Northside of building - Exterior

Doas 2 Inn Condensing Unit AAON CFA-007-A-A-3-DJ00H

Inn Basement NW corner/ Pool Mech.

AHU Seresco NE-214-NS-I-G3NT5452W2E3AN3H

Doas 1 Inn Northside of building - Exterior

Condensing Unit AAON CFA-015-B-A-3-DJ00N

1 Inn Northside of building - Exterior

Fluid Cooler Seresco NG-V-12-EUHSM1-V

H3-CRB-3-0-162C-12H

MUH0571

SLQDB04

Grundfos1 Inn Mechanical Room Doas 4

H3-BLB-3-0-161C-12H

H3-BRB-3-0-141D-12H

SLQDB06

SLQDB10

1 Inn 2nd floor East Wing Ice Machine

3/4" backflow Zurn/Wilkens

Grundfos Magna3 40-120 GF 230V

Hydronic Pump Magna3 65-150 GF 230V

2 Inn Mechanical Room AHU 245 and 145

Hydronic Pump

Schedule A 779 012907 HVAC Page 1

Exhibit A Page 8

Solicitation #:_87470_________

TERMS AND CONDITIONS

1. ACKNOWLEDGMENT: This Agreement contains the complete and final Agreement between the State and the Contractor and no other Agreement in any way modifying any of said terms and conditions will be binding upon the State or the Contractor unless made in writing and signed by the State's and the Contractor's authorized representative.

2. PRICING: Unit price must be entered and extended, and the total price of the solicitation must be shown. If there is an error between the unit price and total price, the unit price shall prevail.

Awarded Prices: Prices listed for each item are firm and cannot be changed. Any revision in price may be rejected at the discretion of the IN Dept. of Administration, and may result in cancellation of the Purchase Order without recourse on the part of the awarded Contractor.

3. TERMINATION FOR CONVENIENCE: This Agreement may be terminated, in whole or in part, by the State whenever, for any reason, the State determines that such termination is in the best interest of the State. Termination shall be affected by delivery to the Contractor of a Termination Notice at least thirty (30) days prior to termination effective date, specifying the extent to which performance of services under which such termination becomes effective. The Contractor shall be compensated for performance prior to the notice date of termination but in no case shall total payment made to Contractor exceed the original Agreement price due on Agreement. No price increase shall be allowed on individual line items if canceled only in part.

4. FUNDING CANCELLATION: When the Director of the State Budget Agency makes a written determination that funds are not appropriated or otherwise available to support continuation of performance of this Agreement, this Agreement shall be canceled. A determination by the Budget Director that funds are not appropriated or otherwise available to support continuation of performance shall be final and conclusive.

5. INSURANCE: If this Agreement provides for work to be performed by the Contractor for the State, the Contractor shall be responsible for providing all necessary unemployment and workers’ compensation, insurance for the Contractor’s employees and liability and property/casualty insurance, as required by the State. Upon request, the Contractor shall furnish a certificate of insurance showing coverage acceptable to the State.

6. DELIVERY: Delivery must be made at time agreed upon. If any indicated or actual delays arise, the using agency must be notified immediately, in writing, with the cause for such delay stated. If any goods are not delivered within the time specified on the Purchase Order, or within a reasonable time not exceeding 30 days after receipt of a Purchase Order if no time is specified, the using agency may refuse to accept such goods, and this Agreement may be cancelled. Each package shall be numbered and labeled with the State's Purchase Order number, contents and weight, and shall contain an itemized packing slip and be properly packed for shipment.

7. QUANTITY: Goods shipped in excess of quantity designated in the Purchase Order may be returned at the Contractor’s expense.

8. COMPLIANCE WITH SPECIFICATIONS: The goods and/or services shall conform strictly to the specifications, drawings, or samples specified or furnished in connection with the bid/quote, all of which are incorporated herein. The Contractor warrants all goods and/or services delivered to be free from defects of material or workmanship. This warranty shall survive any inspection, delivery, acceptance, or payment by the State of the goods and/or services. Inspections shall be on the State's premises unless otherwise specified. The State shall have the right to reject and return at the Contractor's expense, or to require at the Contractor's expense, the correction or replacement of materials, workmanship, or services which are defective or do not conform to the requirements of the Purchase Order.

9. WARRANTY: The Contractor will furnish all parts and maintenance at no charge for a period of at least 90 days or the manufacturer’s standard warranty, whichever is longer, provided that such maintenance and parts are not required because of accident, neglect, misuse, or force majeure event. Contractor shall be responsible for removal and/or disposal of all replaced parts. Prior to the expiration of the warranty period, whenever equipment is shipped for a mechanical replacement purpose, the Contractor shall bear all cost of such shipment including, but not limited to, cost of packing, transportation, rigging drayage, and insurance. All replacements shall be covered by a new warranty.

10. INTELLECTUAL PROPERTY DEFENSE: The Contractor shall, at its own expense, defend, indemnify and hold harmless the State with respect to any claims that the goods and/or services furnished under this Agreement violates any third-party intellectual property rights including, but not limited to, patents, copyrights, trademarks and trade secrets

11. PAYMENTS: All payments shall be made in arrears in conformance with State fiscal policies and procedures and, as required by IC4-13-2-14.8, by electronic funds transfer to the financial institution designated by the Contractor in writing unless a specific waiver has been obtained from the Auditor of State. No payments will be made in advance of receipt of the goods or services that are the subject of this Agreement except as permitted by IC 4-13-2-20.

12. COMPLIANCE WITH LAWS: The Contractor agrees to comply with all applicable federal, state, and local laws, rules, regulations, or ordinances, and all provisions required thereby to be included herein are hereby incorporated by reference. The enactment of any state or federal statute or the promulgation of regulations thereunder after execution of this Agreement shall be reviewed by the State and the Contractor to determine whether the provisions of this Agreement require formal modification.

13. COMPLIANCE WITH TELEPHONE SOLICITATIONS ACT: As required by IC 5-22-3-7, the Contractor and any principals for the Contractor certify that (A) the Contractor, except for de minimis and nonsystematic violations, has not violated the terms of (i) IC 24-4.7 [Telephone Solicitation of Consumers], (ii) IC 24-5-12 [Telephone Solicitations], or (iii) IC 24-5-14 [Regulation of Automatic Dialing Machines] in the previous three hundred sixty-five (365) days, even if IC 24-4.7 is preempted by federal law; and (B) the Contractor will not violate the terms of IC 24-4.7 for the duration of the Agreement, even if IC 24-4.7 is preempted by federal law. The Contractor and any principals of the Contractor certify that an affiliate or principal of the Contractor and any agent acting on behalf of the Contractor or on behalf of an affiliate or principal of the Contractor: (A) except for de minimis and nonsystematic violations, has not violated the terms of IC 24-4.7 in the previous three hundred sixty-five (365) days, even if IC 24-4.7 is preempted by federal law; and (B) will not violate the terms of IC 24-4.7 for the duration of the Agreement, even if IC 24-4.7 is preempted by federal law.

14. NONDISCRIMINATION: Pursuant to IC 22-9-1-10 and Civil Rights Act of 1964, the Contractor and its Agents, if any, shall not discriminate against any employee or applicant for employment, to be employed in the performance of this Agreement, with respect to hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment, because of race, religion, sex, disability, national origin, ancestry or status as a veteran. The Contractor, and its subcontractor(s), if any, shall comply with all applicable affirmative action reporting requirements.

Breach of this covenant may be regarded as a material breach of this Agreement. The Contractor shall comply with Section 202 of Executive Order 11246, as amended, 41 CFR 60-250, and 41 CFR 60-741, as amended.

15. DRUG-FREE WORKPLACE CERTIFICATION: As required by Executive Order No. 90-5, the Contractor hereby covenants and agrees to make a good faith effort to provide and maintain a drug-free workplace. The Contractor will give written notice to the State within ten (10) days after receiving actual notice that the Contractor or an employee of the Contractor in Indiana has been convicted of a criminal drug violation occurring in the Contractor’s workplace.

16. TAXES: Prices listed on an invoice submitted by the Contractor for payment is not to include any tax for which the State is exempt. The State will furnish a tax exempt certificate, if requested by the Contractor. The State will not be responsible for any taxes levied on the Contractor as a result of this Agreement.

17. FORCE MAJEURE: In the event that either party is unable to perform any of its obligations under this Agreement, or to enjoy any of its benefits, because of natural disaster or decrees of governmental bodies not the fault of the affected party (“Force Majeure Event”), the party who has been so affected shall immediately give notice to the other party and shall do everything possible to resume performance. Upon receipt of such notice, all obligations under this Agreement shall be immediately suspended. If the period of nonperformance exceeds thirty (30) days from the receipt of notice of the Force Majeure Event, the party whose ability to perform has not been so affected may, by giving written notice, terminate this Agreement.

18. GOVERNING LAWS: This Agreement shall be construed in accordance with and governed by the laws of the State of Indiana and suit, if any, must be brought in the State of Indiana.

19. INFORMATION TECHNOLOGY ENTERPRISE ARCHITECTURE REQUIREMENTS: If Contractor provides any information technology related products or services to the State, Contractor shall comply with all Indiana Office of Technology (IOT) standards, policies, and guidelines, which are online at http://iot.in.gov/architecture/. Contractor specifically agrees that all hardware, software, and services provided to or purchased by the State shall be compatible with the principles and goals contained in the electronic and information technology accessibility standards adopted under Section 508 of the Federal Rehabilitation Act of 1973 (29 U.S.C. 794d) and IC 4-13.1-3. Any deviation from these architecture requirements must be approved in writing by IOT in advance. The State may terminate this Agreement for default if Contractor fails to cure a breach of this provision within a commercially reasonable time.

https://protect.checkpoint.com/v2/___http:/iot.in.gov/architecture/___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmU5ODY6MTc4NTEzMmNhODcyZDljZjkwYTliMTA0ZTU5ZGJlNzQ1ZTJhMDUxNjRlZWEzOTFhNjI4NGI1N2RiMzY4MDg3YTpwOlQ6Tg

Solicitation #:_87470________

CLAIMING PURCHASING PREFERENCES

Each bidder should review the various procurement preferences allowed by State statute. A summary of the preferences can be under Programs and Preferences located at: https://www.in.gov/idoa/3106.htm.

Each bidder must answer the following questions pertaining to purchasing preferences. No preference will be applied unless these questions have been answered and any required attachments included.

1. Are you claiming the U.S. Manufactured Product Preference (IC 5-22-15-21)

This is per individual line and should be noted below Yes _____ No _____

Vendor must provide information at the individual line level in regards to this preference...If yes, the bidder is certifying under penalties of perjury that each of the bidder’s end products, except those listed under the Exceptions section, is a U.S.

Manufactured Product as described in IC 5-22-15-21. A product is manufactured in the United States, if the cost of its components mined, produced, or manufactured in the United States exceeds 50% of the cost of all its components. (In determining if a product is manufactured in the United States, only the product and its components shall be considered.)

Please list what line items this preference will apply to:

2. Are you claiming the Preference for Steel Products (IC 5-22-15-25) Yes ___ No ___

3. Are you claiming the Preference to Coal Mined in Indiana (IC 5-22-15-22) Yes ___ No ___

4. Are you claiming the Indiana Business Preference (IC 5-22-15-20.5) Yes ___ No ___

Indicate under which provision for which you are claiming to qualify as an Indiana business, fully complete the Indiana Economic Impact Form (State Form # 51778, and include it with your bid/proposal. Vendors who wish to claim one of the Buy Indiana preferences below, must register from https://www.in.gov/idoa/2467.htm. Click on the Supplier Portal Login link, to register and/or update an existing registration. Indicate interest in learning if the business qualifies for Buy Indiana. Upon answering YES, look for more information via email. Respondents may only select one category as shown below.

Indicate your selection by clicking the check box next to the certification paragraph. Supporting documents may be required. They should be uploaded so the certification team can review. Once this is complete, save your selection and exit your account.

Approval will be documented by a system generated notification sent to the point of contact email address provided within the Bidder Registration profile. This is to be attached as a screenshot (copied/pasted) for response evaluation. If this document cannot be provided, affirm Buy IN status in a letter, on company letterhead. Provide sufficient detail so the State can confirm approval of the entity. Buy IN must be affirmatively claimed and documentation submitted per RFQ instructions.

_____ (1) A business whose principal place of business is located in Indiana.

_____ (2) A business that pays a majority of its payroll (in dollar volume) to residents of Indiana.

_____ (3) A business that employs Indiana residents as a majority of its employees.

_____ (4) A business that makes significant capital investments in Indiana.

Any company that can demonstrate a minimum capital investment of $5 million or more in plant and/or equipment or annual lease payments of $2.5 million or more shall qualifies as an Indiana business under category #4.

_____ (5) A business that has a substantial positive economic impact on Indiana.

Any company that is in the top 500 companies (adjusted) for one of the following categories: number of employees (DWD), unemployment taxes (DWD), payroll withholding taxes (DOR), or Corporate Income Taxes (DOR); qualifies as an Indiana business under category #5.

5. Are you claiming the Indiana Manufactured Preference (IC 5-22-15-20.5) Yes ___ No ___

This preference may only be claimed by respondents who claim the Indiana Business Preference.

Submit necessary documentation detailing a substantial amount of manufacturing, assembly, or production of the products proposed is in the State of Indiana.

6. Are you claiming the preference for supplies that contain recycled or post-consumer materials (IC 5-22-15-16) Yes ___ No ___

The preference does not apply when the purchase description is limited to a supply that contains recycled materials or post-consumer materials

If yes, a manufacturer’s certification must be submitted for each item or group of items for which the offeror is seeking a preference or the preference may not be considered.

https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/3106.htm___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OjRiZWQ6MjdhODBmYTU1ODU3MTNhYWVkYjM0ZWViMTZhZTM0ZmM0ZGYyNDc3YjUyYmM4Yzg5MzhhNTUwNTY1MjNmNmUwMTpwOlQ6Tg https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/2467.htm___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OjQ4Yzc6Mjk5NDA2NTYyMzk1MmVlMGI2NjUyY2ZmODJkMDk4NTE1YWVjYTZjMWZjY2FkYzIxN2YzYTg1MzFmNTcwNzBjNjpwOlQ6Tg

CLAIMING PURCHASING PREFERENCES continued

7. Are you claiming the preference for soybean oil based ink (IC 5-22-15-18) Yes ___ No ___

8. Are you claiming the preference for soy diesel/bio diesel (IC 5-22-15-19) Yes ___ No ___

9. Are you claiming the Indiana Small Business Preference (IC 5-22-15-23) Yes ___ No ___

If yes, bidder must indicate which category of small business concern applies:

___ Wholesale business with annual sales of four million dollars ($4,000,000) or less during its last fiscal year. “Wholesale business, means a business that derives its principal source of income (over 50% of gross revenues) from sales to retailers, other merchants, or industrial, institutional or commercial users who will use the goods for resale or business use. This definition distribution activities.

___ Service business with average sales of five hundred thousand dollars ($500,000) or less for the current and preceding three (3) fiscal years and which employs no more than twenty-five (25) persons. “Service business, “ means a business that derives its principal source of income (over 50% of gross revenues) from the sale of useful artistic, educational, intellectual, literary, or scientific labor from which no necessary tangible commodity is derived.

___ Retail business or business selling services with annual sales and receipts of five hundred thousand dollars ($500,000) or less.“Retail business,” means a business that derives its principal source of income (over 50% of gross revenues) from the sale of supplies to the ultimate consumer.

___ Manufacturing business, which employs no more than one hundred (100) persons. “Manufacturing business” means a business that derives its principal source of income (over 50% of gross revenues) from the sale of goods the firm produces at its own facility made from raw, unfinished materials, as distinguished from the final product.

___ A business in any of the following sectors is not a small business if it employees more than one hundred (100) persons or if its annual sales exceed 5 Million dollars ($5,000,000):

(A) Information Technology

(B) Life Sciences

(C) Transportation

(D) Logistics

___ A business that has a current verification as a veteran owned small business as defined by IC 5-22-14-3.5(a)(1-3).

10. Are you claiming the preference for Indiana farm products (IC 5-22-15-23.5) Yes ___ No ___

11. Are you claiming the preference for foods/beverages that contain high levels of calcium (IC 5-22-15-24) Yes ___ No __

12. Are you claiming the preference for Businesses providing specialized employee services (IC 5-22-15-26)?

Yes ___ No __ If yes, submit the completed Affidavit of Eligibility with solicitation response.

https://www.in.gov/idoa/procurement/supplier-resource-center/programs-and-preferences/preferences/ https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/procurement/supplier-resource-center/programs-and-preferences/preferences/___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OjE4M2U6ZGY4OTMxNDJmN2UwNjBjOWZlZTgyZjJkMWIwNmVjMzQ4ODIzYzM2MGVkM2UzMWMxMjgwYzc2NDQ3ODY2ZmM5ZjpwOlQ6Tg

SF47895 (ELEC1/12)

MINORITY & WOMEN'S BUSINESS ENTERPRISES SUBCONTRACTOR COMMITMENT

Indiana Code 4-13-16.5 and 25 IAC 5 governs the Division of Supplier Diversity program as it relates to the certification, oversight, and responsibilities around the certified Indiana Minority and/or Women Business Enterprises (MWBE). The contract goal for this solicitation is 8% Minority participation and 11% for Women participation.

If participation exists, the vendor must submit with its quote an MWBE Subcontractor Commitment Form. The entity must be on the State of Indiana Certified M/W/IVOSB list at https://www.in.gov/idoa/mwbe.

If participation is met through the use of vendors who supply products and/or services directly to the Respondent, the Respondent must provide a description of products and/or services provided that are directly related to this quote and the cost of direct supplies for this quote. Respondents must complete the Subcontractor Commitment Form in its entirety. The total amount proposed should match the amount entered on the Supplier Commitment form. The subcontractor commitment shall apply to the life of the contract including any time after the initial term.

A signed letter(s), on company letterhead, from the MBE(s) and/or WBE(s) must accompany the MWBE Subcontractor Commitment Form. Each letter shall state and will serve as acknowledgement from the MBE and/or WBE of its subcontract amount, a description of products and/or services to be provided on this project and approximate date the subcontractor will perform work on this contract.

Questions about those rules and requirements should be directed to: Division of Supplier Diversity at (317) 232-3061 or the Supplier Diversity website at https://www.in.gov/idoa/mwbe.

Prime Contractors must ensure that the proposed subcontractors meet the following criteria:

• Must be on the State of Indiana Certified M/W/IVOSB list at https://www.in.gov/idoa/mwbe, on or before the proposal due date.

• Prime Contractor must include with their proposal the subcontractor’s M/WBE Certification Letter provided by IDOA to show current status of certification.

• Each firm may only serve as one classification – MBE, WBE, or IVOSB (see Section 1.22).

• A Prime Contractor who is an MBE or WBE must meet subcontractor goals by using other listed certified firms. Certified

Prime Contractors cannot count their own workforce or companies to meet this requirement. See 25 IAC 5-6-2(d))

• Must serve a Valuable Scope Contribution (VSC). The firm must serve a value-added purpose on the engagement, as confirmed by the State.

• Must provide goods or services only in the industry area for which it is certified.

• Must be used to provide the goods or services specific to the contract.

• National Diversity Plans are generally not acceptable.

MINORITY & WOMEN’S BUSINESS ENTERPRISES SUBCONTRACTOR LETTER OF COMMITMENT

A signed letter(s), on company letterhead, from the MBE and/or WBE must accompany the MWBE Subcontractor Commitment Form.

Each letter shall state and will serve as acknowledgement from the MBE and/or WBE of its subcontract amount, a description of products and/or services to be provided on this project, and approximate date the subcontractor will perform work on this contract.

By submission of the proposal, the Respondent acknowledges and agrees to be bound by the rules and requirements of the State’s Division of Supplier Diversity. Questions about those rules and requirements should be directed to: Division of Supplier Diversity at

(317) 232-3061 or the Supplier Diversity website at https://www.in.gov/idoa/mwbe.

https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/mwbe___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmJkODc6MTAwZWM2ODkzMTIzYWVhYTZjN2FlNDBmM2E0NTc5MjIzN2QzNDNkZDU0NTc1YmFjMmM3NTU0Y2ExNDAxZDZjMTpwOlQ6Tg https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/mwbe___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmJkODc6MTAwZWM2ODkzMTIzYWVhYTZjN2FlNDBmM2E0NTc5MjIzN2QzNDNkZDU0NTc1YmFjMmM3NTU0Y2ExNDAxZDZjMTpwOlQ6Tg https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/mwbe___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmJkODc6MTAwZWM2ODkzMTIzYWVhYTZjN2FlNDBmM2E0NTc5MjIzN2QzNDNkZDU0NTc1YmFjMmM3NTU0Y2ExNDAxZDZjMTpwOlQ6Tg https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/mwbe___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmJkODc6MTAwZWM2ODkzMTIzYWVhYTZjN2FlNDBmM2E0NTc5MjIzN2QzNDNkZDU0NTc1YmFjMmM3NTU0Y2ExNDAxZDZjMTpwOlQ6Tg

STATE OF INDIANA MBE/WBE SUBCONTRACTOR COMMITMENT FORM

Quote Number:

TOTAL Quote AMOUNT:

Respondent Firm

Telephone Number

Address Fax Number

City/State/Zip Code

Email Address

Representative

Authorizing Signature

Date Printed Name and Title

Please check if additional forms are attached.

Page ________ of __________

FORM MUST BE COMPLETED IN ITS ENTIRETY WITH COMPLETED LETTERS OF COMMITMENT.

MBE Firm WBE Firm Company Name: Contact Person:

Address: E-mail:

Telephone Number:

Fax Number:

Sub-Contract Amount:

Sub-Contract Percentage of Total Quote:

Describe service/product to be provided. Include the applicable UNSPSC that applies to this commitment.

Provide approximate dates when Sub-Contractor will perform on this project:

MBE Firm WBE Firm

Fax Number:

INDIANA VETERAN OWNED SMALL BUSINESS ENTERPRISES SUBCONTRACTOR COMMITMENT

Indiana Code 4-13-16.5 and 25 IAC 5 governs the Division of Supplier Diversity program as it relates to the certification, oversight, and responsibilities around the certified Indiana Veteran Owned Small Business Enterprises (IVOSB). The contract goal for this solicitation is 3%.

If participation exists, the vendor must submit with its quote an IVOSB Subcontractor Commitment Form. The entity must be on the State of Indiana Certified M/W/IVOSB list at https://www.in.gov/idoa/mwbe.

If participation is met through the use of vendors who supply products and/or services directly to the Respondent, the Respondent must provide a description of products and/or services provided that are directly related to this quote and the cost of direct supplies for this quote. Respondents must complete the IVOSB Subcontractor Commitment Form in its entirety. The total amount proposed should match the amount entered on the Supplier Commitment form. The subcontractor commitment shall apply to the life of the contract including any time after the initial term.

A signed letter(s), on company letterhead, from the IVOSB(s) must accompany the IVOSB Subcontractor Commitment Form. Each letter shall state and will serve as acknowledgement from the IVOSB of its subcontract amount, a description of products and/or services to be provided on this project and approximate date the subcontractor will perform work on this contract.

Questions about those rules and requirements should be directed to: Division of Supplier Diversity at (317) 232-3061 or the Supplier Diversity website at https://www.in.gov/idoa/mwbe.

Prime Contractors must ensure that the proposed subcontractors meet the following criteria:

INDIANA VETERAN OWNED SMALL BUSINESS ENTERPRISES SUBCONTRACTOR LETTER OF COMMITMENT

A signed letter(s), on company letterhead, from the IVOSB must accompany the IVOSB Subcontractor Commitment Form. Each letter shall state and will serve as acknowledgement from the IVOSB of its subcontract amount, a description of products and/or services to be provided on this project, and approximate date the subcontractor will perform work on this contract.

By submission of the proposal, the Respondent acknowledges and agrees to be bound by the rules and requirements of the State’s Division of Supplier Diversity. Questions about those rules and requirements should be directed to: Division of Supplier Diversity at

(317) 232-3061 or the Supplier Diversity website at https://www.in.gov/idoa/mwbe.

• Must be on the State of Indiana Certified M/W/IVOSB list at https://www.in.gov/idoa/mwbe, on or before the proposal due date.

• Prime Contractor must include with their proposal the Subcontractor’s M/WBE Certification Letter provided by IDOA to show current status of certification.

• Each firm may only serve as one classification – MBE, WBE, or IVOSB (see Section 1.22).

• A Prime Contractor who is an MBE or WBE must meet Subcontractor goals by using other listed certified firms. Certified Prime Contractors cannot count their own workforce or companies to meet this requirement.

See 25 IAC 5-6-2(d))

• Must serve a Valuable Scope Contribution (VSC). The firm must serve a value-added purpose on the engagement, as confirmed by the State.

• Must provide goods or services only in the industry area for which it is certified.

• Must be used to provide the goods or services specific to the contract.

• National Diversity Plans are generally not acceptable.

https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/mwbe___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmJkODc6MTAwZWM2ODkzMTIzYWVhYTZjN2FlNDBmM2E0NTc5MjIzN2QzNDNkZDU0NTc1YmFjMmM3NTU0Y2ExNDAxZDZjMTpwOlQ6Tg https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/mwbe___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmJkODc6MTAwZWM2ODkzMTIzYWVhYTZjN2FlNDBmM2E0NTc5MjIzN2QzNDNkZDU0NTc1YmFjMmM3NTU0Y2ExNDAxZDZjMTpwOlQ6Tg https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/mwbe___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmJkODc6MTAwZWM2ODkzMTIzYWVhYTZjN2FlNDBmM2E0NTc5MjIzN2QzNDNkZDU0NTc1YmFjMmM3NTU0Y2ExNDAxZDZjMTpwOlQ6Tg https://protect.checkpoint.com/v2/___https:/www.in.gov/idoa/mwbe___.YzJ1OnN0YXRlb2ZpbmRpYW5hOmM6bzpkMTc5NGMwNmY3YzliYzBkMTQ1MGM5MzI5ZjQ4MjQyNTo2OmJkODc6MTAwZWM2ODkzMTIzYWVhYTZjN2FlNDBmM2E0NTc5MjIzN2QzNDNkZDU0NTc1YmFjMmM3NTU0Y2ExNDAxZDZjMTpwOlQ6Tg

STATE OF INDIANA IVOSB SUBCONTRACTOR COMMITMENT FORM

Quote Number:

TOTAL Quote AMOUNT:

Respondent Firm

Telephone Number

Address Fax Number

City/State/Zip Code

Email Address

Representative

Authorizing Signature

Date Printed Name and Title

Please check if additional forms are attached.

Page ________ of __________

FORM MUST BE COMPLETED IN ITS ENTIRETY WITH COMPLETED LETTERS OF COMMITMENT.

Fax Number:

Fax Number:

1 Legal Name of firm:

Address/City/State/Zip Code:

Telephone #/Fax #/Website:

4 Federal Tax Identification

Number:

5 State/Country of domicile/incorporation:

6 Location of firm's headquarters or principal place of business:

7 Name of parent company or holding company (if applicable):

8 State/Country of domicile/incorporation of company listed in #7:

9 Address of company listed in #7:

10 IN Department of Workforce Development (DWD) account number:

11 IN Department of Revenue (DOR) account number:

12 Number of Indiana resident employees per most recently completed IRS Form W-2 distribution:

Total number of employees per most recently completed IRS Form W-2 distribution:

14 Total amount of payroll paid to Indiana resident employees per most recently completed IRS Form W-2…