RFQ_Exhibit_B_-_Administrative_and_Legal_Forms.docx

FORM N – NON-COLLUSION DECLARATION

Team Member:

☐ Joint Venture ☐ Partnership - General ☐ Partnership - Limited ☐ Partnership - Association ☐ Limited Liability Company ☐ Other:

Year Established:

Federal Tax ID:

State of Incorporation:

Date of Incorporation:

California Department of Industrial Relations (DIR) Registration Number:

DUNS Number (if any):

Name of Chair or Chief Executive Officer:

Name of Chief Financial Officer:

Team Member Representative

Name:

Firm:

Address:

Email:

Phone:

Complete the following sections for entities comprising the Team Member, only needed if the Team Member is a Joint Venture or Partnership

Team Member 1 (Joint Venture or Partnership):

Firm (or other):

☐ Joint Venture ☐ Partnership - General ☐ Partnership - Limited ☐ Partnership - Association ☐ Limited Liability Company ☐ Other:

Roles:

☐ No

Contact Name:

Contact Address:

Contact Email:

Contact Phone:

Team Member 2 (Joint Venture or Partnership):

Firm (or other):

☐ Joint Venture ☐ Partnership - General ☐ Partnership - Limited ☐ Partnership - Association ☐ Limited Liability Company ☐ Other:

Roles:

Contact Name:

Contact Address:

Contact Email:

Contact Phone:

Team Member 3 (Joint Venture or Partnership):

Firm (or other):

☐ Joint Venture ☐ Partnership - General ☐ Partnership - Limited ☐ Partnership - Association ☐ Limited Liability Company ☐ Other:

Roles:

Contact Name:

Contact Address:

Contact Email:

Contact Phone:

Under penalty of perjury, I certify that the foregoing is true and correct, and that I am an Authorized Representative of the Team Member to which this form relates:

Signature:

Printed Name:

Title:

Date:

FORM F – BUSINESS ORGANIZATION

Page 1 of 2 Exhibit B – Administrative and Legal Forms [Instructions: Include a letter on Insurance Company letterhead as shown]

Transbay Joint Powers Authority 425 Mission Street, Suite 250 San Francisco, CA 94105

Re: Engineering, Design, and Construction Support Services for the Portal 10-UR Utility Relocation Project for Transbay Joint Powers Authority Letter of Intent to Issue Insurance

Dear Transbay Joint Powers Authority, We represent _________________________ (the Respondent) as _________________________’s insurance broker of record. We write in support of Respondent’s submission in response to the Transbay Joint Powers Authority’s (TJPA) Request for Qualifications to provide Engineering, Design, and Construction Consultant Services for the Portal 10-UR Utility Relocation Project.

We affirm that we have reviewed and understand the insurance requirements contained in the RFQ. We affirm that, if awarded the ultimate contract contemplated under this RFQ, Respondent will be able to fully comply with all insurance requirements as presented in this RFQ, for itself as well as for all of its subconsultants, for both onsite and offsite work.

Regards, Signature Name of Authorized Signatory Title Name of Insurance Company

FORM G – INSURANCE LETTER

Page 1 of 1 Exhibit B – Administrative and Legal Forms

[Instructions: Include financial statements prepared by a Certified Public Accountant, including all exhibits and notes, for the three most recently completed fiscal years]

FORM H – FINANCIAL STATUS

Page 1 of 1 Exhibit B – Administrative and Legal Forms Organizational conflict of interest means that because of other activities or relationships with other persons, a person is unable or potentially unable to render impartial assistance or advice to the TJPA, or the person's objectivity in performing work is or might be otherwise impaired, or a person has an unfair competitive advantage.

[Instructions: For each Team Member, include an organizational conflict of interest letter covering the items below]

1. Name of Team Member and name of the Respondent Team.

2. The name, address, telephone number, and federal taxpayer identification number, if applicable.

3. A description of the nature of the services rendered by or to be rendered on the Project or related thereto.

4. A statement of any past (within the past three years), present, or currently planned financial, contractual, organizational, or other interests relating to the performance of the Work of the Project.

a. For contractual interests, such statement must include the name, address, telephone number of the client or client(s), a description of the services rendered to the previous client(s), and the name of a responsible officer or employee who is knowledgeable about the services rendered to each client, if, in the three years preceding the date of the statement, services were rendered to the TJPA or any other client respecting the same subject matter of the Project, including planning, financing, and approvals. The client and contract number under which the services were rendered must also be included, if applicable.

b. For financial interests, the statement must include the nature and extent of the interest and any entity or entities involved in the financial relationship. For these and any other interests enough such information must be provided to allow a meaningful evaluation of the potential effect of the interest on the performance of the work of the Project.

5. A statement that no actual or potential conflict of interest or unfair competitive advantage exists with respect to the services to be provided in connection with the contract.

6. A signature by an authorized representative, including typed name, title, and date.

Failure to provide the required statement may result in a Respondent being determined ineligible for award. Misrepresentation or failure to report any fact may result in the assessment of penalties associated with false statements or such other provisions provided for by law or regulation.

FORM I – ORGANIZATIONAL CONFLICTS OF INTEREST

General

☐ No ☐ n/a If no, explain:

☐ No ☐ n/a If no, explain:

Business Matters

☐ No If yes, explain:

☐ No If yes, explain:

☐ No If yes, explain:

☐ No If no, explain:

☐ No If yes, explain:

☐ No If yes, explain:

☐ No If yes, explain:

☐ No If yes, explain:

☐ No If yes, explain:

Debarment, Suspension, and Other Responsibility Matters

"Principals," for the purposes of this certification, means officers; directors; owners; partners; and persons having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a subsidiary, division, or business segment, and similar positions).

The Signatory certifies, to the best of its knowledge and belief, that the Team Member and/or any of its Principals:

The Team Member shall provide immediate written notice to the TJPA if, at any time prior to contract award, the Team Member learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

Team Members may provide clarifying information regarding any of their responses on a separate page. The TJPA reserves the right to request additional information about any response. Failure of the Team Member to furnish a certification or provide such additional information as requested by the TJPA may render the SOQ being deemed nonresponsive.

Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by this provision. The knowledge and information of a Signatory is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

The certification of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Signatory knowingly rendered an erroneous certification, the TJPA may terminate the contract resulting from this solicitation for default.

Under penalty of perjury, I certify that the foregoing is true and correct, and that I am an Authorized Representative of the Team Member to which this form relates:

Signature:

Printed Name:

Title:

Date:

FORM J – CERTIFICATIONS AND QUESTIONNAIRE

Page 1 of 3 Exhibit B – Administrative and Legal Forms

49 U.S.C. Section 40118 41 CFR Part 301-10

Certificate of Compliance

The bidder or offeror hereby certifies that it will meet the requirements of 49 U.S.C. 40118 (the “Fly America” Act) in accordance with the General Services Administration's regulations at 41 C.F.R. Part 301-10. See Contract Appendix 7 – Federal Requirements for more information.

Date:

Signature:

Company Name:

Title:

Certificate of Non-Compliance

**If a foreign air carrier was used, the certification shall adequately explain why services by a U.S. flag air carrier was not available or why it was necessary to use a foreign air carrier.

The bidder or offeror hereby certifies that it cannot comply with the requirements of 49 U.S.C. 40118 (the “Fly America” Act) in accordance with the General Services Administration's regulations at 41 C.F.R. Part 301-10. See Contract Appendix 6 – Federal Requirements for more information.

Date:

Signature:

Company Name:

Title:

Explanation:

FORM K – FLY AMERICA CERTIFICATION

Page 1 of 1 Exhibit B – Administrative and Legal Forms The Consultant certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid 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 an agency, a member of Congress, an officer or employee of Congress, or an employee of a member 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.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for making lobbying contacts to 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.

(3) The Consultant shall require that the language of this certification be included in all Subcontracts, and that all subconsultants shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was 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. Section 1352 (as amended by the Lobbying Disclosure Act of 1995) and U.S. DOT regulations, “New Restrictions on Lobbying,” specifically 49 CFR 20.110. Pursuant to 31 U.S.C. 1352(c)(1)-(2)(A), any person who makes a prohibited expenditure or 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.

The Consultant certifies and affirms the truthfulness and accuracy of each statement of this certification and disclosure, if any. In addition, the Consultant understands and agrees that the provisions of 31 U.S.C. Section 3801 et seq., apply to this certification and disclosure, if any.

Date:

Consultant Name:

Authorized Representative Name:

Signature:

Title:

FORM L – NEW RESTRICTIONS ON LOBBYING CERTIFICATION

Page 1 of 1 Exhibit B – Administrative and Legal Forms [Instructions: If the Respondent is a joint venture, include a letter on the joint venturer’s letterhead as shown]

[DATE]

Transbay Joint Powers Authority 425 Mission Street, Suite 250 San Francisco, CA 94105

Re: The Engineering and Design Consultant for Utility Relocation for Transbay Joint Powers Authority Joint Venturer Joint and Several Liability Letter

Dear Transbay Joint Powers Authority, ________________________________________ (the Joint Venturer) agrees to be held jointly and severally liable for any and all of the duties and obligations of ________________________________________ (the Respondent) under the SOQ and, if awarded, under the Contract for the Engineering and Design Consultant for Underground Utility Project.

Regards, Signature Name and Title of Authorized Signatory Name of the Joint Venturer

FORM M – JOINT VENTURER JOINT AND SEVERAL LIABILITY LETTER

Page 1 of 1 Exhibit B – Administrative and Legal Forms The Respondent or Proposer declares:

· The SOQ or Proposal is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation.

· The SOQ or Proposal is genuine and not collusive or sham.

· The Respondent or Proposer has not directly or indirectly induced or solicited any other Respondent or Proposer to put in a false or sham Proposal.

· The Respondent or Proposer has not directly or indirectly colluded, conspired, connived, or agreed with any Proposer or anyone else to put in a sham bid, or to refrain from proposing.

· The Respondent or Proposer has not obtained information regarding any aspect of any other Respondent or Proposer’s SOQ or Proposal, designs, construction methodologies, pricing, strategies, or any related information.

· The Respondent or Proposer has not, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the Cost Proposal of the Respondent or Proposer or any other Respondent or Proposer, or to fix any overhead, profit, or cost element of the Cost or Price Proposal, or of that of any other Respondent or Proposer.

· All statements contained in the SOQ or Proposal are true.

· The Respondent or Proposer has not directly or indirectly, submitted its Cost Proposal or Price Proposal or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, to any corporation, partnership, company association, organization, bid or proposal depository, or to any member or agent thereof to effectuate a collusive or sham SOQ or Proposal, and has not paid, and will not pay, any person or entity for such purpose.

Any person executing this declaration on behalf of a Respondent or Proposer that is a corporation, partnership, joint venture, limited liability company, limited liability partnership, or any other entity, hereby represents that they have full power to execute, and does execute, this declaration on behalf of the Respondent or Proposer.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct:

Date:

Respondent Name:

Authorized Representative Name:

Signature:

Title:

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