RFQ_PACKET_214-343691_Power_Wheelchair_COMP.pdf

02/07/2025

REQUEST FOR QUOTE

RFQ # 214-343691

You are invited to review and respond to this Request for Quote (RFQ) for a Power Wheelchair to be picked up by a consumer located in Glendale, CA 91203. Therefore your facility must be situated within 20 miles driving distance to the end-user. In submitting your quote, you must comply with the Scope of Work and all instructions outlined in this RFQ and on the DR815.

Note: all agreements entered into with the State of California will include by reference General Terms and Conditions that may be viewed and downloaded at: http://www.dgs.ca.gov/pd. A hard copy can be provided by contacting the person listed below.

Questions regarding this RFQ may be submitted by email to the department contact noted below.

Any questions regarding this RFQ must be received NO later than Friday, February 141h by 4:00pm. Questions received after the due date and time will not be accepted.

To be considered, all pages must be completely received prior to the quote due date and time specified in this solicitation.

The RFQ Due Date and Time is:

FRIDAY, FEBRUARY 21ST BY 4:00PM

Quotes received after the due date and time will not be accepted.

ALL QUESTIONS AND RFQ RESPONSES MUST BE SUBMITTED TO:

Email: Bianca.Buenaventura@dor.ca.gov

ATTN: Bianca Buenaventura

Gavin Newsom, Governor

State of California Health and Human Services Agency

Department of Rehabilitation Contracts & Procurement Section

721 Capitol Mall 6th Floor, Sacramento, CA 95814 Office (916) 558-5680 Fax (916) 558-5681 http://www.dgs.ca.gov/pd

ATTACHMENT 1

Request for Quote (RFQ) Requirements

Scope of Work Provide with your RFQ response (DR815) a detailed description, specifications and model number(s) of the item(s) requested in the Scope of Work.

The requirements of SAM Chapters 4800 thru 5365.3, the Purchasing Authority Manual and the State Contracting Manual (SCM) Vol. 2 apply to this RFQ/purchase.

Freight/Shipping/Delivery Charges, Set Up and Training Include with response a detail price breakdown of all freight, shipping, delivery charges, set-up and training. An original receipt is required for any freight or shipping cost over $50.00.

Warranty Warranty information must be stated as a separate item in RFQ response.

Method of Award The award will be made to the lowest responsive and responsible bidder meeting all administrative and technical requirements, terms and conditions of this solicitation.

Responsive Bidder: A supplier provides a bid response that is compliant with solicitation requirements and indicates performance without material deviation from the terms and conditions of the proposed contract.

Responsible Bidder: A supplier who is responsible and submits a responsive bid is one who clearly indicates compliance without material deviation from the solicitation's terms and conditions and who possesses the experience, facilities, reputation, financial resources and other factors existing at the time of contract award.

Newly Manufactured Goods All Goods furnished under this RFQ/Contract shall be Newly Manufactured Goods unless specified otherwise in this RFQ; used or reconditioned Goods are prohibited.

Change Orders Any Purchase Order resulting from this quote may be amended, modified, or terminated at any time by mutual agreement of the parties in writing. Change orders amending, modifying or terminating the Purchase Order, including any modifications of the compensation payable, may be issued only by the Department of Rehabilitation Procurement Officer. All such change orders shall be in writing and issued only upon written concurrence of the supplier. Termination, as that term is used in this section, does not include termination for default of the supplier.

Bidder Declaration Requirements All bidders must complete the Bidder Declaration Form GSPD-05-105 (ATTACHMENT 2) and include it with the bid response. If a vendor utilizes a subcontractor(s) to provide services for this RFQ, the Vendor must identify any subcontractors on the GSPD-05-105 prior to services rendered. 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.

All bidders are required to provide CUF documentation using the State’s Master Bidder Declaration (GSPD-05-105) for purchases over $5,000. When completing the declaration, bidders must identify all SB and or DVBE subcontractors proposed for participation in the contract.

Bidders awarded a contract are contractually obligated to use the SB or DVBE subcontractor for the work identified unless the State agrees to a substitution. The DOR must be notified in writing that a substitution is requested and any substitution of a SB or DVBE firm must be approved by the State.

POST CONSUMER-RECYCLED CONTENT CERTIFICATION: The Bidder shall certify in writing under penalty of perjury, the minimum, if not exact, percentage of post -consumer material as defined in the Public Contract Code Section 12200, in products, materials, goods, or supplies offered or sold to the State regardless of whether the product meets the requirements of Section 12209. The Bidder shall include in the bid, the signed certification form included with this packet

(ATTACHMENT 3).

Payee Data Record The successful bidder will be required to submit a Payee Data Record, STD. Form 204 (ATTACHMENT 4) listing their Taxpayer Identification Number. An electronic version of this form can be found at http://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf.

Seller’s Permit Bidder must provide the following document prior to award.

You must provide your company’s California retailer seller’s permit or certification of registration and, if applicable, the permit or certification of all participating affiliates, issued by the California Department of Tax and Fee Administration (CDTFA), 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. In order to expedite the process of verifying the validity of the permit, provide the CDTFA permit number in the space provided below (or attach a copy of the permit with your quote.)

Retailer Seller’s Permit Number: _______________________

Void Contract for Tax Delinquency (AB1424) Any agreement that a state agency enters into after July 1, 2012, is void if the contract is between a state agency and a contractor whose name appears on either list of the 500 largest tax delinquencies pursuant to Section 7063 or 19195 of the Revenue and Taxation Code. (Public Contract Code sec. 10295.4). In accordance with Public Contract Code Section 10295.4, agencies are required to cancel agreements with entities that appear on either list. (Franchise Tax Board) https://www.ftb.ca.gov/about-ftb/newsroom/top-500-past-due-balances/index.html (California Department of Tax and Fee Administration) https://www.cdtfa.ca.gov/taxes-and-fees/top500.htm http://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf https://www.ftb.ca.gov/about-ftb/newsroom/top-500-past-due-balances/index.html https://www.cdtfa.ca.gov/taxes-and-fees/top500.htm https://www.cdtfa.ca.gov/taxes-and-fees/top500.htm

Federal Debarment, Suspension, Ineligibility And Voluntary Exclusion By accepting and fulfilling this agreement for goods and/or services, the contractor/vendor certifies that neither it nor its principals is presently debarred, suspended, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (System for Award Management) https://sam.gov/SAM/

DARFUR CONTRACTING ACT CERTIFICATION: Effective January 1, 2009, all solicitations for goods or services must address the requirements of the Darfur Contracting Act of 2008 (Act).

(Public Contract Code sections 10475, et seq.; Stats. 2008, Ch. 272). The Act was passed by the California Legislature and signed into law by the Governor to preclude State agencies generally from contracting with “scrutinized” companies that do business in the African nation of Sudan (of which the Darfur region is a part), for the reasons described in Public Contract Code section 10475.

A scrutinized company is a company doing business in Sudan as defined in Public Contract Code section 10476. Scrutinized companies are ineligible to, and cannot, quote on or submit a proposal for a contract with a State agency for goods or services. (Public Contract Code section 10477(a)).

Therefore, Public Contract Code section 10478 (a) requires a company that currently has (or within the previous three years has had) business activities or other operations outside of the United States to certify that it is not a “scrutinized” company when it submits a quote or proposal to a State agency (ATTACHMENT 5).

A scrutinized company may still, however, submit a quote or proposal for a contract with a State agency for goods or services if the company first obtains permission from the Department of General Services (DGS) according to the criteria set forth in Public Contract Code section 10477(b).

Executive Order N-6-22 – Russia Sanctions On March 4, 2022, Governor Gavin Newsom issued Executive Order N-6-22 (the EO) regarding Economic Sanctions against Russia and Russian entities and individuals. “Economic Sanctions” refers to sanctions imposed by the U.S. government in response to Russia’s actions in Ukraine, as well as any sanctions imposed under state law. By submitting a bid or proposal, Contractor represents that it is not a target of Economic Sanctions. Should the State determine Contractor is a target of Economic Sanctions or is conducting prohibited transactions with sanctioned individuals or entities, that shall be grounds for rejection of the Contractor’s bid/proposal any time prior to contract execution, or, if determined after contract execution, shall be grounds for termination by the State.

Executive Order N-12-23 – Generative Artificial Intelligence (GenAI) The State of California seeks to realize the potential benefits of GenAI, through the development and deployment of GenAI tools, while balancing the risks of these new technologies.

Bidder / Offeror / Contractor must notify the State in writing if their solution or service includes, or makes available, any GenAI including GenAI from third parties or subcontractors.

The State has developed a GenAI Reporting and Factsheet (STD 1000) to be completed by the Bidder / Offeror / Contractor.

Failure to submit the GenAI Reporting and Factsheet (STD 1000) will result in disqualification of the Bidder / Offeror / Contractor.

https://sam.gov/SAM/ https://www.documents.dgs.ca.gov/dgs/fmc/pdf/std1000.pdf

Failure to report GenAI to the State may void any resulting contract. The State reserves its right to seek any and all relief it may be entitled to as a result of such non-disclosure.

Upon receipt of a Bidder / Offeror / Contractor GenAI Reporting and Factsheet (STD 1000), the state reserves the right to incorporate GenAI Special Provisions into the final contract or reject bids/offers that present an unacceptable level of risk to the state.

ATTACHMENT 2

BIDDER DECLARATION - GSPD–05–105

1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form):

a. Identify current California certification(s) (MB, SB, SB/NVSA, DVBE): ____________ or None ____ (If “None”, go to Item #2)

b. Will subcontractors be used for this contract? Yes ___ No ___ (If yes, indicate the distinct element of work your firm will perform in this contract e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary.

c. If you are a California certified DVBE:

(1) Are you a broker or agent? Yes ___ No ___

(2) If the contract includes equipment rental, does your company own at least 51% of the equipment provided in this contract (quantity and value)? Yes ___ No ___ N/A ___

2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary):

Subcontractor Name Contact

Person Phone Number &

Fax Number

Subcontractor Address&

Email Address

CA Certification

(MB, SB, DVBE

or None)

Work performed or goods provided for this contract

Corresponding % of bid price

Good Standing?

51% Rental?

3. CERTIFICATION: By signing this form, I certify under penalty of perjury that the information provided is true and correct.

Printed Name: ____________________________ Signature: _____________________________

Date Signed: __________________

State of California—Department of General Services, Procurement Division GSPD–05–105 (EST 8/05) Written Version Page ___of ____

BIDDER DECLARATION Instructions

All prime bidders (the firm submitting the bid) must complete the Bidder Declaration.

1.a. Identify all current certifications issued by the State of California. If the prime bidder has no California certification(s), check the line labeled “None” and proceed to Item #2. If the prime bidder possesses one or more of the following certifications, enter the applicable certification(s) on the line:

• Microbusiness (MB)

• Small Business (SB)

• Small Business Nonprofit Veteran Service Agency (SB/NVSA)

• Disabled Veteran Business Enterprise (DVBE) 1.b. Mark either “Yes” or “No” to identify whether subcontractors will be used for the contract. If the response is “No”, proceed to Item #1.c. If “Yes”, enter on the line the distinct element of work contained in the contract to be performed or the goods to be provided by the prime bidder. Do not include goods or services to be provided by subcontractors.

Bidders certified as MB, SB, SB/NVSA, and/or DVBE must provide a commercially useful function as defined in Military and Veterans Code Section 999(e)(2)(A) for DVBEs and Government Code Section 14837(d)(4)(A) for small/microbusinesses. For questions regarding commercially useful function determinations made in conjunction with certification approval, contact the Department of General Services, Procurement Division, Office of Small Business and DVBE Certification (OSDC), OSDC Certification and Compliance Unit via email at: osdchelp@dgs.ca.gov.

Bids must propose that certified bidders provide a commercially useful function for the resulting contract or the bid will be deemed non-responsive and rejected by the State. For questions regarding the solicitation, contact the procurement official identified in the solicitation.

Note: A subcontractor is any person, firm, corporation, or organization contracting to perform part of the prime’s contract.

1.c. This Item is only to be completed by businesses certified by California as a DVBE.

(1) Declare whether the prime bidder is a broker or agent by marking either “Yes” or “No”. The Military and Veterans Code Section 999.2 (b) defines “broker” or “agent” as a certified DVBE contractor or subcontractor that does not have title, possession, control, and risk of loss of materials, supplies, services, or equipment provided to an awarding department, unless one or more of the disabled veteran owners has at least 51-percent ownership of the quantity and value of the materials, supplies, services, and of each piece of equipment provided under the contract.

(2) If bidding rental equipment, mark either “Yes” or “No” to identify if the prime bidder owns at least 51% of the equipment provided (quantity and value). If not bidding rental equipment, mark “N/A” for “not applicable.”

2. If no subcontractors are proposed, do not complete the table. Read the certification at the bottom of the form and complete “Page ___ of ___” on the form.

If subcontractors will be used, complete the table listing all subcontractors. If necessary, attach additional pages and complete the “Page ___ of ___” accordingly.

Subcontractor Name, Contact Person, Phone Number & Fax Number—List each element for all subcontractors.

Subcontractor Address & Email Address—Enter the address and if available, an Email address.

CA Certification (MB, SB, DVBE or None)—If the subcontractor possesses a current State of California certification(s), verify on the OSDC website (www.pd.dgs.ca.gov/smbus) that it is still valid and list all current certifications here. Otherwise, enter “None”. [Note: A SB/NVSA should not be participating as a subcontractor]

Work performed or goods provided for this contract—Identify the distinct element of work contained in the contract to be performed or the goods to be provided by each subcontractor.

Certified subcontractors must provide a commercially useful function for the contract. (See paragraph 1.b above for code citations regarding the definition of commercially useful function.)

If a certified subcontractor is further subcontracting a greater portion of the work or goods provided for the resulting contract than would be expected by normal industry practices, attach a separate sheet of paper explaining the situation.

Corresponding % of bid price—Enter the corresponding percentage of the total bid price for the goods and/or services to be provided by each subcontractor. Do not enter a dollar amount.

Good Standing?—Provide a response for each subcontractor listed. Enter either “Yes” or “No” to indicate that the prime bidder has verified that the subcontractor(s) is in good standing for all of the following:

• Possesses valid license(s) for any license(s) or permits required by the solicitation or by law

• If a corporation, the company is qualified to do business in California and designated by the State of California Secretary of State to be in good standing

• Possesses valid State of California certification(s) if claiming MB, SB, and/or DVBE status

• Is not listed on the OSDC website as ineligible to transact business with the State 51% Rental?—This pertains to the applicability of rental equipment. Based on the following parameters, enter either “N/A” (not applicable), “Yes” or “No” for each subcontractor listed.

Enter “N/A” if the:

• Subcontractor is NOT a DVBE (regardless of whether or not rental equipment is provided by the subcontractor) or

• Subcontractor is NOT providing rental equipment (regardless of whether or not subcontractor is a DVBE) Enter “Yes” if the subcontractor is a California certified DVBE providing rental equipment and the subcontractor owns at least 51% of the rental equipment (quantity and value) it will be providing for the contract.

Enter “No” if the subcontractor is a California certified DVBE providing rental equipment but the subcontractor does NOT own at least 51% of the rental equipment (quantity and value) it will be providing.

3. Read the certification at the bottom of the page. An individual that is authorized to bind the firm contractually is to print their name, sign and date the form. Also, complete the “Page ___of ____” accordingly.

ATTACHMENT 3

The State Agency Buy Recycled Campaign (SABRC) is a state mandated program that requires the reporting of all purchases made within 11 specified product categories. All state agencies are required to verify the recycled content of all products purchased within each of these categories.

All businesses shall certify in writing to the contracting officer or his or her representative the minimum percentage, if not exact percentage, of postconsumer recycled-content (PCRC) material in the products, materials, goods, or supplies offered or sold to the State regardless of whether the product meets the minimum content requirements specified in law (see reverse side). The certification shall be furnished under penalty of perjury. The certification shall be provided regardless of content, even if the product contains no recycled material. A State agency may waive the certification requirement if the percentage of postconsumer material in the products, materials, goods, or supplies can be verified in a written advertisement, including, but not limited to, a product label, a catalog, or a manufacturer or vendor Internet website.

Contractor/Company Name___________________________________________________________________________

Address_____________________________________________________________________Phone_______________

Purchase Order #

RFQ #

RFP #

IFB #

Cal Card Order #

Item # Product or Services Description 1Percent Postconsumer Recycled- Content Material

2SABRC

Product Category Code

M eets SA

B R

C

Public Contract Code sections 12205 (a) (1), (2), (3) and (b) (1), (2), and (3)

Pursuant to Public Contract Code 12205(a)(1), I certify under penalty of perjury under the laws of the State of California that the above information is true and correct.

Print Name Signature Title Date

(See footnotes on the next page.)

STATE OF CALIFORNIA

Department of Resources Recycling and Recovery (CalRecycle)

To be completed by the State agency

CalRecycle 74 (Revised 01/10 for State Agencies) State Agency:

Postconsumer-Content Certification

Purchasing Agent: PO #:

Phone: E-mail:

FOOTNOTES:

1. “Postconsumer recycled-content material” is defined as products that were bought, used, and recycled by consumers. For example, a newspaper that has been purchased, recycled, and used to make another product would be considered postconsumer material.

2. “Product category” refers to one of the categories listed below, into which the reportable purchase is best placed.

3. If the product does not belong in any of the product categories, enter “N/A.” Common “N/A” products include wood products, natural textiles, aggregate, concrete, and electronics such as computers, TV, software on a disk or CD, and telephones.

4. Reused or refurbished products, there is no minimum content requirement. (PCC 12209 (l)) Code Product Categories Product Examples Minimum Postconsumer Content Requirement

Examples are inclusive but are not limited to the individual product.

1 Paper Products Paper janitorial supplies, cartons, wrapping, packaging, file folders, and hanging files, building insulation and panels, corrugated boxes, tissue, and toweling.

30 percent by fiber weight postconsumer fiber.

2 Printing and Writing Papers

Copy, xerographic, watermark, cotton fiber, offset, forms, computer printout paper, white wove envelopes, manila envelopes, book paper, note pads, writing tablets, newsprint, and other uncoated writing papers, posters, index cards, calendars, brochures, reports, magazines, and publications.

30 percent by fiber weight postconsumer fiber.

3 Mulch, Compost, and Co-compost Products

Soil amendments, erosion controls, soil toppings, ground covers, weed suppressants, and organic materials used for water conservation; yard trimmings and wood byproducts that are separated from the municipal solid waste stream or other source of organic materials such as biosolids or other comparable substitutes such as livestock, horse, or other animal manure, food residues or fish processing byproducts; mechanical breakdown of materials.

80 percent recovered material that would otherwise be normally disposed of in a landfill.

4 Glass Products Windows, test tubes, beakers, laboratory or hospital supplies, fiberglass (insulation), reflective beads, tiles, construction blocks, desktop accessories, flat glass sheets, loose-grain abrasives, deburring media, liquid filter media, and containers.

10 percent postconsumer, by weight.

5 Lubricating Oils Intended for use in a crankcase, transmission, engine, power steering, gearbox, differential chainsaw, transformer dielectric, fluid, cutting, hydraulic, industrial, or automobile, bus, truck, vessel, plane, train, heavy equipment, or machinery powered by an internal combustion engine.

70 percent re-refined base oil.

6a Plastic Products Printer or duplication cartridges, diskette, carpet, office products, plastic lumber, buckets, wastebaskets, containers, benches, tables, fencing, clothing, mats, packaging, signs, posts, binders, sheet, buckets, building products, garden hose, and trays.

10 percent postconsumer, by weight.

6b Printer or Duplication Cartridges

a. Have 10 percent postconsumer material, or

b. Are purchased as remanufactured, or

c. Are backed by a vendor-offered program that will take back the printer cartridge after their useful life and ensure that the cartridge is recycled and comply with the definition of recycled as set forth in section Public Contract Code 12156.

7 Paint Water-based paint, graffiti abatement, interior and exterior, and maintenance. 50 percent postconsumer paint (exceptions when 50 percent postconsumer content is not available or is restricted by a local air quality management district, then 10 percent postconsumer content may be substituted).

8 Antifreeze Recycled antifreeze and antifreeze containing a bittering agent or made from polypropylene or other similar non-toxic substance.

70 percent postconsumer material.

9 Tires Truck and bus tires and those used on fleet vehicles and passenger cars. Retreaded: Must use an existing casing that has undergone retreading or recapping process in accordance with Public Resource Code (commencing with section 42400).

10 Tire- Derived Products Flooring, mats, wheelchair ramps, playground cover, parking bumpers, bullet traps, hoses, bumpers, truck bedliners, pads, walkways, tree ties, road surfacing, wheel chocks, rollers, traffic control products, mudflaps, and posts.

50 percent recycled used tires.

11 Metal Staplers, paper clips, steel furniture, desks, pedestals, scissors, jacks, rebar, pipe, plumbing fixtures, chairs, ladders, file cabinets, shelving, containers, lockers, sheet metal, girders, building and construction products, bridges, braces, nails, and screws.

10 percent postconsumer material, by weight.

For additional information, please visit www.calrecycle.ca.gov/BuyRecycled/StateAgency/ http://www.calrecycle.ca.gov/BuyRecycled/StateAgency/

ATTACHMENT 4

DEPARTMENT OF REHABIITATION CONTRACTS & PROCUREMENT

72 CAPITOL MALL

SACRAMENTO CA 95814

ATTACHMENT 5

DARFUR CONTRACTING ACT CERTIFICATION

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

Therefore, to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete only one of the following three paragraphs (via initials for Paragraph # 1 or Paragraph # 2, or via initials and certification for Paragraph # 3):

Company/Vendor Name (Printed) Federal ID Number

Printed Name and Title of Person Initialing (for Options 1 or 2)

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

OR

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

OR

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

CERTIFICATION For # 3.

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective proposer/bidder to the clause listed above in # 3. This certification is made under the laws of the State of California.

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County and State of

STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

REQUEST FOR QUOTE

DR 815 (Rev. 08/15) Page 1 of 2

RFQ NUMBER: QUOTE DUE DATE: TIME DUE:

DOR CONTACT: PHONE: FAX:

E-MAIL:

Line Qty Description

Unique Circumstances:

It is unlawful for any person engaged in business within this state to sell or use any article or product as a "loss leader" as defined in Section 17030 of the Business and Professions Code.

FEDERAL DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

By accepting and fulfilling this agreement for goods and/or services the contractor/vendor certifies that neither it nor its principles is presently debarred, suspended, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal Department or Agency.

(Reference website: http://www.sam.gov)

VOID CONTRACT FOR TAX DELINQUENCY (AB1424)

Any agreement that a state agency enters into after July 1, 2012, is void if the contract is between a state agency and a contractor whose name appears on either list of the 500 largest tax delinquencies pursuant to Section 7063 or 19195 of the Revenue and Taxation Code. (Public Contract Code sec.

10295.4). In accordance with Public Contract Code Section 10295.4, State Agencies are required to cancel agreements with entities that appear on either list, the Franchise Tax Board list, located at: https://www.ftb.ca.gov/aboutFTB/Delinquent_Taxpayers.shtml, Board of Equalization located at:

http://www.boe.ca.gov/cgi-bin/deliq.cgi

Award will be made based on lowest cost unless unique circumstances dictate otherwise. Bid quotes will be accepted by U.S. Mail, E-mail, or FAX.

Your bid quote must include the RFQ number and all information requested. FAX bid quotes will be considered only if they are sent to fax number listed above. Bid quotes sent to any other fax number or DOR Contact will not be considered. To be considered, all pages of the faxed bid quote must be received prior to the bid opening time. The information received will be considered “the complete bid”. Please be advised, there is a heavy demand placed on fax machines receiving bids and the State assumes no responsibility if a supplier cannot transmit the bid via fax or if the entire bid is not received prior to the bid opening time.

Current State of California Bidder Instructions (GSPD-451) apply to this solicitation. The GSPD-451 is available at the DGS Procurement Division website under Model Bidder Instructions tab at: http://www.dgs.ca.gov/pd/Resources/ModelLanguage.aspx.

Current State of California General Provisions (GSPD-401 non-IT or IT) also apply to this solicitation. The GSPD-401 is available at the DGS Procurement Division website located under General Provisions (IT & Non-IT) tab at: http://www.dgs.ca.gov/pd/Resources/ModelLanguage.aspx .

For Consumer purchases – DOR will make every effort to solicit quotes from small businesses whenever possible.

By submitting a bid quote, you are acknowledging your acceptance of the Terms and Conditions of the Bidder Instructions and General Provisions.

For Administrative Purchases – The Small Business preference and DVBE advertising requirements apply to this solicitation. The DVBE Incentive has been waived for this solicitation. The Small Business preference regulations are located at the DGS Procurement Division website at:

http://www.pd.dgs.ca.gov/smbus/default.htm. The DVBE program requirements are located at the DGS Procurement Division website at:

http://www.documents.dgs.ca.gov/pd/delegations/STD840.doc. The current DVBE incentive and exemption requirements are located at the DGS Procurement Division website at: http://www.pd.dgs.ca.gov/dvbe/dvbeincentive.htm.

For IT goods and/or services, special provisions apply to this solicitation. The IT Special Provisions Modules are available at the DGS Procurement Division website under IT Modules (Special Provisions) tab at: http://www.dgs.ca.gov/pd/Resources/ModelLanguage.aspx.

The State is required to purchase recycled content products whenever possible. The Recycled Content Certification must be included with your bid quote. The verification form is available at: http://www.calrecycle.ca.gov/BuyRecycled/StateAgency/Forms/CalRecycle074.pdf.

By submitting a bid quote, you are acknowledging your acceptance of the terms and conditions of the Small Business preference, DVBE advertising requirements, DVBE incentive and Bidder Instructions and General Provisions.

https://www.ftb.ca.gov/aboutFTB/Delinquent_Taxpayers.shtml http://www.boe.ca.gov/cgi-bin/deliq.cgi http://www.dgs.ca.gov/pd/Resources/ModelLanguage.aspx http://www.dgs.ca.gov/pd/Resources/ModelLanguage.aspx http://www.pd.dgs.ca.gov/smbus/default.htm http://www.documents.dgs.ca.gov/pd/delegations/STD840.doc http://www.pd.dgs.ca.gov/dvbe/dvbeincentive.htm http://www.dgs.ca.gov/pd/Resources/ModelLanguage.aspx http://www.calrecycle.ca.gov/BuyRecycled/StateAgency/Forms/CalRecycle074.pdf

STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

REQUEST FOR QUOTE

DR 815 (Rev. 08/15) Page 2 of 2

RFQ NUMBER: DOR CONTACT:

Supplier Name Supplier Address, City/State, Zip Person Contacted Phone Number Fax Number Certified Small/Micro Business Yes # No SM MB DVBE Date Quote Received Date Quote Expires Seller’s Permit Warranty Period Delivery Date Line Qty Description Unit $ Extension 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

FOB Destination, Freight Prepaid Price of freight included in cost of commodity – no additional freight charges added by vendor. State does not own goods during shipment.

FOB Destination, Freight Prepay and Add Seller prepays freight and adds cost to the invoice. State accepts responsibility for freight upon delivery. Cost of freight must be noted and added in price extension. If freight costs are $50.00 or more, the vendor must attach a copy of the actual freight bill with the invoice to process payment. Freight costs of $500 or more must be approved by Transportation Management call (916) 376-1888 for best rates.

FOB Origin, Freight Collect State accepts ownership responsibility for merchandise at the Seller’s dock and pays freight charges. This is not a suggested method, if used Transportation Management must be called at (916) 376-1888. Cost of freight is an evaluation item and must be noted and added in price extension.

Total Quote (Tax is not an evaluation item, add tax to the purchase order)

PREPARED BY:

PRINT NAME:

DATE:

Line Item Qty COST 1 1

1 QTY: 1 Motor Package 8.5 MPH - Propulsion 2 QTY: 1 9x3 pneumatic casters w/insert, Black 3 QTY: 1 Seat height modification 4 QTY: 1 LED Light package, R-NET, Power Reclining Back 5 QTY: 1 R-Net Pm 120 A Fully Expandable Controller 6 QTY: 1 Harness For Expandable Controller 7 QTY: 1 R-Net Standard Joystick with color screen and lights 8 QTY: 1 RH Swing-away Joystick Mount 9 QTY: 1 Standard 50° Power Tilt + Power Recline Mec. Shear

10 QTY: 1 Add Alta 11' Power Seat Elevation Module Ebx 11 QTY: 1 Ebx Multi Power Control Tilt - Recl - Elevate 12 QTY: 1 Matrx Elite E2S Back 1618 - Complete 13 QTY: 1 70° Angle Adjustable Swingaway footrests heavy duty 14 QTY: 2 Angle Adjustable Footplates - Width 16-17 15 QTY: 2 Heel Loop (standard) 16 QTY: 1 Medium Curved Headrest Pad 5" X 10" 17 QTY: 1 Multi-Axis Headrest Removable Mnt Hardware 18 QTY: 2 Hip & Thigh Pad Adjust (Sml: 10"X 4") Each 19 QTY: 2 Curved Hip & Thigh Sup. Hdw, Adj. & Rem.

2 1

SUBTOTAL:

SHIPPING:

TOTAL:

RFQ 214-343691

DR815 Attachment

All Bids Due FRIDAY, FEBRUARY 21 BY 4:00PM

JAY J2 Wheelchair Cushion 16X18

Power Wheelchair similar to or like the ALLTRACK R3 POWER WHEELCHAIR with the following specifications:

Item Description