RFQ_PACKET_5724-561697_Truck_Bed_Modification.pdf

05/07/2024

REQUEST FOR QUOTE

RFQ # 5724-561697

You are invited to review and respond to this Request for Quote (RFQ) for a truck bed modification. 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 Thursday, May 16 by 2:00p.m.

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:

TUESDAY, MAY 28 BY 2:00PM

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; State Contracting Manual (SCM) Vol. 3 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) On September 6, 2023 Governor Gavin Newsom issued Executive Order N-12-23 (the EO) establishes statewide policy for the state’s use of Generative Artificial Intelligence (GenAI), such as those involving consequential decisions affecting access to essential goods and services. GenAI is defined as follows: “Generative Artificial Intelligence (GenAI): The class of AI models that emulate the structure and characteristics of input data in order to generate derived synthetic content. This can include images, videos, audio, text, and other digital content.” – State Administrative Manual (SAM), section 4819.2 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. Bidders/Offerors must notify the State in writing if their solution or service includes, or https://sam.gov/SAM/ makes available, any GenAI technology, including GenAI from third parties or subcontractors. The State has developed a GenAI Disclosure & Factsheet to be completed by the Bidder/Offeror. Failure to disclose GenAI to the State and submit the GenAI Disclosure & Factsheet will result in disqualification of the Bidder/Offeror and 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 GenAI Disclosure & Factsheet 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.

STATE OF CALIFORNIA

Department of Resources Recycling and Recovery (CalRecycle) CalRecycle 74 (Revised 01/23)

Postconsumer Recycled-Content Certification

To be completed by the State agency

State Agency:

Purchasing Agent: PO #:

Phone: E-mail:

The State Agency Buy Recycled Campaign (SABRC) is a state mandated program that requires the reporting of all purchases made within 16 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 the minimum percentage in writing to the contracting officer or his or her representative, if not the 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.

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

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

Pursuant to Public Contract Code 12205(b)(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

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, aggregate, concrete, and electronics such as computers, TV, software on a disk or CD, and telephones.

4. For reused or refurbished products, there is no minimum content requirement. (PCC 12209(l))

California Department of Resources Recycling and Recovery (CalRecycle)

State Agency Buy Recycled Campaign (SABRC) - SABRC@CalRecycle.ca.gov

Code* Product Categories Product Subcategories Product Examples in each SABRC Category (PCC 12207 ) Examples include, but are not limited to, these individual products/materials.

Minimum Post-Consumer Content Requirement per Statute (PCC 12209 )

1A Paper Products Toilet Paper Toilet paper. 45 percent by fiber weight post-consumer fiber.

1B Paper Products Paper Towels Paper towels. 40 percent by fiber weight post-consumer fiber.

1C Paper Products Facial Tissues Facial tissue. 10 percent by fiber weight post-consumer fiber.

1D Paper Products Toilet Seat Covers Toilet seat covers. 20 percent by fiber weight post-consumer fiber.

1E Paper Products General Purpose Paper Wipes General purpose paper wipes. 40 percent by fiber weight post-consumer fiber.

1F Paper Products Food Serviceware Napkins, plates, bowls, food trays, takeout boxes, and placemats. 40 percent by fiber weight post-consumer fiber.

1G Paper Products Miscellaneous Paper Products Cartons, wrapping, packaging, file folders, hanging folders, building insulation and panels, corrugated boxes.

30 percent by fiber weight post-consumer fiber.

2 Printing and Writing Papers

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 post-consumer fiber.

3A Soil Amendments and Toppings

Compost Soil amendments, soil conditioner for potting or plant mix, organic materials used for water conservation; 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.

3B Soil Amendments and Toppings

Mulch Ground covers, weed suppressants. 80 percent recovered material that would otherwise be normally disposed of in a landfill.

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

25 percent post-consumer, by weight.

4B Glass Products Fiberglass Fiberglass (insulation), 30 percent post-consumer, 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.

6 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.

20 percent postconsumer, by weight, is remanufactured or has a take back program.

7A Paint: Low-VOC: < 50 grams/liter Water-based paint, graffiti abatement, interior and exterior, and maintenance. 50 percent post-consumer paint.

7B Paint: Other VOC: > 50 grams/liter

Water-based paint, graffiti abatement, interior and exterior, and maintenance. 50 percent post-consumer paint.

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

70 percent post-consumer material.

9 Tires (Retreaded tires)

Truck and bus tires, and those used on fleet vehicles (and passenger cars where available).

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 surfacing, sports surfacing, parking bumpers, bullet traps, hoses, bumpers, truck bedliners, pads, walkways, tree ties, wheel chocks, rollers, traffic-related products, mudflaps, accessibility ramps, paths and sidewalks, animal care products, including, but not limited to, horse arena surfacing, stall mats, cow mats, and equestrian barn and breezeway flooring, artificial turf, landscaping and rubber mulch, outdoor surfacing, pavers and tiles, and posts.

50 percent recycled used tires.

11A Metal Products Metal Products 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 post-consumer material, by weight.

11B Metal Products Vehicles Vehicles. 10 percent post-consumer material, by weight.

12 Building Finishes

Open Office Panel Systems

Open office panel systems. Middle range of state contracts.

13 Carpet Carpet Determined by DGS and Posted in SCM.

14A Erosion Control Products

Compost Filter Socks Compost filter sock. 100 percent post-consumer material.

14B Erosion Control Products

Compost Blanket Compost blanket, layer of compost protecting bare soil surfaces. 100 percent post-consumer material.

14C Erosion Control Products

Hydraulic Mulch Hydraulic mulch or erosion control process that uses fiber slurry and tackifier. 100 percent post-consumer material.

15A Textiles Textiles 0 percent post-consumer material.

15B Textiles General Textile Wipes General purpose wipes. 100 percent post-consumer material.

16A Pavement

Surfacing Rubberized Pavement Surfaces

Rubberized asphalt concrete and chip seal. 15 percent post-consumer material.

16B Pavement Surfacing

Recycled Asphalt Pavement

Recycled Asphalt Pavement 25 percent post-consumer material.

*It is each agency’s prerogative to assign internal codes/object codes for post-consumer recycled content products based on their internal paper or computer tracking systems.

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

ATTACHMENT 4

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

Please See DR 815: Request for Quote and additional Attachments