S-63400-00008124 Attachments B through F_~1.docx

ATTACHMENT B

OFFEROR INFORMATION AND CERTIFICATION SHEET

Legal Name of Offeror:

Address:

City, State, Zip:

State of Incorporation:

Entity Type:

Contact Name:

Telephone:

Email:

Oregon Business Registry Number (if required):

Any individual signing below hereby certifies they are an authorized representative of Offeror and that:

Offeror understands and accepts the requirements of this INTERMEDIATE PROCUREMENT. By submitting a Offer, Offeror agrees to be bound by the Contract terms and conditions in Attachment A and as modified by any Amendment, except for those terms and conditions that Agency has reserved for negotiation, as identified in the INTERMEDIATE PROCUREMENT.

Offeror acknowledges receipt of any and all Amendments to this INTERMEDIATE PROCUREMENT.

Offer is a Firm Offer for 180 days following the Opening.

If awarded a Contract, Offeror agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Contract.

I have knowledge regarding Offeror’s payment of taxes and by signing below. I hereby certify that, to the best of my knowledge, Offeror is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

Offeror does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Offeror does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owned or an emerging small business. If applicable, Offeror has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into a contract with an anticipated contract price of $150,000 or more with a Offeror that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.

Offeror complies with ORS 652.220 and does not unlawfully discriminate against any of Offeror’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class. “Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.

Contractor’s continuing compliance constitutes a material element of this Contract and a failure to comply constitutes a breach that entitles Agency to terminate this Contract for cause.

Contractor may not prohibit any of Contractor’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Contractor may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

Offeror is not engaged in the provision of broadband Internet access service, or if at any time Offeror is engaged in or may engage in the provision of broadband Internet access service Offeror is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Contract.

Offeror and Offeror’s employees, agents, and subcontractors are not included on:

the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/ Offeror certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Offeror, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the INTERMEDIATE PROCUREMENT. If any changes occur with respect to Offeror’s status regarding conflict of interest, Offeror shall promptly notify the State in writing.

Offeror certifies that all contents of the Offer (including any other forms or documentation, if required under this INTERMEDIATE PROCUREMENT) and this Offer Certification Sheet are truthful and accurate and have been prepared independently from all other Offerors, and without collusion, fraud, or other dishonesty.

Offeror understands that any statement or representation it makes, in response to this INTERMEDIATE PROCUREMENT, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Contract being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

Offeror acknowledges these certifications are in addition to any certifications required in the Contract and Statement of Work in Attachment A at the time of Contract execution.

Authorized Signature

Date

ATTACHMENT C

REFERENCE CHECK FORM

Offeror Name: __________________________________________ Reference #1:

Reference #2:

Reference #3:

Questions to be answered during reference check includes, but is not limited to, the following:

1. How would you rate the Offeror’s overall quality of services provided and your overall relationship with the Offeror?

2. How would you rate the Offeror’s delivery of service?

3. How would you rate the Offeror’s responsiveness to product feedback and requests?

ATTACHMENT D

COST SHEET

All Pricing Must Be Held Firm For 45 Days.

TASKS AND DELIVERABLES TO BE PROVIDED:

Please provide pricing according to the Sample Contract’s deliverables listed within the Statement of Work.

B. HOURLY RATES:

Please provide hourly rates below.

Please sign and date below and return with offer.

Signature: ________________________________________________________ Name Title Date

ATTACHMENT E

Certified DisadvantageD Business OUTREACH PLAN

Offeror Name:

Date:

Contact Name:

Telephone:

Email:

“Certified Firm” means a small business certified under ORS 200.055 by the Oregon Certification Office for Business Inclusion and Diversity (COBID) as minority-owned businesses, woman-owned businesses, businesses that service-disabled veterans owned, and emerging small businesses.

Certified Firms must have an equal opportunity to participate in the performance of contracts financed with state funds. By submitting its offer, Offeror certifies that it has taken, and if there are further opportunities, will take reasonable steps to ensure that Certified Firms are provided an equal opportunity to compete for and participate in the performance of any subcontracts resulting from this procurement.

The information submitted in response to this clause will not be considered in any scored evaluation.

1. Is Offeror an Oregon certified firm? Yes |_| No |_| If yes, indicate all certification type(s): DBE |_| MBE |_| WBE |_| SDV |_| ESB |_| Oregon State Certification Number: __________________________

2. Include a list of Certified Firms that Offeror has had a contractual relationship with within the last two years.

3. Include a list of firms that Offeror has had a contractual relationship with within the last two years that are not Certified Firms but may be minority-owned, woman-owned, service-disabled veteran-owned or emerging small businesses.

4. Does Offeror foresee any subcontracting opportunities for this procurement? Yes |_| No |_| If no, do not complete the rest of this form and submit this first page with your Offer.

If yes, please complete the following pages and submit all pages with your Offer.

Certified Disadvantaged Business Outreach Plan

5. Describe the steps Offeror will take to solicit Certified Firms for subcontracting opportunities if awarded a contract from this procurement.

6. Describe the subcontracting opportunities and the approximate dollar value of each that may be available, if awarded a Contract.

7. Would Offeror be willing to report the identity of each subcontractor and the value of each subcontract to COBID if awarded a Contract from this procurement?

ATTACHMENT F

RESPONSIBILITY INQUIRY

Agency will determine responsibility of a Proposer prior to award and execution of a Contract. In addition to this form, Agency may notify Proposer of other documentation required, which may include but is not limited to recent profit-and-loss history, current balance statements and cash flow information, assets-to-liabilities ratio, including number and amount of secured versus unsecured creditor claims, availability of short and long-term financing, bonding capacity, insurability, credit information, materials and equipment, facility capabilities, personnel information, record of performance under previous contracts, etc. Failure to promptly provide requested information or clearly demonstrate responsibility may result in an Agency finding of non-responsibility and rejection.

1. Does Proposer have available the appropriate financial, material, equipment, facility and personnel resources and expertise, or ability to obtain the resources and expertise, necessary to demonstrate the capability of Proposer to meet all contractual responsibilities? YES |_| / NO |_|.

2. Within the last five years, how many contracts of a similar nature has Proposer completed that, to the extent that the costs associated with and time available to perform the contract remained within Proposer′s control, Proposer stayed within the time and budget allotted, and there were no contract claims by any party? Number: ____ How many contracts did not meet those standards? Number: ____ If any, please explain.

Response:

3. Within the last three years has Proposer (incl. a partner or shareholder owning 10% or more of Proposer’s firm) or a major subcontractor (receiving 10% or more of a total contract amount) been criminally or civilly charged, indicted or convicted in connection with:

obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract, violation of federal or state antitrust statutes relating to the submission of bids or Proposals, or embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property? YES |_| / NO |_|.

If "YES," indicate the jurisdiction, date of indictment, charge or judgment, and names and summary of charges in the response field below.

Response:

4. Within the last three years, has Proposer had:

any contracts terminated for default by any government agency, or any lawsuits filed against it by creditors or involving contract disputes? YES |_| / NO |_|.

If "YES," please explain. (With regard to judgments, include jurisdiction and date of final judgment or dismissal.)

Response:

5. Does Proposer have any outstanding or pending judgments against it? YES |_| / NO |_|.

Is Proposer experiencing financial distress or having difficulty securing financing? YES |_| / NO |_|.

Does Proposer have sufficient cash flow to fund day-to-day operations throughout the proposed contract period? YES |_| / NO |_| If "YES” on the first question or second question, or “NO” on the third question, please provide additional details.

Response:

6. Within the last three years, has Proposer filed a bankruptcy action, filed for reorganization, made a general assignment of assets for the benefit of creditors, or had an action for insolvency instituted against it? YES |_| / NO |_|.

If "YES," indicate the filing dates, jurisdictions, type of action, ultimate resolution, and dates of judgment or dismissal, if applicable.

Response:

7. Does Proposer have all required licenses, insurance and/or registrations, if any, and is Proposer legally authorized to do business in the State of Oregon? YES |_| /NO |_|.

If "NO," please explain.

Response:

AUTHORIZED SIGNATURE

By signature below, the undersigned Authorized Representative on behalf of Proposer certifies to the best of his or her knowledge and belief that the responses provided on this form are complete, accurate, and not misleading.

By: __________________________________________________________________________ Authorized Signature Date

RFP #S-63400-00008412 Attachments B-F Page 2 of 2