SBE-MBE-WBE;_Disclosure_of_Lobby_Activities;_Debarment_and_Suspension_and_UEI_FORM.pdf

ISSUED FOR BID

2/10/2022

SBE/MBE/SBE/LSA FORMS

00 03 06-1

SMALL, MINORITY, AND WOMEN’S BUSINESS ENTERPRISES/LABOR

SURPLUS AREA FIRMS FORMS

SECTION 1: GENERAL OVERVIEW

The project is funded partially or wholly with Federal dollars. Consequently, the City is proceeding in accordance with Federal Aid project funding procedures: Proposers are required to certify that they meet all federal requirements per the funding Agency, including but not limited to all applicable equal opportunity laws and regulations.

The purpose of this document is to provide a summary of the SBE/MBE/WBE/Labor Surplus Area Firms “Good Faith” effort for federally funded projects.

2 CFR 200.321 (b) provides six affirmative steps for ensuring that SBE/MBE/WBE firms are used when possible. These six steps must be followed for all procurements. These affirmative steps are:

1. Place qualified small and minority businesses and women’s business enterprises on solicitation lists;

2. Assure that small and minority businesses, and women’s business enterprises are solicited whenever they are potential sources;

3. Divide total requirements, when economically feasible, into smaller tasks or quantities to permit maximum participation;

4. Establish delivery schedules, where the requirement permits, which encourage participation

5. Use the services and assistance of the Small Business Administration, and the Minority Business Development Agency of the Department of Commerce; and

6. Require the prime contractor, if subcontracts are to be let, to take the five affirmative steps listed above.

SECTION 2: PRIME CONTRACTOR & RECIPIENT RESPONSIBILITIES

While you are not required to award contracts or subcontracts to SBE/MBE/WBEs, such firms must be provided the opportunity to compete to participate. All recipients of federal funds, as well as their prime contractors and subcontractors, must make every effort to solicit bids from eligible SBE/MBE/WBEs and firms within labor surplus areas. This information must be documented and reported to the City and Federal Agency as described in this document.

The SBE/MBE/WBE/Labor Surplus Area firms responsibilities of the prime contractor are:

1. To conduct a “Good Faith” effort to ensure maximum SBE/MBE/WBE/Labor Surplus Area firm participation in the project;

2. Complete or obtain from SBE/MBE/WBE/Labor Surplus Area firm subcontractors, all of the completed forms required in these guidelines (Forms 1-4) and submit them to the City; and

3. Report actual SBE/MBE/WBE/Labor Surplus Area firm participation on a quarterly basis to the City.

4. Report final SBE/MBE/WBE/Labor Surplus Area firm participation at project completion.

00 03 06-2

The SBE/MBE/WBE/Labor Surplus Area firms responsibilities of the Agency are:

1. To ensure that the prime contractor meets the responsibilities identified in these guidelines; and

2. Submit all documentation identified in these guidelines to Federal Agency and maintain all records in the project files for later access or auditing.

SECTION 3: “GOOD FAITH” EFFORT PROCESS

Any public or private entity receiving federal funds must demonstrate that efforts were made to attract SBE/MBE/WBEs and firms in labor surplus areas. The process to attract the aforementioned businesses is referred to as the “Good Faith” effort. This effort requires the City, prime contractor and any subcontractors to take the steps listed below to assure that SBE/MBE/WBEs and firms in labor surplus areas are used whenever possible as sources of supplies, construction, equipment or services. Failure to take the steps outlined below and submit Form 3A, SUMMARY OF BIDS RECEIVED FROM SUBCONTRACTORS, SUPPLIERS, AND BROKERS (SBE/MBE/WBE/LSA & NON-MBE/WBE), prior to bid opening, shall cause the bid to be rejected as non-responsive. Use Forms 1 through 3 to document the process, and Form 4 for certification. If it is not practical or possible to comply with one or more of the five steps, prepare an explanation and submit it with bid proposal.

STEP 1: Divide the total requirements, when economically feasible, into small tasks or quantities to permit maximum participation. Evidence submitted must illustrate that the work was divided into small proprietary portions (e.g. paving, electrical, landscaping, revegetation).

STEP 2: Establish delivery schedules, when work requirements permit, that encourage maximum MBE/WBE/Labor Surplus Area Firm participation.

STEP 3: Use the services of the U.S. Small Business Administration (SBA) and the Minority Business Development Agency (MBDA) of the U. S. Department of Commerce (DOC) in soliciting qualified MBE/WBEs. Use the services of Employment and Training Administration of the U.S. Department of Labor in determining labor surplus areas. Utilization of these resources is required at no cost. These agencies offer several services, including Internet access to databases of MBE/WBEs. SBA’s database is (https://www.sba.gov/partners/contracting-officials/small-business-procurement). (See page 11 for instructions to access the database).

For additional assistance, the recipient or contractor can telephone the local offices of both agencies in their area (SBA Minority Enterprise Development Offices and DOC MBDA Regional Centers). The Internet web sites also include names, addresses, and phone or fax numbers of local SBA and MBDA centers. There are contact phone numbers listed in Step 5 that will assist you in reaching the two offices if the Internet is unavailable. Do not write to these sources.

The prime contractor must provide documentation that the local SBA/MBDA offices or web sites were notified of the contracting bid opportunity at least ten working days prior to bid opening (five working days for referrals from SBA/MBDA or web sites) and solicitation to SBE/MBE/WBE subcontractors at least seven working days prior to bid opening.

Documentation must not only include the efforts to contact the information sources and list the contract opportunity, but also the solicitation and response to the bid request.

https://www.sba.gov/partners/contracting-officials/small-business-procurement

00 03 06-3

STEP 4: Include qualified SBE/MBE/WBEs on solicitation lists (Form 1) and record the information. Solicitation should be as broad as possible. The following web sites include a list of available sources for expanding the search for eligible MBE/WBEs:

https://www.sba.gov/partners/contracting-officials/small-business-procurement and http://www.mbda.gov. If SBE/MBE/WBE sources are not located, explain why and describe the efforts made. See Step 5 for more detailed information.

For all contracts, the prime contractor must send invitations to at least three (or all, if less than three) SBE/MBE/WBE vendors for each item of work referred by sources contacted. The invitations must adequately specify the items for which bids are requested. A list of all sub-bidders, including the bidders not selected and non SBE/MBE/WBE subcontractors, and bid amount for each item of work must be submitted on Form 3A. A sample list is shown in Form 3B, Sample Summary of Bids Received from Subcontractors on page 9. If a low bid was not accepted, an explanation must be provided.

STEP 5: SBE/MBE/WBE/Labor Surplus Area Firms potential resources centers.

Federal Agencies (must be contacted):

Name and Address Telephone and Web Site

U.S. Small Business Administration (213) 634-3855

312 N Spring St. Small Business Procurement Database:

Los Angeles, CA https://www.sba.gov/partners/contracting-officials/small-business-procurement

RE: Minority Enterprise Development Offices

U.S. Department of Commerce (213) 989-3153 or

(213) 353-9400

Minority Business Development Agency

1055 Wilshire Blvd, Suite 900 https://www.mbda.gov/

Los Angeles, CA 91107 RE: Business Development Centers

U.S. Department of Labor (866) 487-2365

Employment and Training Administration Labor Surplus Areas

200 Constitution Ave NW https://www.dol.gov/agencies/eta/lsa http://www.mbda.gov/

00 03 06-4

Washington, DC 20210 RE: LSA list (updated every FY)

State Agencies (optional contacts):

Name and Address Telephone and Web Site

California Department of Transportation (916) 324-0449

(CALTRANS) Civil Rights https://dot.ca.gov/programs/civil-rights

1120 N Street

Sacramento, CA 95814

CA Public Utilities Commission (CPUC) Utility Supplier Diversity Program

505 Van Ness Avenue https://www.cpuc.ca.gov/supplierdiversity/

San Francisco, CA 94102-3298

Local Agencies (optional contacts):

City of Los Angeles Department of Public Works Bureau of Contract Administration

(213) 847-1922

1149 S. Broadway Suite 300 https://bca.lacity.org/

Los Angeles, CA 90015

00 03 06-5

FORM 1

SMALL, MINORITY, AND WOMEN’S BUSINESS ENTERPRISE (SBE/MBE/WBE) AND LABOR SUPRLUS AREA FIRMS

“GOOD FAITH” EFFORT LIST OF SUBCONTRACTORS SOLICITED

Contractor Name Contractor Address Category (MBE or

WBE)

How Located

Date of Contact

Contact Method

Task Description

Delivery Schedule

Response (Yes/No)

00 03 06-6

FORM 2

SMALL, MINORITY, AND WOMEN’S BUSINESS ENTERPRISE (SBE/MBE/WBE) AND LABOR SUPRLUS AREA FIRMS

“GOOD FAITH” EFFORT BIDS RECEIVED LIST

Contractor Name Category (MBE or

WBE)

Task Description Bid Amount Selected (Check)

Explanation for Not Selecting

00 03 06-7

FORM 3A

SUMMARY OF BIDS RECEIVED FROM SUBCONTRACTORS,

SUPPLIERS, AND BROKERS (SBE/MBE/WBE/LSA & NON-MBE/WBE)

THIS SUMMARY IS PREPARED BY THE PRIME CONTRACTOR

Type of Job Company Name Selected Bid Amount MBE WBE LSA NON

List type of jobs alphabetically, from low to high in each category and selected low bidder. All other types of bidders such as DBE, SWBE SMBE, and Non MBE/WBE should be shown in the "Non" column.

00 03 06-8

FORM 3B (SAMPLE)

SUMMARY OF BIDS RECEIVED FROM SUBCONTRACTORS,

SUPPLIERS, AND BROKERS (SBE/MBE/WBE/LSA & NON-MBE/WBE)

THIS SUMMARY IS PREPARED BY THE PRIME CONTRACTOR

Type of Job Company Name Selected Bid Amount MBE WBE LSA NON

Asphalt Gillerti & Sons X $123,750 X

Americash $131,850 X

Caltex $176,775 X

Bore & Jack State Boring X $208,870 X

Jack Bore $208,870 X

Alotta Boring $227,472 X

Electrical Square Fasteners, Inc $20,190 X

REM Sleep Co X* $24,189 X

Tram Electic $30,120 X

Masonry Welch, Inc. X $20,383 X

Cheatum $36,000 X

Pipe (Supplier) Cal-Pipe Co. X $203,200 X

Norcal Pipe Co. $260,00 X

Striping Orange Peel X $8,597 X

Crispy Boys Co. $9,370 X

Sweat Co. $11,785 X

*REM Sleep Co. selected over Square Fasteners, Inc. due to incomplete bid by Square Fasteners.

List type of jobs alphabetically, from low to high in each category and selected low bidder. All other types of bidders such as DBE,SWBE SMBE, and Non SBE/MBE/WBE should be shown in the "Non" column.

00 03 06-9

FORM 4

SMALL, MINORITY, AND WOMEN’S BUSINESS ENTERPRISE/LABOR SURPLUS FIRMS

POSITIVE EFFORT CERTIFICATION BY PRIME CONTRACTOR

1a. Project Name:__________________________________________ 1b. Federal Project Number: _________________________________

1. I ____________________ and hereby authorized to make the following certifications for

(authorized representative) Prime Contractor

SBE/MBE/WBE/LABOR SURPLUS AREA FIRMS

The bidder has obtained ___________% of SBE/MBE/WBE/Labor Surplus Area Firms participation for this contract.

Also submitted are Forms 1 through 3 that contain a complete list of those firms solicited, bids received, and summary of those subcontracted with or with whom other types of agreements were made. The list includes the names of the firm, address, and dollar amount involved.

The following affirmative steps as required by 2 CFR 200.321 (b) have been taken:

1. Contractor placed qualified small and minority businesses and women’s business enterprises on solicitation lists;

2. Contractor assured that small and minority businesses, and women’s business enterprises are solicited whenever they are potential sources;

3. Contractor divided total requirements, when economically feasible, into smaller tasks or quantities to permit maximum participation by small and minority businesses, and women’s business enterprises;

4. Contractor established delivery schedules, where the requirement permits, which encourage participation by small and minority businesses, and women’s business enterprises; and

5. Contractor used the services and assistance of the Small Business Administration, and the Minority Business Development Agency of the Department of Commerce.

In accepting these responsibilities, I hereby certify to the above.

Company Name

Signature of Authorized Representative Date

Name and Title of Authorized Representative

00 03 06-10

INSTRUCTION FOR ACCESSING SMALL BUSINESS ADMINISTRATION DATABASE

1. Go to https://www.sba.gov/partners/contracting-officials/small-business-procurement

2. Under Location of Profile - States, scroll down to and click on California

3. Scroll down to Ownership and Self-Certifications. Click on Any Minority Owned and Any Self-

Certified Women-Owned Small Business, do separate run for each classification.

4. Scroll down to Specific Nature of Business, enter appropriate NAICS code or go to Keywords and enter phrases for work to be performed by the subcontractor (electrician, piping, rebar, trucking, landscape, etc.)

5. Scroll to General Nature of Business and click on Construction

6. Scroll to the bottom of the screen and click on Search Using These Criteria.

7. For additional contractors, scroll to No more matches, click on Refine Search and repeat the process by changing the type of contractor you are searching for in no. 6, Keyword

PROJECT:____________________________________________________

NONLOBBYING CERTIFICATION FOR FEDERAL AID CONTRACTS

A. The undersigned certifies, by signing and submitting this form, to the best of his or her knowledge and belief, that:

1. No State, Federal or Local Agency 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 any State or Federal agency; a

Member of the State Legislature or United States Congress; an officer or employee of the Legislature or Congress; or any employee of a Member of the

Legislature or Congress, in connection with the awarding of any State or Federal contract; the making of any State or Federal grant; the making of any State or

Federal loan; the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any State or 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 influencing or attempting to influence an officer or employee of any State or Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this State or Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure of

Lobbying Activities”, in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

B. 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 Section 1352, Title

31, U.S. Code. Any person who 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.

C. The Contractor,__________________________, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C.Chap. 38, Administrative Remedies for False Claims and Statements, apply to this certification and disclosure, if any.

[Name and Title of Contractor’s Authorized Official]

[Signature] [Date]

Standard Form-LLL Disclosure of Lobbying Activities

COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT TO 31 U.S.C. 1352

1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:

a. contract

a. bid/offer/application

a. initial

b. grant b. initial award b. material change

c. cooperative agreement c. post-award

d. loan For Material Change Only:

e. loan guarantee year ____ quarter _________

f. loan insurance date of last report __________

4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime:

Prime Subawardee

Tier _______ , if known

Congressional District, if known Congressional District, if known

6. Federal Department/Agency: 7. Federal Program Name/Description:

CFDA Number, if applicable ____________________

8. Federal Action Number, if known: 9. Award Amount, if known:

10. Name and Address of Lobby Entity 11. Individuals Performing Services

(If individual, last name, first name, MI) (including address if different from No. 10)

(last name, first name, MI)

(attach Continuation Sheet(s) if necessary)

12. Amount of Payment (check all that apply) 14. Type of Payment (check all that apply)

$ _____________ actual planned a. retainer

b. one-time fee

13. Form of Payment (check all that apply): c. commission

a. cash d. contingent fee

b. in-kind; specify: nature _______________ e deferred

Value _____________ f. other, specify __________________________

15. Brief Description of Services Performed or to be performed and Date(s) of Service, including officer(s), employee(s), or member(s) contacted, for Payment Indicated in Item 12:

(attach Continuation Sheet(s) if necessary)

16. Continuation Sheet(s) attached: Yes No

17. Information requested through this form is authorized by Title 31 U.S.C. Section 1352. This disclosure of lobbying reliance was placed by the tier above when his transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C.

1352. This information will be reported to Congress semiannually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than

$100,000 for each such failure.

Signature: ________________________________________

Print Name: _______________________________________

Title: ____________________________________________

Telephone No.: ____________________ Date: ___________

Authorized for Local Reproduction

Federal Use Only: Standard Form - LLL

Standard Form LLL Rev. 04-28-06

Distribution: Orig- Local Agency Project Files

INSTRUCTIONS FOR COMPLETING LAPM 10-Q DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subawardee or prime federal recipient at the initiation or receipt of covered federal action or a material change to previous filing pursuant to title 31 U.S.C.

Section 1352. The filing of a form is required for such payment or agreement to make payment to lobbying entity for influencing or attempting to influence 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 a covered federal action. Attach a continuation sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of

Management and Budget for additional information.

1. Identify the type of covered federal action for which lobbying activity is or has been secured to influence, the outcome of a covered federal action.

2. Identify the status of the covered federal action.

3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last, previously submitted report by this reporting entity for this covered federal action.

4. Enter the full name, address, city, state, and zip code of the reporting entity. Include Congressional District if known.

Check the appropriate classification of the reporting entity that designates if it is or expects to be a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the first tier. Subawards include but are not limited to: subcontracts, subgrants, and contract awards under grants.

5. If the organization filing the report in Item 4 checks "Subawardee" then enter the full name, address, city, state, and zip code of the prime federal recipient. Include Congressional District, if known.

6. Enter the name of the federal agency making the award or loan commitment. Include at least one organization level below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7. Enter the federal program name or description for the covered federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loan commitments.

8. Enter the most appropriate federal identifying number available for the federal action identification in item 1 (e.g., Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract grant.

or loan award number, the application/proposal control number assigned by the federal agency). Include prefixes, e.g., "RFP-DE-90-001."

9. For a covered federal action where there has been an award or loan commitment by the Federal agency, enter the federal amount of the award/loan commitments for the prime entity identified in item 4 or 5.

10. Enter the full name, address, city, state, and zip code of the lobbying entity engaged by the reporting entity identified in

Item 4 to influence the covered federal action.

11. Enter the full names of the individual(s) performing services and include full address if different from 10 (a). Enter

Last Name, First Name and Middle Initial (Ml).

12. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the lobbying entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.

13. Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment.

14. Check all boxes that apply. If other, specify nature.

15. Provide a specific and detailed description of the services that the lobbyist has performed or will be expected to perform and the date(s) of any services rendered. Include all preparatory and related activity not just time spent in actual contact with federal officials. Identify the federal officer(s) or employee(s) contacted or the officer(s) employee(s) or Member(s) of Congress that were contacted.

16. Check whether or not a continuation sheet(s) is attached.

17. The certifying official shall sign and date the form, and print his/her name title and telephone number.

Public reporting burden for this collection of information is estimated to average 30-minutes per response, including time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project

(0348-0046), Washington, D.C. 20503. SF-LLL-Instructions Rev. 06-04

DEBARMENT AND SUSPENSION CERTIFICATION

I. PRIMARY CONTRACTOR

In accordance with Title 2 CFR, Part 180, “OMB Guidelines to Agencies on Government wide Debarment and Suspension (nonprocurement)”, the prospective bidder, under penalty of perjury, certifies the following:

A. He/she or any person associated therewith in the capacity of owner, partner, director, officer, or manager, is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any federal agency; has not been suspended, debarred, voluntarily excluded, or determined ineligible by any federal agency within the past three (3) years; does not have a proposed debarment pending; and has not been indicted, convicted, or had a civil judgment rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past three (3) years. Any exceptions to this certification must be disclosed to City of Pasadena;

B. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (A) of this certification;

and

C. Have not within a three-year period preceding this application/bid had one or more public transactions (Federal, State or local) terminated for cause or default.

If unable to certify any or all aforementioned statements, the Contractor shall attach an explanation to this Form.

Exceptions will not necessarily result in denial of recommendation for award, but will be considered in determining Bidder’s responsibility. Disclosures must indicate to whom exceptions apply, initiating agency, and dates of action.

Exceptions to the Federal Government Excluded Parties List System maintained by the General Services Administration are to be determined by the Federal Agency.

[Name] [Title]

PROJECT:

DEBARMENT AND SUSPENSION CERTIFICATION

I. LOWER TIER COVERED TRANSACTIONS (SUBCONTRACTORS)

In accordance with Title 2 CFR, Part 180, “OMB Guidelines to Agencies on Government wide Debarment and Suspension (nonprocurement)”, the lower tier entity of ___________________________ (Contractor), under penalty of perjury, certifies the following:

A. He/she or any person associated therewith in the capacity of owner, partner, director, officer, or manager, is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any federal agency; has not been suspended, debarred, voluntarily excluded, or determined ineligible by any federal agency within the past three (3) years; does not have a proposed debarment pending; and has not been indicted, convicted, or had a civil judgment rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past three (3) years. Any exceptions to this certification must be disclosed to City of Pasadena;

B. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (A) of this certification;

and

C. Have not within a three-year period preceding this application/bid had one or more public transactions (Federal, State or local) terminated for cause or default.

If unable to certify any or all aforementioned statements, the Subcontractor shall attach an explanation to this Form.

Exceptions will not necessarily result in denial of recommendation for award, but will be considered in determining Bidder’s responsibility. Disclosures must indicate to whom exceptions apply, initiating agency, and dates of action.

Exceptions to the Federal Government Excluded Parties List System maintained by the General Services Administration are to be determined by the Federal Agency.

Lower Tier Participant:___________________________________________

[FIRM NAME]

[Name] [Title]

PROJECT:

CITY OF PASADENA

UNIQUE ENTITY IDENTIFIER (UEI)

PROJECT: ___________________________________________________________________

CONTRACTOR NAME: _______________________________________________________

BUSINESS ADDRESS:

STREET: _____________________________________________________________________

CITY: ________________________________________________________________________

STATE: ______________________________________________________________________

ZIP CODE: ____________________________________________________________________

UEI: __________________________

12-character alphanumeric value from SAM.gov

CONTACT NAME: ____________________________________________________________

TELEPHONE NO: _____________________________________________________________

Submit this form with the Bid. If you fail to submit your UEI, your Bid may be deemed non-responsive.