Solicitation_Documents_11Sept2020.docx

Volume 1 Documents

Volume 2 Documents

Common Contract Documents

Highway (HCR) Contract Documents image4.emf

Form 7468A.pdf

PS Form 7468A September 2001

SOLICITATION NO.

DATE OF SOLICITATION

CONTRACT NO.

BEGIN CONTRACT TERM

END CONTRACT TERM

CITY & STATE

CITY & STATEFOR MAIL SERVICE

IN OR BETWEEN

OFFEROR: A completed cost worksheet must be submitted with your offer. This worksheet will assist you in determining the cost you expect to incur in performing this service. Please retain a copy of this form for future reference. The instructions for completing this form are listed on the reverse.

OFFEROR'S NAME AND ADDRESS (Include Apt./Suite No./ZIP+4)

NUMBER OF DRIVERS ON ROUTE

FULL-TIME PART-TIME

Remarks:

BASIS FOR DETERMINING COST

Cost Segment COST AS OF

No. of Units Per Year

Unit Cost Annual CostX = (Annual miles) (Rate per mile)

Item

1a. Vehicle Cost

(1) Motor Vehicles

(2) Trailers

1b. Operational Cost (Repairs, repair labor, tires, etc.)

3. Vehicle Registration

4. Miscellaneous

5. General Overhead

6. Fuel (Miles per gallon)

7. Oil (Quarts)

8. Insurance

9. Road Taxes

10. Tolls

11. Total Fixed and Operational Cost (Lines 1-10)

12. Straight Time

13. Overtime

14. Payroll Taxes (Itemized)

a. Social Security

b. Workman's Compensation

c. Federal Unemployment Comp.

d. State Unemployment Comp.

15. Fringe Benefits

a. Health & Welfare

b. Vacation

c. Holiday

d. Pension

16. Total Operation Labor Cost (Lines 12-15)

17. Supplier's Wages (Personal Driving or Supervision)

18. Total Cost (Lines 11, 16 & 17)

19. Return on Investment

20. TOTAL OFFER (Lines 18 & 19)

2. Taxes

Offeror's Signature Date

(Gallons) (Per gallon)

(Quarts) (Per quart)

(Hours) (Per hour)

(No. of employees or hours)

(Rate)

(Trips) (Per trip)

Taxable wages

HIGHWAY TRANSPORTATION CONTRACT — COST WORKSHEET

A

Line 1A, Vehicle Cost Complete annual miles from route schedule, rate per mile and annual cost of vehicle/trailer. Annual cost is derived by adding vehicle purchase price and finance charges and subtracting anticipated trade-in or salvage value. Divide the result by the estimated service life of the vehicle to obtain annual vehicle cost. Divide annual cost by scheduled miles to determine the rate per mile.

Line 1B, Operational Cost Complete annual miles from route schedule, rate per mile and annual cost. This line item includes vehicle repair costs, repair labor, tires and other miscellaneous operational costs not listed on this form.

Line 2, Taxes Gross receipts or personal property tax cost for vehicles used on route, where applicable.

Line 3, Vehicle Registration Annual cost of state and local vehicle registration fees.

Line 4, Miscellaneous Annual cost of miscellaneous items not listed on this form.

Line 5, General Overhead General overhead should include all management expenses not included in other items. It will include the cost for such items as supervision, office expenses, telephone, garage rents, parking fees, bulk fuel handling cost, terminal cost, insurance costs other than for vehicles, etc.

Line 6, Fuel Show consumption rate (miles per gallon), total annual gallons expected to be used on route, average cost per gallon and annual cost.

Line 7, Oil Show expected annual consumption, cost per quart and expected annual cost.

Line 8, Insurance This line is to reflect cost of insurance on vehicles used in the performance of service on the route. (Insurance coverage carried for terminal facilities, key-man insurance coverage, etc. should be included in Line 5, General Overhead.)

Line 9, Road Taxes This line should reflect cost incurred for federal highway use tax, state highway use tax, state mileage tax and state road tax.

Line 10, Tolls Show cost of toll for bridge, turnpike, ferry, tunnel, etc.

Line 11, Total Fixed and Operational Cost Sum of Lines 1 through 10.

Line 12 and 13, Straight Time and Overtime (Hired Drivers) Show expected operational payroll cost of all employees not otherwise included in Lines 1B and 5. Do not include wages for any personal operation of service. All fringe benefits will be shown in Line 15. (Terminal employee's or supervisor's wages are to be included in Line 1B or Line 5, and, therefore, are not to be considered in this line).

Line 14, Payroll Taxes (Itemized) This line should reflect taxes on labor cost for employee hours shown in Lines 12 and 13. It will include cost of social security, workman's compensation, unemployment taxes, etc. Self employment social security tax is a personal tax and not a business cost.

Line 15, Fringe Benefits This line should reflect the cost of employee health and welfare, pension, vacation and holiday benefits, based on the number of employees shown in Line 12. Fringe benefits are computed on the basis of hours paid employees, up to a maximum of eight hours per day or forty hours per week, unless specified otherwise in a collective bargaining agreement. In cases where an employee does not perform forty hours per week, the fringe benefits should be prorated in accordance with the number of hours of work performed.

Line 16, Total Operation Labor Cost Sum of Lines 12 through 15.

Line 17, Supplier's Wages Show wages for your personal operation of route or part of it, including your supervision. (Employee supervision cost should be reflected in Line 5, General Overhead.)

Line 18, Total Cost Sum of Lines 11, 16 and 17.

Line 19, Return on Investment The return expected on funds invested in those portions of facilities and/or capital equipment (e.g., trucks) which are devoted to performing service called for under the contract. This is normally derived by taking fixed percentage of the amount invested.

Line 20, Total Offer Sum of Lines 18 and 19.

PS FORM 7468A INSTRUCTIONS

PS Form 7468-I (Reverse) September 2001 image5.emf

Representations and Certifications.pdf

Representations and Certifications

Name and Address of Offeror (No. and Street, Apt/Suite No., City, County, State, and ZIP+4)

Solicitation or Route No.

Date of Offer or Order

A. Type of Business Organization. The offeror, by checking the applicable blocks, represents that it:

1. Operates as:

• __ a corporation incorporated under the laws of the state of ________; or country of________________ if incorporated in a country other than the United States of America.

• __ an individual;

• __ a partnership;

• __ a joint venture;

• __ a limited liability company;

• __ a nonprofit organization; or

• __ an educational institution; and

2. Is (check all that apply)

• __ a small business concern;

• __ a minority business (indicate minority below):

• __ Black American

• __ Hispanic American

• __ Native American

• __ Asian American;

• __ a woman-owned business; or

• __ none of the above entities.

a. A small business concern for the purposes of Postal Service purchasing means a business, including an affiliate, that is independently owned and operated, is not dominant in producing or performing the supplies or services being purchased, and has no more than 500 employees, unless a different size standard has been established by the Small Business Administration (see 13 CFR 121, particularly for different size standards for airline, railroad, and construction companies). For subcontracts of $50,000 or less, a subcontractor having no more than 500 employees qualifies as a small business without regard to other factors.

b. Minority Business. A minority business is a concern that is at least 51 percent owned by, and whose management and daily business operations are controlled by, one or more members of a socially and economically disadvantaged minority group, namely U.S. citizens who are Black Americans, Hispanic Americans, Native Americans, or Asian Americans. (Native Americans are American Indians, Eskimos, Aleuts, and Native Hawaiians. Asian Americans are U.S. citizens whose origins are Japanese, Chinese, Filipino, Vietnamese, Korean, Samoan, Laotian, Kampuchean (Cambodian), Taiwanese, in the U.S. Trust Territories of the Pacific Islands or in the Indian subcontinent.)

c. Woman-owned Business. A woman-owned business is a concern at least 51 percent of which is owned by a woman (or women) who is a U.S. citizen, controls the firm by exercising the power to make policy decisions, and operates the business by being actively involved in day-to-day management.

d. Educational or Other Nonprofit Organization. Any corporation, foundation, trust, or other institution operated for scientific or educational purposes, not organized for profit, no part of the net earnings of which inures to the profits of any private shareholder or individual.

3. Is (check all that apply)

• __ a Postal Service employee or a business organization substantially owned or controlled by such an individual

• __ a spouse of a Postal Service employee or a business organization substantially owned or controlled by such an individual

• __ another family member of a Postal Service employee or a business organization substantially owned or controlled by such an individual

• __ an individual residing in the same household as a Postal Service employee or a business organization substantially owned or controlled by such an individual.

(Note: Offers from any of the sources listed in subparagraph A.3, may not be considered for an award pending review and recommendation by the Postal Service Ethics Office.)

B. Parent Company and Taxpayer Identification Number

1. A parent company is one that owns or controls the basic business polices of an offeror. To own means to own more than 50 percent of the voting rights in the offeror. To control means to be able to formulate, determine, or veto basic business policy decisions of the offeror. A parent company need not own the offeror to control it; it may exercise control through the use of dominant minority voting rights, proxy voting, contractual arrangements, or otherwise.

2. Enter the offeror's U.S. Taxpayer Identification Number (TIN) in the space provided. The TIN is the offeror’s Social Security number or other Employee Identification Number (EIN) used on the offeror’s Quarterly Federal Tax Return, U.S. Treasury Form 941, or as required by Internal Revenue Service (IRS) regulations.

Offeror’s TIN: _______________________

3. IRS Form W-9, Request for Taxpayer Identification Number and Certification. You must complete a copy of IRS Form W-9 and attach it to this certification.

4. Check this block if the offeror is owned or controlled by a parent company: ______________

5. If the block above is checked, provide the following information about the parent company:

Parent Company’s Name:_______________________________

Parent Company’s Main Office:__________________________

Address:_____________________________________________

No. and Street:________________________________________

City:________________ State:______ ZIP Code:_____________

Parent Company’s TIN:__________________________________

6. If the offeror is a member of an affiliated group that files its federal income tax return on a consolidated basis (whether or not the offeror is owned or controlled by a parent company, as provided above), provide the name and TIN of the common parent of the affiliated group.

Name of Common Parent: ______________________________

Common Parent’s TIN: _________________________________

C. Certificate of Independent Price Determination

1. By submitting this proposal, the offeror certifies, and in the case of a joint proposal each party to it certifies as to its own organization, that in connection with this solicitation:

a. The prices proposed have been arrived at independently, without consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to the prices with any other offeror or with any competitor;

b. Unless otherwise required by law, the prices proposed have not been and will not be knowingly disclosed by the offeror before award of a contract, directly or indirectly to any other offeror or to any competitor; and

c. No attempt has been made or will be made by the offeror to induce any other person or firm to submit or not submit a proposal for the purpose of restricting competition.

2. Each person signing this proposal certifies that:

a. He or she is the person in the offeror’s organization responsible for the decision as to the prices being offered herein and that he or she has not participated, and will not participate, in any action contrary to paragraph a above; or

b. He or she is not the person in the offeror’s organization responsible for the decision as to the prices being offered but that he or she has been authorized in writing to act as agent for the persons responsible in certifying that they have not participated, and will not participate, in any action contrary to paragraph a above, and as their agent does hereby so certify; and he or she has not participated, and will not participate, in any action contrary to paragraph a above.

3. Modification or deletion of any provision in this certificate may result in the disregarding of the proposal as unacceptable. Any modification or deletion should be accompanied by a signed statement explaining the reasons and describing in detail any disclosure or communication.

D. Certification of Nonsegregated Facilities

1. By submitting this proposal, the offeror certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform services at any location under its control where segregated facilities are maintained. The offeror agrees that a breach of this certification is a violation of the Equal Opportunity clause in this contract.

2. As used in this certification, segregated facilities means any waiting rooms, work areas, rest rooms or wash rooms, restaurants or other eating areas, time clocks, locker rooms or other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment area, transportation, or housing facilities provided for employees that are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin, because of habit, local custom, or otherwise.

3. The offeror further agrees that (unless it has obtained identical certifications from proposed subcontractors for specific time periods) it will obtain identical certifications from proposed subcontractors before awarding subcontracts exceeding $10,000 that are not exempt from the provisions of the Equal Opportunity clause; that it will retain these certifications in its files; and that it will forward the following notice to these proposed subcontractors (except when they have submitted identical certifications for specific time periods):

Notice: A certification of nonsegregated facilities must be submitted before the award of a subcontract exceeding $10,000 that is not exempt from the Equal Opportunity clause. The certification may be submitted either for each subcontract or for all subcontracts during a period (quarterly, semiannually, or annually).

E. Certification Regarding Debarment, Proposed Debarment, and Other Matters (This certification must be completed with respect to any offer with a value of $100,000 or more.)

1. The offeror certifies, to the best of its knowledge and belief, that it or any of its principals:

a. Are ___ are not ___ presently debarred or proposed for debarment, or declared ineligible for the award of contracts by any Federal, state, or local agency;

b. Have ____ have not ___, within the three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense 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 offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property;

c. Are ___ are not ___ presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subparagraph (b) above;

d. Have ___ have not ___ within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in conjunction 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 offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion or receiving stolen property; and

e. Are ___ are not ___ presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subparagraph (d) above.

2. The offeror has ___ has not ___, within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal, state, or local agency.

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

4. The offeror must provide immediate written notice to the contracting officer if, at any time prior to contract award, the offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

5. A certification that any of the items in E.1 and E.2 of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered as part of the evaluation of the offeror’s capability (see the Conduct Supplier Capability Analysis topic of the Evaluate Proposals task of Process Step 2: Evaluate Sources, in the Postal Service’s Supplying Practices). The offeror’s failure to furnish a certification or provide additional information requested by the contracting officer will affect the capability evaluation.

6. Nothing contained in the foregoing may be construed to require establishment of a system of records in order to render, in good faith, the certification required by E.1 and E.2 of this provision. The knowledge and information of an offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

7. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under section 1001, Title 18, United States Code.

8. The certification in E.1 and E.2 of this provision is a material representation of fact upon which reliance was placed when making the award. If it is later determined that the offeror knowingly rendered an erroneous certification, in addition to other remedies available to the Postal Service, the contracting officer may terminate the contract resulting from this solicitation for default.

F. Incorporation by Reference. Wherever in this solicitation or contract a standard provision or clause is incorporated by reference, the incorporated term is identified by its title, its provision or clause number assigned to it, and its date.

The text of incorporated terms may be found at http://about.usps.com/manuals/pm/welcome.htm. If checked, the following provision(s) is incorporated in this solicitation by reference: (contracting officer will check as appropriate)

• ___ Provision 1-2: Domestic Source Certificate - Supplies

• ___ Provision 1-3: Domestic Source Certificate - Construction Materials

• ___ Provision 9-1: Equal Opportunity Affirmative Action Program

• ___ Provision 9-2: Preaward Equal Opportunity Compliance Review

• ___ Provision 9-3: Notice of Requirements for Equal Opportunity Affirmative Action

Printed Name and Title Signature and Date Signed image6.emf

PS Form 2181-D(X).pdf

DISCLOSURE AND RELEASE

FOR CONSUMER REPORTS AND

INVESTIGATIVE CONSUMER REPORTS

Carefully read the following information before you sign and date this document.

I understand that an agent of the United States Postal Service may obtain a consumer report, investigative consumer report, or both, about me, as defined by the Fair Credit Reporting Act. I authorize all corporations, employers, co-workers, references, credit reporting agencies, educational institutions, licensing bodies, courts, law enforcement agencies, governmental agencies or departments, and military services to provide information about my background, including but not limited to driving records, court records, criminal records, credit reports, academic records, professional license records, and employment information or records.

I understand that an investigative consumer report is a special type of consumer report obtained through interviews. The report may contain information about my character, general reputation, personal characteristics, and mode of living. I may submit a written request within a reasonable period of time to obtain a complete disclosure of the nature and scope of that investigation. I understand that I will receive a response in writing within five days of the date the United States Postal Service receives my request.

United States Postal Service Employees or Prospective Employees: I understand that, if I am hired, the United States Postal Service may also obtain a consumer report, investigative consumer report, or both during the course of my employment for employment-related purposes. If I am hired, I also authorize the United States Postal Service to request a consumer report, investigative consumer report, or both about me, for employment-related purposes, at any time during the course of my employment.

United States Postal Service Contractors and Employees of Contractors: I understand that I may receive this disclosure even if I am an independent contractor or am employed by an entity with which the Postal Service contracts for services. The disclosure should not be misconstrued as evidence that I am an employee of the Postal Service or that the Postal Service believes I am its employee.

I agree that this Disclosure and Release will be valid, now or in the future, in original, faxed, copied, or electronic form.

I acknowledge that I have received a copy of “Summary of Your Rights Under the Fair Credit Reporting Act.”

Signature

Printed Name

Date

PS Form 2181-D(X) January 2016

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la

Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer

Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

a person has taken adverse action against you because of information in your credit report;

you are the victim of identity theft and place a fraud alert in your file;

your file contains inaccurate information as a result of fraud;

you are on public assistance;

you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

http://www.consumerfinance.gov/learnmore

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

You many limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-

OPTOUT (1-888-567-8688).

You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

TYPE OF BUSINESS: CONTACT:

1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates

b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:

a. Consumer Financial Protection Bureau

1700 G Street, N.W. Washington, DC 20552

b. Federal Trade Commission: Consumer

Response Center – FCRA

Washington, DC 20580

(877) 382-4357

2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks

b. State member banks, branches and agencies of

a. Office of the Comptroller of the Currency

Customer Assistance Group

1301 McKinney Street, Suite 3450

Houston, TX 77010-9050

b. Federal Reserve Consumer Help Center foreign banks (other than federal branches, federal agencies, and Insured State Branches of

Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or

25A of the Federal Reserve Act

c. Nonmember Insured Banks, Insured State

Branches of Foreign Banks, and insured state savings associations

d. Federal Credit Unions

P.O. Box. 1200

Minneapolis, MN 55480

c. FDIC Consumer Response Center

1100 Walnut Street, Box #11

Kansas City, MO 64106

d. National Credit Union Administration Office of Consumer Protection (OCP) Division of

Consumer Compliance and Outreach (DCCO)

1775 Duke Street

Alexandria, VA 22314

3. Air carriers Asst. General Counsel for Aviation

Enforcement & Proceedings

Aviation Consumer Protection Division

Department of Transportation

1200 New Jersey Avenue, S.E. Washington, DC

20590

4. Creditors Subject to the Surface

Transportation Board

Office of Proceedings, Surface Transportation

Board

Department of Transportation

395 E Street, S.W. Washington, DC 20423

5. Creditors Subject to the Packers and

Stockyards Act, 1921

Nearest Packers and Stockyards

Administration area supervisor

6. Small Business Investment Companies Associate Deputy Administrator for Capital

Access

United States Small Business Administration

409 Third Street, S.W., 8th Floor

Washington, DC 20416

7. Brokers and Dealers Securities and Exchange Commission

100 F Street, N.E.

8. Federal Land Banks, Federal Land Bank

Associations, Federal Intermediate Credit

Banks, and Production Credit Associations

Farm Credit Administration

1501 Farm Credit Drive

McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other

Creditors Not Listed Above

FTC Regional Office for region in which the creditor operates or Federal Trade Commission:

Consumer Response Center – FCRA

Washington, DC 20580 (877) 382-4357

Signature:

Printed Name:

Date:

image7.emf

Form 2025.pdf

Contract Personnel Questionnaire Prepare in duplicate. Type or print all responses. If answer is No, state so. Attach sheets if more space is needed.

Privacy Act Statement: Your information will be used as a basis for an investigation to determine your fitness and suitability for contractual services to the U.S.

Postal Service® (USPS®). Collection is authorized by 39 U.S.C. 3061. Providing the information is voluntary, but if not provided you may be denied access to Postal Service premises, denied access to the mail, or denied participation under a USPS contract. We may disclose your information as follows: in relevant legal pro-ceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel.

1. Print Your Full Name (Last, First, Middle Name) 2. Print Your Mailing Address (Include Apartment/Suite Number)

4a. Home Telephone Number (Include Area Code)

3. City, State and ZIP+4 Code™

5. List Other Names Used. (i.e., maiden name, names by former marriages, names changed legally or otherwise, aliases, nicknames. Specify which and dates used.)

10. Type of Screening (Check one)

13. Contractor’s Name and Mailing Address

14. Have You Had a Security Screening by USPS or Other Federal Agencies Within the Last Year?

11. Are You Presently a Highway Contract Driver?

(If Yes, include Contract Number and Termini.)

12. Highway Contract Number and Termini (If applicable)

7. Date of Birth (MM/DD/YYYY) 8. Place of Birth (City and State/Country) 9. Sex6. Social Security Number (SSN)

15. Dates and Places of Residence. (If actual places of residence differ from the mailing addresses, furnish and identify both. Begin with present residence and go back for the past five years.)

16. Employment. (List ALL periods of employment for the past five years starting with your present employment. Include dates when unemployed.

Give name under which employed if different from name now used.)

From

(MM/YYYY)

To

From

To

Number and Street City State ZIP+4 Code

Employer’s and Supervisor’s Names

Employer’s Address (City, State, Zip+4Code)

Occupation Reason for Leaving

Male Female

Sub-ContractorContractor’s Employee ADPContractor Yes No

18b. Commercial Driver’s License

18a. Do You Have a Valid License? (Driver/Chauffeur) If “Yes”, include License Number, State, and Expiration Date. Yes No Yes No

PS Form 2025, March 2012, (Page 1 of 2) PSN 7530-01-000-9519

4b. Work Telephone Number (Include Area Code)

Other

Agency:

Your Name During Period of Employment

17a. Are You a United States Citizen?

17b. Are You a Citizen of American Samoa or Any Other Territory Owing Allegiance to the United States? Yes No

17c. Provide Alien Registration Number if not a United States Citizen

(Continued on Page 2)

Disposition

Action Taken

Action Taken

22. In the Past 5 years, Have You Been Convicted of any Traffic Violations (Other Than Parking) or Currently Have Charges Pending? (If Yes, complete information below.)

19b. Have you registered with the Selective Service System? If “Yes”, provide your registration number. If “No”, show the reason for your legal exemption.

19a. Are you a male born after December 31, 1959? If “No”, go to 20a. If Yes, go to 19b.

20a. Military Service (Past or Present). (If Yes, complete Items 20b, 20c, 20d, 20e, and 20f.)

20c. Branch of Service (Army, Navy, Air Force, Marines, etc.)

20b. Dates of Service (MM/YYYY)

To From

20d. Serial Number (If none, provide Grade or Rating at time of separation)

20e. Were You Discharged from the Military Service Under Honorable Conditions? (If your discharge was changed to “honorable” or “general” by a Discharge Review Board, answer “Yes”. If you received a clemency discharge, answer “No”.) If No, enter the date and type of discharge you received in the blocks below.

Yes

No

Discharge Date (MM/YYYY) Type of Discharge

20f. While in Military Service, Were You Ever Convicted by Court Martial?

21a. Have You Ever Been Convicted of, or Forfeited Collateral, for Any Felony/Misdemeanor Violation (Except Traffic Violations)?

(Generally, a felony is defined as any violation of law punishable by imprisonment of one year or longer.) Yes No

21b. During the Last 10 Years Have You Forfeited Collateral, Been Convicted, Been Imprisoned, Been on Probation, or Been on Parole for any Violation of Law? (Do not include violations reported in question 21a.)

21c. Have You Ever Been Convicted of, or Forfeited Collateral for Any Assaults, Firearms or Explosives Violations?

21d. Are You Now Under Charges for Any Violation of Law?

21e. Are You Delinquent on any Federal Debt? (Include delinquencies arising from Federal taxes, overpayment of benefits, or other debts to the U.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgage loans.) Yes No

Date (MM/YYYY) Place (City and State) Court Charge

Date (MM/YYYY) Place (City and State) Court Charge

If necessary, attach additional sheets.

If necessary, attach additional sheets.

Warning

Check Here if Your Driver’s Abstract from Department of Motor Vehicles is Attached.

Certification

USPS Official Signature (Sign and print name) Date Signed (MM/DD/YYYY)

For Use of Postal Service Official Responsible for Reviewing for Completeness and Legibility. (See Administrative Support Manual 272.23, Contractor Clearance, for complete instructions.)

Review this form carefully to ensure you have answered all questions fully and correctly. Failure to answer all questions may result in your being denied access to mail and/or Postal Service premises. A fine not to exceed $250,000 or imprisonment of not more than five years or both is provided by law (18 U.S.C. 1001) for making a false statement or concealing any material fact on this Questionnaire.

I certify that the statements made by me on this questionnaire are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

I attest I have advised the Applicant to truthfully complete this Questionnaire, and the Applicant has passed the Drug Screening Test (If applicable, provide documentation).

Applicant’s Signature Date Signed (MM/DD/YYYY)

Date Signed (MM/DD/YYYY)Contractor’s Signature (Sign and print name)

PS Form 2025, March 2012 (Page 2 of 2)

If any answers to 21a - 21d are “Yes”, provide date, place, court location, charge, and disposition on an attached sheet.

Telephone Number (Include area code)

Organization, City, State, and ZIP+4 Code

Telephone Number (Include Area Code)

Court Martial Date (MM/DD/YYYY) Place (City and State/Country) Charge

19. Your Selective Service Record

19c. Registration Number 19d. Legal Exemption Explanation image8.emf

Form 5472.pdf

Pre-Award Questionnaire and Assets and Liabilities Statement

Solicitation No.

1. Nature of Bidder (sole proprietorship, partnership, corporation, etc.)

b. If operating as a Partnership, Attach List of Names, Ages, and Percentage of Ownership of All Partners

c. If operating as a Corporation, Date and State of Incorporation (Attach list of names of corporate officers and majority stockholders, if any, other than officers.)

PS Form 5472, April 2006 (Page 1 of 2) PSN 7530-02-000-9254

2. Describe other business ventures in which the company is, or has been engaged within the past three years. If company has not been engaged full time in business for at least three years, identify the employment and business ventures of the owner, partners, or corporate officers during the period. (Attach additional sheets as necessary to fully explain previous business ventures.)

3. Identify any capacity (e.g., contractor, subcontractor, carrier, driver, etc.) in which the company, its owner, partners, or officers have been engaged in the carrying of the mails within the past five years. If possible, identify routes by number and provide name of contractor and Contracting Officer. If service on any route was terminated by the Postal Service™ for cause, attach explanation.

4. Describe by model, size, and year, the equipment you propose to use on this route. Is the equipment owned or leased? If equipment is not yet acquired, describe the manner proposed for its acquisition.

5. Identify any individual owner, partner, corporate officer, or majority stockholder who is an employee of the U.S. Postal Service®, or who is either the spouse or minor child of an employee of the U.S. Postal Service, or a blood relative of an employee of the U.S. Postal Service residing in the same household with that postal employee. With respect to any affirmative response, identify the postal employee by name and place of work. Postal employees for the purpose of this response include those in full-time, part-time, career and noncareer positions, including specifically persons in positions such as postmaster replacements and rural carrier reliefs.

6. Identify the individuals (owner, partners, officers, employees, etc.) intended to have access to the mails or to postal operations areas during performance of the contract. Indicate which individuals, if any, have previously been screened by the Postal Service for such access.

Name (as shown on bid) Telephone No. (include area code)

Name of Owner Date

a. If Sole Proprietorship

Address (number, street, suite, apt., P.O. Box, etc.) 7. State6. City 8. ZIP+4®

PS Form 5472, April 2006 (Reverse)

Assets and Liabilities Statement Name Date (As of)

Name, Location or Description Amount or Value

Basis for Loan Amount

Assets

Stocks and

Bonds

Notes

Real Estate

Real Estate

Mortgage

Chattel Mortgage

The undersigned authorizes the U.S. Postal Service to make such inquiries as necessary to determine my financial responsibility and capability for performing under the proposed contract based on the pre-award survey information provided.

Signature Title Date

Notes

Cash In Bank

Liabilities

Total LiabilitiesTotal Assets

Taxes

Vehicles image9.emf

Supplier Information Sheet.pdf

Supplier Information Sheet

First Name:

Middle Initial:

Last Name:

Phone:

24 Hr Phone:

Cell Phone:

Email:

Address Line 1:

Address Line 2:

City:

State:

Zip + 4:

County:

image10.emf

Vehicle Info Sheet.pdf

Number (#) of drivers operating routes for this company (ies):

Please list all HCR contract (route) numbers for each TIN:

List all vehicle information requested below for vehicles performing USPS service under these TIN’s

Year

Please Note:

Vehicle Information Sheet, February 2005

VEHICLE INFORMATION SHEET

Attach additional sheets as necessary.

Be sure to include the supplier name on all attachments.

List your company name and address below. All Tax Identification Numbers (TINS) and vehicles listed below will fall under one supplier account. This does not impact the current U. S. Postal Service (USPS) process by which the contracts are managed or paid. This is only to ensure we have correctly captured your information. Additionally, Voyager will be sending all cards to the address indicated on the mailing label of this package. All cards should be sent to a single address for security purposes. If you wish to change that address, please do so on the line below.

List of Tax Identification Numbers that will be operating under this account

VIN Number Vehicle Number**

(Example: ABC Trucking is your company name. However, ABC Trucking also operates XYZ Inc. and QRS Ltd. The vehicles may be used by all three companies. The TINs for all three companies should appear in this section):

The PIN usage scenarios will be forwarded in a later mailing.

Return this sheet to the Supply Management

All transaction cards will be sent to the address of the company name used above PIN numbers will be assigned to each route and will be available for assignment to each driver.

**The vehicle number is assigned by the supplier as a means to identify its equipment. If you do not currently have vehicle numbers assigned to your equipment leave the vehicle number blank and we will default to a sequential numbering beginning with 1. This number will appear on the Voyager Card that is issued for that vehicle.

Make Model

Sheet1 image11.emf

Driver Info Sheet.pdf

Supplier: Route Number:

*Identify any immediate predecessor company by name, address, and dates employed:

Date: Signature:

T200 - 2004

Driver Information Sheet

The following employees are assigned as drivers of the above numbered route and have the length of employment service as shown below:

Employnee Name Social Security No.

Fine of not more than $10,000 or imprisonment for not more than 5 years or both. (See U.S.C. 287, 1001.)

I certify that to the best of my knowledge the above information is true, accurate and complete. I further certify that I will notify promptly the postal Service of any changes or deletions to the information supplied. I further understand that the information furnished is subject to audit.

Name Address Date Employed

Time With You Time with Any

Predecessor Co.*

CIVIL PENALTY FOR PRESENTING FALSE CLAIMS OR STATEMENTS:

The claimant shall forfeit and pay to the United States Postal Service up to $5,000 per claim or statement and up to two times the amount paid by the United States Postal Service. (See U.S.C.

SS3801-3812.)

Furthermore, the claimant may be liable to the United States up to $10,000 per claim or statement and up to three times the amount of damages the Government sustains. (See U.S.C. S3729.)

BEGIN CONTRACT TERM

CRIMINAL PENALTY FOR PRESENTING FRAUDULENT CLAIM OR FOR MAKING FALSE

STATEMENTS:

Sheet1 image12.emf

PS Form 3881-X.pdf

A. Instructions

Supplier and Payee Electronic Funds Transfer (EFT) Enrollment

B. USPS Information: (Contracting officer, purchasing specialist, or other USPS representative completes.)

1. USPS Contact Person's Name

2. USPS Organization Name

4. Mailing Address (No., street, ste., PO box no., city, state, ZIP + 4®)

3. Telephone Number (Include area code)

5. Accounts Payable Supplier Name

6. Accounts Payable Supplier Number

7. Site Name(s)

8. Contract Numbers to Which Payments Referenced Here Apply (If any)

9. Additional Information/Instructions

C. Supplier/Payee Information: (Suppliers/Payees complete and sign this section before Section D is verified.)

Privacy Act Statement: Your information will be used to transmit payment data electronically to your financial institution. Collection is authorized by 39 USC 401, 404, 410, 1001, 1005, 1206, and 2008.

Providing the information is voluntary, but if not provided, your payments will not be processed electronically. We may only disclose your information as follows: in relevant legal proceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel; and to financial entities regarding financial transaction issues. For more information regarding our Privacy Policy visit www.usps.com.

1. Supplier/Payee Name 5. Taxpayer Identification Number

4. Address (No., street, ste., PO box no., city, state, ZIP + 4) 8. Mailing Address (Only if different from C4 - no., street, ste., PO box no., city, state, ZIP + 4)

2. Supplier Contact Person

3. Contact Person Telephone Number (Include area code)

6. Contract Number(s) to Which Payments Referenced Here Apply (Only if different from, or in addition to those listed in B8 above. Add attachment if necessary.)

7. Change All Payments Made by the USPS to you by this EFT Request?

Supplier/Payee Certification: I certify that I am entitled to receive the above described payments from the USPS. By signing this form, I authorize these payments to be transmitted to the financial institution named below, and deposited in the account number specified. The financial institution listed below has provided/verified the accuracy of the information recorded in Section D.

10. Date9. Signature

D. Financial Institution Information: (Complete or verify this section if completed by the requesting supplier or payee named in Section B.

Return the completed form to the requester, or mail it to the address in Section A.)

You (USPS® suppliers and payees) must use this form to initiate or change Electronic Funds Transfer (EFT) payments made through the

USPS Accounts Payable System. To set up EFT payments for the first time, you must bring the form to your financial institution for verifi-cation before you submit it to the USPS for processing. Follow instructions in Sections B through D of the form. Mail the completed form to:

PS Form 3881-X, October 2005

8b. Date Signed

ACCOUNTS PAYABLE SUPPLIER MAINTENANCE GROUP

SAN MATEO ACCOUNTING SERVICE CENTER

UNITED STATES POSTAL SERVICE

2700 CAMPUS DR

SAN MATEO CA 94497-9432

1. Financial Institution Name 2a. Branch Name

3. Branch Address (No., street, city, state, ZIP + 4)

4a. ACH/EFT Coordinator Name 4b. Telephone Number (Include area code)

6. Depositor Account Name/Title5. Depositor Account Number

(Circle one) Checking Savings

7a. Name of Authorized Official 7b. Title of Authorized Official

8a. Financial Institution Signature

2b. Branch Routing Number image13.emf

1982-0207 ALASKA STATES Rev 79.pdf

U.S. DEPARTMENT OF LABOR

EMPLOYMENT STANDARDS ADMINISTRATION

WAGE AND HOUR DIVISION

WASHINGTON, D.C. 20210

REGISTER OF WAGE DETERMINATIONS UNDER

THE SERVICE CONTRACT ACT

By direction of the Secretary of Labor

Daniel W. Simms Director

Division of Wage Determinations

Wage Determination No.:

Revision No.:

Date of Last Revision:

1982-0207 03/19/2020

Note: Under Executive Order (EO) 13658, an hourly minimum wage of $10.80 for calendar year 2020 applies to all contracts subject to the Service Contract Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2015. If this contract is covered by the EO, the contractor must pay all workers in any classification listed on this wage determination at least $10.80 per hour (or the applicable wage rate listed on this wage determination, if it is higher) for all hours spent performing on the contract in calendar year 2020. The EO minimum wage rate will be adjusted annually. Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts.

State: Alaska Area: Alaska Statewide

** Fringe Benefits Required Follow the Occupational Listing **

Employed on contract for mail hauling and delivery within the state.

OCCUPATION TITLE RATECODE FOOTNOTE

Driver/Caser 16.95 Tractor Trailer Driver 24.76 Truck Driver 24.76 Light Vehicle Driver 13.56

Note: Executive Order (EO) 13706, Establishing Paid Sick Leave for Federal Contractors, applies to all contracts subject to the Service Contract Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2017. If this contract is covered by the EO, the contractor must provide employees with 1 hour of paid sick leave for every 30 hours they work, up to 56 hours of paid sick leave each year.