SOWHBY30SB - Price Form.pdf

P R I C E F O R M C O N T R A C T B I D F O R M & S B R A F F I D A V I T –

A T T A C H M E N T - B

Th i s fo rm i s t o b e c o mp le t e d i n i t s e n t i r e t y , i s no t t o b e a l t e red i n a n y wa y an d i s t o con t a i n o n ly t he p r i ce o r p r i c es s t i pu l a t e d o n t h e fo rm.

SHA IFB No.: SOWHBY30SB Pressure washer service and repair - MDOT/SHA Somerset County

Column A Column B Column C Column D

Item / Description

Estimated Quantity Vendor’s Bid per unit

Total Cost ($)

(over contract duration)

(Column B x C)

Line # 1) Quarterly Preventative Maintenance per specification on Landa and Hotsy Units

16 / ea

/ service

Line # 2) Hourly rate – repair technician 30 hours $ ________ / hour $ __________

Line # 3) Repair call trip charge (one per day on repair calls only) Not to be charged on deliveries of supplies or preventative maintenance items

8 trips $ _________ / trip $ __________

Line # 4 A) Replacement repair part – Giant Trigger Gun or equivalent 4 / ea $ _________ / ea $ __________

Line # 4 B) Replacement hose – R2 Hose 100’ 4500 PSI 4 / ea $ _________ / ea $ __________

Line # 5) Repair parts, unspecified – to be billed at current Hotsy / Landa MSRP or market price listing, when parts are used for repair.

Do not alter $ 1,500.00

Line # 6) Detergent / Soap – Truck wash 55-gallon drum Landa Roadshow or SHA approved equal. Delivery included in cost.

16 / ea $ __________/ea $ __________

TOTAL BID AMOUNT (Sum of Column D)

NOTE:

MDO T SH A, i s ex em pt f ro m Ma ry la nd Sa l es a n d U s e Tax es by Ex em pt ion C ert i f ic a te N um b er 3 00 02 5 6- 3 an d f ro m Fe d er al Ex c is e T axe s by Ex em pt io n N um b er 52- 7 3- 03 5 8K. Do no t inc l ud e sa le s tax i n b id p r i ce s .

For the Contractor:

Company Name & Address

City State Zip

Phone _____________________ Fax ______________________Email _____________________________________

Representing the above Company ___________________________________________________

SIGNATURE

Print Name & Title

SOCIAL SECURITY NO. OR

FEDERAL TAX ID NO. _________________________ DATE: ___________________

Maryland Department of Transportation

SMALL BUSINESS CONTRACT AFFIDAVIT

********** PROVIDING FALSE INFORMATION **********

Anyone providing false information to the State of Maryland in connection with obtaining or attempting to obtain a contract under Small Business Reserve or Preference procurement may be subject to the following:

1. A determination by a Procurement Officer that a bidder/offeror is not responsible;

2. A determination that a contract entered into is void or voidable under § 11-204 of the State Finance and Procurement Article of the Annotated Code of Maryland;

3. Suspension and debarment under Title 16 of the State Finance and Procurement Article;

4. Criminal prosecution for procurement fraud (§ 11-205.1 of the State Finance and Procurement Article), perjury, or other crimes; and

5. Other actions permitted by law.

********** FAILURE TO MEET MINIMUM QUALIFICATIONS **********

Any Bidder or potential bidder failing to meet the qualifications of a "small business" specified in § 14-501(c) of the State Finance and Procurement Article will be ineligible to participate in a procurement designated for a Small Business Reserve under § 14-504 or Small Business Preference under § 14-206 - 207. Any person or company bidding on Small Business Reserve or Preference procurement and not qualifying as a small business under § 14-501(c) will have its bid or offer rejected on the ground that the bidder is not responsible.

I AFFIRM THAT:

To the best of my knowledge, information, and belief, as of the date of submission of this Bid/Proposal, (name of firm) meets the qualifications for certification as a Small Business in Maryland. I further affirm that, if for any reason during the term of the contract (name of firm) no longer meets the qualifications of certification as a Small Business in Maryland, I will notify the Procurement Officer within 30 days. I agree that a failure to so notify the Procurement Officer of this change in circumstances may result in this contract being terminated for default.

I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE CONTENTS OF THIS AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF.

SMALL BUSINESS QUALIFICATION NUMBER ___________________

Date of Most Recent Qualification__________________________________

DATE:_____________

BY:_____________________________________________________________

Signature (Authorized Representative and Affidavit)