SPD_SP042SupplierGeneralInformationWorksheet .pdf

Question #

Description Company Name (Provide full legal name) Address 1

Address 2

City

State

Zip Code

Authorized Person’s Name

Telephone Number

Email Address

2 Supplier's Domicile (State)

3 Response

4 Response

For the purposes of evaluation only, Suppliers resident in the State of Georgia will be granted the same preference over Suppliers resident in another state in the same manner, on the same basis, and to the same extent that preference is granted in awarding bids for the same goods or services by such other state to Suppliers resident therein over Suppliers resident in the State of Georgia. NOTE:

For the purposes of this law, the definition of a resident Supplier is a Supplier who is domiciled in the State of Georgia.

Small Business: Can your company be classified as a Small Business?

A Small Business is defined as a business which is independently owned and operated. In addition, such business must have either (1) 300 or fewer employees or (2) $30 million or less in gross receipts per year. Small Businesses are further categorized into tiers:

Tier 1: ten or fewer employees or $1 million or less in gross receipts per year Tier 2: 100 or fewer employees or $10 million or less in gross receipts per year Tier 3: 300 or fewer employees or $30 million or less in gross receipts per year

Also, the State encourages all companies to sub-contract portions of any state contract to small and minority business enterprises. Suppliers interested in taking advantage of the Georgia income tax incentives provided for by the Official Code of Georgia Annotated Section 48-7-38, relative to the use of minority subcontractors in the performance of contracts awarded by the State of Georgia, should visit the website below for more information.

Georgia Resident Business means any business that regularly maintains a place from which business is physically conducted in Georgia for at least one year prior to any bid or proposal to the state or a new business that is domiciled in Georgia and which regularly maintains a place from which business is physically conducted in Georgia; provided, however, that a place from which business is conducted shall not include a post office box, a leased private mailbox, site trailer, or temporary structure.

http://doas.ga.gov/state-purchasing/supplier-services/minority-business-enterprise-certification

Supplier General Information Worksheet

THIS FORM SHOULD ONLY BE USED FOR SUPPLIERS RESPONDING TO SOLICITATIONS POSTED DIRECTLY TO THE GEORGIA PROCUREMENT REGISTRY. IT SHOULD NOT BE USED WITH ELECTRONIC BIDS SOURCED

THROUGH TEAM GEORGIA MARKETPLACE TM , ESOURCE OR JAGGAER SOURCING DIRECTOR.

This spreadsheet requests basic information concerning the Supplier and may establish other requirements the Supplier must meet to be considered eligible for award. Read each question carefully and provide all requested answers.

Supplier General Information

Georgia Resident Business: Can your company be classified as a Georgia Resident Business?

Description

Provide Company Information:

Response

Reciprocal Preference Law O.C.G.A. §50-5-60(b) In which state is your company domiciled?

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Supplier General Information Worksheet

5 Response

Minority Group Percentage of Ownership

African American %

Hispanic / Latino %

Native American %

Asian American %

Pacific Islander %

7 Response

8 Response

9 Response

RUSSIA/BELARUS: A scrutinized company is any sole proprietorship, organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, limited liability company, or other entity or business association, including all wholly owned subsidiaries, majority owned subsidiaries, parent companies, or affiliates of such entities or business associations, that exists for the purpose of making profit owned or operated by the Government of Belarus or the Government of Russia. The Government of Belarus means the Republic of Belarus, and the Government of Russia means the Russian Federation. A scrutinized company is ineligible to submit a response to this solicitation. False certification hereunder may result in a civil penalty in an amount that is equal to the greater of $250,000 or twice the amount of the contract for which a bid or proposal was submitted, contract termination, and any other penalties available under law, rule or policy.

Please answer either a or b in the response column of this worksheet to indicate your answer:

a. I certify my company is NOT a “scrutinized company.”

b. I certify my company is a “scrutinized company.”

Is your company a scrutinized company as defined by O.C.G.A. Section 50-5-84.2?

Please answer either a or b as described below.

Is your company a scrutinized company as defined by O.C.G.A. Section 50-5-84?

Please answer either a, b, or c as described below.

SUDAN: Any Supplier that currently and/or previously, within the last three years, has had business activities or other operations outside of the United States, must certify that it is not a “scrutinized company.” A scrutinized company is a company conducting business operations in Sudan that is involved in power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, but excludes a company which can demonstrate any of the following exceptions noted in O.C.G.A. Section 50-5-84. False certification hereunder may result in civil penalties, contract termination, ineligibility to bid on state contractors for three or more years, and/or any other available remedy. If the Supplier is a scrutinized company, the Supplier shall not be eligible to bid on or submit a proposal for a contract with the State Entity unless DOAS makes a determination in accordance with O.C.G.A. Section 50-5-84 that it is in the best interests of the State to permit the scrutinized company to submit a bid or proposal. Any scrutinized company desiring DOAS to make such a determination should contact both DOAS and the Issuing Officer immediately.

Please answer either a, b or c in the response column of this worksheet to indicate your answer:

a. I certify my company is NOT a “scrutinized company.”

b. I certify my company is a “scrutinized company.”

c. I certify I have requested and received written permission from DOAS to submit a response to this Event in accordance with O.C.G.A. Section 50-5-84.

A Minority Business enterprise means a small business concern which is at least 51% owned and controlled by one or more minorities and is authorized to do and is doing business under the laws of the State of Georgia, paying all taxes duly accessed and domiciled within this state (Official Code of Georgia Annotated §50-5-131).

Minority Business: Can your company be classified as a Minority Owned Business? Indicate below the percentage of company ownership/control attributable to each of the minority groups listed:

Georgia Resident Small Business: Can your company be classified as a Georgia Resident Small Business?

Georgia Resident Small Business means any business that satisfies both requirements:

1) Georgia Resident Business - regularly maintains a place from which business is physically conducted in Georgia for at least one year prior to any bid or proposal to the state or a new business that is domiciled in Georgia and which regularly maintains a place from which business is physically conducted in Georgia; provided, however, that a place from which business is conducted shall not include a post office box, a leased private mailbox, site trailer, or temporary structure.

2) Small Business - defined as a business which is independently owned and operated. In addition, such business must have either fewer than 300 employees or less than $30 million in gross receipts per year.

Is your company a scrutinized company as defined by O.C.G.A. Section 50-5-84.1?

Please answer either a or b as described below.

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Supplier General Information Worksheet

10 Response https://gtc.dor.ga.gov/_/ http://doas.ga.gov/state-purchasing/seven-stages-of-procurement/stage-3-solicitation-preparation

To be eligible for contract award, the supplier must not owe taxes to the State of Georgia. Also, in accordance with Official Code of Georgia Annotated §50-5-82, the State Entity is prohibited from awarding any contract valued at more than $100,000.00 to a nongovernmental vendor if that vendor or an affiliate of the vendor is a “dealer” failing or refusing to collect sales or use taxes on its sales delivered to Georgia. Each Supplier must submit a completed Tax Compliance Form (SPD-SP045), which has been provided as a downloadable document by accessing the link below. In the event the Supplier is being considered for contract award (and the contract is valued at more than $100,000.00), the information provided in the Tax Compliance Form will be submitted by the State Entity to the Georgia Department of Revenue (“DOR”) for a determination as to whether the Supplier is a “prohibited source” or has other tax deficiencies. The State Entity reserves the right to submit the Supplier’s completed form to DOR for review even if the contract is valued at less than $100,000.00.

Download the Tax Compliance Form using the link below and include the completed form as part of your response:

Any supplier identified as a prohibited source will be ineligible for award. Accordingly, the supplier is strongly encouraged to check its tax status now and resolve any outstanding tax liabilities prior to submitting this response. DOR has identified the following source to allow Offerors to check current tax status:

Have you submitted a completed Tax Compliance form?

CHINA: A scrutinized company is any sole proprietorship, organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, limited liability company, or other entity or business association, including all wholly owned subsidiaries, majority owned subsidiaries, parent companies, or affiliates of such entities or business associations, that exists for the purpose of making profit owned or operated by the Government of China. The Government of China means the People’s Republic of China led by the Chinese Communist Party. A scrutinized company is ineligible to submit a bid or proposal in response to this solicitation. False certification hereunder may result in a civil penalty in an amount that is equal to the greater of $250,000 or twice the amount of the contract for which a bid or proposal was submitted, contract termination, and any other penalties available under law, rule, regulation or policy.

Please answer either a or b in the response column of this worksheet to indicate your answer:

a. I certify my company is NOT a “scrutinized company.”

b. I certify my company is a “scrutinized company.”

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