SR 28 Central Corridor Trail_Appendix D_Other Forms.docx

Other Required Forms

Form BAC Buy America and Buy America/Build America (BABA) Certification (To be signed by authorized signatory(ies) of Proposer) The undersigned hereby certifies on behalf of itself and all contractors (at all tiers) the following with regard to the Project:

The undersigned shall comply with the Federal Highway Administration (FHWA) Buy America in 23 CFR 635.410, Build America requirements in 2 CFR 184, and the Department’s requirements, which permits FHWA participation in a contract only if domestic steel, iron, manufactured products and construction materials will be used on the Project.

The undersigned shall comply with the Build America, Buy America Act (BABA) of the Infrastructure Investment and Job Act (IIJA) (Pub. L. No. 117-58 §§ 70901-52) that expands the requirements of the Buy America Act to include permanently incorporated construction materials on Federal-aid projects.

Date: [__________ __, 20__] Signature:

Title:

Proposer’s Name:

Form BC Certificate of Compliance Breach of Contract The undersigned, as the duly authorized representative of the person or entity on whose behalf this Certificate is offered, certifies that:

The undersigned has not been found liable for breach of contract with respect to a previous project, other than for legitimate cause, during the five (5) years immediately preceding the date of advertisement of this RFP.

Disclosure (if none, indicate “none”; if additional space is needed, add an attachment):

Company Name

Signature

Name and Title (Please type or print) Date

Form COI Organizational Conflict of Interest Disclosure Statement The undersigned attention is directed to 23 CFR Part 636 Subpart A and in particular to Subsection 636.116 regarding organizational conflicts of interest. Section 636.103 defines “organizational conflict of interest” as follows:

Organizational conflict of interest means that because of other activities or relationships with other persons, a person is unable or potentially unable to render impartial assistance or advice to the owner, or the person's objectivity in performing the contract work is or might be otherwise impaired, or a person has an unfair competitive advantage.

1. Disclosure Pursuant to Section 636.116(2)(v) In the space provided below, and on supplemental sheets as necessary, identify all relevant facts relating to past, present, or planned interest(s) of the Proposer’s team (including Proposer, all team members and their respective chief executives, directors, and all Key Personnel) which may result, or could be viewed as, an organizational conflict of interest in connection with this RFP. (If none, indicate “none” and complete Section 3 below. If a conflict of interest(s) does exist, list below and complete Section 2 and Section 3.)

Proposer should disclose (a) any current contractual relationships with TTD, (b) any past, present, or planned contractual or employment relationships with TTD and any board member, officer, or employee; and (c) any other circumstances that might be considered to create a financial interest in the contract by any TTD board member, officer, or employee if Proposer is awarded the contract. Proposer should also disclose matters such as ownership of 10 percent (10%) or more of the stock of, or having directors in common with, any of the RFP preparers. Proposer should also disclose contractual relationships with an RFP preparer in the nature of a joint venture, as well as relationships wherein the RFP preparer is a contractor or consultant (or subcontractor or subconsultant) to Proposer or a member of Proposer’s team. The foregoing is provided by way of example, and shall not constitute a limitation on the disclosure obligations.

2. Explanation In the space provided below, and on supplemental sheets as necessary, identify steps that have been or will be taken to avoid, neutralize, or mitigate any organizational conflicts of interest described herein.

3. Certification The undersigned hereby certifies that, to the best of his or her knowledge and belief, no interest exists that is required to be disclosed in this Conflict of Interest Disclosure Statement, other than as disclosed above.

Signature

Name

Title

Company Name , 20 Date

Form DFB Certificate of Compliance Nevada Revised Statutes 338.017, 338.13895, 338.1475, and/or 408.333 The undersigned, as the duly authorized representative of the person or entity on whose behalf this Certificate is offered, certifies that:

The undersigned has not been disqualified from being awarded a contract pursuant to NRS 338.017, 338.13895, 338.1475, and/or 408.333.

Disclosure (if none, indicate “none”; if additional space is needed, add an attachment):

Company Name

Signature

Name and Title (Please type or print) Date

Form IC (Exhibit B) Affidavit Required Under 23 USC Section 112(C) and 2 CFR Parts 180 and 1200 - Suspension or Debarment

STATE OF ______________________________

SS

COUNTY OF ____________________________

I, _____________________________________________________(Name of party signing this affidavit and the Proposal Form) __________________________________________________ (title).

being duly sworn do depose and say: That ______________________________________________ (name of person, firm, association, or corporation) has not, either directly or indirectly, entered into agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with this contract; and further that, except as noted below to the best of knowledge, the above named and its principals:

(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency:

(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgement rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public or private agreement or transaction; violation of Federal or State antitrust statutes, including those proscribing price fixing between competitors, allocation of customers between competitors, and bid rigging; commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, receiving stolen property, making false claims, or obstruction of justice; commission of any other offense indicating a lack of business integrity or business honesty that seriously and directly affects your present responsibility;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and

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

(Insert Exceptions, attach additional sheets) The above exceptions will not necessarily result in denial of award, but will be considered in determining bidder responsibility and whether or not TTD will enter into contract with the party. For any exception noted, indicate on an attached sheet to whom it applies, initiating agency, and dates of action. Providing false information may result in criminal prosecution or administrative sanctions. The failure to furnish this affidavit and required exceptions if any shall disqualify the party.

Signature

Title

Sworn to before me this __________ day of _________________, 20 ______

(SEAL) Notary Public, Judge or other

Form KP Key Personnel Information Name of Proposer:

Registration

Use additional sheets when needed.

Form LC (Exhibit C) Certification Required by Section 1352 of Title 31, United States Code Restrictions of Lobbying Using Appropriated Federal Funds The undersigned certifies, to the best of his or her knowledge and belief that:

(1) No Federal appropriate 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 agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any 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 agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," 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.

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.

1. Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

2. Status of Federal Action:

a. bid/offer/application

b. initial award

c. post-award

3. Report Type:

a. initial filing

b. material change For Material Change Only:

year ______ quarter ______ date of last report _________

4. Name and Address of Reporting Entity:

___ Prime ___ Subawardee Tier ________, if known

Congressional District, if known :

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

Congressional District, if known :

CFDA Number, if applicable : _________________

(attach Continuation Sheet(s) SF-LLLA, if necessary)

11. Amount of Payment (check all that apply):

a. retainer

b. one-time fee

c. commission

d. contingent fee

e. deferred

f. other; specify: __________

12. Form of Payment (Circle all that apply ):

a. cash

b. in-kind; specify: nature _____________ value ______________

14. 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 11:

(attach Continuation Sheet(s) SF-LLLA, if necessary)

15. Continuation Sheet(s) SF-LLLA attached: ___ Yes ___ No

Print Name:

Title:

Telephone No.: Date:

Standard Form LLL (Rev. 7-97)

DISCLOSUREOFLOIVITIES

INSTRUCTIONS FOR COMPLETION OF SF-LLL, 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 a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any 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. Use the SF-LLLA 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 and/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 1st 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 organizational 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 identified 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 commitment for the prime entity identified in item 4 or 5.

10. (a) 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.

(b) 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 (MI).

11. 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.

12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment.

13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature.

14. 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 official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted.

15. Check whether or not a SF-LLLA Continuation Sheet(s) is attached.

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

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, 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, DC 20503.

Form NC Non-Collusion Affidavit

STATE OF

COUNTY OF

The undersigned, being first duly sworn, deposes and says that ________________________________ is the ____________________________ of __________________________________, the entity making the foregoing Proposal. (If the Proposal is a Joint Venture, Partnership, etc., please revise this paragraph to include all signature authorities.)

The Proposal is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization or corporation; the Proposal is genuine and not collusive or sham; the Proposer has not directly or indirectly induced or solicited any other Proposer to put in a false or sham Proposal, and has not directly or indirectly colluded, conspired, connived or agreed with any Proposer or anyone else to put in a sham Proposal or that anyone shall refrain from proposing; the Proposer has not in any manner, directly or indirectly, sought by agreement, communication or conference with anyone to fix any element of the Proposal of the Proposer or any other Proposer, or to secure any advantage against TTD of anyone interested in the proposed Pre-Construction Services Agreement and potential Construction Contract; all statements contained in the Proposal are true; and, further, the Proposer has not, directly or indirectly, submitted its Proposal, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company, association, organization, proposal depository or any member or agent thereof to effectuate a collusive or sham Proposal.

Signature

Printed Name

Title

Company Name

Notary Public in and for said County and State [Seal] My commission expires:

[Duplicate or modify this form as necessary so that it accurately describes the entity making the Proposal and so that it is signed on behalf of all general partners or joint venture partners of the Proposer.] Form SAFE Industrial Safety Record for Proposer and Team Members Performing Installation or Construction Work

PROPOSER’S NAME:

NAME OF TEAM MEMBER:

ROLE OF TEAM MEMBER:

This form shall be filled out separately and provided for the Proposer and each team member of the Proposer’s team that will perform or supervise installation or construction Work for this Project, and including information for any entity in which such team member holds a substantial interest. Information must be provided with regard to all installation and construction work undertaken in the United States (including the State of Nevada) by the entity, with separate statistics relative to the State of Nevada. For team members that are members of joint ventures, information shall be provided as though 100% of the results were for the listed participant. The Proposer may be requested to submit additional information or explanation of data which TTD may require for evaluating the safety record.

1a) Annual average number of employees:1 Nationwide:

Nevada:

1b) Total employee hours worked (in thousands):1,2

2) Number of fatalities/deaths:1

3) Total number of cases with days away from work:1

4) Total number of days away from work:1

5) Total number of cases with job transfer or restricted work activity:1

6) Total number of days of job transfer or restricted work activity:

7) Total number of other recordable cases:

8) Incidence Rate:3 Total Rate Nationwide:

Nevada:

Days Away Rate Nationwide:

Nevada:

Job Transfer/Restriction Rate Nationwide:

Nevada:

DART Rate

9) Insurance Experience Modification (E-Mod) (or NCCI) Rating

ii. List any incidents that resulted in significant injury, loss of life, or major property damage. (List may also be attached to this form.)

iii. List any Occupational Safety and Health Administration (OSHA) citations received and for what. (List may also be attached to this form.)

The above information was compiled from the records that are available to me at this time, and I declare under penalty of perjury under the laws of the State of Nevada that the information is true and accurate within the limitation of those records.

Name of Company (Print) Signature

Address Title

City State and Zip Code Telephone Number