VDOT and all other Attachments.pdf

FIRM DATA SHEET

Funding: (S=State F=Federal) Project No.:

Division:

EOI Due Date:

The prime consultant is responsible for submitting the information requested below on all firms on the project team, both prime and all subconsultants. All firms are to be reported on one combined sheet unless the number of firms requires the use of an additional sheet. Failure to submit all of the required data will result in the Expression of Interest not being considered.

Firm’s Name and Address Firm’s DBE or SWaM Status *

Firm’s Age

Firm’s Annual Gross Receipts

* YD = DBE Firm Certified by DMBE N = DBE or SWaM Firm Not Certified by DMBE NA = Firm Not Claiming DBE or SWaM Status

YS = SWaM Firm Certified by DMBE. Indicate whether small, woman-owned, or small business.

DMBE is the Virginia Department of Minority Business Enterprise

07OCT16-SGP-VII-15-12.12

ATTACHMENT G

USDOT 1050.2A

APPENDIX A

During the performance of this contract, the consultant, for itself, its assignees and successors in interest (hereinafter referred to as the "contractor") agrees as follows:

(1) Compliance with Regulations: The contractor shall comply with the Regulation relative to nondiscrimination in federally-assisted programs of the Department of Transportation (hereinafter, "DOT") Title 49, Code of Federal Regulations, Part 21, as they may be amended from time to time, (hereinafter referred to as the Regulations), which are herein incorporated by reference and made a part of this contract.

(2) Nondiscrimination: The contractor, with regard to the work performed by it during the contract, shall not discriminate on the grounds of race, color, or national origin in the selection and retention of subcontractors, including procurements of materials and leases of equipment. The contractor shall not participate either directly or indirectly in the discrimination prohibited by section 21.5 of the Regulations, including employment practices when the contract covers a program set forth in Appendix B of the Regulations.

(3) Solicitations for Subcontractors, Including Procurements of Materials and Equipment: In all solicitations either by competitive bidding or negotiation made by the contractor for work to be performed under a subcontract, including procurements of materials or leases of equipment, each potential subcontractor or supplier shall be notified by the contractor of the contractor's obligations under this contract and the Regulations relative to nondiscrimination on the grounds of race, color, or national origin.

(4) Information and Reports: The contractor shall provide all information and reports required by the Regulations or directives issued pursuant thereto, and shall permit access to its books, records, accounts, other sources of information, and its facilities as may be determined by the Virginia Department of Transportation to be pertinent to ascertain compliance with such Regulations, orders and instructions.

Where any information required of a contractor is in the exclusive possession of another who fails or refuses to furnish this information the contractor shall so certify to the Virginia Department of Transportation as appropriate, and shall set forth what efforts it has made to obtain the information.

(5) Sanctions for Noncompliance: In the event of the contractor's noncompliance with the nondiscrimination provisions of this contract, the Virginia Department of Transportation shall impose such contract sanctions as it may determine to be appropriate, including, but not limited to:

(a.) withholding of payments to the contractor under the contract until the contractor complies, and/or (b.) cancellation, termination or suspension of the contract, in whole or in part.

(6) Incorporation of Provisions: The contractor shall include the provisions of paragraphs (1) through

(6) in every subcontract, including procurements of materials and leases of equipment, unless exempt by the Regulations, or directives issued pursuant thereto.

The contractor shall take such action with respect to any subcontract. or procurement as the Virginia Department of Transportation may direct as a means of enforcing such provisions including sanctions for non-compliance: Provided, however, that, in the event a contractor becomes involved in, or is threatened with, litigation with a subcontractor or supplier as a result of such direction, the contractor may request the Virginia Department of Transportation to enter into such litigation to protect the interests of the Virginia Department of Transportation, and, in addition, the contractor may request the United States to enter into such litigation to protect the interests of the United States.

ATTACHMENT H1

USDOT 1050.2A

APPENDIX E

During the performance of this contract, the contractor, for itself, its assignees, and successors in interest (hereinafter referred to as the "contractor") agrees to comply with the following nondiscrimination statutes and authorities; including but not limited to:

Pertinent Nondiscrimination Authorities:

• Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et seq., 78 stat. 252), (prohibits discrimination on the basis of race, color, national origin); and 49 CFR Part 21.

• The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, (42 U.S.C. § 4601), (prohibits unfair treatment of persons displaced or whose property has been acquired because of Federal or Federal-aid programs and projects);

• Federal-Aid Highway Act of 1973, (23 U.S.C. § 324 et seq.), (prohibits discrimination on the basis of sex);

• Section 504 of the Rehabilitation Act of 1973, (29 U.S.C. § 794 et seq.), as amended, (prohibits discrimination on the basis of disability); and 49 CFR Part 27;

• The Age Discrimination Act of 1975, as amended, (42 U.S.C. § 6101 et seq.), (prohibits discrimination on the basis of age);

• Airport and Airway Improvement Act of 1982, (49 USC § 471, Section 47123), as amended, (prohibits discrimination based on race, creed, color, national origin, or sex);

• The Civil Rights Restoration Act of 1987, (PL 100-209), (Broadened the scope, coverage and applicability of Title VI of the Civil Rights Act of 1964, The Age Discrimination Act of 1975 and Section 504 of the Rehabilitation Act of 1973, by expanding the definition of the terms "programs or activities" to include all of the programs or activities of the Federal-aid recipients, sub-recipients and contractors, whether such programs or activities are Federally funded or not);

• Titles II and III of the Americans with Disabilities Act, which prohibit discrimination on the basis of disability in the operation of public entities, public and private transportation systems, places of public accommodation, and certain testing entities (42 U.S.C. §§ 12131-12189) as implemented by Department of Transportation regulations at 49 C.F.R. parts 37 and 38;

• The Federal Aviation Administration's Non-discrimination statute (49 U.S.C. § 47123) (prohibits discrimination on the basis of race, color, national origin, and sex);

• Executive Order 12898, Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations, which ensures discrimination against minority populations by discouraging programs, policies, and activities with disproportionately high and adverse human health or environmental effects on minority and low-income populations;

• Executive Order 13166, Improving Access to Services for Persons with Limited English Proficiency, And resulting agency guidance, national origin discrimination includes discrimination because of Limited English Proficiency (LEP). To ensure compliance with Title VI, you must take reasonable steps to ensure that LEP persons have meaningful access to your programs (70 Fed.

Reg. at 74087 to 74100);

• Title IX of the Education Amendments of 1972, as amended, which prohibits you from discriminating because of sex in education programs or activities (20 U.S.C. 1681 et seq).

ATTACHMENT H2

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Revised 2-3-09 Page 1 of 6 Form #T6-2-3-09

VDOT TITLE VI EVALUATION FORM

This Title VI Evaluation Form is used as a Pre-award Review and Post-award Review. VDOT is required to conduct routine assessments prior to releasing funds to ensure Title VI compliance. A pre-award review assists VDOT in determining whether applicants operate in a nondiscriminatory manner.

Pre-award reviews can also be used to require applicants to take preventive measures to ensure that discrimination will not occur in their services as a condition of receiving contracts. Pre-award reviews represent a frontline approach to eliminating and preventing discrimination before it occurs.

Post-Award Reviews are generally conducted after a contractor begins the scope of work. However to minimize the burden on VDOT’s contractors, VDOT has developed a form that serves as both a pre-award and post-award compliance tool.

VDOT must also conduct on-site reviews of prime contractors periodically to ensure that the contractor remains in compliance with Title VI and to verify that the contractor has preventive measures to ensure nondiscrimination by their sub-contractors.

Name of Preparer: Preparer’s Title:

Phone #: Email Address:

Name of Organization: Address of Organization:

Address of Virginia location where project will be done:

Type of Contractor/Organization:

Private Organization Governmental Agency

Supplier Other ____________________

Workforce for Virginia Location(s) Total % Minority % Female

Business Ownership/Control Minority Yes No Female Yes No

DBE Certified Yes No SWAM Certified Yes No

Does your organization currently have contracts or subcontracts with VDOT? Yes No What is your organization’s most recent date of Title VI approval?

Status of Project(s): Value of current Contract(s):

What does your organization have in place to ensure nondiscrimination in your VDOT scope of work and your programs and services?

ATTACHMENT J

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Revised 2-3-09 Page 3 of 6 Form #T6-2-3-09

Organization, Staffing, & Training

1. What type of services will your organization provide VDOT?

2. Identify the person responsible for the administration of Title VI polices and procedures (a Title VI Coordinator). Provide the name, position, title, and contact information.

Title VI/Nondiscrimination

1. Is your Title VI Coordinator, project managers, and other staff made aware of Title VI compliance and regulations relative to nondiscrimination in federally-assisted programs of the Department of Transportation (hereinafter, “DOT”) Title 49, Code of Federal Regulations, Part 21 and the Federal Highway Administration’s 23 Code of Federal Regulations 200? Please explain how they are made aware.

2. What procurement procedures does your organization have in place to ensure nondiscrimination in the selection and retention of subcontractors including procurements of materials and leases of equipment?

3. How does your organization notify your subcontractors and suppliers of their obligations under this contract and the Regulations relative to nondiscrimination on the grounds of race, color, national origin, sex, age, disability and low income populations?

4. Are facilities and meeting areas fully accessible to persons with disabilities?

5. Does your organization have a system in place to accommodate persons with disabilities? If yes, how does your organization notify the public? If no, please explain.

6. How are limited English proficient persons made aware that they can receive translation services for access to services?

7. Has your organization been reviewed by any governmental agencies for compliance with Title VI and other laws and regulations? If yes, provide a copy of the letter identifying the review findings?

Revised 2-3-09 Page 4 of 6 Form #T6-2-3-09

8. Does your organization receive federal assistance (grants, loans, donations of property, or detail of personnel) from any Federal government entity?

9. List any discrimination complaints and/or lawsuits received in Virginia during the reporting period. Include the basis for the complaint (ethnicity, gender, etc.) and summarize the outcome or resolution. If applicable, include a copy of the investigation report.

Disadvantaged Business Enterprises (DBE)

1. Did your organization award any contracts/subcontracts related to VDOT work to DBEs during the reporting period? If yes, provide the following:

The DBE’s name and amount awarded Total # of contracts awarded to DBEs Total dollar amount of contracts awarded to DBEs

I certify that the data given in this report is correct to the best of my knowledge. (Report has to be submitted with original signature, not a photocopy.)

Signature:

(Authorized Officer) (Title) (Date)

For Office Use Only:

Provide award? Yes ______ No _______

Recommendations:

Revised 2-3-09 Page 5 of 6 Form #T6-2-3-09

Appendix A

VDOT is a recipient of federal financial assistance. As a recipient, VDOT is required to comply with Title VI of the Civil Rights Act of 1964, as amended and other nondiscrimination laws and authorities. Title VI of the Civil Rights Act of 1964, and other directives prohibit agencies and sub-recipients receiving federal assistance from discriminating against anyone or any group in the United States on the grounds of race, color, national origin, sex, age, disability, or low-income. The United States Department of Transportation (USDOT) and Federal Highway Administration (FHWA) Regulations

(49) Code of Federal Regulations (CFR), Part 21, and 23 CFR, Part 200 respectively, and other applicable orders and authorities provide guidelines, actions, and responsibilities for VDOT’s implementation of the Title VI Program. These laws and regulations include but are not limited to the following:

The 1970 Uniform Act (42 USC 4601) – prohibits unfair treatment of displacees Section 504 of the 1973 Rehabilitation Act (29 USC 790) – prohibits discrimination based on disability The Federal-Aid Highway Act 1973 (23 USC 324) – prohibits discrimination based on gender The 1975 Age Discrimination Act (42 USC 6101) – prohibits age discrimination (any age) The Civil Rights Restoration Act of 1987 – clarified the original intent of nondiscrimination organization-wide Executive Order 12898 on Environmental Justice (EJ) addresses disproportionately high and adverse human health and environmental effects on minority and low-income populations Executive Order 13166 on Limited English Proficiency (LEP) - ensures people who are limited English proficient (LEP) have meaningful access to services

In brief, these laws and regulations prohibit discrimination in federally assisted programs and activities. Title VI of the 1964 Civil Rights Act states that:

“No person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”

By contracting with VDOT, a contractor is obligated to comply with the laws and regulations listed above and within the Memorandum of Agreement (MOA) executed between the Department and the contractor. VDOT’s Civil Rights Division with the assistance from each applicable division’s Program Manager, monitors an organization’s compliance with the non-discrimination provisions.

To monitor compliance, each contractor and all sub-contractors are required to submit a Title VI Evaluation Form. This requirement is applicable for all contractors.

Revised 2-3-09 Page 6 of 6 Form #T6-2-3-09

The Title VI Evaluation Form provides documentation that a contractor has procedures in place to prevent discrimination in programs and services based on Title VI.

VDOT will request a Title VI Evaluation Form within ten (10) days of notification of selection for new contractors or contractors that do not have a current assessment on file with VDOT. The Assessment Form should be submitted to the Program Manager in the division that is negotiating the contract. These are the divisions we currently receive Title VI Evaluation Forms from:

Right of Way & Utilities Division Location & Design Division

Environmental Division Structure & Bridge Innovative Project Delivery Materials Division

Transportation & Mobility Planning Division

Once the Title VI Evaluation Form is provided to VDOT, the Title VI Coordinator in the Civil Rights Division reviews the information and issues a pre-award letter within fifteen

(15) days of receiving documentation or may schedule an on-site review within the same time frame to confirm information provided in the Assessment Form. VDOT Program Managers have access to a Title VI Log that is updated monthly on the Civil Rights Website. The Title VI Coordinator may request additional information and/or recommend corrective actions. The Title VI Coordinator may randomly schedule on site compliance reviews at the contractor’s office.

If the report is approved for award, a letter is sent out with an expiration date for one year from the date of the approval letter. Typically the letter remains current and on file with VDOT for a period of one year. An updated report is required annually for contractors who continue to perform under a contract with VDOT. It should be noted that if VDOT conducts an on site compliance review the contractor can still be found to be out of compliance during the one year period.

Failure to comply with the nondiscrimination provisions may result in cessation of negotiations, withholding of payments, cancellation, termination, or suspension of the contract in whole or in part.

Should you have any questions about VDOT’s Title VI Program or the Title VI Evaluation Form, you may directly contact the Title VI Coordinator in VDOT’s Civil Rights Division at 804-786-2085 or at robin.underwood@vdot.virginia.gov.

Form C-56 Rev.4-18-99

Form WH-348 (1/68)

U.S. DEPARTMENTOF

LABOR

Wage and Hour and Public Contracts Division

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

STATEMENT OF COMPLIANCE

Form Approved Budget Bureau No. 44-R1093

Date

I, do hereby state:

(Name of signatory party) (Title)

(I) That I pay or supervise the payment of the persons employed by on (Contractor or subcontractor) the ; that during the payroll period commencing on the day of

(Building or work)

20 and ending the day of , 20 , all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made directly or indirectly to or on behalf of said from the full weekly wages earned by any person and that no deductions have been made (Contractor or Subcontractor) either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act as amended (48 Stat. 948.63 Stat. 108, 72 Stat.967; 76 Stat. 357; 40 USC. 276c), and described below:

(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the wok he performed.

(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.

(4) That:

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS

In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below.

or

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

Each Laborer or mechanic listed in the above referenced payroll has been paid as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c) below.

(c) EXCEPTIONS

EXCEPTION (CRAFT) EXPLANATION

Remarks

Name and Title Signature

The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution.

See Section 1001 of Title 18 and Section 231 of Title 31 of the United States code.

ATTACHMENT K

Form C-56 Rev.4-18-99

Form WH-348 (1/68)

INSTRUCTIONS FOR PREPARATION OF

STATEMENT OF COMPLIANCE

This statement of compliance meets needs resulting from the amendment of the Davis-Bacon Act to include fringe benefits provisions. Under this amended law, the contractor is required to pay fringe benefits as predetermined by the Department of Labor, in addition to payment to the minimum rates. The contractor's obligation to pay fringe benefits may be met by payment of the fringes to the various plans, funds, or programs or by making these payments to the employees as cash in lieu of fringes.

The contractor should show on the face of his payroll all monies paid to the employees whether as basic rates or as cash in lieu of fringes. The contractor shall represent in the statement of compliance that he is paying to others fringes required by the contract and not paid as cash in lieu of fringes. Detailed instructions follow:

Contractors who pay all required fringe benefits:

A contractor who pays fringe benefits to approved plans, funds, or programs in amounts not less than were determined in the applicable wage decision of the Secretary of Labor shall continue to show on the face of his payroll the basic cash hourly rate and overtime rate paid to his employees, just as he has always done. Such a contractor shall check paragraph 4(a) of the statement to indicate that he is also paying to approved plans, funds, or programs not less than the amount pre-determined as fringe benefits for each craft. Any exception shall be noted in Section 4(c).

Contractors who pay no fringe benefits:

A contractor who pays no fringe benefits shall pay to the employee and insert in the straight time hourly rate column of his payroll an amount not less than the predetermined rate for each classification plus the amount of fringe benefits determined for each classification in the applicable wage decision. Inasmuch as it is not necessary to pay time and a half on cash paid in lieu of fringes, the overtime rate shall not be less than the sum of the basic predetermined rate, plus the half time premium on the basic or regular rate plus the required cash in lieu of fringes at the straighttime rate. To simplify computation of overtime, it is suggested that the straight time basic rate and cash in lieu of fringes be separately stated in the hourly rate column, thus $3.25/.40. In addition, the contractor shall check paragraph 4(b) of the statement to indicated that he is paying fringe benefits in cash directly to his employees. Any exceptions shall be noted in Section 4(c).

Use of Section 4(c), Exceptions

Any contractor who is making payment to approved plans, funds, or programs in amounts less than the wage determination requires is obliged to pay the deficiency directly to the employees as cash in lieu of fringes. Any exceptions to Section 4(a) or 4(b), whichever the contractor may check, shall be entered in Section 4(c). Enter in the Exception column the craft, and enter in the Explanation column the hourly amount paid the employees as cash in lieu of fringes, and the hourly amount paid to plans, funds or programs as fringes.

1. It is the policy of the Virginia Department of Transportation and Henrico County that Disadvantaged Business Enterprises (DBE) as defined in 49 CFR Part 26 shall have the maximum opportunity to participate in the performance of federally funded consultant contracts. A list of Virginia Department of Minority Business Enterprise certified DBE firms is maintained on their web site (http://www.dmbe.virginia.gov/) under the DBE Directory of Certified Vendors. Consultants are encouraged to take all necessary and reasonable steps to ensure that DBE firms have the maximum opportunity to compete for and perform services on the contract, including participation in any subsequent supplemental contracts. If the consultant intends to subcontract a portion of the services on the project, the consultant is encouraged to seek out and consider DBE firms as potential subconsultants. The consultant is encouraged to contact DBE firms to solicit their interest, capability and qualifications. Any agreement between a consultant and a DBE firm whereby the DBE firm promises not to provide services to other consultants is prohibited. [Include the following wording on federally funded projects without a stated DBE goal: The Department believes that these services support 0% DBE participation.]

FOR PROJECTS WITH DBE GOALS SET,

PARAGRAPHS 2 THROUGH 5 APPLY:

2. Include the following wording and two bullets on state or federally funded projects with a DBE or SWaM goal. In the following sentence and these two bullets, remove references to SWaM on federally funded projects and DBE on a state funded project.

If portions of the services are to be subcontracted to a DBE or SWaM, the following needs to be submitted with your EOI and both must reference the project number(s) for the services:

Written documentation of the prime’s commitment to the DBE or SWaM firm to subcontract a portion of the services, a description of the services to be performed and the percent of participation.

Written confirmation from the DBE or SWaM firm that it is participating, including a description of the services to be performed and the percent of participation.

3. 49 CFR Part 26 requires VDOT to collect certain data about firms attempting to participate in VDOT contracts. This data must be provided on the enclosed Firm Data Sheet.

4. VDOT is also required to capture DBE and SWaM payment information on all professional services contracts. The successful prime consultant will be required to complete C- 63 form for both state and federally funded projects on quarterly basis.

5. Any DBE or SWaM firm must become certified (with the Virginia Department of Minority Business Enterprise) prior to your response being submitted. If DBE or SWaM firm is the prime consultant, the firm will receive full credit for planned involvement of their own forces, as well as the work that they commit to be performed by DBE or SWaM subconsultants.

DBE or SWaM prime consultants are encouraged to make the same outreach efforts as other consultants. DBE or SWaM credit will be awarded only for work actually being performed by them. When a DBE or SWaM prime consultant subcontracts work to another firm, the work counts toward DBE or SWaM goals only if the other firm is itself a DBE or SWaM. A DBE or SWaM prime consultant must perform or exercise responsibility for at least 30% of the total cost of its contract with its own force.

FOR PROJECTS WITH NO DBE GOAL

PARAGRAPHS 6 – 13 APPLIES.

6. DBE or SWaM certification entitles consultants to participate in VDOT’s DBE and SWaM programs. However, this certification does not guarantee that the firm will obtain VDOT work

Mandatory Federal-Aid Professional Services RFP Provisions

Must be included in their entirety

ATTACHMENT L

nor does it attest to the firm’s abilities to perform any particular work.

7. Prior to the time of submittal of the EOI, all business entities, except for sole proprietorships, are required to register with the Virginia State Corporation Commission Information about business registration can be found at https://www.scc.virginia.gov/default.aspx..

Foreign Professional corporations and Foreign Professional Limited Liability Companies (i.e., organized or existing under the laws of a state or jurisdiction other than Virginia) must possess a Commonwealth of Virginia Certificate of Authority from the State Corporation Commission to render professional services.

Any business entity other than a professional corporation, professional limited liability company or sole proprietorships that do not employ other individuals for which licensing is required must be registered in the Commonwealth of Virginia with the Department of Professional & Occupational Regulation http://www.dpor.virginia.gov/, Virginia Board for Architects, Professional Engineers, Land Surveyors and Landscape Architects (Board).

Board regulations require that all branch offices of professional corporations and business entities located in Virginia, which offer or render any professional services relating to the professions regulated by the Board shall be registered as separate branch office with the Board. All offices, including branches, which offer or render any professional service, must have at least one full-time resident professional in responsible charge who is licensed in the profession offered or rendered at that office. All firms involved that are to provide professional services must meet these criteria prior to submitting an Expression of Interest to the < Local Government >. Individual engineers shall meet the requirements of Chapter 4, Title 54.1 of the Code of Virginia.

8. Henrico County assures compliance with Title VI of the Civil Rights Act of 1964, as amended. The consultant and all subconsultants selected for this project will be required to submit a Title VI Evaluation Report (EEO-D2) within 10 work days of notification of selection when requested by the Department. This requirement applies to all consulting firms when the contract amount equals or exceeds $10,000.

9. Henrico County will not consider for award any cost proposals submitted by any consultants and will not consent to subcontracting any portions of the contract to any subconsultants in violation of the provisions of the Federal Immigration Reform and Control Act of 1986, which prohibits employment of illegal aliens.

10. All firms submitting EOI (prime consultants, joint ventures and subconsultants) must have internal control systems in place that meet federal requirements for accounting. These systems must comply with requirements of 48CFR31, “Federal Acquisition Regulations, Contract Cost Principles and Procedures,” and 23CFR172, “Administration of Negotiated Contracts.” All firms selected for a project (prime consultants, joint ventures and subconsultants) must submit their FAR audit data to the Henrico County within ten work days of being notified of their selection. Should any firm on the consultant team fail to submit the required audit data within the ten work days, negotiations may be terminated by the Henrico County and the next most qualified team invited to submit a proposal.

11. Henrico County assures compliance with Title VI of the Civil Rights Act of 1964, as amended. The consultant and all subconsultants selected for this project will be required to submit a Title VI Evaluation Report (EEO-D2) within ten work days of notification of selection when requested by VDOT. This requirement applies to all consulting firms when the contract amount equals or exceeds $10,000.

12. Henrico County does not discriminate against an offeror because of race, religion, color, sex, national origin, age, disability, or any other basis prohibited by state law relating to discrimination in employment.

13. All firms shall complete and include the following completed forms:

Certification Regarding Debarment – Primary Covered Transactions (Prime Consultant) Certification Regarding Debarment - Lower Tier Covered Transactions (Sub-Consultant)

CERTIFICATION REGARDING DEBARMENT

PRIMARY COVERED TRANSACTIONS

(To be completed by a Prime Consultant)

Project: _________________________________________

1. The prospective primary participant certifies to the best of its knowledge and belief, that it 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 (Federal, State or local) transaction or contract under a public transaction;

and have not been convicted of any violations of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification, or destruction of records, making false statements, or receiving stolen property;

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 1) 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.

2. Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

The undersigned makes the foregoing statements to be filed with the proposal submitted on behalf of the offeror for contracts to be let by the Commonwealth Transportation Board.

Signature Title

Date Name of Firm

ATTACHMENT M

CERTIFICATION REGARDING DEBARMENT

LOWER TIER COVERED TRANSACTIONS

(To be completed by a Sub-consultant)

Project: __________________________________________

1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

The undersigned makes the foregoing statements to be filed with the proposal submitted on behalf of the offeror for contracts to be let by the Commonwealth Transportation Board.

Signature Title

Date Name of Firm

Form C-49 PSC

Updated 6/15/2023 COMM0NWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE & SWAM REQUIREMENTS FOR PROFESSIONAL SERVICES CONTRACTS

GOOD FAITH EFFORT DOCUMENTATION

Form Instructions: If, at the time of submitting the Expression of Interest, the Offeror knowingly cannot meet or demonstrate good faith efforts in meeting the required DBE and/or SWaM contract goal(s), form C- 49 PSC shall be submitted.

After contract award, for Limited Services Term contracts, consultants must submit this form at renewal to document DBE / SWaM utilization to date. If goals are being met for current term, submission of page 1 is sufficient. If goals are not being met at the time of renewal, the full form must be submitted.

After contract award, for Project Specific Contracts, consultant must submit this form if or when supplement agreements are requested. For Program Support Services (PSS) contracts, this form shall be submitted with each Annual Work plan (AWP). If goals on PSS Contract are being met, submission of page 1 is sufficient. If goals are not being met at the time of AWP review & approval, the full form must be submitted.

CONTRACT ID: Contract Date(s):

Firm Name:

Renewal Term:

If applicable.

Type of Contract:

UPC # (if Project

Specific Contract)

DBE Goal (As per contract)

SWaM Goal (As per contract)

DBE Expenses to Date:

SWaM Expenses to Date:

Submission Date:

Purpose of Submittal*:

*(Inability to Meet Goal at EOI Submission; Term Renewal; Annual Work Plan; or Supplement Agreement)

If the DBE and/or SWaM goals established for this contract have not been met at the time of renewal or VDOT requests the submittal thereof, the bidder is required to submit good faith efforts as outlined in the contract.

Explanation / Details To Support Demonstration Of Good Faith Effort: (See Page 6 for Add’l Space)

The consultant acknowledges and certifies that this form accurately represents the action taken to secure participation by DBE / SWaM subconsultants.

Firm Name Signature

Title Date

ATTACHMENT N

DEPARTMENT OF TRANSPORTATION

DBE & SWAM REQUIREMENTS FOR PROFESSIONAL SERVICES CONTRACTS

GOOD FAITH EFFORT DOCUMENTATION

CONTRACT ID DATE SUBMITTED

PENDING WORK FOR DBE / SWAM VENDORS

If consultant has ordered work as part of a project based on contract schedule, executed task orders, or assignment in an Annual Work Plan that includes work to be conducted by DBE / SWaM subconsultants but prosecution of work has not yet occurred, please provide details:

The consultant acknowledges and certifies that this form accurately represents the action taken to secure participation by DBE / SWaM subconsultants.

Firm Name Signature

Task Order / Assignment Details (ID #s, Description of Work to be Performed)

Amount of Work Assigned VS Amount of Work Paid to Date

Approx Date of Work to Occur

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY, INCLUDING ANY DOCUMENTATION

DEPARTMENT OF TRANSPORTATION

DBE & SWAM REQUIREMENTS FOR PROFESSIONAL SERVICES CONTRACTS

CONTRACT ID NO. DATE SUBMITTED

WORK SOLICITED / REQUESTED BUT DECLINED BY DBE / SWAM SUBCONSULTANT

Provide information on certified DBE / SWaM subconsultants and the dates on which work was solicited / request was made to participate on this proposal / contract. Include the items of work offered and the dates and methods used for following up initial solicitations to determine whether or not DBEs/SWaM subconsultants were Interested.

The consultant acknowledges and certifies that this form accurately represents the action taken to secure

NAMES and ID#s of DBEs and/or SWaM FIRMS

SOLICITED

DATE OF

INITIAL

SOLICITATION

NAICS (if DBE) and NIGP Codes

(if SWAM)

FOLLOW-UP METHODS AND DATES

DEPARTMENT OF TRANSPORTATION

DBE & SWAM REQUIREMENTS FOR PROFESSIONAL SERVICES CONTRACTS

TELEPHONE LOG FOR DBE/SWAM SOLICTATION / REQUEST TO PARTICIPATE

If the DBE / SWaM goal(s) established has not or cannot be met or VDOT requests the submittal thereof, the bidder is required to submit good faith efforts as outlined in this document. Provide names, addresses, and telephone numbers for the firms listed.

The consultant acknowledges and certifies that this form accurately represents the action taken to secure

DBE / SWaM FIRMS CALLED

TELEPHONE

NUMBER

DATE

CALLED

TIME

CALLED

CONTACT PERSON OR

VOICE MAIL STATUS

DEPARTMENT OF TRANSPORTATION

DBE & SWAM REQUIREMENTS FOR PROFESSIONAL SERVICES CONTRACTS

ADVERTISEMENTS OR PROOFS OF PUBLICATION

If the DBE / SWaM goal(s) established for this contract has not been met or VDOT requests the submittal thereof, the consultant is required to submit good faith efforts as outlined in this document.

Names and dates of each publication / website in which a request for DBE / SWaM subconsultants participation for the project was placed by the consultant. Attach copies of published advertisements or proofs of publication.

The consultant acknowledges and certifies that this form accurately represents the action taken to secure participation by DBE / SWaM subconsultants.

PUBLICATIONS DATES OF ADVERTISEMENT

DEPARTMENT OF TRANSPORTATION

DBE & SWAM REQUIREMENTS FOR PROFESSIONAL SERVICES CONTRACTS

ADDITIONAL DATA TO SUPPORT DEMONSTRATION OF GOOD FAITH EFFORT

If the DBE / SWaM goal(s) established for this contract has not been met or VDOT requests the submittal thereof, the consultant is required to submit good faith efforts as outlined in this document.

The consultant acknowledges and certifies that this form accurately represents the action taken to secure participation by DBE / SWaM subconsultants.

ADDITIONAL JUSTIFICATION TO SUPPORT DEMONSTRATION OF GOOD FAITH EFFORT

Including Details on Future DBE / SWaM Utilization Plan