Vendor Responsibility Form Services.pdf

VENDOR RESPONSIBILITY QUESTIONNAIRE - SERVICES

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To determine a vendor’s qualifications to perform Kenosha County contracts, all contractors and sub-contractors must submit this completed questionnaire to Kenosha County. Kenosha County reserves the right to request additional information or clarification.

This statement shall be kept confidential in compliance with Wis. 66.0901(2).

I. Business Entity Information:

Legal Business Name:

EIN:

Principal Place of Business: Include Street Address, City, State / Zip:

Fax Number:

Phone Number:

Email Address: Website:

Authorized Contact for this Questionnaire Name:

Phone Number: Fax Number:

Title:

Email Address:

List below any other DBA, Trade Name, Other Identity, or EIN used in the last five (5) years, the state or county where filed, and the status (active or inactive) if applicable:

Type: Name: EIN State/County

Filed:

Status

II. Business Characteristics Business Entity Type – Check appropriate box and provide additional requested information:

� Corporation Date of Incorporation:

� Limited Liability Corporation Date Organized � Partnership Date Established � Sole Proprietor How many years in business:

� Other Date Established If other, explain:

Was the business entity formed in Wisconsin? [ ] Yes [ ] No If “no”, indicate jurisdiction where the Business Entity was formed:

[ ] United States, State of:

[ ] Other, Country:

Is the responding Business Entity a Joint Venture? [ ] Yes [ ] No Note: if the submitting business entity is a joint venture, also submit a separate questionnaire for each business entity comprising the Joint Venture.

Identify each person who is, or has been within the past five (5) years, a Business Entity Official or Principal Owner of 5% or more of the firm’s shares, or one of the five largest shareholders or a director, an officer, a partner or a proprietor. For Joint Ventures, provide information for all firms involved. (Attach additional pages, if necessary)

Name:

Title:

Percentage Ownership (enter 0% if not applicable)

Employment Status with the Firm:

[ ] Current [ ] Former

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III. Bid & Contract History:

A. Within the past five (5) years, has the Business Entity, any Affiliate or any predecessor company or entity:

• Received any formal unsatisfactory performance assessment(s) from any entity on any contract? If “Yes”, provide an explanation of the issue(s) on a separate sheet, clearly labeled with the section number and item letter for each response. Include the government entity involved, relevant dates and any remedial or corrective action(s) taken and the status of the issue(s).

[ ]Yes [ ] No

• Been suspended or debarred from any government contracting process or been disqualified on any government procurement?

• Been subject to a denial or revocation of a government pre-qualification? [ ]Yes [ ] No

• Agreed to a voluntary exclusion from bidding/contracting with a government entity? [ ]Yes [ ] No

• Defaulted on or been suspended, canceled or terminated for cause on any contract? [ ]Yes [ ] No

• Been subject to any administrative proceeding, arbitration award, or civil action seeking specific performance, restitution or other monetary award or settlement?

[ ]Yes [ ] No

• Had its surety or bonding company called upon to complete any contract, whether government or private sector?

[ ]Yes [ ] No

IV. Certifications / Licenses Within the past seven (7) years, has the Business Entity, any Affiliate or any predecessor company or entity had: [ ]Yes [ ] No

a) A revocation or suspension of any business or professional permit and / or license? [ ]Yes [ ] No

b) A sanction imposed relative to any business or professional permit and/or license? [ ]Yes [ ] No

c) Are all professional certifications, permits and licenses requested in the bid/RFP packet in full force and effect at this time? If no, provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, the government entity involved, project(s), relevant dates and any remedial or corrective action(s) taken and the status of the issue(s). Provide responses on a separate sheet, clearly labeled with the section number and item letter for each response.

V. Company and Leadership Legal History Within the past seven (7) years, has the Business Entity, any Affiliate or any predecessor company or any individual identified above or authorized to sign, execute or approve bids, proposals, contracts or supporting documentation related to this Invitation to Bid:

a) Been the subject of a criminal investigation, whether open or closed, or an indictment for any business-related conduct constituting a crime under local, state or federal law?

[ ]Yes [ ] No

b) Been the subject of an indictment, grant of immunity, judgment or conviction (including any plea bargain) for conduct constituting a crime?

[ ]Yes [ ] No

c) Received any OSHA citation or Notification of Penalty containing a violation classified as serious or willful?

[ ]Yes [ ] No

d) Had a government entity find a willful prevailing wage or supplemental payment violation? [ ]Yes [ ] No

e) Been the subject of any other federal, state or local citations, notices, violation orders, administrative hearings, arbitration proceedings, or determinations of a violation of any labor law or regulation?

[ ]Yes [ ] No

For each “yes” answer above, provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, the government entity involved, project(s), relevant dates and any remedial or corrective action(s) taken and the status of the issue(s). Provide responses on a separate sheet, clearly labeled with the section number and item letter for each response.

VII Financial and Organizational Capacity

a) Within the past five (5) years, has the Business Entity or any Affiliates had any liquidated damages assessed? If

“Yes”, provide an explanation of the issue(s), the contracting party involved, the amount assessed and the status of the issue(s). Provide answer on a separate sheet, clearly labeled with the section number and item letter for each response.

b) Within the past five (5) years, has the Business Entity or any Affiliate been a party to any civil litigation? If “Yes”, provide an explanation of the issue(s), the parties involved, the jurisdiction handling the case, the file number and the status of the issue(s). Provide answer on a separate sheet, clearly labeled with the section number and item letter for each response.

c) Within the past five (5) years, has the Business Entity or any Affiliate had any liens, claims or judgments filed against the Business Entity that remain undischarged or were unsatisfied for more than 90 days? If “yes”, provide an explanation of the issue(s), relevant dates, the lien holder or Claimants’ names(s), the amount of the lien(s) and the current status of the issue(s). Provide answer on a separate sheet, clearly labeled with the section number and item letter for each response.

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d) In the last seven (7) years, has the Business Entity or any Affiliates initiated or been the subject of any bankruptcy proceedings, whether or not closed, regardless of the date of filing, or is any bankruptcy proceeding pending? If “Yes”, provide the Bankruptcy chapter number, the Court name and the Docket number. Indicate the current status of the proceedings as “Initiated”, “Pending” or “Closed”. Provide answer on a separate sheet, clearly labeled with the section number and item letter for each response.

e) Do you contemplate any change in your capital structure or any substantial increase or decrease in equity capital? If so, provide an explanation on a separate sheet, clearly labeled with the section number and item letter.

f) What is the Business Entities Bonding Capacity? (supporting evidence may be required upon request)

Single Project: $ Aggregate (all projects): $

g) Additional Financial Documentation: Prior to award of a contract, the County reserves the right to require additional substantiating documentation of a firm’s financial capacity to perform a contract. Failure to provide this additional documentation will not necessarily be cause for automatic rejection of a proposal, but may prevent the County from certifying the firm as a “responsible” proposer.

Contractors failing to submit additional financial documentation may be required to provide or increase the amount of a performance bond, at no additional cost to the County, prior to entering into any contract with the County.

VIII Public Record Law Compliance

a) Per Wis. 66.0901(2), the contents of this statement shall be confidential and may not be disclosed except upon the written order of the person furnishing the statement, for necessary use by the public body in qualifying the person, or in cases of actions against, or by the person or municipality.

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CERTIFICATION

The undersigned certifies that he/she:

1) Is knowledgeable about the submitting Business Entity’s business and operations and has full authority to make these statements;

2) Has read and understands all of the questions contained in the questionnaire and has not altered the content of the questionnaire as received from the County of Kenosha in any manner;

3) Has reviewed and/or supplied full and complete responses to each question;

4) To the best of his/her knowledge, information and belief, confirms that the Business Entity’s responses are true, accurate and complete, including all attachments, if applicable;

5) Recognizes that this questionnaire is submitted for the express purpose of assisting the County of Kenosha in making responsibility determinations and that the County will rely on the information disclosed regarding an award of a contract or approval of a subcontract;

6) Acknowledges that the County of Kenosha may, in its sole discretion, by whichever means it may choose, verify the truth and accuracy of all statements made herein;

7) Acknowledges that intentional submission of false or misleading information may disqualify this business entity from entering into this or future contracts with the County of Kenosha; and

8) Agrees to update the information provided herein to include any material changes to the Business Entity’s responses at the time of submission through the contract award notification, and may be required to update the information or provide additional information or clarification at the request of the County during the term of the contract.

DATED THIS DAY OF , 20 .

Name of Business:

Authorized Signature:

Print Name: Title:

Address:

City/State/Zip

Email:

Phone: Fax:

Subscribed and sworn to before me this day of , 20 .

Notary Public

My commission expires: