WC RFB 042-23 Jail Cabinet Hardmount Washer Extractors fillable forms.pdf

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Section 3

PROPOSAL FORMS

Submittal Form A Offeror Background Submittal Form B Cost Proposal Submittal Form C Non-Collusion Certification Submittal Form D Certification Regarding Debarment, Suspension, and Responsibility Submittal Form E Certification of Compliance with the Iran

Divestment Act Submittal Form F Certification Regarding Lobbying Submittal Form G Insurance Documentation e9

SUBMITTAL FORM A – OFFEROR BACKGROUND

PROJECT INFORMATION

RFB Number:

Project Name:

OFFEROR INFORMATION

Name of Company:

Web URL:

Address:

FID #:

Number of Years in Business (Under Current Business Name):

CONTACT INFORMATION

Identify an individual that can be contacted for clarification on this proposal

Name:

Title:

Email:

Telephone:

ADDENDA ACKNOWLEDGEMENT

The Offeror acknowledges receipt of the following addenda and has incorporated the requirements of such addenda into their proposal.

Failure to identify and sign for all addendum may subject the Offeror to disqualification. The Offeror must list all addenda’s (by number), then initial and date to confirm that you have received and incorporated them into your Proposal. The Offeror may add more rows as necessary

Number Initials & Date Number Initials & Date Number Initials & Date

STATEMENT OF CERTIFICATIONS AND ASSURANCES

The Offeror does, hereby, expressly affirm, declare, confirm, certify, and assure ALL of the following:

1. The Offeror has thoroughly reviewed this RFB, contract documents, including the sample agreement, and all pertinent appendices, exhibits, and attachments include as part thereof, and that we fully understand all elements required for the full completion of the project as defined therein.

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2. The Offeror further certifies that, if selected as the successful firm, we will enter into the contract agreement included with this RFB.

3. The prices in his Proposal have been arrived at independently without collusion, consultation, communication or agreement for the purposes of restricting competition as to any matter relating to such prices with any other firms or with any other competitor.

4. The Prices quoted in his Proposal have not been and will not be knowingly disclosed directly or indirectly by respondent to any other firm or competitor prior to the final date and time for submission of such proposal.

5. No attempt has been made or will be made by respondent to induce any other person, partnership, or corporation to submit or not to submit a proposal for the purpose of restricting competition.

6. The Response submitted in response to the RFB shall remain valid for at least 60 days subsequent to the date of the Response opening and thereafter in accordance with any contract pursuant to the RFP.

By signature below, the signatory certifies legal authority to bind the responding entity to the provisions of this RFB and any contract awarded pursuant to it. The Owner may, at its sole discretion and at any time, require evidence documenting the signatory’s authority to be personally bound or to legally bind the responding entity.

DO NOT SIGN THIS DOCUMENT IF YOU ARE NOT LEGALLY

AUTHORIZED TO DO SO BY THE ENTITY RESPONDING TO THIS RFP.

SIGNATURE:

PRINTED NAME:

TITLE:

NAME OF FIRM:

DATE:

SUBMITTAL FORM B–COST PROPOSAL

SECTION 1 – PROJECT COST

The Offeror is required to provide a clear breakdown in this Submittal Form. The Offeror’s Total Project Cost shall include the cost for everything that is necessary to meet the intent of the County as described in this RFB, including, but not limited to: materials, products, suppliers, equipment, fees, overhead, direct and indirect costs, etc.

Quantity Item Description Unit Price Extended

2 UniMac, model PAN055TN0MZA20CTAA, 55 lb.

on premise value line cabinet hard mount washer extractor If bidding an OR EQUAL, Please indicate Make and Model

Bidder must submit spec sheet for make and model of item and include a side by side comparison with the UniMac as indicated herein.

1 Delivery and installation for the above items at the Wayne County Jail, 7268 Route 31, Lyons NY 14489

Total:

Vendor: Phone Number: Email:

SUBMITTAL FORM C – NON-COLLUSION CERTIFICATION

By submission of this bid, each bidder and each person signing on behalf of any bidder certifies, and in the case of a joint bid, each party thereto certifies to its own organization, under penalty of perjury, that to the best of knowledge and belief:

1. The prices in this bid have been arrived at independently without collusion, consultation communication, or agreement for the purpose of restricting competition as to any matter relating to such prices with any other bidder or with any competitor;

2. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to opening, directly or indirectly, to any bidder or to any competitor; and

3. No attempt has been made or will be made by the bidder to induce any other person partnership or corporation to submit or not to submit a bid for the purpose of restricting competition.

The signature of the Bidder to this Bid shall be deemed a specific subscription to the certificate required under

Section 103-d of the General Municipal Law of the State of New York, and the Bidder affirms that the statements herein contained are true under the penalties of perjury.

Sincerely Yours, Bidder:

By:

Signature of Authorized Representative

Title:

Address:

Phone Number:

Date:

SUBMITTAL FORM D – CERTIFICATION REGARDING DEBARMENT,

SUSPENSION, AND RESPONSIBILITY

The undersigned certified, to the best of his/her knowledge and belief, that the Contractor and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

2. Have not within a three-year period preceding the proposal been convicted of or had a civil judgment 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; violation 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;

3. Are not presently indicted or otherwise criminally or civilly charged by a government entity

(Federal, State or Local) with commission of any of the offenses enumerated in paragraph (2) of this certification; and

4. Have not within a three-year period preceding the Agreement had one or more public transactions

(Federal, State or Local) terminated for cause or default.

Print Name of Contractor:

By:

Signature of Authorized Representative

Print Name:

Title:

Date:

SUBMITTAL FORM E– CERTIFICATION OF COMPLIANCE WITH THE IRAN

DIVESTMENT ACT

As a result of the Iran Divestment Act of 2012 (the “Act”), Chapter 1 of the 2012 Laws of New York, a new provision has been added to State Finance Law (SFL) §165-a and New York General Municipal Law §103-g, both effective April 12, 2012. Under the Act, the Commissioner of the Office of General Services (OGS) will be developing a list of “persons” who are engaged in “investment activities in Iran” (both are defined terms in the law) (the “Prohibited Entities List”). Pursuant to SFL §165-a (3)(b), the initial list is expected to be issued no later than 120 days after the Act’s effective date at which time will be posted on the OGS website.

By submitting a bid in response to this solicitation or by assuming the responsibility of a Contract awarded hereunder, each Bidder/Contractor, any person signing on behalf of any Bidder/Contractor and any assignee or subcontractor and, in the case of a joint bid, each party thereto, certifies, under penalty of perjury, that once the Prohibited Entities List is posted on the OGS website, that to the best of its knowledge and belief, that each Bidder/Contractor and any subcontractor or assignee is not identified on the Prohibited Entities List created pursuant to SFL §165-a(3)(b).

Additionally, Bidder/Contractor is advised that once the Prohibited Entities List is posted on the OGS Website, any Bidder/Contractor seeking to renew or extend a Contract or assume the responsibility of a Contract awarded in response to this solicitation must certify at the time of the Contract is renewed, extended or assigned that it is not included on the Prohibited Entities List.

During the term of the Contract, should the County receive information that a Bidder/Contractor is in violation of the above-referenced certification, the County will offer the person or entity an opportunity to respond. If the person or entity fails to demonstrate that he/she/it has ceased engagement in the investment which is in violation of the Act within 90 days after the determination of such violation, then the County shall take such action as may be appropriate including, but not limited to, imposing sanctions, seeking compliance, recovering damages or declaring the Bidder/Contractor in default.

The County reserves the right to reject any bid or request for assignment for a Bidder/Contractor that appears on the Prohibited Entities List prior to the award of a contract and to pursue a responsibility review with respect to any Bidder/Contractor that is awarded a contract and subsequently appears on the Prohibited Entities List.

I, ______________________________________, being duly sworn, deposes and says that he/she is the

________________________________ of the __________________________________ Corporation and that neither the Bidder/Contractor nor any proposed subcontractor is identified on the Prohibited Entities List.

SIGNED

Sworn to before me this ______ Day of _______________, 20__ Notary Public

SUBMITTAL FORM F– CERTIFICATION REGARDING LOBBYING

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No federal appropriated 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 an 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 contract, the making of any federal grant, the making 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* sub-awards at all tiers (including sub-contacts, sub-grants, and Contracts under grants, loans, and cooperative agreements) and that all* sub-recipients 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.

Grantee/Contractor Organization Program Title

Name of Certifying Official Signature

Date

SUBMITTAL FORM G– INSURANCE DOCUMENTATION

The Offeror shall submit the following required insurance forms or a letter of intent from your insurance agent. The Offeror shall submit:

ACORD Form 25 - Certificate of Insurance to evidence all liability coverages as outlined in the RFP document.

A copy of the applicable Additional Insured endorsement form evidencing the coverage endorsed onto the liability policies as required in the RFP document.

New York State Workers’ Compensation Form C105.2 or New York State Insurance Fund form U26.3 to evidence New York State workers’ compensation coverage.

A copy of the applicable Waiver of Subrogation Endorsement Form, evidencing the coverage endorsed onto the Workers’ Compensation policy, either on a specific/scheduled or blanket basis.

The Offeror acknowledges receipt of the following addenda and has incorporated the requirements of such addenda into their proposal. Failure to identify and sign for all addendum may subject the Offeror to disqualification. The Offeror must list al...