WILTTR28SB Attachment B- Price Form blank.pdf

P R I C E F O R M

C O N T R A C T B I D F O R M & S B R A F F I D A V I T –

A T T A C H M E N T - B

Th i s fo rm i s t o b e co mp le t ed i n i t s en t i re ty , i s no t t o b e a l t e red i n an y way an d i s t o co n t a in o n ly t h e p r i ce o r p r i ces s t i p u l a t ed o n t h e fo rm.

SHA IFB No.: WIHMOW28SB

Column A Column B Column C Column D

Item / Description Estimated Quantity Vendor’s Bid Total Cost ($) per Unit of Measure (Column B x C)

Roadside Hand mowing crew days - Per specifications 35 crew days $ per Day $

TOTAL BID AMOUNT (Sum of Column D items)

NOTE:

MDOT SHA, i s exempt f ro m Maryland Sales and Use Taxes by Exempt ion Cer t i f icat e Nu mber 3000256 -3 and f ro m

Federal Ex ci se Tax es by Exempt ion Numb er 52 -73-0 358K. Do not includ e sal es tax in b id pr ices .

For the Contractor:

Company Name & Address

City State Zip

Phone _____________________ Fax ______________________Email ____________________

Representing the above Company _______________________________

SIGNATURE

Print Name & Title

SOCIAL SECURITY NO. OR

FEDERAL TAX ID NO. _________________________ DATE: ___________________

Maryland Department of Transportation

SMALL BUSINESS CONTRACT AFFIDAVIT

********** PROVIDING FALSE INFORMATION **********

Anyone providing false information to the State of Maryland in connection with obtaining or attempting to obtain a contract under

Small Business Reserve or Preference procurement may be subject to the following:

1. A determination by a Procurement Officer that a bidder/offeror is not responsible;

2. A determination that a contract entered into is void or voidable under § 11-204 of the State Finance and Procurement Article of the Annotated Code of Maryland;

3. Suspension and debarment under Title 16 of the State Finance and Procurement Article;

4. Criminal prosecution for procurement fraud (§ 11-205.1 of the State Finance and Procurement Article), perjury, or other crimes; and

5. Other actions permitted by law.

********** FAILURE TO MEET MINIMUM QUALIFICATIONS **********

Any Bidder or potential bidder failing to meet the qualifications of a "small business" specified in § 14-501(c) of the State Finance and

Procurement Article will be ineligible to participate in a procurement designated for a Small Business Reserve under § 14-504 or

Small Business Preference under § 14-206 - 207. Any person or company bidding on Small Business Reserve or Preference procurement and not qualifying as a small business under § 14-501(c) will have its bid or offer rejected on the ground that the bidder is not responsible.

I AFFIRM THAT:

To the best of my knowledge, information, and belief, as of the date of submission of this Bid/Proposal, (name of firm) meets the qualifications for certification as a Small Business in Maryland. I further affirm that, if for any reason during the term of the contract (name of firm) no longer meets the qualifications of certification as a Small Business in Maryland, I will notify the Procurement Officer within 30 days. I agree that a failure to so notify the Procurement Officer of this change in circumstances may result in this contract being terminated for default.

I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE CONTENTS OF THIS

AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF.

SMALL BUSINESS QUALIFICATION NUMBER ___________________

Date of Most Recent Qualification__________________________________

DATE:_____________

BY:_____________________________________________________________

Signature (Authorized Representative and Affidavit)