ATTACHMENT E: PROPOSERS DESIGNATED CONTACTS LIST
Proposers are required to indicate in the space provided below, the designated contact individual’s name:
CITY OF SANTA ROSA
Proposal Process/Scope of Work
Yuri Koslen
Project Manager
CONTRACTOR
Department of Transportation and Public Works
45 Stony Point Rd.
Santa Rosa, CA 95404
(707)543-3335 Voice
[email protected]
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SANTA ROSA PARATRANSIT ATTACHMENT F
ATTACHMENT F: DISCLOSURE FORM
DISCLOSURE OF GOVERNMENTAL POSITIONS
The Prospective CONTRACTOR hereby discloses that the following officers and employees of the CONTRACTOR currently hold the following positions with the identified governmental agency or held such position in the past 12 months.
Name of Owner/Employee ___________________________________________ Name of the Governmental Agency _______________________________________________ Complete Address of Government Agency ___________________________________________ Governmental Position, (e.g. Director, officer and employee) ___________________________ Signature: ___________________________ Title: ______________________________ Firm: _____________________________ Date: ___________________________
DISQUALIFICATION QUESTIONNAIRE
The CONTRACTOR shall complete, under penalty of perjury, the following questionnaire: Has the CONTRACTOR, any officer of the CONTRACTOR, or any employee of the CONTRACTOR who has proprietary interest in the CONTRACTOR, ever been disqualified, removed, or otherwise prevented from bidding on, or completing a federal, state, or local government project because of a violation of law or safety regulation?
Yes ______
No ______
If the answer is yes, explain the circumstances in the following space.
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Attachment to Disclosure of Governmental Positions
The following employee of MV currently holds the following position with the City of Santa Rosa or has held such positions in the past 12 months.
While no current MV employee also holds a position with the City of Santa Rosa, MV currently employs one operator, Byron Mullins, who retired from City Transit.
SANTA ROSA PARATRANSIT ATTACHMENT K
ATTACHMENT K - CERTIFICATION AND RESTRICTIONS ON LOBBYING I, hereby certify
(Name and title of official)
On behalf of that:
(Name of Bidder/Company Name)
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 any agency, a Member of Congress, and 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.
If any funds other than federal appropriated funds have been paid or will be paid to any person influencing or attempting to influence an officer or employee of any agency, a Member of Congress, and officer or employee of Congress, or an employee of a Member of Congress in connection with the 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.
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-contracts, 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 31 U.S.C. § 1352. 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.
Name of Bidder/Company Name:
Type or print name:
Signature of authorized representative: Date / /
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SANTA ROSA PARATRANSIT ATTACHMENT L
ATTACHMENT L - GOVERNMENT-WIDE DEBARMENT AND SUSPENSION (NONPROCUREMENT)
Recipients, contractors, and subcontractors that enter into covered transactions are required to verify that the entity (as well as its principals and affiliates) with which they propose to contract or subcontract is not excluded or disqualified. This is done by: (a) checking the SAM exclusions; (b) collecting a certification from that person (found below); or (c) adding a clause or condition to the contract or subcontract.
Instructions for Certification: By signing and submitting this bid or proposal, the prospective lower tier participant is providing the signed certification set out below.
1) It will comply and facilitate compliance with U.S. DOT regulations, “Nonprocurement Suspension and Debarment,” 2 CFR part 1200, which adopts and supplements the U.S. Office of Management and Budget (U.S. OMB) “Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement),” 2 CFR part 180, 2) To the best of its knowledge and belief, that its Principals and Subrecipients at the first tier:
a) Are eligible to participate in covered transactions of any Federal department or agency and are not presently:
(1) Debarred,
(2) Suspended,
(3) Proposed for debarment,
(4) Declared ineligible,
(5) Voluntarily excluded, or
(6)
Disqualified,
b) Its management has not within a three-year period preceding its latest application or proposal been convicted of or had a civil judgment rendered against any of them for:
(1) 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, (2) Violation of any Federal or State antitrust statute, or, (3) Commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making any false statement, or receiving stolen property,
c) It is 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 listed in the preceding subsection 2.b of this Certification, d) It has not had one or more public transactions (Federal, State, or local) terminated for cause or default within a three-year period preceding this Certification,
e) If, at a later time, it receives any information that contradicts the statements of subsections 2.a – 2.d above, it will promptly provide that information to FTA,
f) It will treat each lower tier contract or lower tier subcontract under its Project as a covered lower tier contract for purposes of 2 CFR part 1200 and 2 CFR part 180 if it:
(1) Equals or exceeds $25,000,,
(2) Is for audit services, or,
(3) Requires the consent of a Federal official, and
g) It will require that each covered lower tier contractor and subcontractor:
(1) Comply and facilitate compliance with the Federal requirements of 2 CFR parts 180 and 1200, and (2) Assure that each lower tier participant in its Project is not presently declared by any Federal department or agency to be:
(a) Debarred from participation in its federally funded Project, (b) Suspended from participation in its federally funded Project, (c) Proposed for debarment from participation in its federally funded Project, (d) Declared ineligible to participate in its federally funded Project, (e) Voluntarily excluded from participation in its federally funded Project, or (f) Disqualified fro m participation in its federally funded Project, and 3) It will provide a written explanation as indicated on a page attached in FTA’s TrAMS platform or the Signature Page if it or any of its principals, including any of its first tier Subrecipients or its Third-Party Participants at a lower tier, is unable to certify compliance with the preceding statements in this Certification Group.
Certification
Contractor:
Signature of Authorized Official: Date / /
Name and Title of Contractor's Authorized Official:
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Exhibit B