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Home My WebLink AboutExhibit 5Miami -Dade County r VENDOR AFRDAVrf s FORM (Uniform County Affidavits) Department of Procurement Management Vendor Assistance Unit 111 NW 1- Street, Suite 1300, Miami, Florida 33128-1974 Telephone: 305-375-5773 Fax No: 305-375-5409 gww.►rtiam Wade.aov(dam Complete tfie Vendor Affidavits Form to update affidavits previously stibn9tted with the Vendor Registration Package. It is the vendor's responsbility, to keep all affidavit information current, complete and accurate, by submitting any modifications to the Deparbnent of Procurement Management; Vendor Assistance Unit FEDERAL EMPLOYER IDENTIFICATION NUXBER (Fum) In order to establish a fife for your firm, you must enter your rrm's FEIN or V none, ttre owner's Social Security Number. This number becomes your 'County Vendor Number' Please .enter your Federal Employee Identification Number (FEIN) or your Social Security Number (SSN). ® F.E.I.N. 59-6000375 ❑ S.S.N. City of Miami Name of Entity, Individual (s), Partners, or Corporation Doing Business As (If same as above, leave blank) 444 SW 2nd Avenue, Miami, FL 33130 Street Address (Post Office addresses are not acceptable) 7. ACAMf-RADE COUNTY OWNERSHIP D(SCLOSURE AFFDA VIT (Sec 2-8.1 of the Miami -Dade County Code) ct. Firms registered to do business with Miami -Dade County must fully disclose their legal name, physical address and ownership. Publicly traded Corporations are exempt from this requirement, but must indicate by letter that it is a Publicly Traded Corporation and include the name of the stock exchange market and symbol where registered. If the contract or business transaction is with a corporation, the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirecdy five percent (5%) or more of the corporation's stock. If the contract or business transaction is with a tent, the full legal name and address shall be provided for each trustee and each beneficiary. (Post Office addresses are not acceptable). (Dupiicafe page if needed for additional names). N no of£cer, cli ector or stockholder owns (5%) or more of stoclr, please write "None" below. NONE FULL LEGAL NAME ME ADDRM % OF OW11�RSt� b- Provide the full legal names and business addresses of any other individuals (other than subcontractors, material men, suppliers, laborers, or lenders) that have, or will have, any interest (legal, equitable beneficial or otherwise) in the contract or business transaction with Miami Dade County (Post Office addresses are not acceptable). N't1oru'; please inn cate in space below: RXL LEGAL NAME TULF ADDRESS % OF OWWERSHP 4/-/2= Z MAM-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (County Ordinance No. 90-133, amending Section 2.8-1(d)(2) of the Miaml-Dade County Code) The fnilowing information is for compliance with all items in the aforementioned Section: 1- Does your firm have a collective bargaining agreement with its employees? Yes 2 Does your firth provide paid health care benefits for its employees? Yes x � 3- Provide a current breakdown (number of persons) of your firm's work force and ownership as to race, national origin and gender: White Black Hispanic Other Males 2 Males 10 Males 12 Males 0 Females Q Females 10 Females 8 Females M y irfrds ociawrv/edge riot i hove read fie aforesrseaff d regsrsesresda sod the essfify k is csxrspliW+ce. �— 3. Ni1JUW-DADF COLNTY EMPLOYMENT DRUG-FREE WORKPLACE CERTIFICATION (Secfion 2-8.12(b) of the Miami- Dade County Code) All persons and entities that contract with Miami -bade County are required to certify that they will maintain a drug-free workplace and such persons and entities are required to provide notice to employees and to impose sanctions for drug violation occurring in the workplace. In compliance with Ordinance No. 92-15 of the Code of Miami -Dade County, the above named firm is providing a drug-free workplace. A written statement to each employee shall inform the employee about: 1- Danger of drug abuse in the workplace 2- The firms' policy of maintaining a drug-free environment at all workplaces 3. AvallablRy of drug counseling, rehabilitation and employee assistance programs 4. Penalties that may be imposed upon employees for drug abuse violations The firm shall also require an employee to sign a statement, as a condition ofemployment'that the employee will abide by the terms of the drug- free workplace policy and notify the employer of any criminal drug conviction occurring no later than five (5) days after receiving notice of such conviction and impose appropriate personnel action against the employee up to and including termination. Firms may also comply with the County's Drug Free Workplace Certification where a person or entity is required to have a drug-free workplace policy by another local, state or federal agency, or maintains such a policy of its own accord and such policy meets the intent of this ordinance. M y bM ndmowkdge that f hove read the doren•cdfoaed requir.rrseals ®d the arTrty k h canp6orsce 4. AUAMPDADE COLWTY DMASR.fTYAND NONDISCR10MATION AFRDAVff (Article 1, Section 2-8.1.5 Resolution 8182-00 Amending R-385-95 of the Miami -Dade County Code) Firms transacting business with Miaml-Dade County shall provide an affidavit indicating compliance with ail requirements of the Americans with Dismbiiities Ad (AAA.). 1, state that this firm, is in compliance with and agrees to continue to comply with, and assure that any subcontractor, or third party contractor shall comply with cif applicable requirements of the laws including, but not limited to, those provisions pertaining to employment, provision of programs aid services, transportation, comm unications, access to fodliitles, renovations, and new construction. The American with Disabilities Ad of 1990 (ADA), Pub. L 101-336, 104 Stat 327,42 US.C. Sections 225 and 611 including Tales I, 11, 111, IV and V. The Rehabilitation Act of 1973, 29 U.S-C. Section 794 The Federal Transit Act, as amended, d9 US.0 Section 1612 The Fair Housing Act as amended, 42 U.S.C. Section 3601-3631 Irl- • L J If.!1 • • /1 1.f.!11l'�Jrlrltlyi=i1°1:11�'ll.•�lt]f Section 2-10.4(4)(0) of the Code of Miami -Dade County (Ordinance No. 82-37), which requires that all property licensed architectural, engirseeruhg, landscape architectural, and land surveyors have an affirmative action plan on file with Miami -Dade County. SecSon 2-8.1.5 of the Code of Miami -Dade County, which requires that firms that have annual gross revenues in excess of five (5) million dollars have an affirmative action plan and procurement policy on file with Miami -Dade County. Firms that have a Board of Directors that are representative of the population make-up of the nation may be exempt. My - Fff, , Is acim.wiedge $wr 1 haw. read the ssi..newloned requcesuen6r hnhd rhe adr7y k i carnpi'—e 4/23/20ne S. ACAMI-DARE COUNTY DEBARMENT DISCLOSURE AFRDAVIT (Section 10.38 of the Miami -Dade County Code) :firms wishing to do business with Miami -Dade County must certify that its contractors, subcontractors, officers, principals, stockholders, or affiliates are not debarred by the County before submitting a bid. 1, confirm that none of this firms agents, officers, principals, stockholders, subcontractors or their affiliates are debarred by MIami-Dade County. My kifia k ockAow edge fbai l have read the aimr nc da d requirenr vft and the eaW k In compRance 6- 1WAWDADE COUNTY VENDOR 05MA77ON TO COUNTY AFFIDAVIT (Section 2-8.1 of the Miami -Dade County Code) Firms wishing to transact business with Mlaml-Dade County must certify that all delinquent and currently due fees, taxes and parking tickets have been paid and no individual or entity in arrears in any payment under a contract, promissory note or other document with the County shall be allowed to receive any new business. 1, confirm that all delinquent and currently due fees or taxes including, but not limited to, real and personal property taxes, convention and tourist development taxes, utility taxes, and Local Business Tax Receipt collected in the normal course by the Miami -Dade County Tax Collector and County issued parking tickets for vehicles registered in the name of the above firm, have been paid. I further affirm that this firm complies with Sedion 2-8.1, which requires that no individual or entity that is in arrears in any payment under a contract, promissory note or other document with the County shall be allowed to receive any new business. Myiu,2� acbzowfedge fbad I have read the odoranarfioaed regrowrmadr and Me achy it iQ earq 1G c 7. MUSMPDADE COUNTY CODE OF BUSNESS ETT4CS AFFiDAVTT (Article .7, Section 2-8.7[) and 2-17W(1) of the Miami -Dade County Code through (6) and (9) of the County Code and County Ordinance No 00-7 amending Section 2- 71.7 (c) of the Comfy Code) Firms wishing to transact business with Miami -Dade County must certify that it has adopted a Code that complies with the requirements of Section 2-8.1 of cine County Code. The Code of Business Ethics shall apply to all business that the contractor does with the County and shall, at a minimum; require the contractor to comply with all applicable governmental rules and regulations. i confine that this firm has adopted a Code of business ethics which complies with the requirements of Sections 2-8.1 of the County Code, and that sudh code of business efftics shall apply to all business that this firm does with the County and shall, at a minimum, require the contractor to comply with all applicable governmental rules and reguiations. tt My cr6a h ockwwiedge that I have read the alareunarfioaed requirerrw-a!s wd the eaFdy k is carnpi'ance 121 8. 1frHAWDADE COUNTY FAMILY LEAVE AFFIDAVIT (Ankle V of Chapter 11, of the Miami -Dade County Code) -firms contracting business with Miami -Dade County, which have more than fifty (50) employees for each working day during each of twenty (20) or more work weeks in the current or preceding calendar year, are required to certify that -they provide family leave to their employees firms with less than the number of employees indicated above are exempt from this requirement but must indicate by letter (signed by an authorized agent) that It does not have the minimum number of employees required by the County Code. i confirm that if applicable, this firm comperes with Article V of Chapter If of the County Code, which requires that firms contracting business with Miami -Dade County which have more than fifty (SO) employees for each working day during each of twenty (20) or more work weeks in the aurrertt or preceding calendar year are required to certify that they provide family leave to their employees My Uffali adwow k -4e Hke I Gore read & aforemeWoaed regaienm* and the ea Wy k in comploom Cr - 9. M AM1 DADS COUNTY WING WAGE AFFiDAVfT (Section 2-8.9 of the Mica i-Dode County Code) All applicable contractors entering into a contract with the Courcy sholi agree to pay the prevailing Drying wage required by this section of the County Code. I confirm that if applicable, this film complies with Section 2-8.9 of the County Code, which requires that alt applicable employers entering a contract with Miami -Dade County shall pay the prevailing living wage required by the section of the County Code. Myid" ac6owk*e Itat f bare read tie aforemieo6wed regt*eareafs ®d fire -Wyk in corrr0rance. 5t 4/23/W% 7o. AVAMI-RADE COUNTY DOMESTIC LEAVE AND REPORTING AFHDA VrT (Article 8, Section 17 A-60 - I I A-67 of the Miami -Dade County Code) Firms wishing to transact business with Miami -Dade County must certify that it is in compliance with the Domestic Leave Ordinance. 1 -confirm that if applicable, this firm compiles with the Domestic Leave Ordinance. This ordinance applies to employers that have, in the regular course of business, fifty (50) or more employees working in Miami -Dade County for each working day during the current or preceding calendar year. My l.Nids ocknowiedge (loaf l hove read the afw...afiooed reyu6remeets oud Jhe eaiity i, is compJioace. AER-RMAHOU 1, being duly swam, do attest under penalty of perjury that the entity is in compliance with oil requirements outlined in the Miami -Dade County Vendor Affidavits i — 10, pages S through S of this Vendor Registration Package. I also attest that I will comply with and keep current all statements swam to in the above affidavits and registration application. 1 will notify the Miami -Dade County, Vendoronce Unit, immediately If any of the statemerrts attested hereto are no longer valid. (Slgnatur Affiant) I (Date) Notary Public — State of: Sergio Torres, Administrator Printed Name of Affiant and Title State SUBSCRIBED AND SWORN TO (or affirmed) before me this by Type of klenfificntron Produced Signature of Notary Public Print or Stamp of Notary Public 4/za/20% /VOTARY PUBLIC INFORMATION day of Counfy of 20 He or she is personally known to me ❑ Or has procluced identification ❑ Number) Eepirofion Date Notary Public Seal