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APPENDIX
AFFIDAVITS
FORMAL BIDS
MIAMI-DADE COUNTY BID NO.: 6819-5/17
MIAMI-DADE COUNTY BID AFFIDAVITS
■ DISABILITY NONDISCRIMINATION AFFIDAVIT
(Resolution R-385-95)
1, being duly first swam, state that this firm, corporation, or organization is in compliance with and agrees to continue
to comply with, and assure that any subcontractor, or third party contractor under this contract complies with all
applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to
employment, provision of programs and services, transportation, communications, access to facilities. renovations,
and new construction.
The Americans with Disabilities Act of 1990 (ADA). Pub. L. 101-336. 1N Stat 327.42 U&C. Sections 225 and 611
including Title L Employment; Title Il, Public Services- Title 111. Public Accommodations and Scm'icez Operated by
Private Entities; Title IV, Telecommunications; and Title V, Miscellaneous Provisions.
The Rehabilitation Act of 1973, 29 U.S.C. Section 794
The Federal Transit Act, as amended 49 U.S.C. Section 1612
The Fair Housin- Act as amended, 42 U.S.C. Section 3601-3631
■ MIAMI-DADE COUNTY DEBARMENT DISCLOSURE AFFIDAVIT
(Ordinance 93-129) See Section 1 (1311)
1, being duly first sworn, upon oath depose, and says that the bidder of this contract or his agents, officers, principals,
stockholder,, tockholders. subcontractor% or their affiliates are not debarred by Miami -Dade County.
• MIA.N11-DADE COUNTY COLLECTION OF TAXES,
FEES AND PARKING TICKETS AFFIDAVIT
(Ordinance 95-178) Section 1 (1-1 E)
1, being first duly sworn state that in compliance with the procedures contained in Section 2-8.1(c) of the Code of
Miami -Dade County, and as amended by Ordinance 95-178, this firm hereby certifies that the foregoing statements
are true and correct_
Thatall delinquent and currently due fees or taxe-s (including, but not limited to. real and personal property taxes.
convention and tourist development taxes. utility taxes, and occupational license taxes) 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.
AFFIDAVIT RELATING TO INDIVIDUALS AND ENTITIES
ATTESTING BEING CURRENT IN THEIR OBLIGATIONS TO
MIAMI-DADE COUNTY (Ordinance 99-162) See Section I (1-31N)
1, being first duly sworn state that in compliance with County Ordinance 99-162, the bidder is not in arrears in any
payment under a contract, promissory note or other loan document with the County, or any of its agencies or
instrumentalities. including the Public Health Trust (hereinafter referred to as "County"). either directly or indirectly
through a firm, corporation, partnership or joint venture in -%v'hich the individual or entity has a controlling financial
interest as that term is defined in Section 2-11.1(b)(8) of the County Code.
Page I of 8 Revised 10/24/01
MIAMI-DADE COUNTY BID NO.: 6819-5/17
• MIAMI -DADS COUNTY DOMESTIC VIOLENCE LEAVE
AFFIDAVIT (Ordinance 99-5 & Resolution R-185-00)
That in compliance with Ordinance No 99-5, Resolution No. 1t-183-00 and the Code of Miami -Dade County. Florida,
the following information is provided and is in compliance with all iters in the aforementioned legislation. As an
employer having, in the regular course of business. fifty (50) or more employees wonting in Miami -Dade County for
each working day during, each of twenty (20) or more calendar work weeks in the current or preceding calendar year.
do hereby certifv to be in compliance with the Domestic Leave Ordinance, codified at I IA -60 et. Seq- of the Miami -
Dade -county Code, and that the obligation to provide domestic violence leave to employees shall be a contractual
obligation.
BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATTESTING
TO AFFIDAVITS ON PAGES I AND 2
Bv:
MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE
Signature of Affiant
Date
20
Printed Name of Affiant and Title Federal Employer Identification Number
Printed Name of Firm
Address of Firm
SUBSCRIBEDAND SWORN TO (or affirmed) before me this day of 20
I-le/She is personally kno"m to me or has presented as identification.
Type of identification
Signature of Notary Serial Number
L_
Print or Stamp Name of Notary Expiration Date
Notary Public — State of
Page 2 of 8 Revised 10/24/01
MIAMI-DADE COUNTY
LIVING WAGE AFFIDAVIT
(County Ordinance 99-44)
BID NO.: 6819-5/17
I. being first duly sworn hereby state and certify that in compliance with County Ordinance 9944 and Section 2-8.9 of the
Miami -Dade County Code, by accepting award of this contract, the bidder or proposer agrees to pay the living wage required
by County Ordinance 99-44 to all employees assigned to this contract. The bidder or proposer further understands that the
current living wage applied to this contract is 59.44 per hour plus health benefits as described in the ordinance. or S10.81 per
hour- without health benefits. The Living Wage required by Ordinance 99-44 is subject to indexing as set -forth in Section "C'*
(Indexing).
Si `nature of Affiant
Printed Name of Affiant and Title
20
Date
/ - / _/ �! / / I _/
Federal Employer Identification Number
Printed Name of Firm
Address of Finn
SUBSCRIBED AND SWORN TO (or affirmed) before me this day of 20
Fle/She is personally known to me or has presented — as identification.
Type of identification
Signature of Notary
Print or Stamp Name of Notary
Notary Public — State of
Page 3 of 8
Serial Number
Expiration Date
11
Revised 10/18/04
MIAMI-DADE COUNTY
BID NO.: 6819-5/17
AFFIRMATIVE ACTION PLAN/PROCUREMENT POLICY AFFIDAVIT
(Code of Miami -Dade County Section 2-8.1.5) (Ordinance No. 98-30)
I, being duly first sworn, hereby state that the bidder of this contract:
❑ has a current Affirmative Action Pian and Procurement Policy, as required by Section 2-8.1.5 of the Code of
Miami Dade County, processed and approved for filing with the Miami Dade County Department of Business
Development (DBD) under the file No. and the
expiration date of
❑ had annual gross revenues in excess of $5,000,000.00 for the previous year and does not have a current
Affrrmative Action Plan and Procurement Policy as required by Section 2-8.1.5 of the Code of Maori Dade
County, processed and approved for filing with the Miami -Dade County DBD. 1 will contact DBD at 305-375-
3I 11 regarding this requirement.
had annual gross revenues less than $5,000,000.00 for the previous year; therefore Section 2-8.1.5 of the Code
of Miami -Dade County is not applicable. However.. I will contact DBD at 305-375-3111 in order to submit the
required affidavit and exemption request.
Witness:
Witness:
signature
By:
The foregoing instrument was acknowledged before me this
FOR AN INDIVIDUAL ACTING IN HIS OWN RIGHT:
By:
Signature
Legal Name and Title
day of 20
FOR A CORPORATION, PARTNERSHIP OR JOINT VENTURE:
By:
with
❑ a
PLEASE NOTE.
having the title of
corporation ❑ partnership ❑ joint venture
Section 240.4(4)(a) of the Code of kfiami-Dade County (Ordinance Na 82-37) requires that all property licensed
architedurul, engineering, Landscape architeatur4 and land surveyors have an ofj`i ma hmv action plan on fde x#th the
Count.
Seciion 24 L 5 of the Code of Miew d -Dade CWmV requires dw firnu that have annuuat gross revenues in excess of five (S)
mn7idm dotlars have an afifnno w action plan and procurement policy onfile with the County. Firms that have a Board of
Directors that are representative of the population make-up of the nation may be ezentpt
Por questions regarding these requirements, please contact the Miami -Bade County Department of Bumtess Development at
305475-3111.
Page 4 of 8 Revised 11/08/04
MIAMI-DADE COUNTY BID NO.: 6819-5/17
CODE OF BUSINESS ETHICS
Code of Nliami-Dade Couniv Section 2-8.1(i)
1, being duly sworn. hereby state and certify that this firm has adopted a Code of Business Ethics that is fully complaint with
the requirements of Section 22-83(i) of the Code of Miami -Dade County as amended. I further acknowledge that failure to
comply with the adopted Code of Business Ethics shall render any contract with Miami -Dade County voidable, and subject this
firm to debarment from County work pursuant to Section 10-3 )8(h)(2) of the Code of Miami -Dade County as amended. I further
acknowledge that failure to submit this affidavit shall render this firm ineligible for contract award.
By:
Signature of Affiant
Printed Name of Affiant and Title
20
Date
Federal Employer Identification Number
Printed Name of Firm
Address of Finn
SUBSCRIBED AND SkN-'ORN TO (or affirmed) before me this day of-, 20
He/she is personally known to me or has presented
Signature of Notary
as identification.
Type of identification
Serial Number
Print or Stamp Name of Notary. Expiration Date
Notary Public — State of
Page 5 of 8 Revised 08/23/01
MIAMI-DADE COUNTY BID NO.: 6819-5/17
FAIR SUBCONTRACTING PRACTICES
(Ordinance 97-35)
In compliance with Miami -Dade County Ordinance 97-35, the Bidder shall submit with the bid proposal a
detailed statement of its policies and procedures (use separate sheet if necessary) for awarding
subcontractors in accordance with Section 1, Paragraph 1.15
❑ NO SUBCONTRACTORS WILL BE UTILIZED FOR TRIS CONTRACT
Signature:.
Date
Page 6 of 8 Revised 01/15/04
MIAMI-DADE COUNTY
Firm Nance of Prime Contractor/Respondent:
Bid No,:
SUIICON•rRACrOR/SSUPPLIER LISTING-
(Ordinance
ISTING(Ordinance 97-104)
Title:
BID NO.: 6819-5/17
This forms, or al comparable listing; aneeling the requirements of Ordinance No. 1k1US,i, be completed, signed and submitted ht° al! ttidders antt respottdcnts
on Colony contracts for purchases of supplies, materials or services, including professional services which involve expenditures of $100,000 or more, and all
bidders and respondents on County or Public lleaitlt Trust construction contracts which involve expenditures of $100,000 or more. A bidder or respondent who
is awarded the contract shall not change or substitute first tier subcontractors or direct suppliers or the portions of the contract v •ork to be performed or
materials to be supplied from those identified, except upon written approval of tile County.
'This form, or a comparable listing; meeting the requirements of Ordinance No. 97-104, 111 ST be completed, signed and submitted even though the bidder or
proposer will not utilize subcontractors or suppliers on the contract. 'rite bidder or proposer should enter the word "NONE" under the appropriate heading of
sub form 100 in those instances where no subcontractors or suppliers will be used on the contract.
Business Name and Address of First Tier
Subcontractor/eSubconsultant
Principal t�iavaaer
Scope of Wot k to be Per€ot med by
Subcontraetor/Subconsultant
(Prancapat Uavner)
Gender Race
Business Name and Address of Direct
Supplier
Principal Owner
Supplies/Nlaterials/Services to be
Provided by Supplier
(Principal Owner)
Gender Race
1 certify that the representations contained in this Subcontractor/Supplicr listing are to the best of city knowledge true and accurate
Prune Contractor/Respondent's Signature
Print Name
(Duplicate if additional apace is needed)
Page 7 of 8
Print Titte Late
FORM t00
Revised 01/15/04
MIAMI-DADE COUNTY BID NO.: 6819-5/17
MIAMI-DADE COUNTY
CERTIFICATION OF RECYCLED
ENVIRONMENTALLY ACCEPTABLE PACKAGING 04W
PRODUCT CONTENT
RESOLUTION (R-738-92)
MINIMUM
CERTIFIED CONTENT
Sid Item
RECYCLED PRODUCTS
RECOVERED MATERIALS
RECYCABLE PRODUCTS
Number
%
Composition
! Type of
Material
%Type
Composition
of
a Material
% Type of
Composition_, Material
_1
F
i
F
F
3
i
3
i
DEFINITIONS
"Rev.,cled Material shall be defined as any waste material or by-products that have been recovered or diverted
from solid waste.
-Recycled Product" shall be defined as any product which is in whole or in part composed of recovered
materials.
"Recyclable Product" shall be defined as the ability of a product and its packaging to he reused,
reconditioned for use. or recycled through existing recycling, collection programs.
"Waste Reducing Product" shall be defined as any product which will result in less waste generated due
to its use rather than another product designed to serve the same function with a greater waste
generation rate. This shall include, but not limited to those products that can be reused, refiled or have a
longer life expeelancy and contain a lesser amount of toxic constituents.
I have the knowledge to certify and do so by certify that the Minimum Materials Content in our product(s) are
as specified on this form and conform with the definitions as shown above.
NAME
E
ADDRESS � 3
i
CITY STATE ZIP i
SIGNATURE TITLE
t �
Page 8 of 8 Revised 01/15/04