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APPENDIX
AFFIDAVITS
FORMAL BIDS
MIAMI-DADE COUNTY BID NO.9056-0/14
MiaZ-Dade County
MIAMW2 Department of Procurement Management
Affirmation of Vendor Affidavits
in accordance with Ordinance 07-143 amending Section 2-8.1 of the Code of Miami -Dade County, effective June 1, 2008,
vendors are required to complete a new Vendor Registration Package, including a Uniform Affidavit Packet (Vendor Affidavits
Form), before being awarded a new contract. The undersigned affirms that the Vendor Affidavits Form submitted with the
Vendor Registration Package is current, complete and accurate for each affidavit listed below.
Federal Employer
Contract No.: Identification Number (FEIN):
Contract Ville:
Affidavits and Legislation/ Governing Body
Miami -Dade County Ownership Disclosure
Sec, 2-8.1 of the County Code
.___ ..__......_..—.._..----
Miornf-Dade County Employment Disclosure
County Ordinance No. 90-133, ornending Section 2.8- t (d)(2) of
the County Code
-- - - - - -----....__.-- -- __-
Miami -Dods County Employ---..ment- Drug-free
Workplace Certification
Section 2-8.1.2(b) t the County Code
Miami -Dade County Disability Non -Discrimination
Article 1, Section 2-8.1.5 Resolution R 182-00 amending
R-385-95
Miami -Dade County Vendor Obligation to County
Section 2-8.1 of the County Code
--- — - --- -- --- -- - ----- - -- —
Miami -Dade County Code of Business Ethics
Article 1, Section M. Ili) and 2-1 i(b)f1) of the County Code through (6)
and (9) of the County Code and County Ordinance No 00-1 amending
Section 2-11. I fc) of the County Code
Miami -Dade County Family Leave
Article v of Chapter I i of the County Code
Miami -Dade County ifving Wage
Section 2-8.9 of the County Code
_......_..----__-
Miami-Dade County Debarment Disclosure to. Miami -Dade County Domestic Leave and Reporting
Section 10.38 of the County Code Article 8, Section I IA -60 f IA -67 of the County Code
Printed Name of Affiant
Name of Firm
Printed Title of Affiant
Signature of
Date
Address of Firm State Zip Code
Nofary Public Information
Notary Public - State of
Subscribed and swam to (or afrrmed) before me this
by
Type of identification produced
Signature of Notary Public
County of
day of,
20
He or she is personally known tome ❑ or has produced Identification ❑
Serial Number
Print or Stamp of Notary Public Expiration Date Notary Public Seal
Page 1 of 5 Revised 11/20/08
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 THIS CONTRACT
Signature
Date
Page 2 of 5 Revised 11/20/08
MIAMI-DADE COUNTY
Firm Name of Prime Contractor/Respondent:
Bid No.:
SUBCONTRACTOR/SUPPLIER LISTING
(Ordinance 97-104)
Title:
BID NO.: 9056-0114
This forms, or a comparable listing meeting the requirements of Ordinance No. 97-104 MUST be completed, signed and submitted by all bidders and respondents
on County 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 Flealth 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 work to be performed or
materials to be supplied from those identified, except upon written approval of the County.
This form, or a comparable listing meeting the requirements of Ordinance No. 97-104, MUST be completed, signed and submitted even though the bidder or
proposer will not utilize subcontractors or suppliers on the contract. The 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/Subconsultant
Principal Owner
Scope of Work to be Performed by
Subcontractor/Subconsultaut
(Principal Owner)
Gender Race
Business Name and Address of Direct
Supplier
Principal Owner
Supplies/Materials/Services to be
Provided by Supplier
(Principal Owner)
Gender Race
I certify that the representations contained in this Subcontractor/Supplier Listing are to the best of my knowledge true and accurate
Prime Contractor/Respondent's Signature
Print Name
(Duplicate if additional space is needed)
Page 3 of 5
Print'ritie Date
FORM 100
Revised 11/20/08
MIAMI-DADE COUNTY �3
CERTIFICATION OF RECYCLED
ENVIRONMENTALLY ACCEPTABLE PACKAGING %4W
PRODUCT CONTENT
RESOLUTION (R-738-92)
MINIMUM
CERTIFIED CONTENT
Bid item
RECYCLED PRODUCTS
RECOVERED MATERIALS
RECYCABLE PRODUCTS
Number
%
Composition
Type of
Material
%
Compo ition
Type of
Material
%
Composition
Type of
Material
DEFINITIONS
"Recycled 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 be 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, refilled or have a
longer life expectancy 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
ADDRESS
CITY
STATE
ZIP
SIGNATURE
TITLE
COLLUSION AFFIDAVIT
Page 4 of S
Revised 11/20/08
MIAMI-DADE COUNTY BID NO.: 9056-0/14
Note: This affidavit will be requested from all bidders once bids are received and the bidders list is
distributed.
(Code of Miami -Dade County Section 2-8.1.1 and 10-33.1) (Ordinance No. 08-113)
BEFORE ME, A NOTARY PUBLIC, personally appeared who being duly sworn
states: (insert name of affiant)
I am over 18 years of age., have personal knowledge of the facts stated in this affidavit and I am an owner,
officer, director, principal shareholder and/or I am otherwise authorized to bind the bidder of this contract.
I state that the bidder of this contract:
F-11 is not related to any of the other parties bidding in the competitive solicitation, and that the contractor's proposal is
genuine and not sham or collusive or made in the interest or on behalf of any person not therein named, and that the
contractor has not, directly or indirectly, induced or solicited any other proposer to put in a sham proposal, or any other
person, firm, or corporation to refrain from proposing, and that the proposer has not in any manner sought by collusion
to secure to the proposer an advantage over any other proposer.
OR
is related to the following parties who bid in the solicitation which are identified and listed below:
Note:Any person or entity that fails to submit this executed affidavit shall be ineligible for contract award. In the event a
recommended contractor identifies related parties in the competitive solicitation its bid shall be presumed to be
collusive and the recommended contractor shall be ineligible for award unless that presumption is rebutted by
presentation of evidence as to the extent of ownership, control and management of such related parties in the
preparation and submittal of such bids or proposals. Related parties shall mean bidders or proposers or the principals,
corporate officers, and managers thereof which have a direct or indirect ownership interest in another bidder or
proposer for the same agreement or in which a parent company or the principals thereof of one (1) bidder or proposer
have a direct or indirect ownership interest in another bidder or proposer for the same agreement. Bids or proposals
found to be collusive shall be rejected.
By:
Signature of Affiant
Printed Name of Affiant and Title
20 _
Date
Federal Employer Identification Number
Printed Name of Firm
Address of Firm
SUBSCRIBED AND SWORN TO (or affirmed) before me this day of , 20.
He/She is personally known to me or has presented
Signature of Notary
Print or Stamp Name of Notary
Notary Public — State of
Page 5 of 5
Type of identification
Serial Number
Expiration Date
Notary Seal
as identification.
Revised 11/20/08