HomeMy WebLinkAboutcertified formsATTACHMENT "D"
REQUIRED CERTIFIED FORMS
D-1
t RUTH-IN-NEGOTIATIONS CERTIFICATE
FM Number(s):
FAP Number(s):
Project Name:
For any lump - sum or cost - plus - a - fixed -fee professional service agreement over $60,000 the Florida
Department of Transportation (Department) requires the Consultant to execute this certificate and include it with
the submittal of the Technical Proposal.
The Consultant hereby certifies, covenants and warrants that wage rates and other factual unit costs supporting
the compensation for this project's agreement will be accurate, complete, and current at the time of contracting.
The Consultant further agrees that the original agreement price and any additions thereto shall be adjusted to
exclude any significant sums by which the Department determines the agreement price was increased due to
inaccurate, incomplete, or noncurrent wage rates and other factual unit costs. All such agreement adjustments
shall be made within one (1) year following the end of the agreement. For purpose of this certificate, the end of
the agreement shall be deemed to be the date of final billing or acceptance of the work by the Department,
whichever is later.
Name of Consultant:
By: Date:
Authorized Signature
Title:
D-2
DBE PARTICIPATION STATEMENT
Note: The Consultant is encouraged to complete the following information and submit this form with the technical
proposal, However, submission of this form is not mandatory and at the discretion of the Consultant.
Project
Description:
Consultant
Name:
This consultant (is ) (is not_ a Department of Transportation certified Disadvantaged Business Enterprise
(DBE).
Expected percentage of contract fees to be subcontracted to DBE(s):
If the intention is to subcontract a portion of the contract fees to DBE(s), the proposed
DBE sub -consultants are as follows:
DBE Sub -Consultant Type of Work/Commodity
Name of Consultant:
By: Date:
Authorized Signature
Title:
D-3
BID OPPORTUNITY LIST
This information may also be included in your bid or proposal package
Prime Contractor/Consultant:
Address/Telephone Number:
Quotes/Received During Month/Yr:
49 CFR Part 26.11 requires the Florida Department of Transportation to develop and maintain a "bid opportunity
list." The list is Intended to be a listing of all firms that are participating, or attempting to participate, on DOT -
assisted contracts. The list must include all firms that bid on prime contracts or bid or quote subcontracts and
material supplies on DOT -assisted projects, including both DBEs and non -DBEs. For consulting companies
this list must include all subconsultants contacting you and expressing an Interest in teaming with you on a
specific DOT assisted project. Prime contractors and consultants must provide information for No. 1 and
should provide any information they have available on Numbers 2, 3, 4 and 5 for themselves, subcontractors
and subconsultants.
1. Firm Name/Address/Phone: 3. 5. Annual Gross Receipts:
_ DBE Less than $1 Million
Non -DBE _— Between $1-$5 Million
Between $5-$10 Million
4. Between $10-$15 Million
Sub -contractor — More than$15 Million
_ Sub -consultant
2. Age of Firm:
1. Firm Name/Address/Phone:
2. Age of Firm:
1. Firm Name/Address/Phone:
2. Age of Firm:
1. Firm Name/Address/Phone:
2. Age of Firm:
3.
_ DBE
Non -DBE
4.
_ Sub -contractor
Sub -consultant
5. Annual Gross Receipts:
Less than $1 Million
_ Between $1-$5 Million
_ Between $5-$10 Million
_ Between $10-$15 Million
_ More than$15 Million
5. Annual Gross Receipts:
_ Less than $1 Million
_ Between $1-$5 Million
_ Between $5-$10 Million
4. Between $10-$15 Million
Sub -contractor More than$15 Million
Sub -consultant
3. •
DBE
Non -DBE
3.
DBE
Non -DBE
5. Annual Gross Receipts:
Less than $1 Million
Between $1-$5 Million
_ Between $5-$10 Million
4. _ Between $10-$15 Million
_ Sub -contractor — More than$15 Million
Sub -consultant
D-4
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1. Firm Name/Address/Phone: 3. 5. Annual Gross Receipts: *.
DBE Less than $1 Million
Non -DBE ^ Between $1-$5 Million
2.Age ofFirm:
*
1. Firm Name/Address/Phone:
2. Age of Firm:
1. Firm Name/Address/Phone:
2. Age of Firm:
1. Firm Name/Address/phone:
2. Age of Firm:
4.
_ Sub -contractor
Sub -consultant
3.
DBE
_ Non -DBE
4.
_ Sub -contractor
Sub -consultant
3.
DBE
Non -DBE
4.
_ Sub -contractor
Sub -consultant
3.
DBE
Non -DBE
4.
1. Firm Name/Address/Phone: 3.
2. Age of Firm:
Sub -contractor
Sub -consultant
_ Between $5-$10 Million
_ Between $10-$15 Million
More than$15 Million
5. Annual Gross Receipts:
_ Less than $1 Million
Between $1-$5 Million
Between $5-$10 Million
_ Between $10-$15 Million
_ More than$15 Million
5. Annual Gross Receipts:
Less than $1 Million
Between $1-$5 Million
Between $5-$10 Million
_ Between $10-$15 Million
More than$15 Million
5. Annual Gross Receipts:
_ Less than $1 Million
Between $1-$5 Million
r Between $5-$10 Million
Between $10-$15 Million
_ More than$15 Million
DBE
Non -DBE
4.
_ Sub -contractor
_ Sub -consultant
5. Annual Gross Receipts:
Less than $1 Million
_ Between $1-$5 Million
Between $5-$10 Million
_ Between $10-$15 Million
More than$15 Million
(Revised 05101/00)
D- 5
PROPOSED SUBCONSULTANT LISTING
CONSULTANT:
PROJECT:
FM No (s).:
Proposed Subconsuitantl (Type of DBE? Proposed Individual Name Title
Work to Perform) (YeslNo)
D-6
CONSULTANT AFFIRMATION
(For Consultants Utilized for Construction Engineering Inspection Services)
As a requirement of the Acquisition of Professional Services procedure, all consultants utilized for
construction engineering inspection, material sampling and testing work must affirm the following
conflict of interest statement.
Project:
FM No(s):
I hereby affirm that as a consultant under contract with the Department to perform construction
engineering inspection, material sampling and testing work on a project, I will not subcontract with
the construction contractor on the same project.
Name of Consultant:
By: Date:
Authorized Signature
Printed Name:
Title:
D - 7
CONSULTANT AFFIRMATION
(For Consultants Utilized for Preparation of Environmental Management (PD&E) Documents)
As a requirement of the Acquisition of Professional Services procedure, all consultants utilized for
Environmental Management services must affirm the following conflict of interest statement.
Project:
FM No(s):
I hereby certify that neither this firm nor any of the principals of this firm have any financial or other
interest in the outcome of this project.
Name of Consultant:
By: Date:
Authorized Signature
Printed Name:
Title:
D - 8
CERTIFICATION FOR DISCLOSURE OF LOBBYING ACTIVITIES
ON FEDERAL -AID CONTRACTS
(Compliance with 49CFR, Section 20.100 (b))
The prospective participant certifies, by signing this certification, that to the best of his or her
knowledge and belief:
(1) 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
federal agency, a Member of Congress, an officer of 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. -
(2) If any funds other than federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any federal agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall
complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities", in accordance with its
instructions. (Standard Form-LLL can be obtained from the Florida Department of Transportation's
Professional Services Administrator or Contractual Services Office.)
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 Section 1352, Title 31, U.S. Code. 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.
The prospective participant also agrees by submitting his or her proposal that he or she shall
require that the language of this certification be included in all lower tier subcontracts, which exceed
$100,000 and that all such subrecipients shall certify and disclose accordingly.
Name of Consultant:
By:
Date:
Title:
Authorized Signature
D-9
ESTIMATE OF WORK EFFORT FORM
To be discussed and distributed at the scope of services meeting.
Not required for this project.
D-11