HomeMy WebLinkAboutAppendix AffidavitsMIAMI•DAD
COUNTY COUNTY
APPENDIX
AFFIDAVITS
FORMAL BIDS
• � i
MIAMI-DADS COUNTY BID NO.: 6827-0/11
MIAMI-DADE COUNTY BID AFFIDAVITS
• DISABILITY NONDISCRIMINATION AFFIDAVIT
(Resolution R-385-95)
I, being duly first sworn, 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, 104 Slat 327, 42 U.S.C. Sections 225 and 611
including Title 1, Employment; Title 11, Public Services; Title III, Public Accommodations and Services 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 Housing Act as amended, 42 U.S.C. Section 3601-3631
• MIAM1-DADE COUNTY DEBARMENT DISCLOSURE AFFIDAVIT
(Ordinance 93-129) See Section 1 (I.3H)
1, being duly first sworn, upon oath deposes and says that the bidder of this contract or his agents, officers, principals,
stockholders, subcontractors or their affiliates are not debarred by Miami -Dade County.
• MIAMI-DADE COUNTY COLLECTION OF TAXES,
FEES AND PARKING TICKETS AFFIDAVIT
(Ordinance 95-178) Section 1 (1.3 E)
I, being first duly sworn stale 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.
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 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 1 (1.3 N)
I, being first duly swom stale 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 firrn, corporation, partnership or joint venture in which the individual or entity has a controlling financial
interest as that term is defined in Section 2-I1.1(b)(8) of the County Code.
Page 1 of 8 Revised 10/24/01
• MIAMI-DADE COUNTY DOMESTIC VIOLENCE LEAVE
AFFIDAVIT (Ordinance 99-5 & Resolution R-185-00)
That in compliance with Ordinance No 99-5, Resolution No. R-185-00 and the Code of Miami -Dade County, Florida,
the following information is provided and is in compliance with all items in the aforementioned legislation. As an
employer having, in the regular course of business, fifty (50) or more employees working 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 certify to be in compliance with the Domestic Leave Ordinance, codified at 11A-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 1 AND 2
By.
MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE
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Signature of Affiant
20
Date
/ - I / / / / / I
Printed Name of Affiant and Title Federal Employer Identification Number
Printed Name of Fimrt
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 as identification.
Type of identification
Signature of Notary Serial Number
Print or Stamp Name of Notary Expiration Dale
Notary Public — State of
:'YUE.tt•.
Page 2 of 8 Revised 10/24/01
LIVING WAGE AFFIDAVIT
(County Ordinance 99-44)
1, being first duly sworn hereby state and certify that in compliance with Section 2-8.9 of the Mianti-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 $9.81 per hour plus health benefits as described in the ordinance, or $ 1l .23 per hour without health benefits. The
Living Wage required by Ordinance 99-44 is subject to indexing as set -forth in Section "C" (Indexing).
By: 20
Signature of Affiant Date
1 1 1 I 1 1/ I
Printed Name of Affiant and Tide 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 as identification.
Type of identification
Signature of Notary Serial Number
Print or Stamp Name of Notary Expiration Date
Notary Public — State of
Page 3 of 8 8/15/ 05
AFFIRMATIVE ACTION PLAN/PROCUREMENT POLICY AFFIDAVIT
(Code of Miami -Dade County Section 2-8.1.5) (Ordinance No. 98-30)
1, being duly first sworn, hereby state that the bidder of this contract:
❑ has a current Affirmative Action Plan 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
Affirmative Action Plan 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 DBD. I will contact DBD at 305-375-
31 l 1 regarding this requirement
❑ had anmml 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:
Signature Signature
Witness: By:
Signature Legal Name and Title
The foregoing instrument was acknowledged before me this _ day of 20
FOR AN INDIVIDUAL ACTING IN HIS OWN RIGHT:
By:
FOR A CORPORATION, PARTNERSHIP OR JOINT VENTURE:
By: having the tide of
with
❑ a corporation ❑ partnership ❑ joint venture
PLEASE NOTE.
Section 2-1Q4(4)(a) of the Code of Miami -Dade County (Ordinance Na 82-37) requires that all properly licensed
architectural engineering, landscape architectural, and land surveyors haw an affirmative action plan on file with the
County.
Section 24I.S of the Code of Miami -Dade County requires that firms that have annual gross revenues in excess offive (5)
million dollars have an q Srnmatiwe action plan and procurement policy on file uith the County. Ferns that hale a Board of
Directors that are representative of the population make-up of the nation may be exempt
For questions regarding these requirements, please contact the Miami -Dade County Depanbneru of Business Developmen at
305-375-3I11.
Page 4 of 8 Revised 11/8/04
MIAMI-DADE COUNTY
SUBCONTRACTOR/SUPPLIER LISTING
(Ordinance 97-104)
Firm Name of Prime Contractor/Respondent:
Bid No.:
Tide:
BID NO.: 6827-0/11
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 Health 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
Business Name and Address of Direct
Supplier
Principal Owner
Scope of Work to be Performed by
Subcontractor/S u bconsultant
Supplies/Materials/Services to be
Provided by Supplier
(Principal Owner)
Gender Race
(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 Print Title Date
(Duplicate if additional space is needed) FORM I00
4 +
MIAMI-DADE COUNTY
BID NO.: 6827-0/11
MIAMI-DADE COUNTY
CERTIFICATION OF RECYCLED
ENVIRONMENTALLY ACCEPTABLE PACKAGING
PRODUCT CONTENT
RESOLUTION (R-738-92)
MINIMUM CERTIFIED CONTENT
Bid ftcm
Number
RECYCLED PRODUCTS
RECOVERED MATERIALS
RECYCABLE PRODUCTS
%
Composition
Type of
Material
%
Composition
Type of
Material
%
Composition
Type of
Material
DEFINITIONS
"Recycled Material" shall be defined as any waste material or by-pmducts 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 his 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 Icss waste generated due
to its use rather than another product designed to serve the some 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 end do so by certify that the Minimum Materials Content fn our producl(s) are
as specified on this form and conform with the definitions as shown above.
NAME
ADDRESS
CITY
STATE
ZIP
SIGNATURE
TITLE
Page 8 of 8
Revised 08/23/01