DCE-100 CONTRACT REQUEST FORM FOR NEW CONTRACTS

Transcription

1 DCE-100 CONTRACT REQUEST FORM FOR NEW CONTRACTS Deadline (if any, explanation on cover memo): _ LAW MANAGER NO: * (*entry to be made by Law Dept.) [1] DEPARTMENT DEPARTMENT # REPRESENTATIVE [PROJECT MANAGER] TEL# FAX # AGENCY/ORG CODE BUDGET LINE ITEM COMMODITY CODE CAPITAL BUDGET CAPITAL PROJECT # OPERATING BUDGET BID # RFP # WAS SEQRA DONE? [APPLICABLE IN CONSTRUCTION CONTRACTS ONLY] YES NO NOT REQUIRED RESOLUTION NUMBER FUNDING /APPROVING THIS CONTRACT: RES. # FUNDS FOR THIS CONTRACT ARE PROVIDED IN THE FY % OF COUNTY S FINANCIAL PARTICIPATION IN TOTAL COST % PASS THROUGH FUNDING? YES NO NO COUNTY EMPLOYEE IN THIS DEPARTMENT, WHO HAS BEEN INVOLVED IN THIS PROCUREMENT, HAS A CONFLICTING INTEREST OR ACTIVITY, WHICH WOULD CONSTITUTE A PERSONAL GAIN OR A CONFLICT OF INTEREST AS PER ROCKLAND COUNTY CODE 66-3 OR IF YOU BELIEVE THERE MAY BE A CONFLICT, CALL THE LAW DEPARTMENT. MANDATED SERVICES NO YES, If yes, indicate statutory authority: * MWBE REQUIREMENTS NO YES (*REQUIRED) [2] PROCUREMENT POLICY EXEMPTION: NONE PROFESSIONAL SERVICES CONTRACT LESS THAN $35,000 RFP THRESHOLD SOLE SOURCE PROCUREMENT WORKS OF ART FOR PUBLIC DISPLAY SPECIAL PROCUREMENT UNDER SECTION PROFESSIONAL SERVICES WITH PREDETERMINED RATES (SEE INSTRUCTIONS) DESIGNATED PROFESSIONAL SERVICES EMERGENCY PROCUREMENT PROFESSIONAL SERVICES WITH GRANT APPROVAL ORGANIZATIONS [3] LEGAL NAME OF AGENCY/CONSULTANT/CONTRACTOR: ADDRESS: CONTACT PERSON: TEL # : * SIGNATORY AND TITLE: SS# OR FED.ID# *(REQUIRED) PURPOSE OF CONTRACT: [4] TYPE OF AGREEMENT: NEW ONLY CONSULTANT CONTRACTOR LEASE GRANT CONTRACT AGENCY INTERMUNICIPAL LICENSE M.O.U [5] TERM OF AGREEMENT TO [6] PAYMENT SCHEDULE: TOTAL CONTRACT AMOUNT NOT TO EXCEED: $ HOURLY RATE: $ (IF APPLICABLE) NO ($) DOLLAR EXPENDITURE; ENCUMBRANCE TO BE MADE BY PURCHASE ORDER (IF APPLICABLE) [7] SERVICES: (ATTACH A SCHEDULE A DETAILING ALL SERVICES THAT AGENCY/CONSULTANT/CONTRACTOR SHALL PERFORM) NOTE: OTHER SCHEDULES MAY BE REQUIRED. [8] INSURANCE BOX 7 (A) MUST BE CHECKED BEFORE FORM MAY BE AUTHORIZED BY DEPARTMENT. (A) ALL REQUIRED INSURANCE CERTIFICATES TO BE MAINTAINED BY THE DEPARTMENT HAVE BEEN RECEIVED, AND COPIES ATTACHED HERETO. (NOT APPLICABLE TO PUBLIC WORK CONTRACTS) (1) WORKERS COMPENSATION REQUIRED (CERTIFICATE RECEIVED AND ATTACHED AS PER 7(A) (2) WORKERS COMPENSATION NOT REQUIRED, (*SECTION 7A(2)(a) MUST ALSO BE COMPLETED) a. A SIGNED, DATED EXEMPTION CERTIFICATE ISSUED TO CONTRACTOR/CONSULTANT FOR COR EXEMPTION CERTIFICATE NUMBER: **

2 (**NUMBER MUST BE CONFIRMED BY DEPARTMENT FROM: AND INDICATED ABOVE)

3 Contract Request Schedule A (A detailed schedule of the work or services to be provided) Statement of Work (SOW) (The Statement of Work shall define the tasks required for the successful completion of the County's goals and objectives ensuring all minimum requirements are met.) Contract Deliverables (Contract Deliverables are the outputs associated with the Statement of Work. Sample Deliverables include, draft reports, final reports, assessments, studies, meetings, public hearings, number of clients served within a specified time period.) Cost/Price & Payment Section (Total/Estimated contract costs shall be defined as well as method of payment. Define if this is a Completion Contract (paid in full when contract is completed) or if this is a Level of Effort Contract (progress payments will be made upon the completion of certain milestones/deliverables). If progress payments are to be made, the milestones/deliverable for payment must be clearly defined. Retainage requirements shall also be clearly defined.) Supporting Documentation (Supporting Documentation such as copies of vendor s proposals, technical data or drawings should also be included.) Insurance Certificates - (All required insurance certificates; General Liability, Automotive, Professional Liability, Workman s Compensation and Disability shall be included with each contract request and contract extension request.)

4 AFFIDAVIT OF DISCLOSURE OF POLITICAL CONTRIBUTIONS PURSUANT TO CHAPTER 323 OF THE ROCKLAND COUNTY CODE STATE OF NEW YORK) : ss COUNTY OF ROCKLAND) NAME OF REPORTING ENTITY: ADDRESS: TELEPHONE NO.: EXT: TELEFAX NO.: ADDRESS: THE REPORTING ENTITY IS (Check one of the following): AN INDIVIDUAL A PARTNERSHIP A CORPORATION THE REPORTING ENTITY: (Check One) Will enter into a contract with the County of Rockland which did/did not result from public bidding in excess of Ten Thousand Dollars ($10,000.00) this calendar year. Is currently under a contract with the County of Rockland in excess of Ten Thousand Dollars ($10,000.00). THE REPORTING ENTITY, ITS MEMBERS, DIRECTORS, POLICY MAKING OFFICERS, OR MAJORITY SHAREHOLDERS, HAVE DIRECTLY OR INDIRECTLY MADE THE FOLLOWING CONTRIBUTIONS TO THE PERSONS OR ORGANIZATIONS LISTED BELOW. (PLEASE LIST ALL CONTRIBUTIONS HAVING A VALUE IN EXCESS OF TWO HUNDRED DOLLARS ($200.00) PER YEAR MADE TO ANY POLITICAL PARTY OR ANY INDIVIDUAL OR ANY COMMITTEE FOR AN INDIVIDUAL RUNNING FOR PUBLIC OFFICE IN ROCKLAND COUNTY OR IN A DISTRICT IN WHICH ROCKLAND COUNTY IS LOCATED, FOR A PERIOD OF THREE (3) YEARS PRIOR TO THE DATE OF THIS AFFIDAVIT.).: NOTE: PLEASE ANSWER NONE OR LIST EACH CONTRIBUTION SEPARATELY. NAME OF CONTRIBUTOR RELATIONSHIP TO REPORTING ENTITY (Use additional sheets if necessary) CONTRIBUTION DATE OF MADE TO CONTRIBUTION OF VALUE & NATURE OF CONTRIBUTION I am the (Title or Office) of the reporting entity listed above. I make this affirmation based upon my personal review of the books and records of the reporting entity. All of the foregoing information is true to the best of my knowledge, after inquiry. I make these statements under penalty or perjury. SIGNATURE: SWORN to before me this day of PRINT NAME & TITLE:, 201 Notary public bidproc6.frm Rev. 5/96

5 AFFIRMATIVE ACTION PLAN State of New York) :SS County of Rockland being duly sworn, deposes and says that he is the _ of the Corporation. That I (DO) (DO NOT) employ fifteen (15) employees AND I (DO) (DO NOT DO) a minimum of $50,000 per annum business with the County of Rockland. Based on the above information (if both criteria are met), attached hereto, is an Affirmative Action Plan or, because of the above, no Affirmative Action Plan is necessary. SIGNED SWORN to before me this day of 201 Notary Public: **Strike out non-applicable information

6 DISCLOSURE OF SUPPLIER RESPONSIBILITY STATEMENT 1. List any convictions of any person, subsidiary, or affiliate of the company, arising out of obtaining, or attempting to obtain a public or private contract, or subcontract, or in the performance of such contract or subcontract. 2. List any convictions of any person, subsidiary, or affiliate of this company for offenses such as embezzlement, theft, fraudulent schemes, etc. or any other offense indicating a lack of business integrity or business honesty which affect the responsibility of the contractor. 3. List any convictions or civil judgments under state or federal antitrust statutes. 4. List any violations of contract provisions such as knowingly (without good cause) to perform, or unsatisfactory performance, in accordance with the specifications of a contract. 5. List any prior suspensions or debarments by any government agency. 6. List any contracts not completed on time. 7. List any documented violations of federal or state labor laws, regulations or standards, or occupational safety and health rules I,, as Name of Individual Title & Authority Of, declare under oath that the above Company Name Statements, including any supplemental responses attached hereto, are true. Signature FID No.: State of County of Subscribed and sworn to before me on this day of 20 by Representing him/herself to be of the Company

7 CERTIFICATION OF COMPLIANCE WITH THE IRAN DIVESTMENT ACT Pursuant to State Finance Law 165-a, on August 10, 2012 the Commissioner of the Office of General Services (OGS) posted a prohibited entities list of persons who are engaged in investment activities in Iran (both are defined terms in the law) on the OGS website at: By submitting a bid in response to this solicitation or by assuming the responsibility of a Contract awarded hereunder, each Bidder/Contractor, any person signing on behalf of any Bidder/Contractor and any assignee or subcontractor and, in the case of a joint bid, each party thereto, certifies, under penalty of perjury, that once the Prohibited Entities List is posted on the OGS website, that to the best of its knowledge and belief, that each Bidder/Contractor and any subcontractor or assignee is not identified on the Prohibited Entities List created pursuant to SFL 165-a(3)(b). Additionally, Bidder/Contractor is advised that once the Prohibited Entities List is posted on the OGS Website, any Bidder/Contractor seeking to renew or extend a Contract or assume the responsibility of a Contract awarded in response to this solicitation must certify at the time the Contract is renewed, extended or assigned that it is not included on the Prohibited Entities List. During the term of the Contract, should the County receive information that a Bidder/Contractor is in violation of the above-referenced certification, the County will offer the person or entity an opportunity to respond. If the person or entity fails to demonstrate that he/she/it has ceased engagement in the investment which is in violation of the Act within 90 days after the determination of such violation, then the County shall take such action as may be appropriate including, but not limited to, imposing sanctions, seeking compliance, recovering damages or declaring the Bidder/Contractor in default. The County reserves the right to reject any bid or request for assignment for a Bidder/Contractor that appears on the Prohibited Entities List prior to the award of a contract and to pursue a responsibility review with respect to any Bidder/Contractor that is awarded a contract and subsequently appears on the Prohibited Entities List. I,, BEING DULY SWORN, DEPOSES AND SAYS THAT HE/SHE IS THE OF THE CORPORATION AND THAT NEITHER THE BIDDER/CONTRACTOR NOR ANY PROPOSED SUBCONTRACTOR IS IDENTIFIED ON THE PROHIBITED ENTITIES LIST. SWORN to before me this SIGNED day of 201 Notary Public: