Responsibility Determination for General Contractors Who May Desire to Submit Bid Proposals for the Construction of [PROJECT TITLE]

Transcription

1 Responsibility Statement and Questionnaire CITY OF NAPA PUBLIC WORKS DEPARTMENT NAPA, CALIFORNIA [DATE] Responsibility Determination for General Contractors Who May Desire to Submit Bid Proposals for the Construction of The City of Napa (City) will only receive construction bids from general contractors who have been approved to be on the Final Bidders List for this project. General contractors interested in submitting a construction bid for this project must first submit a Responsibility Statement and Questionnaire as described in this document. Firms interested in submitting bids as a subcontractor or material supplier do not need to submit a Responsibility Statement and Questionnaire. Local agencies are using an early responsibility determination procedure to comply with the requirement that they only hire responsible contractors. This procedure allows the local agency to consider the responsibility and capacity of a contractor to perform the work on a given project before the contractor has invested the time and expense necessary to submit a bid. This procedure also provides a mechanism for a reasonable, objective and fair process for determining the ability of interested contractors to satisfactorily complete the project. If you have any questions about the responsibility determination process or the documents to be submitted, please contact the City s project manager, Mark Andrilla, of this office, at (707) Approved for publication Date

2 Responsibility Statement and Questionnaire for the Construction of TABLE OF CONTENTS PART A. NOTICE REGARDING SUBMISSION OF RESPONSIBILITY QUESTIONNAIRE... A-1 PART B. INSTRUCTIONS FOR PREPARING 1. Project Description... B-1 2. Submittal Requirements... B-1 3. Review of Submitted Responsibility Statements and Questionnaires... B-2 4. Protest of City s Decisions... B-2 5. Anticipated Project Time Line... B-3 6. Evaluation Form... B-3 PART C. FORM Contractors desiring to submit bid proposals for this project must complete and submit the forms in Part C as specified in Part A and Part B. 1. Contractor Information... C-1 2. Experience Information... C-2 Present Construction Information Form... C-3 Completed Construction Information Form... C-4 3. Financial Data... C-5 4. Safety Review... C-6 5. Insurance Requirements... C Litigation History... C-8 7. Bonding Requirements... C-8 8. Prevailing Wage Rate Requirements... C-9 9. Integrity Requirements... C-10

3 PART A Page A-1 NOTICE REGARDING SUBMISSION OF Notice is hereby given that sealed Responsibility Statements and Questionnaires will be received by the City of Napa at the Public Works Department, Engineering Division, 1600 First Street, Napa, California, 94559, until 5:00 p.m., [DATE], for the project described herein. Responsibility Statements and Questionnaires should be placed in a sealed enveloped. The following information should be visible on the envelope: Your company name and address Responsibility Statement and Questionnaire For the Construction of Contractors submitting a Responsibility Statement and Questionnaire shall be notified by [DATE], whether or not they have been approved to be placed on the Final Bidders List for this construction project. PROJECT MANAGER: Bidders may discuss the Responsibility Statement and Questionnaire and Contract Documents with the City s Project Manager,, tel:. (Note: Construction Bid Documents will not be issued until approximately [DATE] for the ). In preparing their submittal of a Responsibility Statement and Questionnaire, contractors shall only rely upon the written documents obtained from the Internet site. There is no charge for downloading a copy of these documents from this website. CLARIFICATIONS AND ADDENDA: The City may issue addenda as appropriate for clarification or other reasons during the responsibility process. All requests for clarification or interpretation of the documents must be submitted at least three (3) days before the deadline for receipt of Responsibility Statement and Questionnaires. NOTICE REGARDING RECEIPT OF CONSTRUCTION BIDS The anticipated time line for issuing bid documents and receiving bids for the construction of the project is described in Part B of this document. FINAL BIDDERS LIST: The City will only receive construction bids from general contractors who have been approved to be on the Final Bidders List for this project. General contractors interested in submitting a construction bid for this project must first submit a Responsibility Statement and Questionnaire as described in this document. Firms interested in submitting bids as a subcontractor or material supplier do not need to submit a Responsibility Statement and Questionnaire. If a responsibility protest is filed by a potential bidder, the City will conduct a review as described below in Part B, Section 4. Should the City still maintain that a potential bidder is not approved and they do submit a bid, it will not be opened. A BIDDERS' BOND is not required to be submitted with the Responsibility Questionnaire. However, a Bidders Bond shall be submitted by the bidders approved to be on the Final Bidders List at the time of bid submission. CONTRACTORS LICENSE: The Contractor shall possess a Class A and any other required Contractors Licenses at the time the contract is awarded.

4 PART B Page B-1 INSTRUCTIONS FOR PREPARING 1. PROJECT DESCRIPTION THE PURPOSE OF THIS PROJECT is to construct and including necessary roadway improvements connected with the bridge construction. THE WORK CONSISTS OF constructing [PROJECT DESCRIPTION]. THE CONSTRUCTION COST RANGE of this project is [AMOUNT] to [AMOUNT]. THE CONSTRUCTION TIME FRAME for this project is anticipated to be [DATE] to [DATE]. Preliminary plans for this project are available for review at the City of Napa, Public Works Department, in the Community Services Building at 1600 First Street, Napa, California SUBMITTAL REQUIREMENTS Responsibility Statement and Questionnaire submittals must contain 1. All of the information requested in this document, and 2. The completed form presented in Part C of this document along with any other requested information, including, but not limited to, resumes of key staff that will be working on the project, and financial records. The various required documents that must be attached are described within the form in Part C and are also listed on the last page of that form. The submittal deadline and location is defined above in Part A. Failure to provide required information that is complete and accurate at the time, date and location set forth shall constitute grounds for rejection of the submitted Responsibility Statement and Questionnaire. It shall be the sole responsibility of the contractor to insure that the City has received the required documents. The City is not responsible for any misdirection, late delivery or non-delivery of mail or other communications to City. Notifications regarding the City s determination of which contractors are approved or not-approved to be on the Final Bidders List will be made via facsimile on the date stated below. It shall be the sole responsibility of the contractor to insure City has his proper address and phone number. In preparing their submittal of a Responsibility Statement and Questionnaire, contractors shall only rely upon the written documents issued by the City for this process. 3. REVIEW OF SUBMITTED RESPONSIBILITY STATEMENTS AND QUESTIONNAIRES The City will evaluate the information contained in each applicant s questionnaire and may request additional information pertinent to the questionnaire. The City s decision will be based on the evaluation of several factors including, but not limited to, the items listed in the various forms of this document. The sole and discretionary judgment of the City will determine if the applicant is approved to be included in the Final Bidders List. Should the applicant not be approved, the applicant may protest that decision. This protest must be filed as described below in Section 4. The City s evaluation of the firm s ability, trustworthiness, fitness and capacity to satisfactorily perform the proposed work applies only to this project. During the evaluation of the Responsibility Questionnaire, should any additional information be requested by the City, the applicant must provide that information within two working days of the request. Failure to provide the information within the specified time period may result in disqualification from the process. In order to respect the confidentiality of the information submitted, the City will not publish the information contained in the submitted Responsibility Questionnaires, so far as permitted by law.

5 PART B Page B-2 Notifications regarding the City s determination of which contractors are approved or not-approved to be on the Final Bidders List will be made on [DATE], by facsimile, and by certified mail to the contractor s address as listed on contractor s submittal. It is the sole responsibility of the contractor to insure City has contractor s proper address. 4. PROTEST OF CITY S DECISIONS Protests regarding the City s decisions shall be processed as follows: 1. Any protest concerning the non approval of a contractor must be made in writing by [TIME] on [DATE], to the Public Works Department, City of Napa, 1600 First Street, Napa, California; Attention: Jacques R. LaRochelle. The protest shall set forth the reasons for the protest, and must clearly identify the protesting party. 2. Upon receipt of such a written protest, the Public Works Director or his designee shall hear the case of the contractor on [DATE]. If the contractor is not present at the hearing it will be assumed that the written protest is the contractor s complete protest. Should the contractor desire to appeal the decision made by the Public Works Director or his designee, the contractor may appeal to the City Council by submitting a written request by the close of business on [DATE], to the Public Works Department, City of Napa, 1600 First Street, Napa, California; Attention: Jacques R. LaRochelle. 3. The City Council will then hear and determine the protest on [DATE].

6 PART B Page B-3 5. ANTICIPATED PROJECT TIME LINE (SAMPLE) Event Date Responsibility Statement and Questionnaire Document Available for Distribution to Contractors Due Date of Responsibility Statement and Questionnaire City Notifies Contractors, Approved and Not Approved Contractors Submit Request for Appeal (by 12:00 Noon) City Staff Hears Appeals Contractor Submit Request for Appeal to City Council City Council Hears Appeals City Advertises Allen Road Bridge over the Napa River for construction bids Bid Opening for Allen Road Bridge over the Napa River (anticipated date) City Council Awards Agreement for Construction of the Project (anticipated date) 5. EVALUATION FORM The City of Napa will evaluate each contractor by use of the evaluation form presented on the following three pages. A threshold approval requirement has been established for several of the evaluation items; other evaluation items are subjective. Based on the information provided in their Responsibility Statement and Questionnaire, contractors will be scored on the various approval requirements. Contractors who meet or exceed the requirements will be approved to be on the Final Bidders List for this project. The Evaluation Form is provided below for information only; contractors DO NOT need to fill out or submit the Evaluation Form.

7 PART B Page B-4 Evaluation Form for (Contractor Name): Page 1 of 3 Date: Prepared by: Responsibility Item Approval Requirement CONTRACTOR INFORMATION Corporation, Partnership, Owner Years In Business Contractor s Data or Score Comments Other Business Names Trade Work With Own Forces License Class A EXPERIENCE INFORMATION Current Projects Projects Past Three Years Key Personnel FINANCIAL DATA Evaluation Item Approval Requirement Yr Yr Yr Comments Current Ratio > 1.5 Quick Ratio Debt Ratio Gross Profit Margin Net Profit Margin Net Worth Leverage < 2.5 Working Capital (Wc) 3-Year Trend Profitability V.S. Volume 3-Year Trend BKLOG / WC < 20 Steady/Up Gross/Vol. Steady/Up

8 PART B Page B-5 Evaluation Form for (Contractor Name): Page 2 of 3 SAFETY REVIEW Experience Modification Rate LTIR IR EMR Last Year < 1.0 EMR 4 Year Average < 1.0 EMR 4-Year Trend Steady/Down < 6 Per 200k Hrs < 13 Per 200k Hrs Inspections/Safety/Meetings INSURANCE A.M. Best Rating A:VII General Liability Limits Per Occurrence $1 million Aggregate Deductible Value Automobile Limits $1 million Excess Liability Limits Workers Compensation $1 million LITIGATION Default Termination Pending Litigation Litigation Filed City/County Of Napa None No Major No Major No Major

9 PART B Page B-6 Evaluation Form for (Contractor Name): Page 3 of 3 BONDING Surety s Name California-Admitted Yes A.M. Best Rating Underwriting Capacity A > Contract Value Total Bond Capacity Available Bond Capacity Bonding Rate <3% > Contract Value Staff s Recommendation: Approve Contractor for Final Bidders List Do Not Approve Contractor for Final Bidders List for the following reasons: Division Head s Review / Approval: Mark Andrilla, Senior Civil Engineer I concur with Staff s Recommendation above. I make the following modification of Staff s Recommendation:

10 PART C Page C-1 General contractors desiring to be submit bid proposals for this project must 1) complete the form presented in this Part C, 2) attach the required additional information as indicated below, and 3) submit the same to the City for review per the instructions stated above in Part A and Part B. All information submitted for responsibility evaluation will be considered official information acquired in confidence and the City of Napa will maintain its confidentiality to the extent permitted by law. 1. CONTRACTOR INFORMATION Contractor s Name Contractor must be licensed in the State of California. If a joint venture, the joint venture must be licensed. Provide the following information: Name of license holder exactly as on file with the California State License Board Contractor License Number and Classification Structure of Company (please check one and provide information accordingly) CORPORATION Date of Incorporation: State of Incorporation: President Name: Vice-President's Name: Secretary's Name: Treasurer's Name: PARTNERSHIP Date of Organization: Name and Address of Principals (state whether general or limited partnership): INDIVIDUAL If other than a Corporation or Partnership, describe organization and name of Principals: How many years has your Organization been in business as a Contractor? Years

11 PART C Page C-2 How many years has your Organization been in business under its present business name? Years Under what other entities or former names has your Organization operated? Name Years Name Years Name Years List the type of work normally performed with your own forces: 2. EXPERIENCE INFORMATION One of the criteria to be used to evaluate a contractor s responsibility shall be the contractor s overall company experience and assigned key personnel experience in similar construction. This is of prime importance. However, there will be other criteria, as listed below, that the City deems necessary to ascertain the capabilities and past performance of each contractor. Using the Present Construction Information Form (on the next page), provide information for all major projects currently being performed including, but not limited to, any City of Napa contracts, and other bridge construction projects over $ dollars in construction value. Using the Completed Construction Information Form (on the second next page), provide information for all major projects completed in the past ten years and operational for at least one year including, but not limited to, any City of Napa contracts, and other bridge construction projects over $ dollars in construction value. Attach a list of key personnel who will likely be assigned to the Project. Attach a copy of their resumes.. Key staff to be committed on this Project must have experience in field and engineering coordination and managing work where contractor was acting in a similar role on a Project of similar scope and magnitude listed in Present Construction Information Form and the Completed Construction Information Form.

12 PART C Page C-3 COMPANY EXPERIENCE PRESENT CONSTRUCTION INFORMATION FORM Provide the following information for all projects which involve bridge construction work with a value in excess of $ dollars and are presently under construction. Project Title: Location: Project Description: Project Owner Information: Name: Contact: Telephone: Describe Your Work on the Project: Total Construction Value: $ Percent Complete: % If Your Work Was Performed As A Subcontractor: General Contractor Information: Name: Contact: Telephone Initial Subcontract Value: Final Subcontract Value: Name of Design Architect/Engineer: Contact: Phone No.: Address: Dollar Amount Of Claims: Submitted $ Settled $ Project Title: Location: Project Description: Project Owner Information: Name: Contact: Telephone: Describe Your Work on the Project: Total Construction Value: $ Percent Complete: % If Your Work Was Performed As A Subcontractor: General Contractor Information: Name: Contact: Telephone Initial Subcontract Value: Final Subcontract Value: Name of Design Architect/Engineer: Contact: Phone No.: Address: Dollar Amount Of Claims: Submitted $ Settled $ COPY ADDITIONAL PAGES AS NEEDED

13 PART C Page C-4 COMPANY EXPERIENCE COMPLETED CONSTRUCTION INFORMATION FORM Provide the following information for all projects which involve bridge construction work with a value in excess of $ dollars and completed within the last 10 years and operational for at least one year. Project Title: Location: Project Description: Project Owner Information: Name: Contact: Telephone: Describe Your Work on the Project: Total Construction Value: $ If Your Work Was Performed As A Subcontractor: General Contractor Information: Name: Contact: Telephone Initial Subcontract Value: Final Subcontract Value: Name of Design Architect/Engineer: Contact: Phone No.: Address: Dollar Amount Of Claims: Submitted $ Settled $ Project Title: Location: Project Description: Project Owner Information: Name: Contact: Telephone: Describe Your Work on the Project: Total Construction Value: $ If Your Work Was Performed As A Subcontractor: General Contractor Information: Name: Contact: Telephone Initial Subcontract Value: Final Subcontract Value: Name of Design Architect/Engineer: Contact: Phone No.: Address: Dollar Amount Of Claims: Submitted $ Settled $ COPY ADDITIONAL PAGES AS NEEDED

14 3. FINANCIAL DATA PART C Page C-5 Attach copies of your last three years audited financial statements (Income Statement, Balance Sheet and Cash Flow) and include the most recent financial statement (Income statement, Balance Sheet and Cash Flow) of the current calendar year. If your firm has been in business less than three years, submit financial statements (Income Statement, Balance Sheet and Cash flow) for your firm from the date of inception, including the most recent financial statement (Income Statement, Balance sheet and Cash Flow) for the current Calendar year. You may provide any additional information not contained in the footnotes to the financial statements that would explain any unusual circumstances that may have impacted, either positively or negatively, the financial status of your firm during this period. It is mandatory that this financial information be provided, except as noted above. Supplemental Financial Information Volume of Work (total of construction contracts) for the last three years Net Income for each of the last three years 2008 $ 2008 $ 2009 $ 2009 $ 2010 $ 2010 $ Amount of work currently on backlog, with percent complete as appropriate. For purposes of this evaluation, backlog shall be defined as work the contractor has been ordered, awarded, or contracted to do but which has not yet started. Current Total Project Backlog $ Indicate the size of Project you are most competitive in performing. $ Bank Reference. Provide bank reference, including contact person, address and phone number. Bank: Branch: Address: Telephone: Contact: Other References. Provide list of project owners, architects, engineers, suppliers and trade subcontractors, including contact person, address and phone number. Company Contact Address Phone Company Contact Address Phone Company Contact Address Phone Company Contact Address Phone

15 4. Safety Review PART C Page C-6 Provide your company's experience modification rate (EMR) for the past three years and current year. Attach a letter from your insurance carrier or State Fund on their letterhead verifying the EMR data. YEAR EMR YEAR EMR Are the above rates interstate or intrastate? If intrastate, which state? Describe your company's injury experience for the past three years and the current year. YEAR LTIR IR Has your company been cited by OSHA in the past five years? No Yes How Often? If yes, for what? Name of your proposed senior site representative who will be assigned to this project. List the locations, OSHA incident frequency rates, and lost time frequency rates for each of his/her last three projects. A. B. C. Will your insurance company's loss control specialist visit the project site? No Yes If yes, how often? Monthly Quarterly Annually Do you require documented safety meetings be held for: A. Field Supervisor: No Yes Frequency B. Employees: No Yes Frequency C. New Hires: No Yes Frequency D. Subcontractors: No Yes Frequency Do you conduct documented safety inspections? No Yes How often? Do you have home office safety representatives who visit/audit the job? No Yes How often? Do you have an Injury and Illness Prevention Program (IIPP)? No Yes

16 5. Insurance Requirements PART C Page C-7 Attach evidence of coverage by a qualified Liability Insurer in at least the amounts shown below. The following is an excerpt of the City s construction agreement. This is the minimum insurance that the contractor constructing the project will be required to procure and maintain for the duration of the project. INSURANCE and BONDS. In addition to any other insurance or bond required under this Agreement, the CONTRACTOR shall procure and maintain for the duration of this Agreement the following types and limits of insurance ("basic insurance requirements") herein: a) Automobile liability insurance, providing coverage on an occurrence basis for bodily injury, including death, of one or more persons, property damage and personal injury, with limits of not less than One Million Dollars ($1,000,000) per occurrence; and the policy shall: i) Provide coverage for owned, non-owned and hired autos. b) Broad form commercial general liability insurance, unless otherwise approved by the CITY s Risk Manager, providing coverage on an occurrence basis for bodily injury, including death, of one or more persons, property damage and personal injury, with limits of not less than One Million Dollars ($1,000,000) per occurrence; and the policy shall: i) Provide contractual liability coverage for the terms of this Agreement. ii) Provide products and completed operations coverage. iii) Contain an additional insured endorsement in favor of the CITY, its mayor, council, officers, agents, employees and volunteers. c) Workers' compensation insurance with statutory limits and employer's liability insurance with limits of not less than One Million Dollars ($1,000,000) per accident; and the policy shall contain a waiver of subrogation in favor of the CITY, its mayor, council, officers, agents, employees and volunteers. d) All policies required of the CONTRACTOR shall be primary insurance as to the CITY, its mayor, council, officers, agents, employees, or designated volunteers and any insurance or self-insurance maintained by the CITY, its mayor, council, officers, agents, employees, and designated volunteers shall be excess of the CONTRACTOR's insurance and shall not contribute with it. e) Except for workers compensation, insurance is to be placed with insurers with a Bests' rating as approved by CITY s Risk Manager, but in no event less than A-:VII. Any deductibles, self-insured retentions or insurance in lesser amounts, or lack of certain types of insurance otherwise required by this Agreement, or insurance rated below Bests' A-:VII, must be declared prior to execution of this Agreement and approved by the CITY in writing. f) Unless otherwise approved by CITY s Risk Manager, all policies shall contain an endorsement providing the CITY with thirty (30) days written notice of cancellation or material change in policy language or terms. All policies shall provide that there shall be continuing liability thereon, notwithstanding any recovery on any policy. Copies of policies shall be delivered to CITY on demand. g) The insurance required hereunder shall be maintained until all work required to be performed by this Agreement is satisfactorily completed as evidenced by written acceptance by the CITY. h) The CONTRACTOR shall furnish the City Risk Manager with a certificate of insurance and required endorsements evidencing the insurance and bonds required. The CITY may withdraw its offer of contract if certificates of insurance and endorsements and bonds required have not been provided as required by the Special Provisions. i) Full compensation for all premiums which the CONTRACTOR is required to pay on all the insurance described herein shall be considered as included in the prices paid for the various items of work to be performed under the Agreement, and no additional allowance will be made therefor or for additional premiums which may be required by extensions of the policies of insurance. j) It is further understood and agreed by the CONTRACTOR that its liability to the CITY shall not in any way be limited to or affected by the amount of insurance obtained and carried by the CONTRACTOR in connection with this Agreement.

17 PART C Page C-8 k) Unless otherwise approved by the CITY, if any part of the work under this Agreement is subcontracted, the "basic insurance requirements" set forth above shall be provided by, or on behalf of, all subcontractors even if the CITY has approved lesser insurance requirements for CONTRACTOR. l) CONTRACTOR shall provide performance, labor and material bonds in amounts and in a form suitable to the CITY. CITY shall approve in writing all such security instruments prior to the commencement of work on the Project. 6. Litigation History List any history of claims, litigation disputes, arbitration and/or termination for cause associated with any work contracted on any project in the past 5 years. If Contractor has no history of litigation, claims or disputes, please so state. Have you ever had a contract terminated for default within the past 5 years? No If yes, why and when: Yes Are there any judgments, claims, arbitration proceedings, or suits pending or outstanding against your organization? No Yes (If Yes, attach an explanation.) Has your organization filed any law suits, requested arbitrations or been involved in any litigation with regard to your contract activity within the last five years? If not applicable, check No. No Yes Comments: Are any of the above with the County of Napa or the City of Napa? No Yes 7. Bonding Requirements Attach a certified letter from your bonding company identifying the bonding rate per $1,000, the aggregate and single project bonding capacity of the company together with a list of all currently bonded projects together with their bond penal sum. At the time of bid submission, Contractor must be capable of providing cash, a certified or cashier's check, or a Contractor s bond for 10%of bid amount, not including any alternates. Prior to receiving a Notice to Proceed from the City, Contractor must provide Payment Bond for Public Works and Performance Bond.

18 PART C Page C-9 The "Payment Bond for Public Works shall be in an amount of one hundred percent (100%)of the Contract price as determined from the prices in the Bid Form, as specified in the Award, and shall inure to the benefit of persons performing labor or furnishing materials in connection with the Work of the proposed Contract. This bond shall be maintained in full force and effect until all Work under the Contract is completed and accepted by Owner, and until all claims for materials and labor have been paid. The Performance Bond shall be in an amount of one hundred percent (100%) of the Contract price as determined from the prices in the Bid Form, as specified in the Award, and shall be so conditioned as to insure the faithful performance by the Contractor of all Work under the contract. It shall also insure the replacing, or making acceptable, of any defective materials or faulty workmanship through the end of the guarantee period. Attach documentation from the Contractor's surety, identifying: 1. Name of bonding company/surety. 2. Name and address of agent. 3. a. (1) Whether it is a California admitted surety. (2) Whether it is listed in the current edition of the Federal Register. (3) Its A. M. Best Rating: A:V or better. (4) Its Standard and Poor Rating. OR b. It is an admitted surety insurer which complies with the provisions of the Code of Civil Procedure, Section OR c. It is a company of equal financial size and stability that is approved by the City 's Risk Manager. 4. The Contractor's total bonding capacity. 5. The Contractor's available bonding capacity. 6. The Contractor's bond rate. 8. Prevailing Wage Rate Requirements Pursuant to Labor Code Sections 1770, et seq., the Director of the Department of Industrial Relations has determined the general prevailing rate of wages in the City of Napa for each craft, classification or type of workman needed to execute the contract. The Director s schedule of prevailing rates is on file and open for inspection at the City of Napa, Department of Public Works, 1600 First Street, Napa, California. It shall be mandatory upon the Contractor and upon any Subcontractors under them, to pay not less than the said specific rates to all laborers, workers or mechanics employed by them on the execution of this contract. Describe any instances in which your organization has been fined, penalized or otherwise found to have violated any prevailing wage provisions within the last five (5) years.

19 9. Integrity Requirements PART C Page C-10 If any portion of his responsibility statement and questionnaire is found to have any intentionally misleading information or material discrepancies, the Contractor will be deemed disqualified. The Undersigned declares under penalty of perjury that all of the information submitted on and with this form is true and correct and that this Declaration was executed by an officer of the Company on the day of, 20. Signature Typed or Printed Name and Title Firm Name Address (for delivery of certified mail) City, State, and Zip Code Telephone Number Fax Number The following documents are attached to this Contractor s completed and submitted Responsibility Statement and Questionnaire. An X in the box indicates that the Contractor has attached the indicated documents to this form. List of key personnel and their resumes (required documents) Financial statements (required documents) Letter verifying EMR data (required documents) Evidence of insurance coverage (required documents) Explanation regarding judgments, claims, arbitration proceedings, or suits pending or outstanding against Contractor (if applicable) Bonding information (required documents)