FORM 1 RESPONDENT S CONTACT INFORMATION. The Respondent shall identify the contact information as described below.

Transcription

1 FORM 1 RESPONDENT S CONTACT INFORMATION The Respondent shall identify the contact information as described below. For solicitation purposes, the Respondent s contact person shall be: For contractual purposes, should the Respondent be awarded, the contact person shall be: Name Title Address Telephone Fax

2 FORM 2 - CERTIFICATION OF DRUG-FREE WORKPLACE PROGRAM Preference to businesses with drug-free workplace programs.--whenever two or more bids, proposals, or replies that are equal with respect to price, quality and service are received by the state or by any political subdivision for the procurement of commodities or contractual services, a bid, proposal or reply received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. In order to have a drug-free workplace program, a business shall: (1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. (2) Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. (3) Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1). (4) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than 5 days after such conviction. (5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, any employee who is so convicted. (6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. False statements are punishable at law. Respondent s Name: By: Authorized Signature Print Name and Title

3 FORM 3 - NOTICE OF CONFLICT OF INTEREST Company or Entity Name For the purpose of participating in the solicitation process and complying with the provisions of Chapter 112, of the Florida Statutes, the undersigned corporate officer states as follows: The persons listed below are corporate officers, directors or agents and are currently employees of the State of Florida or one of its agencies: The persons listed below are current State employees who own an interest of ten percent (10%) or more in the company/entity named above: Name of Respondent s Organization Signature of Authorized Representative and Date Print Name

4 FORM 4 - NON-COLLUSION AFFIDAVIT STATE OF COUNTY OF I state that I of, (Name and Title) (Name of Firm) am authorized to make this affidavit on behalf of my firm and its owner, directors and officers. I am the person responsible in my firm for the price(s) and amount(s) of this Response, and the preparation of the Response. I state that: 1. The price(s) and amount(s) of this Response have been arrived at independently and without consultation, communication or agreement with any other Provider, potential provider, Proposal, or potential Proposal. 2. Neither the price(s) nor the amount(s) of this Response, and neither the approximate price(s) nor approximate amount(s) of this Response, have been disclosed to any other firm or person who is a Provider, potential Provider, Proposal, or potential Proposal, and they will not be disclosed before Proposal opening. 3. No attempt has been made or will be made to induce any firm or persons to refrain from submitting a Response for this contract, or to submit a price(s) higher that the prices in this Response, or to submit any intentionally high or noncompetitive price(s) or other form of complementary Response. 4. The Response of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit a complementary or other noncompetitive Response. 5., its affiliates, subsidiaries, officers, director, and employees (Name of Firm) are not currently under investigation, by any governmental agency and have not in the last three years been convicted or found liable for any act prohibited by State or Federal law in any jurisdiction, involving conspiracy or collusion with respect to Proposal, on any public contract, except as follows: I state that I and the named firm understand and acknowledge that the above representations are material and important, and will be relied on by the State of Florida for which this Response is submitted. I understand and my firm understands that any misstatement in this affidavit is, and shall be treated as, fraudulent concealment from the State of Florida of the true facts relating to the submission of responses for this contract. Dated this day of Name of Organization: Signed by: Print Name being duly sworn deposes and says that the information herein is true and sufficiently complete so as not to be misleading. Subscribed and sworn before me this day of Notary Public: My Commission Expires:

5 FORM 5 - STATEMENT OF NO INVOLVEMENT I,, as an authorized representative of the aforementioned company, certify that no member of this firm nor any person having any interest in this firm has been involved with the Department of Management Services to assist it in: 1. Developing this solicitation; or, 2. Performing a feasibility study concerning the scope of work contained in this Invitation to Negotiate. Name of Respondent s Organization Signature of Authorized Representative and Date Print Name

6 FORM 6 SUBCONTRACTING The Respondent shall complete the information below on all subcontractors that shall provide services to the Respondent to meet the requirements of the resultant contract, should the Respondent be awarded. Submission of this form does not indicate the Department s approval, but provides the Department with information on proposed subcontractors for review. Please complete a separate form for each subcontractor. Service: Company Name: Contact: Address: Telephone: Current Registered as Certified Minority Business Enterprise (CMBE) or Women-Owned Business (WBE)? Yes No Federal Employer Identification Number (Employer ID or Federal Tax ID, FEID) Occupational License No: W-9 verification: Yes No In a job description format, describe below the responsibilities and duties of the subcontractor based on the technical specifications or scope of services outlined in this solicitation.

7 FORM 7 ADDENDUM ACKNOWLEDGEMENT FORM This acknowledgment form serves to confirm that the Respondent has reviewed, complied with and/or accepted all Addenda to the solicitation posted on the Vendor Bid System (VBS). Please list all Addenda below. Name of Respondent s Organization Signature of Authorized Representative and Date Print Name

8 FORM 8 BUSINESS/CORPORATE REFERENCE This form must be completed by the person giving the reference on the Respondent. For purposes of this form, the Respondent is the business entity that currently or has previously provided services to your organization, and is submitting a reply to a Florida competitive solicitation. Upon completion of this form, please return original to Respondent. Please use reverse or additional paper if needed. This business reference is for (Respondent s Name): Name of the person providing the reference: Title of person providing the reference: Name of organization person providing the reference works: 1. Please identify your relationship with the Respondent (e.g., customer, subcontractor, etc.). 2. How many years have you done business with the Respondent? a. Please provide dates: 3. If a customer, please describe the primary services the Respondent provides(ed) to your organization. 4. Did the Respondent act as a primary provider or as a subcontractor? 5. What is the number of participants and assets under management serviced by the Respondent? 6. Do you have a business, professional, or other interest in the Respondent s organization? If so, what is the interest? 7. What were the most common user complaints received during the time Respondent provided services to your organization? 8. Please describe your level of satisfaction with the services provided by Respondent. 9. Would you conduct business with the Respondent s organization again? 10. Are there any additional comments you would like to make regarding the Respondent s organization? Dated this day of Name of Organization: Signed by: Print Name Contact Information: RFP No. DMS 14/ Page 1 of 1

9 FORM 9 - PASS/FAIL CERTIFICATION Respondent shall complete and submit this FORM 9 Pass/Fail Certification as part of its proposal. FORM 9 shall be inserted prior to Tab 1 of the proposal. FAILURE TO COMPLETE FORM 9 AS PART OF THE RFP PROPOSAL WILL RESULT IN IMMEDIATE REJECTION OF THE RESPONDENT S PROPOSAL. ANY MODIFICATIONS TO THE PASS/FAIL CERTIFICATION WILL BE CONSIDERED MATERIAL AND WILL RESULT IN REJECTION OF THE PROPOSAL. Form 9 requires certification by the Respondent that: 1. I, the undersigned, certify that the person submitting the proposal is authorized to respond to this RFP on Respondent s behalf. 2. I, the undersigned, certify that Respondent is not a Discriminatory Vendor or Convicted Vendor as defined in sections 7 and 8 of the PUR ormation/convicted_suspended_discriminatory_complaints_vendor_lists/discrimi natory_vendor_list ormation/convicted_suspended_discriminatory_complaints_vendor_lists/convicte d_vendor_list 3. I, the undersigned, certify compliance with section 9 of the PUR I, the undersigned, certify that the Respondent is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List I, the undersigned, certify that Respondent is not on the Suspended Vendor List. ormation/convicted_suspended_discriminatory_complaints_vendor_lists/suspend ed_vendor_list. 6. I, the undersigned, certify that Respondent has provided defined contribution bundled retirement services to at least one 403(b) plan with at least 10,000 participants within the past five years and has a minimum of at least five years of experience as the provider of products and services of similar scope and size to those products and services described in this RFP for 403(b) and/or 401(a) government plans. Page 1 of 4

10 7. I, the undersigned, certify that Respondent has provided a group custodial agreement and/or unallocated group annuity contract, with control over contract termination and trust-to-trust transfer direction at the sole discretion of the Department with its responses to this RFP. Pursuant to the contract(s), the Department may or may not decide at some point in the future to transfer plan assets to another vendor and/or contract. (Attach the group custodial agreement and/or unallocated group annuity contract as a Word document in Response Tab 6). 8. I, the undersigned, if providing mutual funds, certify that Respondent will provide a participant self-directed brokerage window for SUSORP members to obtain mutual funds outside of the core investment line-up, that will be limited solely to mutual funds, and that will exclude the core line-up of mutual funds that will be offered to SUSORP members as a result of this RFP. 9. I, the undersigned, certify that Respondent agrees to work with multiple contacts at the Department, at each covered employer, and with other service providers to effectively implement the SUSORP and/or SMSOAP. 10. I, the undersigned, certify that Respondent agrees to administer the Department s 403(b) SUSORP plan in accordance with the custom Written Plan, Attachment 7 of the RFP. 11. I, the undersigned, certify that Respondent agrees to abide by section 31 of the PUR I, the undersigned, certify that Respondent agrees to exchange data in compliance with the Department s data file format(s), as may be amended from time to time, at no cost to the Department, including, formats listed in Attachment 8 of the RFP. 13. I, the undersigned, certify that Respondent agrees to accommodate excess contributions made to SUSORP members accounts in accordance with section 403(c) of the Internal Revenue Code. 14. I, the undersigned, certify that Respondent is registered with the Florida Department of State and has provided proof of their Florida Department of State registration. 15. I, the undersigned, certify that Respondent provided all of the requested information contained in Section 3.7 with its proposal to this RFP. 16. If chosen to provide group annuity products, I, the undersigned, certify that Respondent agrees to serve both the SUSORP and the SMSOAP plans without regard to plan size or participation levels. Page 2 of 4

11 17. At no cost to the Department or the employers, I, the undersigned, certify that Respondent agrees to provide a proportional share of a minimum of 1,164 visits per year depending upon number of vendors selected. Respondent s representatives will be available on one or more of the 12 state university campuses (see Attachment 9 for a list of locations) for face-to-face meetings with faculty and staff eligible to participate in the SUSORP and as needed for the participants of the SMSOAP. 18. I, the undersigned, if providing a mutual fund platform, certify that Respondent has provided either the preferred mutual fund line-up in Attachment 1, or if proposing an alternative mutual fund option, Respondent agrees to provide only one substitute mutual fund per asset class. Only mutual fund substitutes are permitted (i.e., no fixed annuity, or any other annuity vehicle, can be offered as a substitute). 19. I, the undersigned, if providing an annuity platform, certify that Respondent has provided an investment alternative in each of the required four asset classes listed in Attachment I, the undersigned, if proposing a substitute mutual fund product and/or an annuity product line-up, certify that Respondent will pay all costs associated with the State Board of Administration s review of Respondent s substituted investment product(s) as provided for in Section 3.7, Response Tab 6 of the RFP. 21. I, the undersigned, if providing an annuity platform, certify that Respondent has provided the lowest overall cost per variable annuity option, with Mortality and Expense (M&E) fees of less than one (1) basis point. 22. I, the undersigned, certify that the quoted per-participant fee provided in Attachment 3 is intended to fully cover the cost of providing recordkeeping, trust/custodial, and administrative services for the Program, and that no additional fees are being added to or included in the investment expenses to subsidize these costs (i.e., there are no wrap fees on the investments or inclusion of other fees to offset recordkeeping, trust/custodial, and administrative services). A per-participant fee of $0 will not be permitted. 23. I, the undersigned, certify that any revenue sharing or other funds received from the Program s investments related to recordkeeping, trust/custodial, and administrative expenses will be rebated to participants in accordance with procedures described in the response to Client Specific Question #25 in Attachment 5 and as agreed to by the Department. SIGNATURE PAGE IMMEDIATELY FOLLOWS Page 3 of 4

12 As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. Respondent s (FIRM) Name: By: Authorized Signature Print Name and Title Page 4 of 4