REQUEST FOR QUOTE SOLICITATION NO: #201-35076615 SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES BID DUE: May 19, 201 @ 12:00 P.M. RELEASE DATE: May 12, 201 RETURN BID TO ADDRESS BELOW: Superior Court of California County of Los Angeles Stanley Mosk Courthouse Purchasing/Contracts Administration 111 N. Hill St., Room 105-B Los Angeles, CA 90012 VENDOR (Name and Address below): CONTRACT ANALYST: Art Cuevas acuevas@lasuperiorcourt.org TELEPHONE: (213) 97-0085 FAX: (213) 625-8102 Bid Title: Hardware and Software Support for HP EVA00 SAN Infrastructure BIDS ARE DUE ON OR BEFORE THE DATE SPECIFIED ABOVE. LATE BIDS WILL NOT BE ACCEPTED. BIDS WILL BE VALID UNTIL SELECTION OF A VENDOR. I have read and understand and agree to the terms and conditions herewith, and I am submitting a bid in response to this solicitation. VENDOR S PHONE NUMBER: AUTHORIZED OFFICER S NAME AND TITLE: (PRINT) DATE: SIGNATURE OF VENDOR S AUTHORIZED OFFICER: (MUST BE SIGNED) RETURN THIS COVER PAGE WITH YOUR BID. 1
1.0 SUMMARY The purpose of this Request For Quote (hereinafter referred to as RFQ ) is to solicit Bids from one or more qualified companies (hereinafter referred to as Vendor ) so as to identify, select and recommend a Vendor to the Superior Court of California, County of Los Angeles (hereinafter referred to as COURT ) for the award of a Purchase Order to provide annual hardware and software maintenance for HP EVA00 SAN Infrastructure, beginning June 1, 201 and ending May 31, 2015 (hereinafter referred to as Service ). Interested and qualified Vendors who have demonstrated their ability to successfully provide the Service described in this RFQ are invited to submit Bids, provided they meet the requirements as set forth in Section.0 (Requirements) of this RFQ. A Purchase Order will be awarded to the Vendor who has met or surpassed the COURT S requirements and has submitted the lowest responsive and responsible Bid. 2.0 GENERAL CONDITIONS The COURT will accept Bids until the mentioned due date stated herein. All Bids must be completed on the Price Presentation Form provided in this RFQ. It is the sole responsibility of the Vendor to ensure that their Bid is received on time. The COURT reserves the right to reject any, and all Bids, or to waive any minor irregularities in this process. The COURT reserves the right to seek new Bids when such a procedure is reasonably in the best interest of the COURT to do so. Small Business owned and operated businesses are encouraged to participate in the submission process. 3.0 VENDOR REGISTRATION Vendors are required to register with the County of Los Angeles prior to responding to a solicitation and submitting a Bid to COURT and any Los Angeles County Department or Agency. Vendors can register online on the Los Angeles County Vendor Registration Web site at: http://camisvr.co.la.ca.us/webven Vendors are required to register with the Judicial Branch of California, Administrative Office of the Courts by submitting a Payee Data Record Form (Attachment ) attached to this RFQ. Once the form has been processed a State Vendor I.D. Number will be issued..0 REQUIREMENTS Please see the Specifications (Attachment 1) to this RFQ. It is the Vendor s sole responsibility to read the requirements in the Specifications. If the Vendor fails to meet all the requirements their Bid will be dismissed and deemed invalid. 5.0 SUBCONTRACTING If the Vendor responding to this RFQ decides to subcontract this service to another Vendor, it is the responsibility of the responding Vendor to make sure the Vendor they subcontract with meets all the requirements, terms and conditions and the Specifications of this RFQ. Vendor must submit the name of the person or Vendor and copy of all required documents with their Bid. Failure to do so will result in disqualification of the Bid. 2
6.0 COURT OPTION TO CANCEL, AMEND OR EXTEND RFQ COURT reserves the right to cancel, amend or extend this RFQ, in its sole discretion, at any time prior to approval of a purchase order by COURT. 7.0 KEY DATES This section provides information regarding important dates and deadlines. Release of RFQ...05/12/1 Questions/Request for Clarification Due... 05/15/1 COURT S Response Due...05/16/1 Bids Due...05/19/1 @12:00 p.m. PST 8.0 PAYMENT Full payment will be made upon receipt of a correct and proper invoice submitted to the COURT. 9.0 PAYMENT TERMS Payment terms are net 30 days from the date the invoice is received by the COURT. If there are any discounts being offered by the Vendor, please indicate on the invoice. 10.0 SPECIFICATIONS The Specifications are contained in Attachment 1 of this RFQ. It is the Vendors sole responsibility to read the Specifications in its entirety. 10.1 Overview of Work The COURT S, Court Technology Services ( CTS ) is soliciting bids for annual hardware and software maintenance for HP EVA00 SAN Infrastructure, as specified in the Specifications (Attachment 1). 10.2 Requirements Refer to the Specifications (Attachment 1) for Vendor and other requirements. 10.3 Deliverables 11.0 BID FORMAT Refer to Specifications (Attachment 1) for deliverables. IMPORTANT: BIDS MUST BE SUBMITTED IN THE FORMAT DESCRIBED BELOW, BOTH AS TO SEQUENCE AND CONTENT. FAILURE TO COMPLY WITH THESE PROVISIONS MAY, IN COURT S SOLE DISCRETION, RESULT IN DISQUALIFICATION OF THE BID. 3
11.1 Cover Page Vendor must fill-out, and an authorized principal of firm must sign, the RFQ cover page and submit with their Bid. The Vendor s Bid must start with the cover page. 11.2 Company History and Vendor Requirements 12.0 BID SUBMISSION After the Cover Page Vendor must provide a brief summary of the company s history and relevant background information to demonstrate that they meet the requirements of this RFQ and has the capability to provide the Service as a corporation or other entity. 12.1 Informed Bidders Before submitting Bids, Vendors must fully inform themselves of the requirements, and specifications, materials and services to be provided to COURT by fully reading this RFQ. Failure to do so will be at Vendor s own risk as they cannot secure relief on a plea of error. 12.2 Vendor must submit only one Bid. COURT will accept only one Bid per individual firm, partnership, or corporation under the same or different names. 12.3 The Bid itself may not be faxed, Vendor shall mail (one original and two copies of the Bid) or e-mail one original Bid in a Word or PDF file format to: Art Cuevas, Contract Analyst Superior Court of California County of Los Angeles Purchasing/Contracts Administration Stanley Mosk Courthouse 111 N. Hill Street, Room 105-B Los Angeles, CA 90012 acuevas@lasuperiorcourt.org 12. It is the sole responsibility of Vendor to see that the Bid is received by COURT before the submission deadline of 12:00 p.m. (PST) on May 19, 201. Submitting Vendors shall bear all risk associated with delays in the U.S. Mail and other delivery services. Any BIDS received after the BID Due Date will NOT be considered for review. 12.5 Mailed Bid documents shall be submitted in a sealed package, plainly marked in the upper left-hand corner with the name and address of Vendor, and the words: RFQ FOR ANNUAL HARDWARE & SOFTWARE MAINTENANCE FOR HP EVA00 12.6 Each Bid must observe all provisions of the RFQ in preparing their response. If the specifications in the RFQ are not followed, the Bid may be rejected. 12.7 Submission of a Bid shall constitute acknowledgment and acceptance of all the terms and conditions contained in this RFQ, unless otherwise specified.
13.0 SMALL BUSINESS PREFERENCE (OPTIONAL) 13.1 Qualification for the Small Business incentive is not mandatory. Failure to qualify for the Small Business incentive will not render a proposal non-responsive. 13.2 Vendor will receive a small business preference if, in the COURT S sole determination, Vendor has met all applicable requirements. If Vendor receives the small business preference, the dollar amount of its bid will be reduced (for evaluation purposes only) by an amount equal to 5% of the lowest responsible bid, not to exceed $50,000. Small business participation is not mandatory. Failure to qualify for the small business preference will not render a bid non-responsive. 13.3 To receive the small business preference, Vendor must be either (i) a Department of General Services ( DGS ) certified small business or microbusiness performing a commercially useful function, or (ii) a DGS-certified small business nonprofit veteran service agency. 13. If Vendor wishes to seek the small business preference, Vendor must complete and submit with its bid the Small Business Declaration (Attachment 3). Vendor must submit with the Small Business Declaration all materials required in the Small Business Declaration. 13.5 Failure to complete and submit the Small Business Declaration as required will result in Vendor not receiving the small business preference. In addition, the COURT may request additional written clarifying information. Failure to provide this information as requested will result in Vendor not receiving the small business preference. 13.6 If Vendor receives the small business preference, (i) Vendor will be required to complete a post-contract report; and (ii) failure to meet the small business commitment set forth in its bid will constitute a breach of contract. FRAUDULENT MISREPREPRETATION IN CONNECTION WITH THE SMALL BUSINESS PREFERNCE IS UNLAWFUL AND IS PUNISHABLE BY CIVIL PENALTIES. SEE GOVERNMENT CODE SECTION 182.5. 1.0 DISABLED VETERANS BUSINESS ENTERPRISE ( DVBE ) INCENTIVE (OPTIONAL) 1.1 Qualification for the DVBE incentive is not mandatory. Failure to qualify for the DVBE incentive will not render a proposal non-responsive. 1.2 Eligibility for and application of the DVBE incentive is governed by the COURT S DVBE Rules and Procedures. CONTRACTOR will receive a DVBE incentive if, in the COURT s sole determination, CONTRACTOR has met all applicable requirements. If CONTRACTOR receives the DVBE incentive, the dollar amount of its bid will be reduced (for evaluation purposes only) by an amount equal to 3% of the lowest responsible bid, not to exceed $50,000. 1.3 To receive the DVBE incentive, at least 3% of the contract goods and/or services must be provided by a DVBE performing a commercially useful function. Or, for solicitations of non- IT goods and IT goods and services, CONTRACTOR may have an approved Business Utilization Plan ( BUP ) on file with the California Department of General Services ( DGS ). 5
1. If CONTRACTOR wishes to seek the DVBE incentive: 1. CONTRACTOR must complete and submit with its proposal the Bidder Declaration (Attachment 3). CONTRACTOR must submit with the Bidder Declaration all materials required in the Bidder Declaration. 2. CONTRACTOR must submit with its proposal a DVBE Declaration (Attachment 2) completed and signed by each DVBE that will provide goods and/or services in connection with the contract. If CONTRACTOR is itself a DVBE, it must complete and sign the DVBE Declaration. If CONTRACTOR will use DVBE subcontractors, each DVBE subcontractor must complete and sign a DVBE Declaration. NOTE: The DVBE Declaration is not required if CONTRACTOR will qualify for the DVBE incentive using a BUP on file with DGS. 1.5 Failure to complete and submit these forms as required will result in CONTRACTOR not receiving the DVBE incentive. In addition, the COURT may request additional written clarifying information. Failure to provide this information as requested will result in CONTRACTOR not receiving the DVBE incentive. 1.6 If this solicitation is for IT goods and services, the application of the DVBE incentive may be affected by application of the small business preference. For additional information, see the COURT s Small Business Preference Procedures for the Procurement of Information Technology Goods and Services. 1.7 If CONTRACTOR receives the DVBE incentive: (i) CONTRACTOR will be required to complete a post-contract DVBE certification if DVBE subcontractors are used; (ii) CONTRACTOR must use any DVBE subcontractor(s) identified in its proposal unless the COURT approves in writing the substitution of another DVBE; and (iii) failure to meet the DVBE commitment set forth in its proposal will constitute a breach of contract. FRAUDULENT MISREPREPRETATION IN CONNECTION WITH THE DVBE INCENTIVE IS A MISDEMEANOR AND IS PUNISHABLE BY IMPRISONMENT OR FINE, AND VIOLATORS ARE LIABLE FOR CIVIL PENALTIES. SEE MIL. & VET. CODE 999.9. 15.0 QUESTIONS/REQUEST FOR CLARIFICATION CONTRACTORS may submit written questions or request clarification regarding this RFQ by e- mail to the Contract Analyst identified below. All questions, without identifying the submitting company, will be compiled with the appropriate answers and issued as an addendum to the RFQ. Questions or request for clarification should be addressed to: Art Cuevas, Contract Analyst Superior Court of California, County of Los Angeles Purchasing/Contracts Administration Stanley Mosk Courthouse 111 N. Hill Street, Room 105-B Los Angeles, CA 90012 acuevas@lasuperiorcourt.org 6
ATTACHMENT 1 - SPECIFICATIONS Technical Specifications for Storage Area Network Maintenance Contract on Hewlett Packard EVA 00 Los Angeles Superior Court, Court Technology Services 111 N. Hill St Room 25A10 Los Angeles CA 90012 213-97-6366 Contact: Edwin Carrero 213-97-6366 ECarrero@LASuperiorcourt.org --------------------------------------------------------------------------------------------------------------------------------------- MODEL# ITEM DESCRIPTION QTY. S/N S/N S/N S/N HP EVA00 SAN Infrastructure Note: All services to be performed directly by Hewlett Packard. Defective Media Retention Option for All Hard Drives Coverage: 2x7 -hour response for all hardware & software of all contents listed below. Duration: From 06/01/1 to 05/31/15 HA10AC HA107AC HA151AC HP Coverage Type HP -hr 2x7 Hardware Support HP Software 7x2 Support HP Hardware Maintenance Onsite Support HA156AC HP Software Updates Service HA158AC HP Software Technical Unlimited Support UJ559AC UC255AC HP Storage - Return to Hardware Support HP Software Updates - Return to Support AG805C AG638B Original EVA00 (w/8 00GB FC drives) HP EVA00 Dual Cntrl Array w/switch HP M612-A Fibre Channel Drive Enclosure HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive 1 SGA926037Z SGA925005R SGA9200Y6 SGA925005A SGA925005B SGS92706B SGS9270FX SGS9270C8 SGS9270GH SGS92703V1 SGS92709Y SGS927063 SGS9270G3 SGS92703UZ SGS9270GJ SGS9270G8 SGS9270EY SGS927036C SGS9270FT SGS9270GK SGS9270CC SGS9270G0 SGS927096 SGS92705W SGS9270G6 SGS9270R SGS9270GA SGS92701S SGS9270EX SGS9270BD SGS9270EF SGS9270G1 SGS92703D
HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive HP EVA M612A 00GB 10K FC Drive 252663-D72 Mod PDU 2A HV NA/JPN AF002A HP Universal Rack 1062 G2 Shock ALL AF062A HP 10K G2 600mm Stabilizer Kit AF05A HP 1062G2 Side panel ALL 2 1 1 1 SGS9270AV SGS927029 SGS9270FY SGS9270A9 SGS92703VR SGS9270AW SGS9270G9 SGS9270C9 SGS92709K SGS92708C SGS92703S SGS9270A0 SGS9270G2 SGS9270FJ SGS92703H SGS9270F0 SGS9270BY SGS9270GN SGS92706 SGS9270FU CN0851151 CN0851157 USE928PD7S AG638B -shelf Upgrade to EVA00 (w/8+2 spare 600GB FC drives) HP M612-A Fiber Channel Drive Enclosure HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive HP EVA M612A 600GB 10K FC Drive 2 SGA93025S SGA93026D SGA93028D SGA93028C SGS9008BP SGS9008L6 SGS910KJ3 SGS910KJV SGS9008LJ SGS9008FV SGS910KJW SGS910JSZ SGS9008A9 SGS9008FH SGS910KMS SGS910JR2 SGS9008D3 SGS90088M SGS910JT7 SGS910JY9 SGS9008K5 SGS9008CP SGS910K8Z SGS910JS5 SGS9008GL SGS9008HN SGS910KJJ SGS910JRX SGS9008G8 SGS910K73 SGS910JRM SGS910K91 SGS90088J SGS910KJH SGS910KJX SGS910KMT SGS9008HE SGS910JMP SGS910KJM SGS910JT2 SGS9008AG SGS910K9M SGS910K92 SGS910JT0 SGS9008GJ SGS910KEC SGS910K15 SGS910KJY SGS9008FT SGS910JSV SGS910KJF SGS910K98 SGS910K9L SGS910JSW TOTAL COST FOR THE ONE-YEAR TERM: $
ATTACHMENT 2 - SMALL BUSINESS DECLARATION Complete this form only if Bidder will claim the small business preference associated with this solicitation. Please review the Small Business Declaration Instructions before completing this form. If Bidder submits incomplete or inaccurate information, it will not receive the small business preference. SECTION I. COMPLETE IF BIDDER IS A SMALL BUSINESS If Bidder is not a Small Business, skip this section. 1. DGS Supplier ID number: 2. Small Business Certification active from to 3. Will Bidder subcontract any portion of the contract work to subcontractors? If yes: A. State the percentage of the contract work Bidder will subcontract: B. Describe the goods and/or services to be provided by Bidder itself in connection with the contract: C. Explain how Bidder is performing a commercially useful function for purposes of this contract. (Please see the instructions for the definition of commercially useful function. ). Bidder must submit a copy of its Small Business certification approval letter along with this declaration. SECTION II. COMPLETE IF BIDDER IS A NON-PROFIT VETERAN SERVICE AGENCY (NVSA) If Bidder is not an NVSA, skip this section. 1. DGS Supplier ID number: 2. NVSA Certification active from to 3. Bidder must submit a copy of its NVSA certification approval letter along with this declaration. 2
SMALL BUSINESS DECLARATION (cont.) SECTION III. CERTIFICATION I, the official named below, certify under penalty of perjury that the information provided in this form is true and correct. I am duly authorized to legally bind Bidder to this certification. This certification is made under the laws of the State of California. Company Name (Printed) Address Tax ID Number Telephone Number By (Authorized Signature) Printed Name and Title of Person Signing Date Executed Executed in the County of in the State of 3
SMALL BUSINESS DECLARATION INSTRUCTIONS General Instructions In this form, (i) DGS refers to the Department of General Services, (ii) Small Business refers to an entity certified by DGS as a small business or a microbusiness, (iii) Bidder refers to a person or entity that submits a response to a competitive solicitation issued by the JBE, including both IFBs and RFPs; and (iv) bid refers to a response to a competitive solicitation issued by the JBE, including both IFBs and RFPs. If Bidder will claim the small business preference in a solicitation where a small business preference is offered, it must complete the Small Business Declaration. If no small business preference is offered, or Bidder does not claim the small business preference, Bidder should not complete the Small Business Declaration. The JBE will determine whether Bidder is eligible to receive the small business preference based on information provided in the Small Business Declaration. The JBE may, but is not obligated to, verify or seek clarification of any information set forth in the Small Business Declaration. If Bidder submits incomplete or inaccurate information, it will not receive the small business preference. Instructions for Section I Skip this section if Bidder is not itself a Small Business. 1. Provide Bidder s DGS Supplier ID number. This number is in Bidder s DGS Supplier Profile, accessible at www.bidsync.com/dpxbiscasb. 2. Provide the applicable dates. These dates are listed in Bidder s DGS Supplier Profile, accessible at www.bidsync.com/dpxbiscasb. 3. If Bidder will subcontract any portion of the contract work, answer yes and complete subparts A-C. If Bidder will not subcontract any portion of the contract work, answer no and skip subparts A-C. Subpart A: This percentage is equal to the amount to be paid by Bidder to all subcontractors divided by Bidder s total bid price, multiplied by 100. Enter a percentage; do not enter a dollar amount. For example, if the amount to be paid by Bidder to subcontractors is $35,000 and Bidder s total bid price is $125,000, enter 28% (35,000 125,000 = 0.28; 0.28 x 100 = 28). Subpart B: Provide a detailed description of the goods and/or services the Bidder itself will provide for the contract. In other words, provide a detailed description of the goods and/or services that will not be subcontracted. Attach additional sheets if necessary. Subpart C: Provide an explanation of how the Bidder s goods and/or services constitute a commercially useful function for purposes of the contract. Pursuant to Government Code section 1837, a business is deemed to perform a commercially useful function if the business does all of the following: (i) is responsible for the execution of a distinct element of the work of the contract; (ii) carries out its obligation by actually performing, managing, or supervising the work involved; (iii) performs work that is normal for its business services and functions; (iv) is responsible, with respect to products, inventories, materials, and supplies required for the contract, for negotiating price, determining quality and quantity, ordering, installing, if applicable, and making payment; and (v) is not further subcontracting a portion of the work that is greater than that expected to be subcontracted by normal industry practices. Note: a business will not be considered to perform a commercially useful function if its role is limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of Small Business participation. Attach additional sheets if necessary.
SMALL BUSINESS DECLARATION INSTRUCTIONS (cont.). Each entity certified as a Small Business by DGS will have received a Small Business certification approval letter. Bidder must submit a copy of its Small Business certification approval letter. Instructions for Section II Skip this section if Bidder is not an NVSA. 1. Provide Bidder s DGS Supplier ID number. This number is in Bidder s DGS Supplier Profile, accessible at www.bidsync.com/dpxbiscasb. 2. Provide the applicable dates. These dates are listed in Bidder s DGS Supplier Profile, accessible at www.bidsync.com/dpxbiscasb. 3. Each entity certified as an NVSA by DGS will have received a certification approval letter. Bidder must submit a copy of its certification approval letter. Instructions for Section III Provide Bidder s full legal name, tax ID number, address, and telephone number in the appropriate boxes. The certification must be signed by an authorized Bidder representative in the box labeled By (Authorized Signature). Provide the name and title of the authorized Bidder representative, and the date, county, and state where that person signed the certification, in the appropriate boxes. 5
SECTION 1. MUST BE COMPLETED BY ALL DVBEs ATTACHMENT 3 - DVBE DECLARATION Disabled Veteran Business Enterprise (DVBE) name: DGS Supplier ID number: SECTION 2. MUST BE COMPLETED BY ALL DVBEs Check only one box in Section 2 and provide original signatures of all disabled veteran (DV) owners and managers of the DVBE. I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code (MVC) section 999.2(b), of the goods and/or services provided by the DVBE in connection with the solicitation identified above. Pursuant to MVC 999.2(f), I (we) declare that the DVBE is a broker or agent for the following principal. (attach additional sheets if more than one principal) Principal Name: Principal Phone: Principal Address: Disabled veteran owners and managers of the DVBE: (attach additional sheets if necessary) Printed Name of DV owner/manager Date signed Signature of DV owner/manager Printed Name of DV owner/manager Date signed Signature of DV owner/manager Printed Name of DV owner/manager Date signed Signature of DV owner/manager 6
SECTION 3. MUST BE COMPLETED BY DVBEs THAT PROVIDE RENTAL EQUIPMENT AND ARE NOT BROKERS/AGENTS Skip this section if (i) the DVBE is not providing rental equipment or (ii) the DVBE indicated in Section 2 that it is a broker or agent. Check applicable boxes below 3 and provide original signatures of all DV owners and managers of the DVBE. Pursuant to MVC 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with MVC 999 et seq. The undersigned owner(s) own(s) at least 51% of the quantity and value of each piece of equipment that will be rented in connection with this solicitation. I (we), the DV owner(s) of the equipment, have submitted to DGS my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in MVC 999.2 (c) and (g). Disabled veteran owners of the DVBE: (attach additional sheets if necessary) Printed Name of DV owner Tax ID Number of DV owner Address of DV owner Signature of DV owner DV owner Telephone Number Date signed Printed Name of DV owner Address of DV owner Signature of DV owner Tax ID Number of DV owner Telephone # of DV owner Date signed Disabled veteran managers of the DVBE: (attach additional sheets if necessary) Printed Name of DV manager Date signed Signature of DV manager Printed Name of DV manager Date signed Signature of DV manager 7
DVBE DECLARATION INSTRUCTIONS General Instructions In this form, (i) DGS refers to the Department of General Services; (ii) Bidder refers to a person or entity that submits a response to a competitive solicitation issued by the JBE, including both IFBs and RFPs; and (iii) bid refers to a response to a competitive solicitation issued by the JBE, including both IFBs and RFPs. If Bidder wishes to claim the DVBE incentive in a solicitation where a DVBE incentive is offered, it must submit a DVBE Declaration completed by each DVBE that will provide goods and/or services in connection with its bid. If Bidder is itself a DVBE, it must complete the DVBE Declaration itself. If Bidder will use one or more DVBE subcontractors, each DVBE subcontractor must complete a DVBE Declaration. If no DVBE incentive is offered, or Bidder does not wish to claim the DVBE incentive, Bidder should not submit a DVBE Declaration. In addition, if Bidder wishes to claim the DVBE incentive using a DVBE Business Utilization Plan (BUP) on file with DGS, Bidder should not submit a DVBE Declaration. Note that a BUP cannot be used to qualify for the DVBE incentive in a non-it services solicitation. The JBE will determine whether Bidder is eligible to receive the DVBE incentive based on information provided in the DVBE Declaration. The JBE may, but is not obligated to, verify or seek clarification of any information set forth in the DVBE Declaration. If Bidder submits incomplete or inaccurate information, it will not receive the DVBE incentive. Instructions for Section 1 Provide the full legal name of the DVBE, and its DGS Supplier ID number. This number is in the DVBE s DGS Supplier Profile, accessible at www.bidsync.com/dpxbiscasb. Instructions for Section 2 Check only one box. If the DVBE is not a broker or agent, check the first box. If the DVBE is a broker or agent, check the second box and provide the name, address, and phone number of the principal for which the DVBE is an agent or broker. Military and Veterans Code section 999.2(b) defines broker or agent as an individual or entity that does not have title, possession, control, and risk of loss of materials, supplies, services, or equipment provided to [a JBE], unless one or more of the disabled veteran owners has at least 51-percent ownership of the quantity and value of the materials, supplies, services, and of each piece of equipment provided under the contract. All disabled veteran owners and managers of the DVBE must sign and date Section 2. If there are insufficient signature blocks for all disabled veteran owners and managers to sign, attach additional sheets. Instructions for Section 3 The DVBE must complete Section 3 only if both of the following are true (i) the DVBE will provide rental equipment in connection with the contract, and (ii) the DVBE checked the first box in Section 2, indicating that it is not a broker or agent. If (i) the DVBE will not provide rental equipment in connection with the contract, or (ii) the DVBE checked the second box in Section 2, indicating that it is a broker or agent, the DVBE should not check a box in Section 3 or provide the signatures in Section 3. Check each box in Section 3 if the corresponding statement is true. All disabled veteran owners of the DVBE must sign and date Section 3, in the signature blocks designated for disabled veteran owners. Each disabled veteran owner of the DVBE must also provide his or her tax ID number, address, and telephone number in the signature block. If there are insufficient signature blocks for all disabled veteran owners, attach additional sheets. All disabled veteran managers of the DVBE must sign and date Section 3, in the signature blocks designated for disabled veteran managers. If there are insufficient signature blocks for all disabled veteran managers, attach additional sheets. 8
ATTACHMENT DATA PAYEE DATA RECORD FORM FOLLOWS 9
1 Instructions PAYEE DATA RECORD (in lieu of IRS W-9) Required in lieu of IRS W-9 form when receiving payments from the Judicial Council of California - Administrative Office of the Courts (AOC) on behalf of the Superior Courts of California See page two for additional instructional information and Privacy Statement. Complete all information on this form, sign, date, and return the form. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in this form will be used to prepare Information Returns (1099). If this form was provided to you by one of the Superior Courts of California, return the form to the court. If this form was provided to you by the Judicial Council of California - Administrative Office of the Courts, submit the completed form to TCAFS.VendorRequest@jud.ca.gov or mail the form to the following address: Judicial Council of California - Administrative Office of the Courts Trial Court Administrative Services Division Vendor Maintenance Unit P.O. Box 981268 West Sacramento, CA 95798 SECTIONS 2 THRU 5 TO BE COMPLETED BY VENDOR PAYEE'S LEGAL NAME - AS SHOWN ON FEDERAL INCOME TAX RETURN 2 Legal Name BUSINESS NAME - IF DIFFERENT FROM ABOVE REMITTANCE MAILING ADDRESS CITY, STATE, ZIP CODE, PHONE NUMBER E-MAIL ADDRESS BUSINESS ADDRESS (if different from remittance mailing address) CITY, STATE, ZIP CODE, FACSIMILE NUMBER 3 Payee Entity Type Complete One Box Only NOTE A taxpayer identification number is required Resident Status check the appropriate box 5 Certification NOTE See instructions on page 2 Vendor Contact Information and signature ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) - PARTNERSHIP CORPORATION EXEMPT (NON-PROFIT) LIMITED LIABILITY COMPANY CORPORATION LEGAL GOVERNMENT CORPORATION MEDICAL OTHER ESTATE OR TRUST INDIVIDUAL/SOLE PROPRIETOR ENTER SOCIAL SECURITY NUMBER (SSN) - - If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN; however, the IRS prefers that you use your SSN. An employee vendor is not required to provide a SSN. California Resident - Qualified to do business in California or maintains place of business California Nonresident (see reverse side) - Payments to non-resident for services may be subject to State Income Tax withholding. No services performed in California Copy of Franchise Tax Board waiver of State Withholding attached Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person, as defined by the IRS. I hereby certify under the penalty of perjury that the information provided on this document is true and correct. Should my information change, I will promptly notify the AOC at the address listed in Section 1. VENDOR REPRESENTATIVE'S NAME (Type or Print) TITLE E-MAIL AUTHORIZED VENDOR SIGNATURE DATE TELEPHONE 6 Vendor Category Court Contact Assigned Vendor Number SECTION 6 TO BE COMPLETED BY COURT Please choose from the AOC Vendor category below to help us expedite payment ARBITRATOR VOLUNTEER OTHER (description required) CONTRACTOR GRAND JURY RENT COURT APPT. COUNSEL INTEREST PAYMENTS ONLY DECEASED FINAL PAYMENT COURT REPORTER COURT INTERPRETER: (indicate language) EMPLOYEE MEDIATOR GARNISHMENT TRUSTEE PAYMENT TERMS COURT CONTACT NAME PHONE NUMBER EMAIL FOR AOC USE ONLY (Form updated 02/01/2013) Assigned By:
Requirement to Complete Payee Data Record A completed Payee Data Record (in lieu of the IRS W-9) is required for payments and will be kept on file at the Judicial Council of California - Administrative Office of the Courts, Trial Court Administrative Services Division. Since each state agency with which you do business must have a separate Payee Data Record on file, it is possible for a payee to receive a similar form from various state agencies. SECTIONS 2 THRU 5 TO BE FILLED OUT BY VENDOR Enter the payee s legal name. Sole proprietorships must also include the owner s full name. 2 3 5 6 An individual must list his/her legal name as it appears on his/her Federal Income tax return. If a different name is used, that name should also be entered, beneath the legal name. The mailing address should be the address at which the payee chooses to receive correspondence. The business address is the physical location of business, if different than mailing address. The phone number, e-mail address, and facsimile number should also be provided. Check the box that corresponds to the payee business type. Check only one box. Corporations must check the box that identifies the type of corporation. The State of California requires that all parties entering into business transactions that may lead to payment(s) from the State provide their Taxpayer Identification Number (TIN). The TIN is required by the California Revenue and Taxation Code Section 1866 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other information returns as required by the Internal Revenue Code Section 6109(a). The TIN for individuals is their Social Security Number (SSN). A sole proprietor may have both a Federal Employer Identification Number (FEIN) and a SSN, the IRS prefers that sole proprietors user their SSN. Only partnerships, estates, trusts, and corporations will enter their FEIN. Are you a California resident or non-resident? A corporation will be defined as a resident if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California. A partnership is considered a resident partnership if it has a permanent place of business in California. An estate is a resident if the decedent was a California resident at the time of death. A trust is a resident if at least one trustee is a California resident. For individuals and sole proprietors, the term resident includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a non-resident. Payments to all non-residents may be subject to withholding. Non-resident payees performing services in California or receiving rent, lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments withheld for State income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the calendar year. For information on Non-resident Withholding, contact the Franchise Tax Board at the numbers listed below: Withholding Services and Compliance Section: 1-888-792-900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov This form must be signed. Provide the name, title, e-mail, and telephone number of the individual completing this form. Also, provide the date the form was completed. Certification Instructions: You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. If you are not a U.S. Citizen or U.S. person, as defined by the Internal Revenue Service, a different form may be required and tax withholdings may apply. See IRS website http://www.irs.gov/businesses/international/index.html for additional information. SECTION 6 TO BE FILLED OUT BY COURT Please check the box that best describes the type of business/work the vendor provides. This will assist us in processing payment and tax withholdings. If the court is sending the request, please include contact information to assist with processing your request. Not including court contact information may delay processing the request. Privacy Statement: Section 7(b) of the Privacy Act of 197 (Public Law 93-579) requires that any federal, State, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and State law imposes non-compliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise the right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.