RFQ TIA PROJECT # SGRC-081, PI# 0016244 SWE PROJECT # 21-3349-B

CITY OF DOUGLAS

302 S. Madison Ave

DOUGLAS, GEORGIA 31533

(912) 389-3463 Phone

(912) 384-5076 Fax

afolsom@cityofdouglasga.gov

Page 01: Statement of No Bid

Page 02: Company Information

Page 03: Insurance Specifications

Page 04: Private Employer Affidavit

Page 05: Certification of "No Employees"

Page 06: Georgia Security and Immigration Compliance Act

Page 09: Appendix A

Page 11: Hold Harmless Agreement

Page 12: E-Verify

Page 13: W-9

COMPANY INFORMATION

Company Name: ____________________________________________

Address: ___________________________________________________

City, State, Zip: _____________________________________________

Phone: ____________________________________________________

Fax: ______________________________________________________

Email: _____________________________________________________

Rep. Printed Name: __________________________________________

(Type or Print Legibly)

Rep. Signature/Title: _________________________________________

Tax ID#: ____________________ or SS # ______________________

CITY OF DOUGLAS, GA

REFERENCE SHEET

NAME: _________________________________ PHONE: _____________________

NAME: _________________________________ PHONE: _____________________

NAME: _________________________________ PHONE: _____________________

INSURANCE SPECIFICATIONS PAGE:

Insurance is required on projects being done on City property as specified on the Request for Quote unless waived by City of Douglas. A Certificate of Insurance made out to City of Douglas must be furnished before any work can begin.

Please provide the following information.

Liability Insurance coverage*:

Bodily Injury $_____________________________________________________

(Minimum $1,000,000. required)

Property Damage $__________________________________________________

(Minimum $1,000,000. required)

Workman's Compensation $___________________________________________

(Statutory coverage as required by the State of Georgia.)

*Liability coverage must be provided to include premises, operations, products and completed operations.

* Subcontractors - It shall be the responsibility of the selected bidder to ensure that all

subcontractors comply with the same insurance requirements referenced above.

Private Employer Affidavit Pursuant To O.C.G.A. 36-60-6(d)

By executing this affidavit under oath, the undersigned private employer verifies one of the following with respect to its application for a business license, occupational tax certificate, or other document required to operate a business as referenced in O.C.G.A. 36-60-6(d):

Section 1. Please check only one:

(A) ________ On January 1st of the below-signed year, the individual, firm, or corporation employed more than ten (10) employees.

*** If you select Section 1(A), please fill out Section 2 and then execute below.

(B) ________ On January 1st of the below-signed year, the individual, firm, or corporation employed ten (10) or fewer employees.

*** If you select Section 1(B), please skip Section 2 and execute below.

Section 2.

The employer has registered with and utilizes the federal work authorization program in accordance with the applicable provisions and deadlines established in O.C.G.A. 36-60-6. The undersigned private employer also attests that its federal work authorization user identification number and date of authorization are as follows:

__________________________________

Name of Private Employer

__________________________________

Federal Work Authorization User Identification Number

__________________________________ Date of Authorization

---------------------------------------------------------------------------------------------------------------------

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on ______, ___, 20___ in _____ (city), ______ (state).

__________________________________

Signature of Authorized Officer or Agent

__________________________________

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE ______ DAY OF ______________, 20___. _______________________________________________ NOTARY PUBLIC

My Commission Expires: __________________________

Certification of "No Employees" under O.C.G.A. 13-10-91(b)(5)

By signing this form, the undersigned contractor verifies it has no employees and has no plans to hire employees for the purpose of executing the contract (named below) for the Georgia Department of Audits and Accounts. The contractor agrees to provide the Georgia Department of Audits and Accounts with a copy of a state issued driver's license or a state issued identification card as proof that he/she is authorized to perform the work related to this contract. Failure to submit this signed statement and/or provide the required license or identification card would prohibit the Georgia Department of Audits and Accounts from acquiring any additional or future services with you or your company.

Name of Contractor

Name of Project/Contract

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on __________, _____, 20__ in _______________(city), _____(state).

___________________________________ Signature of Authorized Officer or Agent ___________________________________ Printed Name and Title of Authorized Officer or Agent

Reminder: Copy of Driver's License Required

SECURITY AND IMMIGRATION COMPLIANCE

Contractor Affidavit under O.C.G.A. 13-10-91(b) (1)

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of GEORGIA DEPARTMENT OF HUMAN SERVICES has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. 13-10-91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

_____________________________________

Federal Work Authorization User Identification Number

_____________________________________

Date of Authorization

_________________________________

Name of Contractor

_____________________________________

Name of Project

GEORGIA DEPARTMENT OF HUMAN SERVICES

Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

_________________________________

Signature of Authorized Officer or Agent

__________________________________

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE DAY OF , 20 .

_________________________________

NOTARY PUBLIC My Commission Expires:

_________________________________

SECURITY AND IMMIGRATION COMPLIANCE

Subcontractor Affidavit under O.C.G.A. 13-10-91(b) (3)

By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with on behalf of GEORGIA DEPARTMENT OF HUMAN SERVICES has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. 13-10-91. Furthermore, the undersigned subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned subcontractor will contract for the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the subcontractor with the information required by O.C.G.A. 13-10-91(b). Additionally, the undersigned subcontractor will forward notice of the receipt of an affidavit from a sub-subcontractor to the contractor within five business days of receipt. If the undersigned subcontractor receives notice that a sub-subcontractor has received an affidavit from any other contracted sub-subcontractor, the undersigned subcontractor must forward, within five business days of receipt, a copy of the notice to the contractor. Subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

_________________________________

Federal Work Authorization User Identification Number

_________________________________

Date of Authorization

_________________________________

Name of Subcontractor

_________________________________

Name of Project

_________________________________

Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on ___________________, 20_____ in (city), (state).

_________________________________

Signature of Authorized Officer or Agent

_______________________________

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE DAY OF , 20 .

_________________________________

NOTARY PUBLIC

My Commission Expires:

_________________________________

SECURITY AND IMMIGRATION COMPLIANCE

Sub-subcontractor Affidavit under O.C.G.A. 13-10-91(b) (4)

By executing this affidavit, the undersigned sub-subcontractor verifies its compliance with O.C.G.A. 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract for (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract) and

_____________________________________________ on behalf of GEORGIA DEPARTMENT OF HUMAN

SERVICES has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. 13-10-91. Furthermore, the undersigned sub-subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned sub-subcontractor will contract for the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the sub-subcontractor with the information required by O.C.G.A. 13-10-91(b). The undersigned sub-subcontractor shall submit, at the time of such contract, this affidavit to (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract). Additionally, the undersigned sub-subcontractor will forward notice of the receipt of any affidavit from a sub-subcontractor to (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract). Sub-subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows: _________________________________

Federal Work Authorization User Identification Number

_________________________________

Date of Authorization

_________________________________

Name of Sub-subcontractor

_________________________________

Name of Project

_________________________________

Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

_________________________________

Signature of Authorized Officer or Agent

_______________________________

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE DAY OF , 20 .

_________________________________

NOTARY PUBLIC My Commission Expires: _________________________________

Appendix A

During the performance of this contract, the contractor/consultant, for itself, its assignees and successors in interest (hereinafter referred to as the "contractor") agrees as follows:

Compliance with Regulations

The contractor shall comply with the Regulations relative to non-discrimination in federally assisted programs of United States Department of Transportation (USDOT), Title 49, Code of Federal Regulations, part 21, as they may be amended from time to time, (hereinafter referred to as the Regulations), which are herein incorporated by reference and made a part of this contract.

Non-discrimination

The contractor, with regard to the work performed by it during the contract, shall not discriminate on the grounds of race, color, sex, or national origin in the selection and retention of sub-contractors, including procurement of materials and leases of equipment. The contractor shall not participate either directly or indirectly in the discrimination prohibited by Section 21.5 of the Regulations, including employment practices when the contract covers a program set forth in Appendix B of the Regulations.

Solicitations for Sub-contracts, Including Procurement of Materials and Equipment

In all solicitations either by competitive bidding or negotiations made by the contractor for work to be performed under a sub-contract, including procurement of materials or leases of equipment, each potential sub-contractor or supplier shall be notified by the contractor of the contractor's obligations under this contract and the Regulations relative to nondiscrimination on the grounds of race, color, sex, or national origin.

Information and Reports

The contractor shall provide all information and reports required by the Regulations or directives issued pursuant thereto, and shall permit access to its books, records, accounts, other sources of information, and its facilities as may be determined by the contracting agency or the appropriate federal agency to be pertinent to ascertain compliance with such Regulations, orders and instructions. Where any information required of a contractor is in the exclusive possession of another who fails or refuses to furnish this information, the contractor shall so certify to GDOT or the USDOT as appropriate, and shall set forth what efforts it has made to obtain the information

Sanctions for Non-compliance

In the event of the contractor's non-compliance with the non-discrimination provisions of this contract, the contracting agency shall impose such contract sanctions as it or the USDOT may determine to be appropriate, including, but not limited to:

With holding payments to the contractor under the contract until the contractor complies, and/or;

Cancellation, termination, or suspension of the contract, in whole or in part

Incorporation of Provisions

The contractor shall include the provisions of paragraphs (1) through (5) in every sub-contract, including procurement of materials and leases of equipment, unless exempt by the Regulations, or directives issued pursuant thereto. The contractor shall take such action with respect to any sub-contractor or procurement as the contracting agency or USDOT may direct as a means of enforcing such provisions including sanctions for noncompliance.

Provided, however, that in the event a contractor becomes involved in, or is threatened with, litigation with a sub-contractor or supplier as a result of such direction, the contractor may request GDOT enter into such litigation to protect the interests of the state and, in addition, the contractor may request the USDOT enter into such litigation to protect the interests of the United States.

HOLD HARMLESS AGREEMENT

This Hold Harmless Agreement entered into on this the day of ,

20 , by and between and the City of , a

Municipal Corporation.

WITNESSETH: That the undersigned hereby assumes all risk of liability, for his self and anyone with him while on City property, and agrees to hold harmless the City of Douglas from any negligence or injury resulting from the undersigned providing services to the City of Douglas.

It is understood by the undersigned that the undersigned is considered an independent contractor and is responsible for compliance to workers compensation insurance coverage applicable to the undersigned and should the undersigned or any employee or third person be injured or incur any loss as a result of the performance of the services, then the undersigned agrees to hold the City of Douglas harmless from any and all liability.

In Witness Thereof, the parties have affixed their hands and set their seals this day and year first above written.

THE CITY OF

BY:

Contractor

WITNESS:

NOTARY

To ENROLL LINK http://www.uscis.uov/e-vcrify

CONTRACTOR AFFIDAVIT AND AGREEMENT

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. 13-10-91, stating affirmatively that the individual, firm, or corporation which is contracting with

(Name of public employer) has registered with and is participating in a federal work authorization

Program* [any of the electronic verification of work authorization programs operated by the

United States Department of Homeland Security or any equivalent federal work authorization Program operated by the United States Department of Homeland Security to verify information

Of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA),

P.L. 99-603], in accordance with the applicability provisions and deadlines established in

O.C.G.A. 13-10-91.

The undersigned further agrees that, should it employ or contract with any subcontractor(s) in Connection with the physical performance of services pursuant to this contract with (name of public employer), contractor will secure from such subcontractor(s) similar verification of Compliance with O.C.G.A. 13-10-91 on the Subcontractor Affidavit provided in Rule 300-1001.08 or a substantially similar form. Contractor further agrees to maintain records of such

Compliance and provide a copy of each such verification to the (name of the public employer) at the time the subcontractor(s) is retained to perform such service.

__________________________________________ EEV / Basic Pilot Program* User Identification Number

__________________________________________ BY: Authorized Officer or Agent Date

(Contractor Name)

__________________________________________ Title of Authorized Officer or Agent of Contractor

__________________________________________ Printed Name of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF , 20 . _________________________________ NOTARY PUBLIC My Commission Expires: _________________________________ As of the effective date of O.C.G.A. 13-10-91, the applicable federal work authorization program is the "EEV / Basic Pilot Program" operated by the U. S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA). (End of Form)