Backup Documents 09/08/2020 Item #16F1-f (07/28/2020 in Absentia) ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE b F i F
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing fines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2. Risk-Management Risk
3. County Attorney Office County Attorney Office SRT by JH 7/28/20
/s/
4. BCC Office Board of County BS by JH/s/ 9/8/20
Commissioners
5. Minutes and Records Clerk of Court's Office , J3o ia,3°'
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above,may need to contact staff for additional or missing information.
Name of Primary Staff Maggie Lopez/Community and Human Phone 239-252-8043
Contact/ Department Services AND Jessica Suarez/Purchasing
Agenda Date Item was July 28"',2020 Ratified on September 8h, Agenda Item Number 16Fi4
Approved by the BCC 2020
Type of Document First Amendment with Quest Corporation of Number of Original
Attached America,Inc.,to oversee a COVID-19 media Documents Attached
campaign and related public assistance
PO number or account N/A
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature?STAMP OK N/A
2. Does the document need to be sent to another agency for additional signatures? If yes, N/A
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be ML
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the ML
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's ML
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip N/A
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on September 08,2020 and all changes ML
made during the meeting have been incorporated in the attached document. The
County Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made,and the document is ready for the
Chairman's signature.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
16F1F
MEMORANDUM
Date: September 11, 2020
To: Maggie Lopez, Supervisor
Community & Human Services Division
From: Teresa Cannon, Sr. Deputy Clerk
Minutes & Records Department
Re: First Amendment to Agreement #19-7537 w/Quest
Corporation of America, Inc. - "Affordable Housing
Marketing Outreach Campaign"
Attached for your records is a scanned copy of the document as referenced above,
(Item #16F1f) adopted by the Board of County Commissioners on Tuesday,
September 8, 2020.
If you have any questions, please feel free to contact me at 252-8411.
Thank you.
Attachment
I6F1F
FIRST AMENDMENT TO AGREEMENT #19-7537
FOR
AFFORDABLE HOUSING MARKETING OUTREACH CAMPAIGN
btr
THIS AMENDMENT, made and entered into on this duk oc S a e), by and
between Quest Corporation of America, Inc. (the "Contractor") and C-bllier County, a political
subdivision of the State of Florida, (the "County":
WHEREAS, on October 8, 2019 (Agenda Item 16.D.4), the County entered into an
Agreement with Contractor for the marketing, public relations, and communication plan for housing
affordability; and
WHEREAS, on June 23, 2020 (Agenda Item 11.B), the County approved entering into a
Coronavirus Relief Act funding agreement with the Florida Department of Emergency Management.
WHEREAS,the parties desire to amend the Agreement to: (1) include expanded services for
the media campaign,to include advertising,for the implementation for Federal CARES funding received
by Collier County; (2) increase the contract value of this Agreement by $80,000 for this added service;
and (3) inclusion of Federal Provisions and Certifications (CFDA 21.019-CARES ACT).
NOW, THEREFORE, in consideration of the mutual promises and covenants herein
contained, it is agreed by the parties as follows:
1. Exhibit A-1 Scope of Services is hereby incorporated into the Agreement outlining the scope of
services to be performed under this First Amendment.
2. Exhibit C- Federal Provisions and Certifications is hereby incorporated into the Agreement.
3. All fees charged for services performed under Exhibit A-1 shall be in accordance with the fees
outlined in Exhibit B-Fee Schedule.
4. All other terms and conditions under this Agreement shall remain the same.
Words Slr-ael ough are deleted; Words Underlined are added
* * * * *
[Signature Page to Follow]
Page 1 of 4 CAC,
First Amendment to Agreement# 19-7537
16F1F
IN WITNESS WHEREOF, the parties have executed this First Amendment on the date and year first
written above by an authorized person or agent.
ATTEST:
Crystal K. Kinzel, Clerk of Court& BOARD OF COUNTY COMMISSIONERS
Comptroller COLLIER COUNTY, FLORIDA
,44,%.,teZeoftwa`aft•
By:
q / Burt L. Saunders, Chairman
Dates: 1�f-`faia°
(SEAL) Attest- Vic.Chairman's
Signh'pn{y.
Contractor's Witnesses: CONTRACTOR:
QUEST CORPORATION OF AMERICA,
C- INC.
irst Witness /
By:
k1/w8E-,et y L L(Ate- Si nature
TType/print witne nameT •
4-J9
—�(C�hf' A+
TType/print signature at titlet
Second Witness
--Ed54 2i 6reAl'
TType/print witness nameT Date
pprov s to or an Legali :
Approved in absentia per Resolution
2000-149 on 7 - Dep ty County Attorney
By: El-eC Print Name
Leo E. Ochs, Jr., Co y anager
[Exhibit A-1 Scope of Services to follow this page]
4
Page 2 of 4
First Amendment to Agreement# 19-7537
16F1F
FIRST AMENDMENT TO AGREEMENT #19-7537
FOR
AFFORDABLE HOUSING MARKETING OUTREACH CAMPAIGN
THIS AMENDMENT, made and entered into on this (date), by and
between Quest Corporation of America, Inc. (the "Contractor") and Collier County, a political
subdivision of the State of Florida, (the "County":
WHEREAS, on October 8, 2019 (Agenda Item 16.D.4), the County entered into an
Agreement with Contractor for the marketing, public relations, and communication plan for housing
affordability; and
WHEREAS, on June 23, 2020 (Agenda Item 11.B), the County approved entering into a
Coronavirus Relief Act funding agreement with the Florida Department of Emergency Management.
WHEREAS,the parties desire to amend the Agreement to: (1) include expanded services for
the media campaign,to include advertising,for the implementation for Federal CARES funding received
by Collier County; (2) increase the contract value of this Agreement by $80,000 for this added service;
and (3) inclusion of Federal Provisions and Certifications (CFDA 21.019-CARES ACT).
NOW, THEREFORE, in consideration of the mutual promises and covenants herein
contained, it is agreed by the parties as follows:
1. Exhibit A-1 Scope of Services is hereby incorporated into the Agreement outlining the scope of
services to be performed under this First Amendment.
2. Exhibit C-Federal Provisions and Certifications is hereby incorporated into the Agreement.
3. All fees charged for services performed under Exhibit A-1 shall be in accordance with the fees
outlined in Exhibit B-Fee Schedule.
4. All other terms and conditions under this Agreement shall remain the same.
Words Struck Through are deleted; Words Underlined are added
* * * * *
[Signature Page to Follow]
Page 1 of 4 CAO,
First Amendment to Agreement# 19-7537
16F1F
#19-7537 "Marketing and Outreach Campaign and Implementation Services"
Exhibit A-1 — SCOPE OF SERVICES
(FIRST AMENDMENT)
The Community and Human Services Division is requesting the following actions be added to the current
scope for the above referenced contract.This amendment to the scope of service is to cover the cost to develop
content.
1. Add to the website a disaster tab for disaster information. All additional information should be in both
English and Spanish and ADA compliant. It should include the following information:
A. COVID-19 information would be posted such as General COVID-19 information and any relevant
links to partner pages
B. Types of assistance available (Rental/mortgage assistance, COVID testing, any other to be
determined assistance that is approved by the Board of County Commissioners for distribution)
C. Links to services, application portals, and any necessary partner information.
Hourly Rate (Time and Material Not-to Exceed) $85/hr
2. Additional print campaign in both English and Spanish to include, but not limited to, a combination of the
following:
A. Educational/information pieces(such as advertisements not editorials)placed in the local newspapers
of general circulation. Topics to include, but not limited to:
a. Safety procedures to reduce risk of contracting COVID-19 (i.e. social distancing, wearing
masks, washing hands, staying home, etc.).
b. Where to get tested, why testing is important, different types of testing and other medical
resources.
c. What to do if you test positive information.
d. Where to find various types of assistance (e.g., rental/mortgage, health care, etc.).
B. Billboard campaign to provide public service information. Topics to include, but not limited to:
a. Safety procedures to reduce risks
b. Where to be tested, why testing is important,types of testing, etc.
c. What to do if you test positive.
d. Where to find assistance.
Hourly Rate (Time and Material Not-to Exceed) $85/hr
3. Radio/Television/Social media Campaign in both English and Spanish to include, but not limited to:
A. Collier TV Public Service Announcement spots
B. Local TV Public Service Announcement spots
C. Radio Public Service Announcement spots
D. Public Service Announcements through the major social media outlets such as Facebook, Twitter,
Instragram,Nextdoor, etc.
Hourly Rate (Time and Material Not-to Exceed) $85/hr
Page 3 of 4
First Amendment to Agreement# 19-7537 CAO
EXHIBIT C
16F1F
FEDERAL PROVISIONS AND CERTIFICATIONS
(CFDA 21.019-CARES ACT)
CONTAINING 5 PAGES, FOLLOWING THIS PAGE
Page 4 of 4
First Amendment to Agreement# 19-7537 CAp
16F1F
FEDERAL PROVISIONS AND CERTIFICATIONS
CFDA 21.019-CARES ACT
The supplemental conditions contained in this section are intended to cooperate with, to supplement, and to modify the general conditions and other
specifications.In cases of disagreement with any other section of this contract,the Supplemental Conditions shall govern.This is an acknowledgement that
the United States Department of the Treasury financial assistance through the State of Florida,Division of Emergency Management under the CARES Act,
section 601(d)of the Social Security Act will be used to fund all or a portion of the contract.The contractor will comply with all applicable Federal law,
regulations,executive orders,CARES Act policies,procedures,and directives.Pursuant uniform requirements of federal awards(2 CFR Part 200.23)the
definition of CONTRACTOR is an entity that receives a Contract/Purchase Order.
Termination: See Standard Purchase Order and/or Contract Terms and Conditions
Suspension and Debarment:(1)This contract is a covered transaction for purposes of 2 C.F.R.pt. 180 and 2 C.F.R.pt.3000.As such the contractor is
required to verify that none of the contractor,its principals(defined at 2 C.F.R.§180.995),or its affiliates(defined at 2 C.F.R.§ 180.905)are excluded
(defined at 2 C.F.R.§180.940)or disqualified(defined at 2 C.F.R.§180.935). (2)The contractor must comply with 2 C.F.R.pt.180,subpart C and 2 C.F.R.
pt.3000,subpart C and must include a requirement to comply with these regulations in any lower tier covered transaction it enters into. (3)This certification
is a material representation of fact relied upon by the County.If it is later determined that the contractor did not comply with 2 C.F.R.pt.180,subpart C and
2 C.F.R. pt.3000,subpart C,in addition to remedies available to the County,the Federal Government may pursue available remedies,including but not
limited to suspension and/or debarment.(4)The bidder or proposer agrees to comply with the requirements of 2 C.F.R.pt.180,subpart C and 2 C.F.R.pt.
3000,subpart C while this offer is valid and throughout the period of any contract that may arise from this offer.The bidder or proposer further agrees to
include a provision requiring such compliance in its lower tier covered transactions.
Contractors placed on the State of Florida convicted vendor list following a conviction for a public entity crime or on the State of Florida discriminatory vendor
list may not submit a bid on a contract to provide any goods or services to a public entity,may not submit a bid on a contract with a public entity for the
construction or repair of a public building or public work,may not submit bids on leases of real property to a public entity,may not be awarded or perform
work as a contractor,supplier,subcontractor,or consultant under a contract with a public entity,and may not transact business with any public entity in
excess of$25,000.00 for a period of thirty-six(36)months from the date of being placed on the convicted vendor list or on the discriminatory vendor list.
Contracting with small and minority businesses,women's business enterprises,and labor surplus area firms§200.321 (a)The Solicitor must take
all necessary affirmative steps to assure that minority businesses,women's business enterprises,and labor surplus area firms are used whenever possible.
(b)Affirmative steps must include:(1)Placing qualified small and minority businesses and women's business enterprises on solicitation lists;(2)Assuring
that small and minority businesses,and women's business enterprises are solicited whenever they are potential sources;(3)Dividing total requirements,
when economically feasible,into smaller tasks or quantities to permit maximum participation by small and minority businesses,and women's business
enterprises;(4) Establishing delivery schedules,where the requirement permits,which encourage participation by small and minority businesses, and
women's business enterprises;(5)Using the services and assistance,as appropriate,of such organizations as the Small Business Administration and the
Minority Business Development Agency of the Department of Commerce;and(6)Requiring the prime contractor,if subcontracts are to be let,to take the
affirmative steps listed in paragraphs(1)through (5) of this section. Contractors may seek opportunities with minority businesses,women's business
enterprises,and labor surplus area firms using the Dynamic Small Business Search tool:http://dsbs.sba.qov/dsbs/search/dsp dsbs.cfm
Rights to Inventions Made Under a Contract or Agreement(37 CFR§401.2): Not applicable.
Byrd Anti-Lobbying Amendment(31 U.S.C.§1352(as amended)($100,000 or more): Contractors who apply or bid for an award of$100,000 or more
shall file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or
organization for influencing or attempting to influence an officer or employee of any agency,a member of Congress,officer or employee of Congress,or an
employee of a member of Congress in connection with obtaining any Federal contract,grant,or any other award covered by 31 U.S.C.§1352.Each tier
shall also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award.Such disclosures are forwarded
from tier to tier up to the recipient.'
Clean Air Act(42 U.S.C.7401-7671 q.)and the Federal Water Pollution Control Act(33 U.S.C.1251-1387)($150,000 or more),as amended Contractor
agrees to comply with all applicable standards,orders or regulations issued pursuant to the Clean Air Act(42 U.S.C.7401-7671q)and the Federal Water
Pollution Control Act as amended(33 U.S.C.1251-1387),and will report violations to FEMA and the Regional Office of the Environmental Protection Agency
(EPA).
Procurement of Recovered Materials(§200.322)(Materials Over$10,000):($10,000 or more):1.In the performance of this contract,the Contractor shall
make maximum use of products containing recovered materials that are EPA-designated items unless the product cannot be acquired—a.Competitively
within a timeframe providing for compliance with the contract performance schedule;b.Meeting contract performance requirements;or c.At a reasonable
price.2.Information about this requirement,along with the list of EPA-designated items,is available at EPA's Comprehensive Procurement Guidelines web
site, https://www.epa.gov/smm/comprehensive- procurement-guideline-cpg-program 3. The Contractor also agrees to comply with all other applicable
requirements of Section 6002 of the Solid Waste Disposal Act.'
Administrative,Contractual,or Legal Remedies(over$250,000):Unless otherwise provided in this contract, all claims,counter-claims, disputes and
other matters in question between the local government and the contractor,arising out of or relating to this contract,or the breach of it,will be decided by
arbitration,if the parties mutually agree,or in a Florida court of competent jurisdiction.
Page 1 of 5
FEDERAL PROVISIONS AND CERTIFICATIONS
I bF1F
CFDA 21.019-CARES ACT
COLLIER COUNTY
Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a) Are not presently debarred,suspended, proposed for debarment,declared ineligible,or voluntarily excluded
from covered transactions by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting
to obtain, or performing a public(Federal, State or local)transaction or contract under a public transaction;
violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal,
State or local)with commission of any of the offenses enumerated in paragraph (I)(b) of this certification;
and
(d) Have not within a three-year period preceding this application/proposal had one or more public transactions
(Federal, State or local)terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.
�c�n� NAlv 1 YO /y329`l
'Blame DUNS Number
ijcSl.Skid— Vee /9, ,cSi ± J9- 333/86
Title Tax ID Number
Clies f airdYS7On kwcL
Firm
17 o acne/a- L Lando / J � 136 3
Sign ure
Page 2 of 5
16F1F
FEDERAL PROVISIONS AND CERTIFICATIONS
CFDA 21.019—CARES ACT
COLLIER COUNTY
Certification Regarding Lobbying
The undersigned certifies, to the best of his or her knowledge, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person
for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal
contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant,
loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or
cooperative agreement, the undersigned shall complete and submit Standard Form- LLL, "Disclosure Form to
Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents for all
subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements)and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction
imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). Any person who fails to file
the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.
The Contractor, c.k/k(S1 (30't.I , certifies or affirms the truthfulness and accuracy of each
statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the
provisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any.
In addition, the Contractor understands and agrees that the provisions of 11.062, Florida Statutes., apply to this
certification and disclos re, if any.
�� Signature of Contractor's Authorized Official
r ql-e i1/tC/(/ y/A 1 J V 'Name of Authorized Official and Title
7// L) Date
Page 3 of 5
1 6F1F
FEDERAL PROVISIONS AND CERTIFICATIONS
CFDA 21.019—CARES ACT
COLLIER COUNTY
ANTICIPATED DISADVANTAGED, MINORITY,WOMEN OR VETERAN PARTICIPATION STATEMENT
Status will be verified. Unverifiable statuses will require the PRIME to either provvde a revised statement or provide source documentation that validates a
status.
A. PRIME VENDOR/CONTRACTOR INFORMATION
1 PRIME NAME PRIME END NUMBER CONTRACT DOLLAR AMOUNT
IS(E PRIME E DAe0/ O DISADVANTAGED. —3 33 51g ACTIVITY OF THIS CONTRACT._Y0,000
0,DO0
VETERAN Y
MINORITY OR WOMEN BUSINESS ENTERPRISE? DBE? V lllN CONSTRUCTION?
Y �✓
(DBE/MBEJWBE)OR HAVE A SMALL DISADVANTAGED
BUSINESS SA CERTIFICATION fROM THE SMALL BUSINESS MBE? Y N CONSULTATION? �� N
ADMINISTRATION? A SERVICE DISABLED VETERAN? WBE? / N OTHER? Y (N )
5DB8A? Y (N
IS MS SUBMISSION A REVISION? Y L N. iF ITS,REVISION NUMBER
B. IF PRIME HAS SUBCONTRACTOR OR SUPPUER WHO IS A DISADVANTAGED MINORITY,WOMEN-OWNED,SMALL
BUSINESS CONCERN OR SERVICE DISABLED VETERAN,PRIME IS TO COMPLETE THIS NEXT SECTION
DBE M/WBE SUBCONTRACTOR OR SUPPLIER TYPE OF WORK OR ETHNICITY CODE SUB/SUPPLIER PERCENT OF CONTRACT
VETERAN NAME SPECIALTY (See Below) DOLLAR AMOUNT DOLLARS
TOTALS:
C. SECTION TO BE COMPLETED BY PRIME VENDOR/CONTRACTOR
NAME F SUBMFTIER D TE TffLE OF SUBMITTER
►Ct n e << k���Y 'j// C Assist&k.t 1
EMAIL ADDRESS OF PRIME[SUBMTTTER) �> /TELEPHONE NUMBER FAX
)FAX NUMBER /
I/4/1e. 1)&c 1Yl-t'y C yce t sc .00417 1,6-66,;)-l0, /_3 0 3 4/c 6 - 16
NOTE:This inform/ ation is used to track and report anticipated DBE or MBE participation in federally-funded contracts. The anticipated DBE or
MBE amount is voluntary and will not become part of the contractual terms. This form must be submitted at time of response to a
solicitation. d and when awarded a County contract,the prime will be asked to update the information for the grant compliance files.
ETHNICITY CODE
Black American BA
Hispanic American HA
Native American NA
Subcont.Asian American SAA
Asian-Pacific American APA
Non-Minority Women �LdW
Other:not of any other group listed O
D.SECTION TO BE COMPLETED BY COLLIER COUNTY
DEPARTMENT NAME COLLIER CONTRACT"IIFBIPFP or PO/Eq. GRANT PROGRAM/CONTRACT
ACCEPTED BY: DATE
Page 4 of 5
FEDERAL PROVISIONS AND CERTIFICATIONS 16 F 1 F
CFDA 21.019—CARES ACT
COLLIER COUNTY GRANT CC:SPLl rICE FORt.1
rtID OPPORTUNITY LIST FOR COMMODITIES AND CONTRACTUAL SERVICES
AND PROFESSIONAL CONSULTANT SERVICES
.'t is the policy of Cotliet County that disadvantaged businesses and minority vendors,as defined in the Code of Federal Regulations(CFR)or
Florida Statutes iFs),must ha.'e the opportunity to participate on contracts with federal and/or state grant assist ce.
Prime Contractor/Prime Consultant: I 4)t4( ki L 0 f;/Vt447 C .. . 4njrl( 4_
Address and Phone Number: / /� �u i /(/- l i , LCvlCh94a
I..ca 7 //«�J 3y63S
Procurement Number/Advertisement Number:
The list below is intended to be a listing of firms that are,or attempting to,participate on the project numbered above. The list must
include the firm bidding or quoting as prime,as well as subs and suppliers quoting for participation. Prime contractors and consultants must
provide information for Numbers 1,2,3,and 4;and,should provide any information they have for Numbers 5,6,7,and B. This form must
be submitted with the bid package.1. Federal Tax ID Number: C -37J
3 C � 6. DBE B. Annual Gross Receipts
2. firm Name: E tl
Non-DBE Less than$1 million
3. Phone Number: - Between$1-5 million
4.Address O - EBetween$5-10 million
4kii /0 kr 7. Subcontractor Between$10-15 million
3ic, - Subconsultant _More than$15 million
5.Year Firm Established: Ei1. Federal Tax ID Number: 6. DBE B. Annual Gross Receipts
2. Firm Name: Non-DBE Less than$1 million
3. Phone Number: —•Between$1-5 million
4. Address E Between$5-10 million
7. Subcontractor Between$10-15 million
Subconsultant More than 5 15 million
5. Year Firm Established:
1. Federal Tax ID Number: 6. DBE B. Annual Gross Receipts
2. Firm Name: Non-DBE Less than$1 million
3. Phone Number: Between$1-5 million
4.Address Between$5-10 million
7.ESubcontractor Between;10-15 million
Subconsultant Mare than$15 million
5. Year Firm Established:
1. Federal Tax ID Number: 6. DBE B.Annual Gross Receipts
2. Firm Name: —• Non-DBE Less than$1 million
3. Phone Number: Between$1-5 million
4.Address Between$5-10 million
7.ESubcontractor Between 5 10-15 million
Subconsultant More than$15 million
5.Year Firm Established:
Page 5 of 5
(At)