#08-5011 (WO Haskins 2009)
WORK ORDERlPURCHASE ORDER # 4 5001 06432
Agreement for "Fixed Term Underground Utility Contracting Services"
Dated: March 11,2008 (RFP/Bid 08-5011)
This Work Order is for professional underground utility contracting services for work known as:
Project Name: Shell Island Road Restoration Project
Project No: 51101
The work is specified in the proposal dated February 23, 2009 which is attached hereto and made a
part of this Work Order. In accordance with Terms and Conditions of the Agreement referenced
above, and in accordance with the Department of Interior, Code of Federal Regulations, Title 43. the
following Attachment C, Attachment D. Attachment E, and Exhibit F are attached. Work
Order/Purchase Order # is assigned to: Haskins, Inc. This work will be
completed in conjunction with the Florida Department of Environmental Protection (FDEP). FDEP
will be reimbursing Collier County for any funds expended in accordance with this work order.
Scope of Work: As detailed in the attached proposal and the following:
. Task I Mobilization
. Task II Selective Hand Clearing of Mangroves
. Task III Culvert Installation
. Task IV Backfill Swale
. Task V Roadway
. Task VI Silt Fence
* Task VII Allowances
Schedule of Work: Complete work within 76 days from receipt of the Notice to Proceed which is
accompanying this Work Order.
Compensation: In accordance with Article Five of the Agreement, the County will compensate the
Firm in accordance with following methodes): DNegotiated Lump Sum I2JLump Sum Plus
Reimbursable Costs (to be reimbursed by FDEP to Collier County based upon percent complete) D
Time & Material (established hourly rate - Schedule A) DCost Plus Fixed Fee, (define which
method will be used for which tasks) as provided in the attached proposal.
Task I
Task II
Task III
Task IV
Task V
Task VI
Task VII
TOTAL FEE
$
$
$
$
$
$
$
$
15,000.00 (Lump sum)
25,500.00 (Lump sum)
52,500.00 (Lump sum)
123,500.00 Crime & Materials)
52,512.00 (Lump sum)
30,000.00 (Lump sum) .
200 ,988.00 (T,'fn(. oj- ~(\o.b ')
500,000.00
Any change made subsequent to final department approval will be considered an additional service
and charged according to Schedule" "of the original Contract Agreement.
"
APPROVED BY:
41,ql T\C1
~
4/(4)0'1
Date
PREPARED BY:
4/ ;iO<1
I te
ACCEPTED BY:
dministrator
)ri /
',}f
JiQ)!,; 1
4/nloc;
I Date
APPROVED BY:
Signature of Auth 'ze Company Officer
4j;1/t9
date
Harlan Haskins. President
Type or Print Name and Title
, ......
Attest Co',:' .,;.,.."
t-:-, ~ ',< '" ~~.' '. V' .. .~; ".
Dwight E. Btbck',cterlt,:"i.,
. ~',:"- .-. " \-~;
f.. .
Board of County Commissioners
COllier~, Florida /_
By: ~ d7J-t.4
Donna Fiala, Chairman
Sco
Item# .lllt:L
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QUOTE RESPONSE FORM
FROM:
ffiSK /MS /Aic.
Board of County Commissioners
Collier County Government Center
Naples, Florida 34112
RE:RFQ#85011SWM/SISWUBO- "Shell Island Stormwater Improvement Project"
Dear Commissioners:
The undersigned, as Quoter, hereby declares that he/she has examined the site of th
work and informed himself/herself fully in regard to all conditions pertaining to the plac
where the work is to be done; and that he/she has examined the Specifications for th
work and the documents hereto attached, The Quoter further declares that the on
persons, company or parties interested in the Quotation to be entered into as principa
are named herein; that this Quotation is made without connection with any other persol
company or parties making a Quote; and it is in all respect fair and in good faith, withol
collusion or fraud.
The Quoter further certifies that he/she has familiarized himselflherself with the Feden:
State and Local laws pertaining to the type of work proposed.
The Quoter agrees, if this Quote is accepted, to Contract with the OWNER in the fon
of a County issued numbered purchase order, to furnish work in full, in complel
accordance with shown, noted, described and reasonably intended requirements I
these Plans, Specifications, Contract Documents and all Addenda hereto for the Ur
Prices on the following pages.
The service to be furnished by us is hereby declared and guaranteed to be
conformance with the specifications of the County. The undersigned do agree th,
should this Quotation Response be accepted, to commence work with the issuance I
the Notice to Proceed and to complete required work no later than March 31, 200~
unless otherwise agreed to by all parties.
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.
IN WITNESS WHEREOF, WE have hereunto subscribed our names on this 2'3 -1a
of -Fe:Hu4Af ' 20~ in the County of aL.~ . in the State of R... , .
~"/NS /i.u;..
Firm's Complete Legal Name
-'.Q..15b EN~pe'sg A.ie
(Address)
~ I-no- SPI2,/'tG.S. H..~
(City, State, ZIP)
Phone No: 941- /Bfk
Fax No: ?<l7- ~7
,
Check one of the following:
D Sole Proprietorship
12{ Corporation or PA,
State of R-
D Limited Partnership
D General Partnership
////I#/l6le
Title
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Haskins Inc.
Shell Island Road Drainage Improvements
ll!lII+____ DHc"DIIon _ _ ~_~J Un"Pr1co I JgIlI I
_--'-IMoblllzotlon ____________ _____ ---' _ ~I 15,00000 15,000.00_~
'~M~~Boncl,...OUMl-bul.dr8wlng.1or S~~OTALl ,---=--=---= ~+==1- --;~,oo [
---j- ---------
2 .
3
~=::=~:::~::: ~==-_ ::::'=_ ~~~---:.-_ts ~&Q9~OJ> $$=~-~~:-: .:.-----_-
____________~____ -----=t:- ----L ---- -$ 4.50.9QQ~__
::==::: ...-~1:u-~~::: ~:f-=
___L~5~=;~'~:::::;~=_=--~11-~~:= L.-~t)2QQ~-l:7.~QQ-r -
Lpcation~-.R~:::::1:~x2i3R~c: ~--- --~~:-~Jt f_n=_1__--m ~_I;_a;,_~~j--8,0Q9~OO $--~. 8,0Q9.00___._~-=
__~_ ~---'-'::IL__ _ __ _~~ _+_ _ _ ._____ ~________u._.____H. ..---
QonslnICt Double 14 X 23 ERCP 130 + 50
L_~~7:-~~i~~ER9_~~~ __-____ - _~~oo~J~=~~~-~=:r$ _4,599.90' $ -~~OO.~ __
_.=~..-c':n-=~~~~~~~~p--- -~i- _-'~;:j;9_. -- ==,~~ _ .; 6~~_ ~.ooo~_ --=
1- ------ - - ----- SUBTOT~ -- -=t:- ___.---J S 52,&00,00 -
· ~.:.::.~~::=;~~~ ... '~. -jct-=l--_:f -
=:::.::..-:--- - .~ -_ --i~~L= ..:tJ'-='oo~~= L . ..
- ~__I~;::~~~::-=:..~~=-=___~t:== ~:_~~-J~~y=+1=~- ---,~;~-==_~ooi~=--
~~:..:..:::..:.-- ..t- .. ~~:=t:-f:~l::;:-=t -. .
------__ -------- 8UaTOTALo:t-___--j==t---. S 52,512.00--
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A TT ACHMENT C
Contract Provisions
All contracts awarded by a recipient, including small purchases, shall contain the following provisions as
applicable:
I. Equal Employment Opportunity - All contracts shall contain a provision requiring compliance
with Executive Order (E.O,) 11246, "Equal Employment Opportunity," as amended by E.O.
11375, "Amending Executive Order 11246 Relating to Equal Employment Opportunity," and as
supplemented by regulations at 41 CFR part 60, "Office of Federal Contract Compliance
Programs, Equal Employment Opportunity, Department of Labor."
2. Copeland "Anti-Kickback" Act (t8 U.S.c. 874 and 40 U.S.c. 276c) - All contracts and
subgrants in excess of $2000 for construction or repair awarded by recipients and subrecipients
shall include a provision for compliance with the Copeland "Anti-Kickback" Act (18 U.S.C. 874),
as supplemented by Department of Labor regulations (29 CFR part 3, "Contractors and
Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or
Grants from the United States"). The Act provides that each contractor or subrecipient shall be
prohibited from inducing, by any means, any person employed in the construction, completion, or
repair of public work, to give up any part of the compensation to which he is otherwise entitled.
The recipient shall report all suspected or reported violations to the Federal awarding agency.
3. Davis-Bacon Act, as amended (40 U.S.c. 276a to a-7) - When required by Federal program
legislation, all construction contracts awarded by the recipients and subrecipients of more than
$2000 shall include a provision for compliance with the Davis-Bacon Act (40 U.S.C. 276a to a-7)
and as supplemented by Department of Labor regulations (29 CFR part 5, "Labor Standards
Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction").
Under this Act, contractors shall be required to pay wages to laborers and mechanics at a rate not
less than the minimum wages specified in a wage determination made by the Secretary of Labor.
In addition, contractors shall be required to pay wages not less than once a week. The recipient
shall place a copy of the current prevailing wage determination issued by the Department of Labor
in each solicitation and the award of a contract shall be conditioned upon the acceptance of the
wage determination. The recipient shall report all suspected or reported violations to the Federal
awarding agency.
4. Contract Work Hours and Safety Standards Act (40 U.S.c. 327-333) - Where applicable, all
contracts awarded by recipients in excess of $2000 for construction contracts and in excess of
$2500 for other contracts that involve the employment of mechanics or laborers shall include a
provision for compliance with Sections 102 and 107 of the Contract Work Hours and Safety
Standards Act (40 U.S.C, 327-333), as supplemented by Department of Labor regulations (29 CFR
part 5). Under Section 102 of the Act, each contractor shall be required to compute the wages of
every mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of
the standard work week is pennissible provided that the worker is compensated at a rate of not less
than 1 \I, times the basic rate of pay for all hours worked in excess of 40 hours in the work week,
Section 107 of the Act is applicable to construction work and provides that no laborer or mechanic
shall be required to work in surroundings or under working conditions which are unsanitary,
hazardous or dangerous. These requirements do not apply to the purchases of supplies or materials
or articles ordinarily available on the open market, or contracts for transportation or transmission
of intelligence.
5. Rights to Inventions Made Under a Contract or Agreement - Contracts or agreements for the
performance of experimental, developmental, or research work shall provide for the rights of the
Federal Government and the recipient in any resulting invention in accordance with 37 CFR part
40 I, "Rights to tnventions Made by Nonprofit Organizations and Small Business Firms Under
Government Grants, Contracts and Cooperative Agreements," and any implementing regulations
issued by the awarding agency.
DEP Contract No. RM086, Attachment C, Page I of 3
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6. Clean Air Act (42 U.S.c. 7401 et seq.) and the Federal Water Pollution Control Act, as
amended (33 U.S.c. 1251 et seq.) - Contracts and subgrants of amounts in excess of $100,000
shall contain a provision that requires the recipient to agree to comply with all applicable
standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C. 7401 et seq.) and
the Federal Water Pollution Control Act as amended (33 U,S.C. 1251 et seq.). Violations shall be
reported to the Federal awarding agency and the Regional Office of the Environmental Protection
Agency (EPA).
7. Byrd Anti-Lobbying Amendment (31 U.S.c. 1352) - Contractors who apply or bid for an award
of $1 00,000 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.
8. Debarment and Suspension (E.O.s 12549 and 12689) - No contract shall be made to parties
listed on the General Services Administration's List of Parties Excluded from Federal Procurement
or Nonprocurement Programs in accordance with E.O.s 12549 and 12689, "Debarment and
Suspension." This list contains the names of parties debarred, suspended, or otherwise excluded by
agencies, and contractors declared ineligible under statutory or regulatory authority other than
E.O, 12549. Contractors with awards that exceed the small purchase threshold shall provide the
required certification regarding its exclusion status and that of its principal employees,
9, Section 508 of the Federal Water Pollution Control Act, as amended (33 U.S.c. 1368) and
Section 1424(e) of the Safe Drinking Water Act (42 U.S.c. 300h-3(e)) - Contracts and
subgrants of amounts in excess of $1 00,000 shall contain a provision that requires the recipient to
agree to comply with all applicable standards, orders or regolations issoed pursuant to Section 508
of the Federal Water Pollution Control Act, as amended (33 U.S,c. 1368) and Section 1424(e) of
the Safe Drinking Water Act (42 U,S.C. 300h-3(e)). Violations shall be reported to the Federal
awarding agency and the Regional Office of the Environmental Protection Agency (EPA).
10. Compliance with all Federal statutes relating to nondiscrimination - These include but are not
limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352), which prohibits
discrimination on the basis of sex; (b) Section 504 of the Rehabilitation Act of 1973, as amended
(29 U.S.C, 795), which prohibits discrimination on the basis of handicaps: (c) the Age
Discrimination Act of 1975, as amended (42 U,S.c. 6101-6107), which prohibits discrimination
on the basis of age: (d) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as
amended, relating to nondiscrimination on the basis of drug abuse; (e) the Comprehensive Alcohol
Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as
amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (I) Sections
523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee-3), as
amended, relating to confidentiality of alcohol and drug abuse patient records; (g) Title VlJI ofthe
Civil Rights Act of 1968 (42 U,S.c. 3601 et seq,), as amended, relating to nondiscrimination in
the sale, rental or financing of housing; (h) any other nondiscrimination provisions in the specific
statute(s) made: and, (i) the requirements of any other nondiscrimination statute(s) that may apply,
11. Compliance with the requirements of Titles II and III of the Uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) that provide for fair and
equitable treatment of persons displaced or whose property is acquired as a result of Federal or
federally assisted programs. These requirements apply to all interests in real property acquired for
project purposes regardless of Federal participation in purchases.
12. Compliance with the provisions of the Hatch Act (5 U.s.c. 150t -1508 and 7324 -7328) that
limit the political activities of employees whose principal employment activities are funded in
whole or in part with Federal funds.
DEP Contract No. RM086, Attachment C, Page 2 of 3
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13. Compliance, if applicable, with flood insurance purchase requirements of Section 102(a) of
the Flood Disaster Protection Act of 1973 (P.L. 93-234) that requires recipients in a special
flood hazard area to participate in the program and to purchase flood insurance if the total cost of
insurable construction and acquisition is $10,000 or more.
14. Compliance with environmental standards which may be prescribed to the following: (a)
institution of environmental quality control measures under the National Environmental Policy
Act of 1969 (P.L. 91-190) and Executive Order 11514; (b) notification of violating facilities
pursuant to E.O, 11738: (c) protection of wetlands pursuant to E.O. 11990: (d) evaluation of flood
hazards in floodplains in accordance with E.O. 11988; (e) assurance of project consistency with
the approved State management program developed under the Coastal Zone Management Act of
1972 (16 U.S.C. 1451 et seq.); (I) conformity with Federal actions to State (Clean Air)
Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C.
7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking
Water Act of 1974, as amended (P.L. 93-523): and (h) protection of endangered species under the
Endangered Species Act of 1973, as amended (P.L. 93-205).
15. Compliance with the Wild and Scenic Rivers Act of 1968 (16 U.S.c. 127t et seq.) related to
protecting components or potential components of the national wild and scenic rivers system.
16, Compliance with Section 106 of the National Historic Preservation Act of t966, as amended
(16 U.S.c. 470), E.O. 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (t6 U.S.c. 469a-l et seq.).
17. Compliance with P.L. 93-348 regarding the protection of human subjects involved in research,
development, and related activities supported by this award of assistance.
18. Compliance with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7
U.S.c. 2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held
for research, teaching, or other activities supported by this Agreement.
19. Compliance with the Lead-Based Paint Poisoning Prevention Act (42 U.S,c. 4801 et seq.) that
prohibits the use of lead-based paint in construction or rehabilitation of residence structures.
20. Compliance with the mandatory standards and policies relating to energy efficiency that are
contained in the State energy conservation plan issued in accordance with the Energy Policy and
Conservation Act (Pub. L. 94-163, 89 Stat. 871).
21. Compliance with the Drug Free Workplace Act. The recipient shall comply with the provisions
of the Drug-Free Workplace Act of 1988 (Public Law 100-690, Title V, Sec. 5153, as amended by
Public Law 105-85, Div. A, Title VII!, Sec. 809, as codified at 41 U,S.c. 3702) and DoC
Implementing regulations published at 43 CFR Part 43, "Govemmentwide Requirements for
Drug-Free Workplace (Financial Assistance)" published in the Federal Register on November 26,
2003,68 FR 66534), which require that the recipient take steps to provide a drug-free workplace.
22. Compliance with the Buy American Act (41 U.S.c. 10a-lOc) By accepting funds under this
Agreement, the Grantee agrees to comply with sections 2 through 4 of the Act of March 3, 1933.
popularly known as the "Buy American Act." The Grantee should review the provisions of the
Act to ensure that expenditures made under this Agreement are in accordance with it. It is the
sense of the Congress that, to the greatest extent practicable, all equipment and products purchased
with funds made available under this Agreement should be American-made.
23. Compliance with the Trafficking Victims Protection Act of 2000 (2 CFR Part 175) By
accepting funds under this Agreement, the Grantee agrees to implement the requirements of (g) of
section 106 of the Trafficking Victims Protection Act of 2000 (TVPA), as amended (22 U.S,C.
7104(g),
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
DEP Contract No. RM086, Attachment C, Page 3 of 3
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ATTACHMENT D
REGULATIONS
Formal regulations concerning administrative procedures for Department of Interior (001) grants appear
in Title 43 of the Code of Federal Regulations. The following list contains regulations and Office of
Management and Budget Circulars which may apply to the work oerformed under this Agreement.
General
43 C.F.R. 17 I Nondiscrimination in federallv assisted orograms of the 001
I
Grants and Other Federal Assistance
43 C.F.R. 12 Subpart C - Uniform administrative requirements for grants and cooperative
agreements to state and local governments
43 C.F,R. 12 Subpart F - Uniform administrative requirements for grants and agreements with
institutions of higher education, hosoitals and other nonprofit organizations
43 C.F.R, 18 New restrictions on lobbving
43 C,F,R, 43 Governmentwide requirements for drug-free workplace
Other Federal Rel!nlations
2 C.F.R, 1400 I Suspension and Debarment
48 C.F.R, 31 I Contract Cost Principles and Procedures
Office of Manae:ement and Budl'et Circulars
A-21 (2 CFR 220) Cost Princinles for Educational Institutions
A-87 (2 CFR 225) Cost Principles for State, Local, and Indian Tribal Governments
A-122 (2 CFR Cost Principles for Non-Profit Organizations
230)
A-133 Audit Requirements
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
DEP Contract No. RM086, Attachment D, Page 1 of 1
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ATTACHMENT E
Appnwed by OMS
.....-
DISCLOSURE OF LOBBYING ACTIVITIES
C...omplete this form to disclose lobbying activities pursuant to 31 U.S.c. 1352
(See reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of J.'ederal Action:
3. Report Type:
o
a. contract
b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f loan insurance
o
a. bid/offer/application
b. initial award
c. post.award
o
a. initial filing
b. material change
For Material Change Only:
year quarter
date of last report
4. Name and Address of Reporting Entity:
S. If Reporting Entity in No.4 Is Subawardee, Enter Name
and Address oCPrime:
o Prime
o Subawardce
Tier
, if known:
Congressional District, if known:
Congressional District, if known:
6. Federal DepartmeatlAgeDcy:
7. Federal Procram NameJDescription:
CFDA Number, if applicable:
8. Federal Action Number, ifknawn:
9. Award Amount, ifknown:
s
10. a. Name and Address of Lobbying Entity
(if individual, last na~,fir9t name, MJ):
b. Individuals Performing Services (includIng address if
different from No. 100)
(last name, first name, MJ):
attach Continuation Sheet(s
Signature:
Print Name: ~lAc! ~WS
Tille: p~/~
T.I.phon. No.: Z5i -747- /~
Da": 4)fe9
11. InformatioD requested through tbis form is autboriud by tide 31 D.S.C.
SediOll 1351:. This disclosure of lobbying activities is a marerial
representatioD of fact upon which reliaDce wu placed by the tier above
when tbiI trallSaclioD wu made or entered intO. This disdosu~ is required
pursuant to 31 U.S.c. 1351:. This iafOnJIaOOD will be reported to CODgrellS
semi-aDDually aDd will be available for pnblif: inspKtton. Any penon who
f.ils to file the requiftd disclosure sbaD be subject to . civil peaalty of not
les. tbl. 510,000 IUId not more than SIOO,OOO for eacb such failure.
i'!
Authorized rOf Local Reproduction
Standard Form - LlL (Rev 7 - 97)
FedeJ'a1 UseOnly~j
DEP Contract No. RM086, Attacbment _, Page lof2
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INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether snbawardee or prime Federal recipient, at
the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to tille 31
U.S.c. section 1352. The filing of a form is required for each payment or agreement to make payment to any
lobbying entity for inOuencing or attempting to inOuence an officer or emptoyee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered
Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the
implementing guidance published by the Office of Management and Budget ror additional information.
I. Identify the type of covered Federal action for which lobbying activity is andlor has been secured to
influence the outcome of a covered Federal action.
2. Identify the statns of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material
change to the information previonsly reported, enter the year and quarter in which the change occurred.
Enter the date of the last previously snbmitted report by the reporting entity for this covered Federal
action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional
District, if known. Check the appropriate classification of the reporting entity that designates if it is or
expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first
subawardee of the prime is the 1st tier. Subawards include but are not limited to subeontracts,
subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Suhawardee", then enter the full name, address,
city, state and zip code of the prime Federal recipient, Inclnde Congressionat District, if known.
6, Enter the name of the Federal agency making the award or loan commitment. Include at least one
organizationallevet below agency name, if known. For example, Department of Transportation, United
States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item I). If known, enter
the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements,
loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in
item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement
numher; the contract, grant, or loan award number; the application/proposal control number assigned
by the Federal agency). Include prefixes, e.g., "RFP-DE.90-001."
9. For a covered Federal action where there has been an award or loan commitment by tbe Federal agency,
enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the Inbbying entity engaged by the reporting
entity identified in item 4 to InOuence the covered Federal action.
(b) Enter the full names of the Individual(s) performing services, and include full address if different
from 10 (a). Enter Last Name, First Name, and Middle Initial (MI).
11. The certifying official shall sign and date the form, print hislher name, tille nnd telephone number.
Public n:porting burden (or tbis collection of iaformanon is estimated to average 30 minutes per response, including time for reviewing
instructions, searthing existing data !ourtes, gathering and maintaining the dati needed, and completing and reviewing the colledioD of
informadon. Send comments regarding the burden estimate or any otber aspect of this eolledioD of information, including suggestions
for redudng this burden, to the Office of Management and Bud~et. Paperwork Reduction Projed (0348..0046). Washiagton, D.C. 20503.
DEP Contract No. RM086.Attachment_. Page 2 of2
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EXHIBIT "F"
DECLARATION OF DEBARMENT
The bidder, in accordance with Section XXIX of the prevailing Collier County
Purchasing Policy, (knoWn as "Debarment and suspension") shall sign the
appropriate declaration under this exhibit. In doing so, the undersigned hereby
declares that:
1-\~IN~ ~c.
Name of Business
1. They are a prospective contractor, vendor, affiliate, or otherwise interested
or affected party as deflOed under Section XXIX of the Collier County
Purchasing Policy.
2. They are not nor have not been debarred or suspended by any public
entity within the last five (5) years of the date of this submission,
3. Signature of this declaration constitutes a material representation of fact
upon which reliance was placed when this submission was entered and
evaluated. Further, should it subsequently be determined that the
signatory knowingly or unknowingly rendered an erroneous declaration;
the County shall reserve the right to reject the bid offer associated with
this declaration andlor suspend/debar the bidder/signatory.
4. They shall provide immediate written notice to the person to whom this
proposal is submitted if at any time they Ieam that its declaration was
erroneous when submitted or has become erroneous by reason of
changed circumstanceS.
5. Should the proposed agreement be entered into, they shall not knowingly
enter into any subcontract or supplier agreement with a person or entity
who is debarred, suspended, declared ineligible, or voluntarily excluded
from participation in this agreement, unless otherwise authorized by the
Collier County Purchasing/General Services Director.
The bidder shall sign the appropriate declaration below and comply with any
accompanying requirements set forth therein:
(A) I hereby declare that my firm nor its principals is presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any public agency.
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(B) I am unable to declare that my firm is in compliance with one or more
statements contained within this declaration and I shall attach an
explanation for determination by the Collier County Purchasing Director.
Narne(s) and T1t1e(s) of AuthorIzed Representative(s)
Name of &.In...
Authorized Slgnature(s)
Date
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Partial Name: haskins
State: FLORIDA
CT Code: E (Non Procurement)
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