497 - Dry Chemical Extinguishing Agent

INVITATION TO BID
Page 1of 3
(This is not an order.)
Buyer:Jules Gilliam
216-664-2621
JGilliam@clevelandohio.gov
CITY OF CLEVELAND
Requestor:Janet Baird
Division of Purchases & Supplies 216-265-6060
601 Lakeside Avenue JBaird@clevelandairport.com
Room 128
Cleveland, OH 44114
Procurement Folder RFB No. RFB Description
162128 RFB 3001 202600000000497 Dry Chemical Extinguishing Agent - October 2026
RFB Closing Date/Time Department/Division Public Bid Opening Date/Time
October 15, 2026 3:00 PM 3001 October 15, 2026 3:00 PM
SCHEDULE OF EVENTS
Event Description Event Date
Group/ Commodity Description Item Quantity/ Service Catalog
Line# UOM Dates Discount
1 / 1 Ansul Dry Chemical Extinguishing Agent, Purple-K, 50 lb 20.00000 /
Pail EA
Ansul Dry Chemical Extinguishing Agent Purple-K
50 lbs. Pail - MFR#850-9335 Purple-K
******Vendor MUST BE AN AUTHORIZED DISTRIBUTOR OF PRODUCT & PROOF MUST BE SUBMITTED WITH BID******
Manufacturer Name: _________________________________
.
Item/Product Number: _______________________________
Number of Days for Delivery After Award: _____________ Container Size & Type: _____________
.
*****PLEASE NOTE: Unit Costs MUST Include: Shipping & Handling and ANY Applicable Costs*****
.
*****Vendor MUST Submit Product & Warranty Information if Applicable with Bid Submission*****
.
***********The Bid Must Be Submitted to: CityofClevelandbids@Clevelandohio.Gov - ONLY***********
.
Ship To: Vendor Response
CHIA CENTRAL RECEIVING Unit Price Extension Delivery Days
CHIA CENTRAL RECEIVING
$ $ Day(s)
19451 FIVE POINTS RD
Cleveland, OH 44135
Vendor Response Vendor Total Amount for Items Vendor Total Amount for Services Payment Discount Offer
$ $ % Day(s)
TERMS OF DELIVERY
Price quoted shall be F.O.B. delivered to the place designated on purchase order. No other terms will be acceptable.
Delivery quoted must be stated in terms of work days after receipt of the order.
All charges for shipping must be included within the Unit Price for each item quote unless otherwise designated by a separate line with a
specified dollar amount inclusive of all shipping charges.
No freight charges will be considered nor processed for payment unless apart of the original quote submitted prior to bid award.

INVITATION TO BID
Page 2of 3
(This is not an order.)
Buyer:Jules Gilliam
216-664-2621
JGilliam@clevelandohio.gov
CITY OF CLEVELAND
Requestor:Janet Baird
Division of Purchases & Supplies 216-265-6060
601 Lakeside Avenue JBaird@clevelandairport.com
Room 128
Cleveland, OH 44114
Procurement Folder RFB No. RFB Description
162128 RFB 3001 202600000000497 Dry Chemical Extinguishing Agent - October 2026
RFB Closing Date/Time Department/Division Public Bid Opening Date/Time
October 15, 2026 3:00 PM 3001 October 15, 2026 3:00 PM
EVALUATION CRITERIA
Group/
Evaluation Criteria Description Response Type
Line #
1 / 1 Lowest and best bidder under Chapter 181 C.O. NONE
BIDDER AGREES TO COMPLY WITH ALL TERMS AND CONDITIONS BELOW AND ON REVERSE SIDE OF THIS BID
Shipping/Freight Charges
ALL CHARGES FOR SHIPPING MUST BE INCLUDED WITHIN THE UNIT PRICE OF EACH QUOTE UNLESS
OTHERWISE DESIGNATED BY A SEPARATE LINE ITEM WITH A SPECIFIED DOLLAR AMOUNT INCLUSIVE OF
ALL SHIPPING CHARGES.
NO FREIGHT CHARGES WILL BE CONSIDERED NOR PROCESSED FOR PAYMENT UNLESS APART OF THE
ORIGINAL QUOTE SUBMITTED PRIOR TO BID AWARD.
Call Buyer Only
Bidders must address all questions to the Buyer (See Above.) Do NOT contact the "Requestor." Contract only the Buyer listed
above.
MSDS required
A Material Safety Data Sheet is required to be shipped with each specific applicable item on this PO.
No Price increase
This Purchase Order does not permit price increases.
Missing information
It is each bidder's individual responsibility to determine for themselves, in advance of bid submission, the accuracy and
completeness of any and all information in an RFB. If a potential bidder does not notify the Division of Purchases and Supplies
in advance of the bid opening date of any possible discrepancy then any such discrepancy or erratum cannot be the basis for a
protest of award. Contact the Buyer immediately if there is a question of accuracy or completeness in these bid documents.

INVITATION TO BID
Page 3of 3
(This is not an order.)
Buyer:Jules Gilliam
216-664-2621
JGilliam@clevelandohio.gov
CITY OF CLEVELAND
Requestor:Janet Baird
Division of Purchases & Supplies 216-265-6060
601 Lakeside Avenue JBaird@clevelandairport.com
Room 128
Cleveland, OH 44114
Procurement Folder RFB No. RFB Description
162128 RFB 3001 202600000000497 Dry Chemical Extinguishing Agent - October 2026
RFB Closing Date/Time Department/Division Public Bid Opening Date/Time
October 15, 2026 3:00 PM 3001 October 15, 2026 3:00 PM
BIDDER MUST COMPLETE & SIGN BELOW
NAME OF THE FIRM:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
FED ID # / SSN #:
PHONE NO.: FAX NO.:
EMAIL ADDRESS:
PLEASE PRINT CONTACT NAME:
AUTHORIZED SIGNATURE: DATE:
All bids and related documents must be enclosed in a sealed envelope and marked with the RFB number.
RETURN BID TO: Division of Purchases & Supplies
601 Lakeside Ave
Room 128, City Hall
Cleveland, OH 44114

Effective Immediately: In accordance with Codified Ordinance 181.13 (1) the City shall
receive competitive sealed bids through email. All City of Cleveland bids estimated to be
less than 50K in value will be submitted and received electronically via email. All bids
must be emailed to CityofClevelandbids@clevelandohio.gov. Upon receipt of your bid,
you will receive a reply indicating your bid has been received.
Bidder's Instructions
See enclosed Terms & Conditions. Read and follow all terms and conditions of the bid.
Bids must be submitted to CityofClevelandbids@clevelandohio.gov, the Document ID Number
and Buyer's Name must be identified in the email subject line. Also clearly state the
Document ID Number, Bid Description, Buyer's Name and Closing Date.
PLEASE NOTE: Bids received after the Closing Date, Closing Time
or
sent to
any other email address not identified in the Bidders
Instructions cannot be considered.
Northern Ireland Affidavit must be completed, signed and included with each bid.
The bid must be submitted to: CityofClevelandbids@Clevelandohio.Gov
The bid documents must include:
The Document ID Number and Buyers Name in email subject line
PDF File of Request For Bid Form
Terms & Conditions.
Northern Ireland Affidavit.
Wage Theft Form.
Contact the Buyer immediately at the number on the Bid Form if you do not have all the
required documents.

TERMS AND CONDITIONS
1. Acceptance of Purchase Order, This Purchase Order shall be effective when Seller executes it, otherwise indicates its acceptance, or delivers to the City of Cleveland any of the goods
o O O r r r d d d e e e r r r e b d b yy h e tt r hh e ee i CC n ii o tt r yy r ssh e haa n ll d ll e cc r oo s nn ss f tt o ii r tt t uu h tte e e aa C n i n t aa y cc a cce n epp y tt o aa f nn cc t ee h e oo ff s s e s r uu v cc i hh c e o o s f f f f o e e r r r d e ss r uub e bij d ee cc h tt e r tt e oo i n tt . hh ee I f ee xx th pp i rr s ee s P sss u r cc c oon h nd a dii s tt e ii oo O nn r t d thh e aa r tt h tt a hh s ee SS b ee e ll e ll n eer r i a s as s ss u se e en d n tt b tt y oo a t a h nn e yy C a a i d d t d d y i i t t i i i n o o r n n a e a l l s p oo o rr n d s di e if t t ft o ee r a ree n nn tt o t f te f e e rr r mm , ss t c h c o e o n n n t t t a a h i i e n n e i e d s d s hh u ee a rr n ee c ii e nn .. o f AA n t n h yy i s a a d P d d u d i r i t c t i h o o a n n s a al e l
or different terms or conditions contained in any acknowledgement of the purchase by the Seller shall automatically be deemed objected to by the City and shall not be binding upon the
City unless specifically accepted by the City in writing.
3
2
.
.
j
b E
I
o
n u n
n r y a
d
t
d d
l
e
i r
g m
r e
m
o
ne
e f
e
r r
i
e
n
w A
f
r w
m t
r g e
i
r
s
i n
c
r i
a ,
t c
a
t e e t
t
t e
c n
,
i
o e
o
m
o
n c n
s
e
nc
o
t
n w w
.
n
s
t i i s
, a
t , t t
a S
h i h
e n t
t T
l d
r u
l
r h e
e
t e
n
i
e
s
r
e e s
x
p n
s p
t o
s
ee h
e h
r ce e
a n e
d tt
l s
e t e t
l e
r
s
n o o
s
, t
i
t s
,
i
n
t u u r
ii d
h c e c
nn e
e h h
cc
a
m l
i
l
g
n
m m n
uu
a
i
r a s
dd
t
f
e t t
ii
t
y
e r
n
t
n
e
,
u m
ge
a r c e .
d a
t
s
n
e t
i
t
t
f t
o
l e o
n
o
b
n r
s
r
e
d n n
t t
, ee
o w
yv a s
e
s
b
' n '
e i d
d
n
f f
d
e e
t e
e h e
h
s
r
s o ,
e
,
s
l a
,
a d
p
rr
t a
ii
r h
h ss
t e
a ii
i
nn r
R e
gg m
e s
,, l
q
o e
a
o
u
e s
n
c
e
c s c
d s
u u
t
r t r
r
r h
e
r
f
i
p
i e
o
n
l
n
r a
g g C
B c
i , ,
i
t
e
o o y
s d
r r ,
, a
aa
t
i
n
ll t
h
l
d
l s
e
e e g
s
g o
B
e f e
u i
d f d
p d
l i l
e
c y y
r S
e a
s
a r
c
r s
e
r
h
, ii
d e
ss
e d
a ii
s
g
u
nn e
l
gg
a
n
e n
o o t
y
r s r
o
,
f
o
p
o
r
c
I
a c
i
e
tt
c n
o
u
ee
u d
r
r
mm
r r
ss
r e
o
i
,,
i
r
m n n
a
p
a
g
c
g
n
l
n o
f o f
d d n
y r r
a t a
e o o
e nn
e m m
m yy
s
p
t t
s o
h
s
h f
p
e
r
e r
e a
p
c
p o
n
e
i
e m
f e
rr
i
a s
o
s
c
l o
u
o
a
l nn
s t
aa
i
c l
c
l
o
l
o n
a ii
m a
i nn
m
m
n
jj
u
s u
m
u
d
,
n
rr
/ i
yy
o
d ,
c
,
r
e
a
i i m
o t
n n
t
a
i
c

c
h
n l
o
l
e
u d
n
u

d
r
s d
s
i i
,
,
a
n n
t
g
r
g l
t e
i
a
d d
p
a e
c
b e
r
a i
h
a
e
l t
m
t
s
i h h
e e
t , i ,
n n
e p
t t
s p
a
r ,
s
r
t
o
,
o
i
l p
i
p o
o
e
f
s e
n
r s
a s
r e t
, n
t s y
y
y ,
o ,
d
r
d s a u a
a i
i m
g
m t
n
a
r
a s
c
,
e
g g
o e
e e
r
c
m p
, ,
m
a
e o e
ui
n r
i
n
sn
a t
n
t
ce
t s
c
s
l
e
l
, ,
u o u
d
d f
w
d
w
i
h h
i
h
n a n
e e
g
e
c g
r t
t
t
l i
e h h
t o o
b
o
e e
s n s
y
s s ,
4. a l L o r L a o li r i g e i f r f i aa e i p s m m u u bb s n o i i ii s i s i t r t ll n e e t n s ii t , , gg tt , o o y y o o o f f e oo r r r o o m un LL f f o o o p t ii t t t l s aa s o h h h t o bb t of e r e e r r ii y i r i r r ll e no c c w ii w e t ri t tt t i i s yy e s s l sc , l .. c i e e a oo a h , s , I b I b nn n u i t n n i t n i b ll o o c e n S ii n a c tt e aa o o l yy t l nn b e l yy e i e i u d e v n n v l r p p ee l t w s e t e nn e o i o rr t tt o r r t ss i t r t h n s o , o s , s h h nn a o o a o u a r l s o r r p l o l l p r i r b l b s tt e t t i e e f s hh h h e c c u u e e r e e a a l r s u u t n p C p C , s i s i i r i r n i e e t s o t o n g y p h o y p o t e e e f f f b b r h d r r e e t t e t t o o y h h y f m r l l e e u i o i o u r aa t f f f b s b h n a a a ll i i e i y i ee n s s d l l y h f u u f c b i r o r o o pp n e e r y r n e g o t t o a r a f r f h e o n s n a f e t o t s s c i n i t u u C t r c , c h i c c i i o e t h i h pp y r sn a g a , g g c t f o t o o l o ee o r o r u o d o d d o d d d s b i p m p s s r r e n r c o g c o t t t o ff o h a o e i v t i e u t e h t b b s s i r s p e , d e e r , e e d d i o r i i i n n n f n p f bb c c a t o a a i yy i r h r c c d t d t e m c e t i c e h h e n a o n o f i i s tt r n a r s s aa i d c d a ll P l P a e a n u O n O o n o r d o c r , c . e r r e e e o o c o c m b r f r ww oo p r i n i n s h l b e t ss t u e e o a h ee h c c c y c qq h a t a t e h uu u h u h e e g e s e s t n e s o n e e h t t o d o d e ii d o o e f e r aa s f f ss e l a l cc a t a o n rr o dd f n n y ii aa y b y s pp mm p h e rt i i a a a i a i m l m r p g oo g n l t p n r n ee e y e o s i s o r o , r , n d ff , f f a u e e s s n oo s c c c o u rr u e ta t e c i d c i p p n r h o a e o e e g i n n s n n s n g a o a e u o o o l l c l o r r t o e t t o i d d i x m d o e d e s c s e p s e f s e f l f aa n e e e i oo ss e d c c f a f g t t n m l a t a m i c i i h a nn a n e n g e y y y y e s s w p n a a a d s d i r t i i ee p t i d d s o s c h p c r c e g g e t rr o o a a i h i i o o l p n r p e d d l t tt s s e o ii r pi , n , c o n o e t a nn q o o a i . b . u r r o n l i n T e T b b y r a h a h a l e t c e s s e m o pa a e e e t c t C d n C d a t h i i t l u e t t u o s o y p y r g p g ' o ' , oo o s o s f nn o m a O t l l i n d h a a a i a s s i a n b n l s s bi y yy o i i P n t r l o c i t c i O n c l ty l s . a y a a o e l o i i o r f v n m m i n S i n o a e o c a f l f f e n o n l s p y e p r y r r o r m o c r a o o c d l t d l r u u aa i u n i ii c o c t i nm t s n t t
thereof which gives rise to the claim.
5. R w e a m i e v d er i e o s f . a T n h y e o t c h i e ty r ' b s r r e e a m c e h d i o e f s t h s e h a s l a l m b e e o c r u a m n u y l a o t t i h v e e r a p n ro d v i r s e i m o e n d . i A e c s c h e e p r t e a i n n c e ss pp o ee f cc li a ff n ii y ee dd i t dd e oo m s nn oo o tt r p eexx a cc y ll m uu e dd n ee t aa n t ny h y e r rr e ee f mm o ee r dd e ii s ee h ss a l a a l l l n l l o o o w t w e e w d d a b i by v y e l l a aa n ww y o o b r f r e ii a nn c e h eq . quuity. Waiver of any breach shall not constitute
6. Default, Payment or acceptance of any items after the delivery date shall not constitute a waiver oft thhee City's right ttoo ctanaceln theise ortders wiitha reespaectr tot suibseeqluenet sdel icvheerlile sn.o T t h ree lCiietvey
S
r
e
e
l
s
l
e
e
r
r
v e
f
s
r o
th
m
e
l i
r
a
i
b
g
i
h
l
t
it y
t o
f o
r
r
e a
t
s
e
o
n
n
d
a
e
b
r
l
o
e
r
t e
d
s
e
t
l
i
i
n
v
g
e r
a
y
n
o
d
f n
in
o
s
n
p
c
e
o
c
n
ti
f
o
o
n
r m
b
i
ef
n
o
g
r e
g o
p
o
a
ds
y m
n
e
o
n
r
t
c
o
o
r
n st
a
i
c
t
c
u
e
t
p
e
t
a
an
w
c
a
e.
i v
T
e
h
r
e
o f
C
a
i t
n
y
y
's
o
f
f
a
t
i
h
lu
e
r
C
e
i
t
t
o
y '
i
s
n s
r
p
ig
e
h
c
t
t
s
a
o
n
r
d
r
a
e
c
m
c
e
e
d
p
i
t
e s
o r
f o
r
r
e j
b
e
r
c
e
t
a
g
c
o
h
o
o
ds
f
,
c o
m
n
a
t
t
r
e
a
r
c
i
t
a
.
l s
T
,
h e
or
C
a
i
r
t
t
y
ic
r
l
e
e
s
s
e
s
r
h
v
a
e
l
s
l
t
n
h
o
e
t
r
r
i
e
g
l
h
i
t
e
t
v
o
e
reject any or all items not in conformity with the specifications noted within this purchase order in any respect.
789 F.O.B. Destination. Freight terms are F.O.B. Destination, Freight Prepaid, unless otherwise approved in writing by the Commissioner of Purchases and Supplies.
N P N a o o t n n e - - n A A t s s , s s T i i r g g n a a m m d e e e n n m t t a , , r N N k e e o i r r t n h C e e o r r p t y h r i i ss g c h o t n t I r, n a f c r t i , n n g no e r m e a n n t yo . i S n e t l e l r e re r s a t g h r e e re e e s i n t , o s d dh e a f ll e n b d e , a e s n s ti i r g e n l e y d a o t r i i s t t s s u o bc w o n n t e r x a p c e t n e s d e , b y al l t h c e l a S i e m l s le , r d e e x m c a e n p d t s u , p a o n n d t a h c e t p i r on i s o r t h w a ri t t m te a n y c b o e n s a e s n s t e r o f f e t d h a e g C a i i t n y s . t the City for all alleged
ppaatteenntt., ttrraaddeemmaarrkk,, aanndd//oorr ccooppyyrriigghhtt iinnifrriinnggeemmeenntt rreessuullttiinngg ffrroomm tthhee uuse or resale of goods covered by the PO, and to indemnify and hold the City harmless against all costs, expenses,
legal fees, and judgments related to such claims, demands, and actions.
10. Timing. Time is of the essence in this contract. Failure to deliver within the time specified shallI eennttiittllee tthhee CCiittyy,, in addition to any other rights or remedies, to cancel this order and
purchase the goods elsewhere, in which event the Seller shall be responsible for any increase in cost.
11. Implied Warranty. In addition to its standard warranty, Seller warrants that all goods supplied willb e free and clear of all liens and encumbrances, good and merchantable titie being
b p in u e r t o c h f h e a g S s o e e o l d l d , e r a a . n n U d d p m t o h e n a r t c r h e S c a el e n l i t e p a r t b w b l i y e l l S q e n u l a o l l t e i r t s y u o . b f s p t A i a l t l y u m g t e o e n o t d , s g w o i o ll d c aa o n n nd f o mC r e m ri c t h o at t n h ty e a C b' i l t e y s t ' i s t s s l n e p e w e ci c i i lf f li i vc c ea a st t ti i o o inn n s s t o o h r r e C t t i h h e t e y a a . n p A p p l r r l o o v v g e e o d d o d s s s a a w m m i p p l l l l e e b a a e s s f r t t e h h e e e f c c r a a s o s e e m m m a a n a y y y b d b e ee f ,, e a a c n n ts d di w w n i i l l d l e l s b b i e e g n f f , i i t t m a f fo o t r r e r t t i h h a e e l s k k n n or o o w w w o n n r pp k uu m rr a pp n oo s ss h eess i p f t o o a r r n w w d h h w i i i c c l h h l
anything without the City's written consent.
13 C
a
C
c
ah
t
na
u
cn
a
egl
l
l e
c
a
o
tO
s
ir
t
od ne
f
,r
oo
s
rr
T . h
w w
eN
o o
o
r r
Ci
k k
ct hy
a a
a
n n
ns
d d
gh ael
mm
sl
aa tt
ihn
ee
a
rr
tv
ii
he
aa
e
ll
t
ss
Ph Oe
aa
,
pn
r
p p
ii
ll
tg
ii
sh
cc
tp
aa
rt
bb
io
ll
c
e
e
e
c s a,
ss
n
oo
ct
ll
ee
ee
l
ll
r
yy
mt s
t
h
t
,
o
i
o
s c
tt
oo
hh
n
i
r
i
d
ss
di et
oo
ri
rr
,o
dd
no
ee
sr
rr
, al
tt
ne
hh
ny
aa
g
tt
tu hn
hh
,d
aa
eo
vv
lr
ee
i av
bb
te
ee
rt
ee
ea
nn
dc h
ee
pm
xx
oe
pp
rn
ee
tt
c
i
c
s
t
o
t
n
ee
a
dd
ro ef
w w
p
h h
teh
e e
ri
n n
ms io
SS
fr
ee
fd
ll
ee
ll
d
e
r
e
,
rr
, ww
rr
ii
ee
tt
cc
h
e
h
e
o
ii
ou
vv
u
e
t
e
t
ss
t c h
nn
ae
oo
u
ft
Cs
ii
ie
cc
t,
ee
y a
o o
sn
f f
dp
c ca
i
a
tt
nn
s
cc ee
lt
l
i
l
a
ll
b
aa
ie
tt
l
ii
i
oo
tny
nn ..
f a
T
o
T
r
h
p
h
s
ee
pu
C
c
C
r
i
h
i
o
ttyy
c n a n
m
d
m
c
aa
e
yy
l
,
l
,
a
aa
ti
tt
o
i
n
i t t s
s
s
h
oo
a
pp
l
tt
l
ii o
b
onn
e
,,
l
c c
i
a a
m
n n
i
c c
t
e
e
e l
d
l t
t
thh
o
ii
S
ss
e
o
l
o
l
rr
e
ad
r
ee
'
r
s
r
w i w i n i t s t o h h l o o v u u e t t n l c l i y i a a b b p i i r l l o i i c t t y y e et t d o oi S Sn e eg l ts l l, e e o r r r ( ( e ( e d x x ) c c e e c p p o t t m m ffo i orr t s c c o o a n n f b i o r o e r r a m m c i i h n n g g i n s s t h h i h i p e p m m p e e e n n r t t f s s o r tt m hh a ee n L C c i e t o y f p a re n v y i o o b u l s i l g y a a t a t i c i o o c n n e p u u t n n e d d d e e ) r r i t f t h h S i i e s s l a a l g e p r r r e ( e e a e ) m m e ec n ena t ts o e o r s r o otf f o a a ex n n i y y s t o o , t t h h (b e e ) r r b w w e r r i i c t t o t t m e e e n n s a a g g i r n r s e e o e e l m m v e e en n n t t t , w w ( i c i t ) t h h b t t e h h c e e o m CC e iitt s yy t oo h ff e C C s l l u e e b v v j e e e l l c a a t n n o d d , f . bankruptcy or
14. s C e o r m v p ic l e i s a . n S c e e l l w e i r t s h h a L l a l w d s e . f e S n e d ll a er n d sh h a o l l l d c t o h m e p l C y i t w y i h t a h r a m l l l e f s e s d e f r r a o l m , s a t n a y te l , o a s n se d s , l o d c a a m l a l g a e w s s , , o or r r d c ai os nm t a s na c a e r ns i , s e i r n ue g l es f s r ,, o a m rn d o l r r e c e a g,u u l s ua e t d ei o i wn n s a o i n nS y t w eh a el y m la b n y eu S fr e a l c l 't er us ' r s e a a a c c t n t u u d a a l l s a o o l r r e a o a l l fl l et e g g he e ed d g v v o i i o o o d l l s a a t t i i a o o n n n d o o pf f e a a r n n f y y o rf f e e md d ae e nr r ac a le l .1 .o sft atthee.
15. c A o o o r c r n c l l t e o o r s c c a s e a c l l t t l l / o a a o w w r R , . d d e e c oo h r o rr , i r dd d w ii c s h nn h : a i a n c n o S cc h v e ee e l ,, v e l e r e r r r u r u l l o s o e e h c c o a o c c l rr u u l r r r r s s p ee r gg l l a u o u a s ll v s t aa t i . tt d ii e oo nn a .. ccess to pertinent records relative to this contract/order for a period of three (3) years after the last receipt of payment is made under this
16. MMaatteerriiaall SSaaffeettyy DDaattaa SShheeeettss:: AAnnyy ssuubbsstance delivered as a part of this order must be properly labeled in accordance with all applicable regulations and must be accompanied by a
Material Safety Data sheet (MSDS).
17. V s e et n t u l e e . me A n n t y o n d i f s i p na u l t e d e a c r i i s s i i o n n g o u f n a d n e y r d t i h s i p s u t o e r , d e S r e l n l o er t s d h i a s ll p o p s r e o d c e of e d b d y i l a i g g r e e nt e l m y e w n i t t s h h t a h l e l b p e e r d f e o c r i m d a e n d c e b y o f a t c hi o s u r o t r d o e f r c i o n m p ac e c t o e r n d t a n ju c r e i s w d i i t c h t i t on h e i C n i C ty u ' y s a d h i o re g c a t i C o o n. u n T t h y e in the State o O f r O d h i i n o a . n c P e e n of di t n h g e
CCiittyy ooff CClleevveellaanndd sshhaallll ggoovveerrnn..
18. Tax. Buyer is exempt from Federal and State taxes for tangible personal property. Sellers doing business with the Buyer may not be exempt from payiinngg sales tax to their suppplliiers for
materialsk to ffuullfoillll ccoonnttrraaccttuuaall oobblliiggaattiioonnss w w i i t t h h t t h h e e BBuuyveerr,. nnoorr sshhaallll aannyy SSeelllleerr bbee a a u u t t h h o o r r i iz z e e d d ttoo uussee t t h h e e B B u u y y e e r r ' ' s s T T a a x x EExxeemmppttiioon number in acquiring such materials, without tthhe prior
19. i i D s s o s s c u u u a a m n n c e c e n e t o o a f f t a a i o s s n i i g . g n n S e e e d d l l T er aa s x h a E l x l e c m l p e t a mi r o ly n m C a er r t k if a ib l c l a d t o e. c u A m e T n aa t x a t E i x o e n m p w t it il h o n t h C e e a r p ti p f l i i lc c a a t b e l i e s v a a v l a i i d l p a P b O le n u u p m o b n e r w . ritten request.
20. C p P P t c C i i h i a a a i t e t t y y y y r y . y m m m e s e e s e f U U hh o n n n n a n a r t t t l ll l e l e l e s T T s s s h bb e h e s s a ee a r r l o l o m l m ss t l t s s uu h o h b . bb . e p e i e j e r r e P e P r w v c cc a a a i i a tt t s y y s l e e e m m c t t o o u e e a ss l n n s tt d d a aa t t e e t a tt d d e ee w w f u u d dd i i u c c l l l f i t t l i l l nn r i i a b b o o o t t e n n n e h h m d e e o o t m m c r r P h P a a o e O O s d s d m e , e . e r p e t t e l o t o c t i i f e f h h e n n f f e t e i e a a p bb t t t c c yy e e r c c e r r o o o t t l m m f r r h h e s s i e d e d a n s a a o o CC e v n n f f i i o c c o p t p t i e e f a y a y c t v e y w w bb h m i m o i yy e t r e e t h h n r n r C r e i e t t e t t t a a c h h y s s s s e e e . h h o o i a a n t n p t N l l t e e l o l o o r r o b b f f m m p r e e a s s a a f nn n n y o i o y e y e m n n n t t a e c c l t 3 n t 3 o o 0 h h 0 t a u u e e c n n f dd c t t f f o aa e e e a r yy p r r e c ss g t c c e o a f i l f o o n o a a r r f c d i i t o o e s m m t m i m h o o a i a t s t f r r s r h h i i t e e s c s s h e o i i o rr e r n n n ee v t g g cc g t i r ee o o c o a ii o e u u c c pp s d t t t tt , s o o s o o o f h o o f f f a r r t l a t a h l h t s i i pp c h e s s rr r o e v n oo o o S i s r pp r e c t ee l e i aa rr l s t nn e , u i r y y t w n ' e v s h o o o a i t t i i c n c h c n c c e e h b v e e r r e o . e p i v v I t t t c e t e r r a e r a a r s , n n n h I w c i s a s s s h e l a a l i l c l e o a a c t t f b t t i i h e e e a o o e r r n n n . . u v y n e A w A w d r l l i i d e l l e t r a r f h n c cr s e l le t t c t a a h t h o i mi i e e o m m v o d S e s s S r e e t f l o fe t h o l r o e a e r f r r t r n a . . o m m v t T n o o o h r c e h n n a o e e c c b n y y a l f a s e o c d d h c r u t u e o e d m e p i i t t s o o n h a c r r g e n o t t u c g C o o n e o i t o b b t b d y e e p y s e c c a r t o o o i n i h m r m o d e e d e c s p , S e d d e a r i el u u f y v l e e i a m e c s r n e t e f y n s o r r , t f o o h b t m m y y o f d i t t t a t t n h h t h h a h e e e l e e e
City will date from receipt by the City of acceptable goods and invoice and not from date of invoice.
21. Insurance, Unless otherwise stated in the specifications, whenever labor is involved, the Seller shall procure and maintain insurance against claims for injuries to persons or damages to
O p p
ff
c
p
c r r
o o
h
o
oo o
l
o
ll
i mm
i
p p
ll
o mm
c
e e
oo y
e r e r
ww
a t t
ii
nn
o
n y y
nn
cc
r
, ,
gg
d ii w
c
w n
m
n m
m
h
o
h gg a
i i v
i i i
n n e
ww c c n
i i r
oo h t h
a m m
rr a
g
m m kk
u u
i
e
. a . a
m
n
m
y y TT
a
a
ii
h h a
n
n a
nn
r ee
d
r
ss
i A i
uu
s C s C
i
.
rr
e e ii
m
M
aa
t t
m
t f .
nn
yy
e
r r
c
B
c d e
o i
e
e o i s
i
s m s m
c a c
t t t
o t o
oo o o
v
r
e v
rr bb
e l e
ai i ee
r y r
t n n
a a
i a a
u
c c
g
n
g
d d
p
o og
e e
d d n n
o
e
i
e o
i
n n
n nn
d d e e f c c
t aa
n t t t t
h c
o
c
o o i i
e c c
o o c
o
c
o
n n l
C r
aa e
r o
w s w c
d
c
d
s
m
h i i
a
h
a
t
p
t
n
t
n
p p h
a c
h h
c
o o
e n
a
e
l t l t n
y
i h i h
ww
c
'
c e e A
ii
y y
s t
:
t
ss a a
h
e
h
e
r
s s r r V
e
vv
tt
I a
c
a ii
hh e
I c n c n
ee i
ee
p
o ss a a
ee t
,, r d d
ss
d d m
t
m
t o
b i i a
ii
a
f
e t t t
mm
t i i e
n aa
e o o a r
o tt
r n n i n
t ee
a a a a
i dd
i l l l
c
i s s
v e v
n i i , ,
a
s
a
n n e
f l
u e
l
s s
r
r
u
u q
u
u e
e o
r
e
u r r e
m
e i
l
q
l
d d p
ii
a .
t
.
mm
m p
h ii
T e T p
e tt
h
s
n h r
s
u
:
e
c :
t e o
a
v
1
a S
r 1
S e
))
n e
r
e d y l d
i
l
P P
l
e
/ l
u
b e
u r
e o
r
r
r
r y r
o c c
s s s
f h
t t
h
h h u
a
h h a
a
a
a
p
s
l e e
s
l
n
p l
e e
l
y
C C
s s
n i i i o e
c
t
l
t o
l
t s
a e
y
e
y n i
n ss
.. p l f
s c s
r y y T T
e
o
t t l
h h t t v
h h l
e h h e i
a a a
e e
t
d
n n
S S
i
e C C e e
$ o $
i d l i l
n 5 5
l t t l t
0 0
e y y e
o
o
, ,
r r
r 0
i i
0
t s s n
0 0
h h
r
h
0 0
ww e a
e
a
: :
r l r
d
l C l i
u
i l i
G G
t
c
t i
e e
s s i
t
y n
n n
u n u
i
.
e e
gg b b
o
T
r r
m m
n
a a
a
h
a
i i t
i o l
e t t
f
l
LL
e a a i
i
a
i t
l l n s
aa
l
h
l s tt
bb e
u r
i
r
l
r 3 e
l
e
c
e
i
0
i
q q r
o t t
u u (
v
r
y
d
y
s i i
e
a ) r r
r iI
y e e
a n
m d s d
g s
u a
e un
b s i i
r
e t n n
o
f
a
s s
r
o
n
b
s
u u r
c
e i r r
p
e
e
a a
o
l
,u
n
l
n i i t
i w
c c c
c
e e
i
e c
y
n
t
a
r .
c s n c
h
e e e c
S
S r d r e
a e
e t
a
t l l
l
f i i
$
l
l
s f o l e
5 e
i r i ro c
n r 0
c a b r
0
a t
m
u t m
,
e r e s
u
u
c0
s e s i
s
s
0
d n
t
t t
0
t u e o o
e
c s
c d
d e s t t
e o
e s h h i
m
m
m>
e e n
o
i o
b
t
n
n t C s
i
C
s
s h i i
nn
i
t
t e t t
e
n
r
r y y S
d
s a
a
t u b t
t
b
s
a
s
r e e
e
e
i
t a f
u
l
n
e n o t o
t g
c o r h r
h l
e f e e
e e
e
S
l
t
a
c t
i i
e h h o
n m m
l e e
i
m
d i
l
t t
w e b w
. . $
r o i o
2 2
'
2
r n r
,
s
) )
k k e
0
, i
P P
,
0
d n
u u 0
w w s s
, r r
i i i u
0 e c
n t r t
0 n h
g h a h
0 a a
l n
s s
e
p
bb c
e e
oo
r
l e
s s
d i d
o
m s ii
3d $
i h ll
u 5
t a yy
c
s
0
l
5
,
t ,
l i i
s 0
n n i b
0
j j n
0 a 0
e u a c
n
r r l p
a d
y y u
,
r
n
d
c
i l
d
i u
o
i
0
m n m
m
i
o
g a i
p v
t r s b
e l G
s y
r
o
e :
d o
t
o a i
e
f f
e
n
G
l
d
s $ d y
e
$ 1
e n o
1 i , a
e p
, n 0 n
e r
0 j 0
r
y
a
u 0 0
a l
r , ,
t
i y 0 0
L i
n 0 0
i o
a s 0
a
0
n
u n
b s
r
i
f f d a
l
o o
a
n
i
r
g
p c
t g
r e
y
e e
r
o a a
e
p
I
c o c
g
e
n
r h h
a
r
s t
t
u
s pp
e
y
r
e ee
. a
l rr d
A
f
n
ss a -
c u
oo m
s
i
e t
nn n a
t o
s
a
g
w m
a u
im
e
o
r n
to
. a
b
d
hb
n
i
T
i
c
b
$
l l
h e
o
11
e e
e
d
, m
i L L
0 a ,
l
a
i
0
a
i
y a
b 0
b
n
b
, o
i i
t
i
e0
l
v
n l
a 0
i
e
j i
i 0
t t u
n l
y y
i
r
e i f m
y I
o m
I
d i r i
n n a
t t
s
b
s
e
n
s s
u u
y a
d r
a
r
a c t
a
r r
a p
h h
n
e
n
e
r
e
c c o
a t t
e e p
c C h h c
e
i e e
m m
i
r
t
u u
d m y
t
m e
s s y
i i n
t t
s t n
d
n h ,
b b
a i
a
i l
e e
m
m
a m l n u
a i
u
i
b
n n
d
g
m m e
e e e f
w a a
f
e
f l
i c
f
c x
e e i
t c c c
c c m
h e e
t t
e
i
p n s
t f
p t t
f s
s
o
r a a
o r o
o
r
b b f
f
p l o l
a a
r e e e
$ n n
r
1 y
a
y
a t t
,
h n n y
0 o o
e d d
0 w w
d
0
C
n n
d a d
,
i
e e
o m o
0
t
d d 0
y a
, .
n n
0
g o o a
h f h
e t t n
i o i
d
r r r
i l i
e e
i n n
e
n
d d
m f f
a
o i e e
a a c
t r t r s
h n n
o o c
d d
o r r o
o
f n
n cn
p p t
c o
$
o
l l r
u
1 a
n n
a i
r
, c c
- -
b 0
r
e e
o o
u 0
e w w
t a a 0
n
e
h n
,
c
l l 0
e ee
i i w 0
d d
m m i
w
0 i i t
v v i
t t h
e e
f
t
o o
n
o
h h
t r
i
n
i
n h
a c c
e e
i
t
l
t
$
a
e
h
e
h c
2
c e e
u u ,
o h
s s
l
0
l v i i
e e 0
e a a a
d 0 d
r c b b
,
c a i i
ii 0
i l l g
nn
i d i
0
e t t e
t 0 t
y y n
h
m
h g
t
e
o
e
o a
e
; f f i
p n p
n t t
e
O
e
t
e
h h
r r
R a e e
a if
i
l
S S
o
$ n
o
e e
a r
1 e l l
g m
, d
r
l l
g a
0 e e
r a
r 0
n
r b .
e
. 0
c
y
g
,
e
TT
a
0 t hh
o t
h 0 ee e
f e
0
Seller.
22. Workman's Compensation: Whenever labor is involved, the Seller shall subscribe to and comply with the Workmen's Compensation Laws ooff tthhee State of Ohio aanndd pay
such premiums as may be required there under and to save the City harmless from any and all liability arising from or under said act. He shall also furnish a
copy of the official certificate or receipt showing the pa ymentss herein referred ttoo belore commencing any work.
23. A I I n u n s s t p p h e e o c c r t f i i i t o o y n n t a a o n n B d d i n A A d c c , c c e e A p p l t t l a a p n n a c c r e e t . i . e N N s o o t o m m t a a h t t i e e s r r o i i r a a d l l e r r r e e c c a e e g i i r v v e e e e d d s b b t y h y a t t t h h t e e h e C C i i r t t e y y p p r p e u u s r r e s s n u u t a a a n t n t i t v tt e oo s t t n h h a e e m p p e u u d r r c c h h h e a a r s s e e e i n o o , r r i d d n e e c r r l u i i d s s i s s n u u g e e d d i n u u n n al d d l e e a r r t t t t a h c e h tt m e e rr n m ts s , a pnods s c e o s n s d f i u t l i l o n a s n d of c t o h m i p s l b e i t d e d a o u c th u o m r e i n t t y t s a o h n a t b l y i l n b o d e f s t d a h i e e d e S p m e a e l r l d t e i r a e h c s e c . r e e pt i e n d until
t i I n h n i i e t t i i C a a i l l t ii y nn ss h pn a ee s cc tt h ii a oo d nn, r o o e r r a s a a o t t n aa a n b n l yy e l l o a at t p e e p r r o r t t t i i u m m n e e i i t iff y t t h h to e e i dd n ee s ff p ee e cc c tt t ss s c c a o o i n n d t t a a m i i a n n t e e e r d d i a ii l nn . t t A hh l ee l m m m a a a t t t e e e r r r i i i a a a l l l w w w e e h r r i e e c n h n o o i t t s r r d e e i a a s s s c o o o n n v a e a r b b e l l d y y t a a o s s c c b e e e r r t t d a a e i i f n n e a a c b b t l l i e e v e uu o pp r oo n w n h t t i h h c e e h ii nn d ii o tt e iia s all n im o n t ss pp c ee o cc n tii f oo o nn r ,, m m m t aa o y y a b n b e y e r r w e a t e r u r r e a n n e d t d y a i o t f t t h t h h e e e S s S e e e l l l e l e e r r r ' s s h e ee r xx e pp i ee n nn , ss u ee p f o o n r
f f w u u a l l l l y c c a r r f e e f d a e i i c t t t oo t rr h e r r e e C p p i l i t a c y c ' e e s m m e d e n i n t s t c . , o u N n o t p g r o oi o v d i s le g r e e s t . u r S n u e c d h a s ri d g e h f t e c t t o i v r e e t s u h r a n l , l o o bf f ef f e e r r r e e e p d d l a t t c o o e d t t h h w e e i t CC h iit o ty u y t a a r w r i r i s i s i t i n n t g g e n f f r r a o u o t m m h o t t r h h i e e z a C C t i i i t t o y y n ' ' s s f r r r e e o c c m e e i i t n p h t t e o o C f f o d d m e e m f f i e e s c c t s t i i i v v o e e n g g e o o r o o o d d f s s , , P s u s h r h a c a l l h l l a s n n e o o s t t a e e x n x c d c l l u S u d u d p e e p a l a i n n e y y s . o o t t S h h u e e c r r h l l r e e g e g a a t l l u , , r e n e q q s u u h i i a t t l a a l b b l i ien n o o r
contractual remedies the Cityy mmaayy hhaavvee tthheerreefioorree..
25. Non-appropriation of Funds. As with any other public entity, an Agreement, Contract,o r issuance of Purchase Order by the City is contingent upon the legal availability of funding and
the allocation of said funds. The City reserves the right to cancel any ongoing Agreement, Contract, or Purchase Order immediately, by giving written notice to the Seller, in the case of
26. a E t t C h h q . f e e u O a a i . t t l l , e e u a r r r O n e m m p d b p oo y o f h f r e t t t t r h h u h e i e i n i s s i n a t r p P m y u p u , a r r r d o e c p T n e h r h a a a i i s s a s e e p t a i A O r n g r t g r d o e b e f e o r t m d ,, h e t y i t s h n h t t e o A s i g S a s e r a p l a e p l r e " e o m r c p e s o s r n n h i t t a a r l t b a l e c y c t f r " o u e , m n f p a d e n l r s d e y o n r w c t e i h f . t e u h n A S d e a i l l c c n l l o o e g t m r m e p f l i r o l s e r m e a t s t t , e e h " e c c c c o o o o s n n p n p d e t y y i c r t i o o a f i f f c i o t c n t t o h s h p r e e r " a o E E n w j q q d e i u u c t a t a r h , l e i l c n q O O o u p t p i m p h p r m o e o e o r r m m d t t e e u i u n a n t n t n i y i s i t t y n o y i r g m C C s o p l l e o f a a r s u u v C e s i s h d c e e a e . i p o i s s n t a a e v v a r a a i " i 1 l c l 8 a a o 7 b b n l l t o e e r f a a a t t c t h t t e t o h h r e C e " o C C d i i i i n t t f y y i t o e h o d f f e O C C E r l l q d e e u v i v a e n e l l a l a n a O n c n p d d e p s o w w e r e o b t b f s s u i C i n t i t i e e e t . v y e l C a l n a d u , s e O , h S i e o c t 1 i 9 o 7 n 6 . 18 8 7 D 2 . u 2 2 r 2 7 i ( 9 n b ( ( g
jeh092311

Subject: Submission of NORTHERN IRELAND FAIR EMPLOYMENT
PRACTICES DISCLOSURE
Each bidder and/or appropriate parties should complete the DISCLOSURE and
submit it with the bid, if possible. If not submitted with the bid, it must be completed
and submitted to the Commissioner of Purchases and Supplies prior to any contract
being awarded by the City. If a bidder or appropriate parties fail to complete and
submit it, they shall not be eligible for a contract award.

NORTHERN IRELAND FAIR EMPLOYMENT PRACTICES DISCLOSURE
INSTRUCTIONS: Pursuant to Codified Ordinance Sec. 181.36, the information requested
on this page must be supplied by all Contractors and any Subcontractors having more
than
a
fifty percent (50%) interest in the proposed contract prior to any contract being
awarded by the City of Cleveland. Any Contractor or Subcontractor who is deemed to
have made a false statement shall be declared to have acted in default of its contract
and shall be subject to the remedies for default contained in its contract. For failure to
cure such a default, the Contractor or Subcontractor shall be automatically excluded
from bidding for the supply of any goods or services for use by the City for a period of
two years.
CHECK WHICHEVER IS APPLICABLE:
A. () The undersigned or any controlling shareholder,* subsidiary, or parent
corporation of the undersigned is NOT ENGAGED IN ANY BUSINESS OR TRADING FOR
PROFIT IN NORTHERN IRELAND. (If paragraph A. is checked, proceed to the signature
line.)
B. () The undersigned or any controlling shareholder,* subsidiary, or parent
corporation IS ENGAGED IN ANY BUSINESS OR TRADING FOR PROFIT IN NORTHERN
IRELAND. (If paragraph B. is checked, please either check the stipulation contained in
paragraph C. or attach documentation that shows that the undersigned has complied
with the stipulation contained in paragraph .
C. () The undersigned and all enterprises identified in paragraph B. are
TAKING LAWFUL AND GOOD FAITH STEPS TO ENGAGE IN FAIR EMPLOYMENT
PRACTICES WHICH ARE RELEVANT TO THE STANDARDS EMBODIED IN THE
"MacBRIDE PRINCIPALS FOR FAIR EMPLOYMENT IN NORTHERN IRELAND." A copy of
the MacBride Principles can be obtained from the Office of the Commissioner of
Purchases and Supplies. In lieu of checking this paragraph, the undersigned must
attach documentation which the undersigned believes shows compliance with the
stipulation contained in this paragraph C.
Name of Contractor
or
Subcontractor
By:
Title:
*"Controlling shareholder" means any shareholder owning more than fifty
percent (50%) of the stock in the corporation or more than twenty-five percent (25%)
of the stock in the corporation if no other shareholder owns a larger share of stock in
the corporation.

WAGE THEFT AND PAYROLL FRAUD DISCLOSURE
SUMMARY:
Bidders on certain City contracts, recipients of Assistance, and any of their prospective
subcontractors must disclose any wage theft or payroll fraud violations over the last three
years. Unless they receive a waiver from the City's Fair Wage Employment Board,
violators are placed on the City's Adverse Determination List, which prevents them from
entering into new contracts with or receiving Assistance from the City. This disclosure
requirement and the waiver process are set forth in Chapter 190 of the Codified
Ordinances of Cleveland, Ohio, 1976 ("Chapter 190").
INSTRUCTIONS:
Pursuant to Chapter 190, the information requested on this document must be provided
by any person or entity bidding on or making a proposal for a Construction or
Improvement Contract or a Service Contract, or applying for Assistance, and any of their
prospective subcontractors.
Any person or entity that is deemed to have made a false statement shall be declared to
have acted in default of its contract and shall be subject to the remedies for default
contained in its contract.
DEFINITIONS:
"Adverse Determination" means a final action or adjudication that the person or entity in
question has committed Wage Theft or Payroll Fraud and is further defined in Chapter
190.
"Assistance" means any form of City financial assistance, except for financial assistance
provided for the development, rehabilitation or other means of providing residential
housing. Assistance includes but is not limited to: grants; economic development loans;
tax credits, incentives and abatements; subsidies; and bonds. Assistance does not include
financial assistance which is received from another government or other entity with the
City acting only as a conduit or fiscal agent for the funds, where the City exercises no
control over the identity of any recipient or of the terms of the contract. Community
Development Block Grant Funds are not considered conduit funds and, to the extent they
otherwise qualify, are included as Assistance.
"Construction or Improvement Contract" means any contract entered into pursuant to
Chapter 167 or Chapter 185 of the Codified Ordinances.
"Payroll Fraud" means concealing an entity's true payroll tax liability or other financial
liability to a government agency from government licensing, regulatory or taxing
agencies through misclassification of employees, failure to report or underreported

payment of wages, or executing a cash transaction while failing to maintain proper
records of reporting and withholding.
"Service Contract" means any contract or subcontract between a person, business or
corporation and the City of Cleveland that primarily involves the furnishing of services to
the City (as opposed to the purchase of goods or other property or the leasing of
property), and shall be limited to the following categories of services: food service,
janitorial, security services, parking lot attendants, home health care, health care aides,
waste management, automotive repair services, landscaping, towing contracts, building
and maintenance services, carpentry, clerical services, urban forestry, housekeeping,
street maintenance and repair, and sidewalk maintenance and repair. This includes
services performed on City-owned premises including the following City-owned
locations: airports, parking lots, municipal parks, recreational facilities, and City-owned
buildings. Contracts that are primarily for the purchase of goods or other property are not
considered Service Contracts.
"Wage Theft" means a violation of the Ohio Prompt Pay Statute, RC 4113.15; the Ohio
Minimum Fair Wage Standards Act, RC Chapter 4111; Oh. Const. Art. II, Sec. 34a; RC
Chapters 4109 or 4115; RC 4113.17, 4113.18, 4113.52 or 4113.61; or a violation of any
substantially equivalent federal or state law; as any of these laws may be amended or
superseded.
CHECK WHICHEVER IS APPLICABLE:
(A) ( ) The undersigned person or entity HAS NOT had any Adverse Determinations
within the last three (3) years.
(B) ( ) The undersigned person or entity HAS had any Adverse Determinations within
the last three (3) years.
If (B) is checked, then in an attachment(s) to this form, please disclose all Adverse
Determinations within the last three (3) years.
Name of Person or Entity: __________________________
Signature: __________________________
Printed Name of Signatory: __________________________
Title of Signatory: __________________________
Date: __________________________