Pleasant Hill Urban Design Master Planning Services

Attachment "A"
Required Submission Documents
MaconBibb County
Summary of Attachment "A" Required Documents
Bidder Qualification Form
List of SubContractors
Bidder Minority Participation Goal
Financial & Legal Stability Statement
Insurability Statement
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
NonCollusion Affidavit
Instructions and additional information regarding the three forms below can be found on
our website under the Procurement Department Documents tab if needed.
MaconBibb County Vendor Application
Form W9
EVerify Affidavit

Attachment "A"
Required Submission Documents
BIDDER QUALIFICATION FORM
Company Name: ______________________________________________________________________
Address: ____________________________________________________________________________
When Organized: ______________ Where Incorporated: __________________________________
How many years have you engaged in business under the present firm name? _____________________
Credit available for this contract? ________________________________________________________
Contracts now in hand? ________________________________________________________________
Has bidder ever refused to execute a contract at the original bid amount? _________________________
Has bidder ever been declared in default on a contract? _______________________________________
Comments: __________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Company Name: _____________________________________________________________________
Authorized By (typed name): ____________________________________________________________
Authorized Signature: _________________________________________________________________
Title: ________________________________________ Date: ________________________________
References
Following is a reference list of contracts that are similar to this project:
NAME OF PROJECT/DATE LOCATION CONTACT PHONE #
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_____________________________________________________________________________________
_____________________________________________________________________________________
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
______ DAY OF __________________, 201___ My Commission Expires: _________________
_____________________________________ [NOTARY SEAL]
Notary Public

Attachment "A"
Required Submission Documents
LIST OF SUB-CONTRACTORS
I do , do not , propose to sub-contract some of the work on this project. I propose to sub-contract
work to the following contractors.
NAME/ADDRESS TYPE OF WORK % of Contract
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Contractor Name

Attachment "A"
Required Submission Documents
BIDDER MINORITY PARTICIPATION GOAL
(Attach additional pages if required.)
I do , do not , propose to employ the minority sub-contractors as listed below on some of the work
on this project.
NAME/ADDRESS TYPE OF WORK % of Contract
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Contractor Name

Attachment "A"
Required Submission Documents
FINANCIAL & LEGAL STABILITY STATEMENT
Please check appropriate item(s):
__ Firm has the financial capability to undertake the work and assume the liability required if awarded this solicitation.
__ Firm has the legal capability to undertake the work and assume the responsibilities required if awarded this solicitation.
Pending litigations (if any) will not affect the firm's ability to perform on this contract, if awarded.
Company Name: ____________________________________________________________________________
Authorized By (typed name): ___________________________________________________________________
Authorized Signature: ________________________________________________________________________
Title: ________________________________________ Date: _______________________________________
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
_____ DAY OF _________________, 201___ My Commission Expires: _____________
____________________________________ [NOTARY SEAL]
Notary Public

Attachment "A"
Required Submission Documents
INSURABILITY STATEMENT
Please check appropriate item(s):
__ By submission of this form, this firm confirms the ability to acquire and maintain the required levels of
insurance as outlined in the bid document. It is the understanding of this firm that proof of Insurance must be
provided prior to contract execution and maintained throughout the entire term of the contract.
Company Name: ____________________________________________________________________________
Authorized By (typed name): ___________________________________________________________________
Authorized Signature: ________________________________________________________________________
Title: ________________________________________ Date: _______________________________________
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
_____ DAY OF _________________, 201___ My Commission Expires: _____________
____________________________________ [NOTARY SEAL]
Notary Public

Attachment "A"
Required Submission Documents
Macon-Bibb County
Procurement Department
700 Poplar Street, Suite 308
Macon, Georgia 31202-0247
Tel: (478) 803-0550 * Fax: (478) 751-7252
www.maconbibb.us
CERTIFICATION REGARDING DEBARMENT, SUSPENSION
INELIGIBILITY AND VOLUNTARY EXCLUSION
The Bidder/offer certifies, by submission of this Proposal or acceptance of this contract, that neither it nor
its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary
excluded from participation in this transaction by any Federal department or agency. It further agrees by
submitting this proposal that it will include this clause without modification in all lower tier, transactions,
proposals, contracts, and subcontracts. Where the Bidder/offeror or any lower tier participant is unable to
certify to this statement, it shall attach an explanation of this solicitation/proposal.
Dated at this________day of_______________________, 2019.
Signature of Contractor: ______________________________________
Title: ______________________________________________________
For Macon Bibb County Personnel Only:
Macon Bibb County Procurement Department will verify that the above bidder/offer certifies, by submission
of this Proposal or acceptance of this contract, that neither it nor its principals is presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntary excluded from participation in this
transaction by any Federal department or agency.
Signature of Procurement Officer ____________________________________ Date _____________
Printed Name ________________________________

Attachment "A"
Required Submission Documents
NON COLLUSION AFFIDAVIT
Date:
Project: Bibb County, Georgia
Project #:
Project
Description:
Services General Contracting
Provided:
State of: Georgia
County of: Bibb
I, ______________________________having first been duly sworn, deposes and states as
follows:
I am the party making the foregoing Proposal or Bid; that such Proposal or Bid is genuine and not
collusive or sham; that said Proposer or Bidder has not colluded, conspired, connived, or agreed,
directly or indirectly, with any Proposer or Bidder or person, to put in a sham Proposal or Bid, or
that such other person refrain from proposing or bidding, and has not in any manner, directly or
indirectly sought by agreement or collusion, or communication or conference, with any person, to
fix the Proposal Fee or Bid Price of affiant or any other Proposer or Bidder, or to fix any overhead,
profit or cost element of said Proposal Fee or Bid Price, or that of any other Proposer or Bidder,
or to secure any advantage against Bibb County, Georgia or any person interested in the
proposed Contract; and that all statements in said Proposal or Bid are true; and further, that such
Proposer or Bidder has not directly or indirectly submitted this Proposal or Bid, or the contents
thereof, or divulged information or data relative thereto to any association or to any member or
agent thereof.
Contractor:
____________________________________
(Signature) (Seal)

Attachment "A"
Required Submission Documents
MACON-BIBB COUNTY
Vendor Application
Date Submitted:
New Application Revised Application
RETURN THIS COMPLETED FORM TO:
Macon-Bibb County Procurement Department Phone: 478-803-0550
700 Poplar Street, Ste. 308 Fax: 478-751-7252
Macon, GA 31201 Email: procurement@maconbibb.us
GENERAL VENDOR INFORMATION
Company Name:
Company Address:
Authorized By (Name):
Title:
Authorized Signature: Date:
Telephone Number: Fax Number:
Email Address:
REMITTANCE INFORMATION (where payments should be sent)
Remit to Name:
Remit to Address:
Phone: Fax: Toll Free:
Contact: Email:
Business Type (choose one): Individual/Sole Proprietor Single member LLC
Business - incorporated Business - not incorporated/partnership
LLC: C S P (circle one) Other (Specify):
Social Security #: Federal Tax ID #:
PURCHASE ORDER INFORMATION (where purchase orders should be sent)
Purchase Order Name:
Purchase Order Address:
Phone: Fax: Toll Free:
Contact: Email:
Payment Terms: Discount % # Days Net Due
Freight Terms: Ship Via FOB
E-Verify Information
Private Employer Affidavit is attached :
With E-Verify # _____ With E-Verify exemption selected ______
Contractor Affidavit is attached: (additional affidavit, if applicable)
With E-Verify # _____ Without E-Verify # but a copy of my driver's license is attached since
I have no employees and no intent to hire employees _____
MBE/DBE/WBE STATUS (Select at least one)
Minority Owned (African American, Hispanic, Native American, Asian American) circle one _______
Woman Owned _________ Disabled________ Veteran_______ Not Applicable________
Do you maintain a local office in Macon-Bibb County? Yes______ No_______

W-9
Request for Taxpayer
Give Form to the
Form Identification Number and Certification
requester. Do not
(Rev. October 2018)
Department of the Treasury send to the IRS.
Internal Revenue Service (cid:97) Go to www.irs.gov/FormW9 for instructions and the latest information.
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Attachment "A"
Required Submission Documents
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to
following seven boxes. certain entities, not individuals; see
instructions on page 3):
Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate
single-member LLC Exempt payee code (if any)
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) (cid:97)
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code (if any)
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions) (cid:97) (Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other - -
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
-
Part II Certification
Under penalties of perjury, I certify that:
1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3.I am a U.S. citizen or other U.S. person (defined below); and
4.The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign
Signature of
Here
U.S. person (cid:97) Date (cid:97)
General Instructions *Form 1099-DIV (dividends, including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise
*Form 1099-MISC (various types of income, prizes, awards, or gross
noted.
proceeds)
Future developments. For the latest information about developments *Form 1099-B (stock or mutual fund sales and certain other
related to Form W-9 and its instructions, such as legislation enacted
transactions by brokers)
after they were published, go to www.irs.gov/FormW9.
*Form 1099-S (proceeds from real estate transactions)
Purpose of Form
*Form 1099-K (merchant card and third party network transactions)
An individual or entity (Form W-9 requester) who is required to file an *Form 1098 (home mortgage interest), 1098-E (student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T (tuition)
identification number (TIN) which may be your social security number *Form 1099-C (canceled debt)
(SSN), individual taxpayer identification number (ITIN), adoption
*Form 1099-A (acquisition or abandonment of secured property)
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other Use Form W-9 only if you are a U.S. person (including a resident
amount reportable on an information return. Examples of information alien), to provide your correct TIN.
returns include, but are not limited to, the following. If you do not return Form W-9 to the requester with a TIN, you might
*Form 1099-INT (interest earned or paid) be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)