ACCELERATED BRIDGE PROGRAM
PHASE 1B
ZONE 2
DESIGN-BUILD PROJECT
PIN SABP.07, Contract D900007
INSTRUCTIONS TO PROPOSERS
APPENDIX D
FORMS
April 11, 2012
New York State Department of Transportation
APPENDIX D
Form DesignatorForm Title
Proposal Form
FPForm of Proposal
FP(A)Appendix toForm of Proposal
General Forms
ARAcknowledgement of Receipt
BACBuy America Certificate
CProposer’s Representative
CRCommitment to Assign Identified Resources to Project
DBERecord of DBE Performance
EEOEqual Employment Opportunity Certification
GFProposer’s DBE Good Faith Efforts
ICCertificate Regarding Ineligible Contractors
ISCertificate Regarding Ineligible Subcontractors
KPKey Personnel Information
LCLobbying Certificate
LDBList of Proposed DBEs
LSILetter of Subcontract Intent
NCNon-Collusion Affidavit
NSNamed Subcontractors
PABPayment Bond **
PEBPerformance Bond **
SCDSchedule of Contract Dates
UConflicts of Interest Disclosure
Price Proposal Forms
PPPrice Proposal Cover Sheet
SPSchedule of Prices
PBProposal Bond
** Form to be submitted after Proposal Due Date
Accelerated Bridge Program, Phase 1B, Zone 2PIN SABP.07, Contract D900007 / Instructions to Proposers, Appendix D
April 11, 2012
New York State Department of Transportation
ForM FP - FORM OF PROPOSAL
PROPOSERNAME
TITLE
TELEPHONE No.
ADDRESS
STATE FINANCIAL SYSTEMS VENDOR ID NUMBER
FEDERAL ID NUMBER
TO NEW YORKSTATEDEPARTMENT OF TRANSPORTATION (THE “DEPARTMENT”):
The undersigned proposes to design and construct this Project in accordance with the Part 1 - Design-Build Agreement, Part 2 - Design-Build Section 100, Part 3 - Project Requirements and all other Contract Documents and certifies to furnish and deliver all the materials and to do all work and labor required for the design and construction and other identified activities forthe Accelerated Bridge Program, Phase 1B, Zone2, Contract D900007in Dutchess, Orange, Putnam and WestchesterCounties, New York, at the prices stated in the Schedule of Prices (Form SP). The undersigned also certifies that the undersigned has examined the Site and the RFP, includingParts 1 through 7inclusive of the Contract Documents before submitting the Proposal and is satisfied as to the requirements therein. As further consideration for the award of this Contract, the undersigned agrees to the following terms, conditions and acknowledgments:
SECTION 1.To execute the Contract and to furnish Contract security, as specified in Contract Documents Part 2, DB Section 103-3 and Appendix (Part 1) to this Form FP within the time period prescribed in Section 5.0 to the Instructions to Proposers, and failing to do so, to forfeit the accompanying check or Proposal Bond to the Department as liquidated damages, and the Department may proceed to award the Contract to others.
SECTION 2.To commence Work promptly following the effective date of the Notice to Proceed, and to complete the Work by the milestone dates and completion deadlines specified in the Contract Documents.
SECTION 3.To furnish a performance bond and a payment bond in the amount specified in the RFP for the full, complete and faithful performance of this Contract.
SECTION 4.The undersigned declares that it is the only entity or party interested in the Proposal as principal and that its officers, employees, subsidiaries or parent corporations (check appropriate box following):
Have not in any way participated in any activities in restraint of trade, or been debarred with relation to public contracts either in the State of New York or any other State of the United States or on any federally-assisted contract during the five-year period immediately preceding this Proposal or either directly or indirectly entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free competitive bidding in connection with this Contract.
Have participated in activities in restraint of trade with relation to public contracts either in the State of New York or any other State of the United States or on any federally assisted contracts during the five-year period immediately preceding this Proposal or entered into collusion, or restraint of free competitive bidding on this Contract, and are of the opinion that they are a responsible Proposer entitled to the award of a contract involving, public moneys and attach hereto an explanation of their activities in restraint of free trade, restraint of free competitive bidding, or collusion.
SECTION 5. In accordance with the Contract to repair, maintain and guarantee all work performed thereunder as specified in the Contract Documents.
SECTION 6.The undersigned agrees that any and all claims that the undersigned may have for overcharges resulting from antitrust violations as to goods, services and materials purchased in connection with this Proposal are hereby assigned to the Department, but only to the extent that such overcharges are passed on to the Department. The undersigned further agrees to require its Subcontractors to assign any and all such claims for overcharges to the Department, but only to the extent such overcharges are passed on to the Department, by executing an assignment on a form obtainable from the Engineer prior to the commencement of work by a Subcontractor. The undersigned retains all rights to any such antitrust claims to the extent of any overcharges not passed on to the Department.
The undersigned tenders herewithaProposal Bond in the form of Form PB (see Appendix D to Instruction to Proposers).
ProposerOrganization
By
Title
State of / }ss
County of
CORPORATE ACKNOWLEDGMENT
STATE OF
:SS.:
COUNTY OF
On the ______day of ______in the year ______before me personally came ______to me known, who, being by me duly sworn, did depose and say that he/she/they reside(s) in ______(if the place of residence is in a city, include the street and street number, if any, thereof); that he/she/they is (are) the ______(president or other officer or director or attorney in fact duly appointed) of the ______(name of corporation), the corporation described in and which executed the above instrument; and that he/she/they signed his/her/their name(s) thereto by authority of the board of directors of said corporation.
______
Notary Public
ACKNOWLEDGMENT FOR OTHER ENTITIES (in New York)
STATE OF NEW YORK
:SS.:
COUNTY OF
On the ______day of ______in the year ______before me, the undersigned, personally appeared ______, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity (ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
______
Notary Public
ACKNOWLEDGMENT FOR OTHER ENTITIES (outside of New York)
STATE OF
:SS.:
COUNTY OF
On the ______day of ______in the year ______before me, the undersigned, personally appeared ______, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity (ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument[, and that such individual made such appearance before the undersigned in the ______
(city or political subdivision and the state or county).
______
Notary Public
Accelerated Bridge Program, Phase 1B, Zone 2PIN SABP.07, Contract D900007 / Form FP / Instructions to Proposers, Appendix D
April 11, 2012
New York State Department of Transportation
FORM FP(A) - APPENDIX TO FORM OF PROPOSAL
Appendix to Form of Proposal – Part 1
1.Proposal Validity Period180 days from Proposal Due Date
2.Warranty Period: Per DB §104
3.Proposal Bond (Form PB) 5% of Proposal Amount
4.Performance Bond (Form PEB)100% of Contract Amount
5.Payment Bond(Form PAB)100% of Contract Amount
6. / Design-Builder’s minimum required insurance / Per Contract Documents Part 1 DB Agreement Article 17.- Liquidated DamagesPer Part 1 Design-Build Agreement Article 19.
8.The address of Department’s Designated Representative:
William Howe
Attention: Accelerated Bridge Program Procurement
Office of Contracts Management
New York State Department of Transportation
50 Wolf Road, 6th Floor
Albany New York 12232 USA
email:
Appendix to Form of Proposal – Part 2
(To be completed by the Proposer as part of the Proposal documents)
Extend cell sizes for items 1 through 6 as needed and add rows to item 7 as needed
PROPOSER:- Design-Builder’s proposed insurance policy coverage
- Design-Builder’s proposed Designer
- Design-Builder’s Proposed Named Subcontractors
- Parts of the Project proposed to be subcontracted other than to Named Subcontractors
- Design-Builder’s local address within worksite area
- Contract Time
- RFP Addenda issued by the Department and received by the Proposer:
Addendum No.: / Date:
Accelerated Bridge Program, Phase 1B, Zone 2
PIN SABP.07, Contract D900007 / Form FP(A) / Instructions to Proposers Appendix D
April 11, 2012
New York State Department of Transportation
FORM AR - ACKNOWLEDGMENT OF RECEIPT OF RFP,
ADDENDA AND RESPONSES TO QUESTIONS
(to be attached to Volume 1 of Proposal)
NAME OFPROPOSERWeherebyacknowledgereceiptof the Accelerated Bridge Program, Phase 1B, Zone2RFP datedApril 11, 2012 andsubsequent responses toquestionsand Addenda issued by the Department, as listed below.
Add additional lines in tables below, if needed.
Addendum number: / Date issued by Department:Responses to questions number: / Date issued by Department:
SIGNED
DATE
NAME
(printed or typed)
TITLE
Accelerated Bridge Program, Phase 1B, Zone 2
PIN SABP.07, Contract D900007 / FormAR / Instructions to Proposers Appendix D
April 11, 2012
New York State Department of Transportation
FORM BAC
BUY AMERICA CERTIFICATE
The undersigned certifies on behalf of itself and all proposed subcontractors (at all tiers) that only domestic steel and iron will be used in the Project.
A.Proposer shall comply with the Federal Highway Administration (“FHWA”) Buy America Requirements of 23 CFR 635.410, which permits FHWA participation in the Contract only if domestic steel and iron will be used on the Project. To be considered domestic, all steel and iron used and all products manufactured from steel and iron must be produced in the United States, and all manufacturing processes, including application of a coating, for these materials must occur in the United States. Coating includes all processes which protect or enhance the value of the material to which the coating is applied. This requirement does not preclude a minimal use of foreign steel and iron materials, provided the cost of such materials does not exceed 0.1% of the Contract Price.
B.A false certification is a criminal act in violation of 18 U.S.C. 1001. Should this Contract be investigated, Proposer has the burden of proof to establish that it is in compliance.
C.At Proposer’s request, the Department may, but is not obligated to, seek a waiver of Buy America requirements if grounds for the waiver exist. However, Proposer certifies that it will comply with the applicable Buy America requirements if a waiver of those requirements is not available or not pursued by the Department.
PROPOSERSIGNATURE
NAME (printed or typed)
TITLE
DATE
Accelerated Bridge Program, Phase 1B, Zone 2
PIN SABP.07, Contract D900007 / Form BAC / Instructions to Proposers Appendix D
April 11, 2012
New YorkState Department of Transportation
FORM C
PROPOSER’S REPRESENTATIVE
In accordance with ITP Section 2.2.3, the following person is named as the Proposer’s Representative:
ProposerName of Proposer’s Representative
Company Affiliation
Address
Office phone (direct dial)
Cell phone
Accelerated Bridge Program, Phase 1B, Zone 2
PIN SABP.07, Contract D900007 / Form C / Instructions to Proposers Appendix D
April 11 2012
New YorkState Department of Transportation
FORM CR
COMMITMENT TO ASSIGN IDENTIFIED RESOURCES TO PROJECT
Understanding the Department’s concern that the personnel resources, materials, equipment and supplies specifically represented and listed in this Proposal actually be assigned to the Contract (if awarded to this Proposer) and not also be committed to other Projects.(Name of Proposer)
commits that the personnel resources shown in the Proposal, including identified design staff, and materials, equipment and supplies specifically listed in this Proposal will be available to the extent within this Proposer’s control. If awarded the Contract, this Proposer will undertake all reasonable efforts to provide all the Key Personnel identified in its Proposal on a full time basis for the periods necessary to fulfill their responsibilities.
In making this commitment, we include the following reservations:
(If made without reservation, enter “NONE” above.)
Signed:Printed name:
Title:
Date:
(To be executed by the Proposer’s designated Project Manager)
Accelerated Bridge Program, Phase 1B, Zone 2PIN SABP.07, Contract D900007 / Form CR / Instructions to Proposers Appendix D
April 11 2012
New YorkState Department of Transportation
FORM DBE - RECORD OF DBE PERFORMANCE
PROPOSERThe Proposer hereby confirms that there is no change in the Proposer’s record of DBE performance, relative to the Proposer’s SOQ submission
Signed
Name
Title
Date
Or (B), the Proposer confirms that: (i) there have been changes in the Proposer’s record of DBE performance relative to the Proposer’s SOQ submission; and (ii) the Proposer has completed Form DBE Tables 1 and 2, as needed, addressing all such changes. The changes are the result of [check applicable box(es)]:
The addition of Principal Participant(s) and/or Designer(s) to the Proposer’s organization since the SOQ.
Completion of additional projects involving DBE participation by the Proposer, Principal Participant(s) and/or Designer(s).
Signed
Name
Title
Date
Add rows if needed
Form DBE Table 1 RECORD OF DBE PERFORMANCENAME OF PROPOSER
NAME OF FIRM
ROLE OF FIRM / Principal Participant: / Designer: / QC:
Other (describe):
Provide the information requested below for projects completed during the past 36 months and not included in the SOQ where the firm was the prime contractor or prime consultant.The term “firm” includes any Affiliate including parent companies and subsidiary companies.
For any project where DBE goal was not achieved, use Form DBE Table 2 to provide an explanation, using relevant project name for cross-reference.
PROJECT NAME / DBE participation goal (%) / DBE participation achieved (%) / Current owner contact
(Name/ telephone / email)
Add rows if needed
Form DBE Table 2 EXPLANATION FOR NON-ATTAINMENT OF DBE GOALSNAME OF PROPOSER
NAME OF FIRM
For any project listed in Form DBE Table 1 for which the DBE goal was not achieved, provide a maximum ½ page explanation below. Insert more lines and rows below if needed.
PROJECT NAME / BRIEF EXPLANATION (maximum ½ page per project)
Accelerated Bridge Program, Phase 1B, Zone 2
PIN SABP.07, Contract D900007 / Form DBE / Instructions to Proposers Appendix D
April 11, 2012
New YorkState Department of Transportation
FORM EEO - Equal Employment Opportunity Certification
To be executed by the Proposer, Major Participants andproposed known Subcontractors.
The undersigned certifies on behalf of / that:(Name of entity making certification)
(check one of the following boxes)
It has developed and has on file at each establishment affirmative action programs pursuant to 41 CFR Part 60-2 (Affirmative Action Programs).
It is not subject to the requirements to develop an affirmative action program under 41CFR Part 60-2 (Affirmative Action Programs).
(check one of the following boxes)
It has not participated in a previous contract or subcontract subject to the equal opportunity clause described in Executive Orders 10925, 11114 or 11246.
It has participated in a previous contract or subcontract subject to the equal opportunity clause described in Executive Orders 10925, 11114 or 11246 and, where required, it has filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal Government contracting or administering agency, or the former President’s Committee on Equal Employment Opportunity, all reports due under the applicable filing requirements.
Signature:Title:
Date:
If not Proposer, relationship to Proposer:
Note: The above certification is required by the Equal Employment Opportunity Regulations of the Secretary of Labor (41 CFR 60-1.7(b)(1)), and must be submitted by Proposers only in connection with contracts which are subject to the equal opportunity clause. Contracts that are exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5. (Generally, only contracts of $10,000 or under are exempt.) Currently, Standard Form 100 (EEO-1) is the only report required by Executive Orders or their implementing regulations.
Proposers, Major Participants, and proposed Subcontractors who have participated in a previous contract subject to the Executive Orders and have not filed the required reports should note that 41 CFR 60-1.7(b)(1) prevents the award of contracts and subcontracts unless such contractor submits a report covering the delinquent period or such other period specified by the Federal Highway Administration or by the Director, Office of Federal Contract Compliance, U.S. Department of Labor.
Accelerated Bridge Program, Phase 1B, Zone 2PIN SABP.07, Contract D900007 / Form EEO / Instructions to Proposers Appendix D
April 11, 2012
New YorkState Department of Transportation
FORM GF
PROPOSER’S DBE GOOD FAITH EFFORTS
Form GF is not required if Form LDB demonstrates meeting of the Project DBE goals.
PROPOSER:Proposers shall submit the following information to demonstrate that a good faith effort has been made to provide opportunities for DBE firms on the Project.
Proposers shall submit the following information to remain eligible for selection:
1.A list of the categories of subcontracts that the Proposer determined were appropriate for solicitation during the pre-Proposal period and an explanation regarding any categories not included:
2.The names and dates of advertisement of each newspaper, trade paper, and minority-focus paper (termed “papers”) in which a request for DBE participation for this Project was placed by the Proposer.
(Add rows as needed)
Papers
/Dates of advertisement
3.The names and dates of written notices of all certified DBEs solicited by direct mail or other means for this Project and the dates and methods used for following up initial solicitations to determine with certainty whether the DBEs were interested:
(Add rows as needed)
Names of DBEs solicited
/Dates of solicitations
/ Follow-up methods and dates4.Items of Work for which the Proposer requested bids, proposals or material to be supplied by DBEs, if any; the information furnished to interested DBEs in the way of plans, specifications and requirements for the Work, and any breakdown of items of Work into economically feasible units to facilitate DBE participation. Where there are DBEs available for doing portions of the Work normally performed by the Proposer with its own forces, the Proposer will be expected to make portions of such Work available for DBEs to bid on.