CERTIFICATION CHECKLIST FOR NON-FEDERAL FUNDED CONTRACTS
Contractor Name: Enter Contractor Name
Original or Mod #: Contract Version
Contract #: Enter Contract #
Funding Source: Funding Source
Contract $$ Contract Encumbrance
Date: Drop down tab to select date
Contract Manager Name & Telephone #: Enter name and Phone extension
Included?
☐Y ☐N
1. Budget Confirmation (Informal contracts only)
☐Y ☐N
2. Airport Commission Resolution (Required if ≥ $110,000)
☐Y ☐N
3. Civil Service Commission or DHR Approval (PSC Form 1 and PSC Form 2)
☐Y ☐N
4. 3 sets of signed contract documents, 4 for OCA/BOS (refer to notes)
☐Y ☐N
5. LBE/DBE Data Collection Form for Contract Awards (original contract only)
☐Y ☐N
6. First Source Hiring Agreement (original contract only)
☐Y ☐N
7. Certificate of Insurance and/or Bond:
Amount
☐
7.1
Commercial General Liability
☐
7.2
Commercial Automobile Liability
☐
7.3
☐
7.4
7.5
Workers’ Compensation with
Waiver of Subrogation
Professional Liability
text
text
Umbrella Liability
7.5
Other:text
☐
☐Y ☐N
$Click here to enter
text.
$Click here to enter
text.
$Click here to enter
text.
$Click here to enter
text.
$Click here to enter
text.
$Click here to enter
text.
Expiration Date Add. Insured
Endorsement
Select Date
☐Y ☐N
Select Date
☐Y ☐N
Select Date
☐Y ☐N
Select Date
Select Date
Select Date
8a. CMD Form 3 (original) - Non-Discrimination Affidavit [Construction Contracts (CMD
Attachment 1), A/E and Professional Contracts (CMD Attachment 2), General Services
Contracts (CMD Attachment 3), or Design-Build (CMD Attachment 7)]
Or
☐Y ☐N
8b. CMD Form 10 (modification) - also attach CMD Form 10 for Construction Contracts
(CMD Attachment 1) or A/E and Professional Contracts (CMD Attachment2), Fax to
CMD: (650) 821-7820.
☐Y ☐N
9. OCA approval required?
☐Y ☐N
10. DT CIO approval (if required)
☐Y ☐N
11. OCA (Purchasing) Waiver (if required)
☐Y ☐N
12. CMD Waiver (if required)
☐Y ☐N
13. Prop. “J” Approval (if required)
☐Y ☐N
14.Other (state): Enter additional documents here
Rev. 02/22/16
INSTRUCTIONS FOR CERTIFICATION CHECKLIST
Contractor Name: Enter the vendor/firm name.
Contract #: Enter the contract number assigned at the time of issuing
the competitive solicitation. If you do not have a contract number,
contact CAU.
Original or Modification #: Identify if the contract is an Original
contract or a Modification. For Modification, list the Modification
No. 1 (e.g. Mod No. 1, Mod No. 2, etc).
Date: Enter the date the contract packet is submitted for review.
Contract Encumbrance $$: Enter the requested encumbrance
amount. For Modifications, this equals the additional funding being
added as a result of the Modification.
Funding Source: Indicate the contract funding source (e.g.
AIREEO).
FY: Fiscal year. Construction contract - List all years. Professional –
List CURRENT fiscal year only.
Contract Manager Name & Telephone #: Identify the name and
phone number for the Contract Manager.
7. Certificate of Insurance or Bond: Include copies of current
insurance, waiver of subrogation, bonds and accompanying
endorsements corresponding to dollar amounts stipulated in the
original contract. Ensure that risk management has reviewed and
signed all insurance documents.
8a. CMD Form 3: **For Original Contracts Only** Complete the Form
3 included in CMD Att. 1 (Construction Contracts), CMD Att. 2 (A/E and
Professional Services Contracts), and for General Services Contracts
include Form 3 included in CMD Att. 3 (General Services), CMD Att. 7
(Design-Build). Copies of CMD forms are available at the CMD website:
http://sfgsa.org/index.aspx?page=6058
8b. CMD Form 10: **For Modifications Only >20% increase** For
Construction Contracts, attach a completed copy of CMD Form 10
included in CMD Att. 1; for A/E and Professional Contracts include
the CMD Form 10 included in CMD Att. 2 or others as appropriate.
9. OCA Approval. If OCA will be signing the contract check “Yes”,
otherwise check “No.”
10. Department of Technology (DT) approval: Required for all
technology contract.
11. OCA (Purchasing) Waiver: Required for sole source contracts.
CHECKLIST ITEMS
(Please submit only one set of the certification checklist items
with your contracts)
1. Budget Confirmation: Include an email from the Budget Office
indicating that the informal contract has been budgeted (Chapter 21
<$110,000 or Chapter 6<$600,000).
2. Airport Commission (AC) Resolution: Attach a copy of the
signed and dated Airport Commission resolution. (An AC resolution
is only required if funding> $ 110,000).
3. Civil Service Commission or DHR approval: Include PSC Form
1 and PSC Form 2. NOTE: Not required for Prop J approved
contracts or if Capital Funded and Accounting already has the CSC
paperwork for the maximum amount of money you plan to encumber.
Request the PSC Form 2 by sending an email to Cynthia Avakian
with the following items: Contractor’s name, contract number,
amount to be encumbered in which fiscal year, and PSC #.
4. Signed Contract Documents: Include three copies of contract
documents signed by the vendor. If your contract needs to be
signed by Office of Contract Administration, you will need to
submit FOUR (4) original copies.
5. LBE/DBE Data Collection Form: **For Original Contracts
Only**, Attach a completed copy of the LBE/DBE Data Collection
Form.
6. First Source Hiring Agreement: ** For Original Contracts
Only**, Attach a completed copy of the First Source Hiring
Agreement form (completed for RFP/RFQ)
Rev. 2/22/16
12. CMD Waiver: Required if CMD granted either a 12B or 14B
Waiver.
13. Prop J Approval: For contracts approved under Prop J, attach
the approved Prop J resolution from the Board of Supervisors in lieu
of the Civil Service Commission approval.
ROUTING
Division’s Deputy/Chief, CAU, Legal, Commission Secretary,
Airport Director, Accounting.
*OCA & BOS – Contact CAU
SUMMARY OF REQUIRED FORMS
CHECKLIST ITEM
REQUIRED FOR:
Original
Modification
Budget Confirmation (informal)
X
X
Airport Commission Resolution
X
X
Civil Service Commission or
X
X
DHR Approval (except Prop. J)
Signed contract documents
X
X
LBE/DBE Data Collection Form
X
First Source
X
Certificate of Insurance and/or
X
X
Bond
CMD Form 3
X
CMD Form 10
X
OCA (Purchasing) Waiver
X
X
CMD Waiver
X
X
Prop. J Approval (unless CSC)
X
X
Other
As Needed
Other