City of Charlotte
Engineering & Property Management
4.
Section 5
REQUIRED FORMS
Required Forms
Form A – Execution of Proposal
Form B – Commercial Non-Discrimination Certification
Form C – E-Verify Certification
Form D – Projects Matrix
Form D-1 – Prime Consultant SPSF Certification
Form D-2 – Subconsultant SPSF Certification
Form DBE IS – Disadvantaged Business Enterprise (Example Only. Do not complete)
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
20
City of Charlotte
REQUIRED FORMS
Engineering & Property Management
Form A
Form A – Execution of Proposal
The person executing the Proposal, on behalf of the Company, being duly sworn, solemnly swears (or affirms) that neither he,
nor any official, agent or employee of the Company has entered into any agreement, participated in any collusion, or otherwise
taken any action which is in restraint of full and open competition in connection with any proposal or contract, that the
Company has not been convicted of violating North Carolina General Statute 133-24 within the last three years, and that the
Company intends to do the work with its own bona fide employees or subcontractors and is not proposing for the benefit of
another company.
Submission of a response to this RFQ constitutes certification that the Company and all proposed team members are not
currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this
Project by any State or Federal department or agency. Submission is also agreement that the City will be notified of any change
in this status.
NC General Statute 133-32 and City Policy prohibit any gift from anyone with a contract with the City, or from any person
seeking to do business with the City. By execution of this Proposal, you attest, for your organization and its employees or
agents, that you are not aware that any such gift has been offered, accepted, or promised by any employees of your
organization.
The information contained in this Proposal, including its forms and other documents, delivered or to be delivered to the City, is
true, accurate, and complete. This Proposal includes all information necessary to ensure that the statements therein do not in
whole or in part mislead the City as to any material facts.
Type of Company:
 Sole Proprietor
(check 1 box)
 Partnership
 Corporation _____________________________ (identify the State of incorporation)
 Limited Liability Company ____________________________ (identify the State of incorporation)
 Joint Venture
(if joint venture, complete this “Proposal Submission” sheet for each joint venture company and
identify the “Name of Joint Venture” on each sheet)
NAME OF JOINT VENTURE: _________________________________________________________
Company Legal Name:
Mailing Address:
City/State/Zip:
Phone:
Email:
Printed Name:
Title:
Signature:
Proposal is valid for one-hundred-eighty (180) days from the Proposal due date.
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
21
City of Charlotte
REQUIRED FORMS
Engineering & Property Management
Form B–
Form B – Commercial Non-Discrimination Certification
Project Name:
Little Creek Greenway/U.S. 74 Connectivity Study
RFQ 2015-164
Company’s Name:
The undersigned Company hereby certifies and agrees that the following information is correct:
1. In preparing its bid/proposal, the Company has considered all bids/proposals submitted from qualified,
potential subcontractors and suppliers and has not engaged in discrimination as defined in Section 2 below.
2. For purposes of this section, discrimination means discrimination in the solicitation, selection, or treatment of
any subcontractor, vendor, supplier or commercial customer on the basis of race, ethnicity, gender, age,
religion, national origin, disability or other unlawful form of discrimination. Without limiting the foregoing,
discrimination also includes retaliating against any person or other entity for reporting any incident of
discrimination.
3. Without limiting any other remedies that the City may have for a false certification, it is understood and agreed
that, if this certification is false, such false certification will constitute grounds for the City to reject the
bid/proposal submitted with this certification and terminate any contract awarded based on such bid/proposal.
It shall also constitute a violation of the City’s Commercial Non-Discrimination Ordinance and shall subject the
Company to any remedies allowed thereunder, including possible disqualification from participating in City
contracts for up to two years.
4. As a condition of contracting with the City, the Company agrees to promptly provide to the City all information
and documentation that may be requested by the City from time to time regarding the solicitation and
selection of subcontractors and suppliers. Failure to maintain or failure to provide such information shall
constitute grounds for the City to reject the bid/proposal and to terminate any contract awarded on such
bid/proposal. It shall also constitute a violation of the City’s Commercial Non-Discrimination Ordinance and
shall subject the Company to any remedies that are allowed thereunder.
5. As part of its bid/proposal, the Company shall provide to the City a list of all instances within the past ten years
where a complaint was filed or pending against the Company in a legal or administrative proceeding alleging
that the Company discriminated against its subcontractor, vendors, suppliers, or commercial customers, and a
description of the status or resolution of that complaint, including any remedial action taken.
6. As a condition of submitting a bid/proposal to the City, the Company agrees to comply with the City’s
Commercial Non-Discrimination Policy as described in Section 2, Article V of the Charlotte City Code, and
consents to be bound by the award of any arbitration conducted thereunder.
By: _______________________________________________
SIGNATURE OF AUTHORIZED OFFICIAL
Title: ____________________________________________
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
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City of Charlotte
REQUIRED FORMS
Engineering & Property Management
Form C – E-Verify Certification
Form C – E-Verify Certification
Project Name:
Company’s Name:
Little Creek Greenway/U.S. 74 Connectivity Study
This E-Verify Certification is provided to the City of Charlotte (the “City) by the company signing below
(“Company”) as a prerequisite to the City considering Company for award of a City contract (the “Contract”).
1.
Company understands that:
a. E-Verify is the federal program operated by the United States Department of Homeland Security and
other federal agencies to enable employers to verify the work authorization of employees pursuant
to federal law, as modified from time to time.
b. Article 2 of Chapter 64 of the North Carolina General Statues requires employers that transact
business in this state and employ 25 or more employees in this state to: (i) verify the work
authorization of newly hired employees who will be performing work in North Carolina through EVerify; and (ii) maintain records of such verification ( the “E-Verify Requirements”).
c. North Carolina General Statute 160A-20.1(b) prohibits the City from entering into contracts unless
the contractor and all subcontractors comply with the E-Verify Requirements.
2.
As a condition of being considered for the Contract, Company certifies that:
a. If Company has 25 or more employees working in North Carolina (whether now or at any time during
the term of the Contract), Company has complied and will comply with the E-Verify Requirements
with respect to Company employees working in North Carolina; and
b. Regardless of how many employees Company has working in North Carolina, Company will take
appropriate steps to ensure that each subcontractor performing work on the Contract that has 25 or
more employees working in North Carolina complies with the E-Verify Requirements.
3.
Company acknowledges that the City will be relying on this Certification in entering into the Contract, and
that the City may incur expenses and damages if the City enters into the Contract with Company and
Company or any subcontractor fails to comply with the E-Verify Requirements. Company agrees to
indemnify and save the City harmless from and against all losses, damages, costs, expenses (including
reasonable attorney’s fees) obligations, duties, fines and penalties (collectively “Losses”) arising directly or
indirectly from violation of the E-Verify Requirements by Company or any of its subcontractors, including
without limitation any Losses incurred as a result of the Contract being deemed void.
_____________________________________________
Signature of Company’s Authorized Representative
__________________
Date
Print Name and Title: ___________________________________________________________
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
23
City of Charlotte
REQUIRED FORMS
Engineering & Property Management
Form D – Key Team Member Matrix
FORM D, Part I – PROJECTS MATRIX – RFQ 2015-164
KEY TEAM MEMBERS
Key Team
Member 1
Key Team
Member 2
Key Team
Member 3
Key Team
Member 4
Key Team
Member 5
Personal Information
Name
Name
Name
Name
Name
Role
Role
Role
Role
Role
Involvement
Involvement
Involvement
Involvement
Involvement
Role
Role
Role
Role
Role
Involvement
Involvement
Involvement
Involvement
Involvement
Role
Role
Role
Role
Role
Involvement
Involvement
Involvement
Involvement
Involvement
Professional Designation or License (i.e., AIA, PE, etc.) (list)
Relevant Academic Degree(s) (list)
Proposed Role/Function
Office Location
Number of Years with Current Firm
Availability for the Next 12 Months
Role in Past Projects: List projects cited in RFQ Question 1.7.3 and
Indicate Role of Key Team Member and Level of Involvement for each
project (Major/ Minor or None, as applicable)
1.
2.
3.
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
24
City of Charlotte
REQUIRED FORMS
Engineering & Property Management
Form D – Key Team Member Matrix
FORM D, Part II – PERSONNEL EXPERTISE MATRIX – RFQ 2015-164
KEY TEAM MEMBERS EXPERTISE
Expertise – Indicate Number of Years or Number of Projects for the
following:
Key Team
Member 1
Key Team
Member 2
Key Team
Member 3
Key Team
Member 4
Key Team
Member 5
Name
Name
Name
Name
Name
Environmental Assessments
Mapping
Identification of safety needs
Project cost estimating
Engineering Planning/Preliminary Design Tasks
Pedestrian and Bicycle Facilities Design
NCDOT Roadway Design and Permitting
Community Engagement Approaches
Other areas of expertise – List: below:
This form may be modified to accommodate additional project information and/or staff as long as the basic format is not compromised.
An electronic copy of this form is available online at: http://epmcontracts.charmeck.org
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
25
City of Charlotte
REQUIRED FORMS
Engineering & Property Management
Form D-1 Prime Consultant SPSF Certification
FORM D-1
PRIME CONSULTANT
SMALL PROFESSIONAL SERVICE FIRM CERTIFICATION
Project:
Little Creek Greenway/U.S. 74 Connectivity Study
Consultant Name:
Service Description:
Anticipated Utilization:
Total Utilization:
(Percent)
Submitted by Consultant
Date
Signature
SPSF Status:
 Yes
Title
 No
Instructions for Completing Form D-1:
1. Complete Form D-1 for the prime consultant firm; fill in prime consultant name
2. Enter Service Description – describe work to be performed by the prime firm
3. Enter Anticipated Utilization – Insert percent of work anticipated to be performed by the prime
consultant
4. Signature of the prime consultant is required on each Form D-1 submitted with the qualification
package to be considered for selection
5. Fill in title and date of certification
6. Complete “SPSF Status” section – Check the appropriate box regarding SPSF Status, check Yes if
SPSF, or No if not SPSF
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
26
City of Charlotte
Form D-2
Engineering & Property Management
Subconsultant SPSF Certification
FORM D-2
SUBCONSULTANT
SMALL PROFESSIONAL SERVICE FIRM CERTIFICATION
Project:
Little Creek Greenway/U.S. 74 Connectivity Study
Consultant Name:
Subconsultant Name:
Anticipated Utilization:
Service Description:
Total Utilization:
(Percent)
Submitted by Subconsultant
Signature
SPSF Status:
 Yes
Date
Title
Date
Title
 No
Recommended by Consultant
Signature
Instructions for completing the Form D-2:
1. Complete Form D-2 for each subconsultant firm; fill in prime consultant and subconsultant name
2. Enter Service Description – describe work to be performed by the subconsultant firm
3. Enter Anticipated Utilization – Insert percent of work anticipated to be performed by the
subconsultant
4. Signatures of both the subconsultant and prime consultant is required on each Form D-2
submitted with the qualification package to be considered for selection
5. Fill in title and date of certification
6. Complete “SPSF Status” section – Subconsultant shall check the appropriate box regarding SPSF
Status, check Yes if SPSF, or No if not SPSF
7. In the event the prime consultant firm has no subconsultant, it is required that this be indicated
on Form D-2 form by entering the word “None” or the number “ZERO” and having the prime
consultant sign and submit Form D-2.
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
27
City of Charlotte
Form DBE-IS
Engineering & Property Management
DBE Form
FORM DBE - IS – DISADVANTAGED BUSINESS ENTERPRISE
When payments are made to subconsultants, including material suppliers, firms at all levels (Consultant,
subconsultant) shall provide the City with an accounting of said payments. This accounting shall be
furnished to the City for any given month, by the end of the following month using Form DBE-IS,
attached. In the event the Consultant has no subconsultant participation, the firm shall indicate this on
the Form DBE-IS by entering the word “None” or the number “zero” and the form shall be signed.
A responsible fiscal officer of the payee Consultant, or subconsultant, who can attest to the date and
amount of the payment shall certify that the accounting is correct on the Form DBE-IS by affixing
her/her signature. This information shall be submitted as a part of the requests for payments sent to
the City of Charlotte, who will forward the form to the North Carolina Department of Transportation.
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RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
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Form DBE IS
City of Charlotte
Engineering & Property Management
Subcontractor Payment Information
Submit with Invoice To:
Joe Frey, P.E.
City of Charlotte
Engineering and Property Management
600 E. Fourth Street, 7th Floor
Charlotte, NC 28202
Firm Invoice No. Reference:
City of Charlotte Contract #:
WBS No. (State Project #):
Date of Invoice:
Signed:
Invoice
Line Item
Reference
Payer Name
Payer Federal
Tax Id
Subcontractor /
Subconsultant /
Material Supplier
Name
Subcontractor /
Subconsultant /
Material Supplier
Federal Tax Id
Total Amount Paid to Subcontractor Firms
Amount Paid To
Subcontractor /
Subconsultant /
Material Supplier
This Invoice
Date Paid To
Subcontractor /
Subconsultant /
Material Supplier
This Invoice
$
NOTE: - These documents are scanned into our Fiscal program. Please do not highlight or shade the figures.
I certify that this information accurately reflects actual payments made and the dates the payments were made to Subcontractors/
Subconsultants/Material Suppliers on the above referenced project.
Signature:
Title:
Print Name:
Date:
01/07
RFQ#: 2015-164
Project Name: Little Creek Greenway / U.S. 74 Connectivity Study
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