Oh, State of California, you never cease to amaze me

This file contains the Exhibits used to attach to responses to RFO in California. See Exhibit 2 - Business Information Sheet (Page 7 of this PDF) About 2/3 if the way down, see Sexual Orientation of Prime Business Owner Your options are: N/A, Lesbian, Gay, Bisexual, Opt not to state Apparently heterosexual vendors need not respond?

Credit where due: I first heard about this on 2/28/13 while listening to the Afternoon News with Kitty ONeal on KFBK, when Kelly Brothers came on with afternoon financial news. You can hear the clip here (discussion starts at 5:37): [Link]

Title: RFO-Exhibits 12-89424 Filename: 9.99 RFO-Exhibits [Link] File Dated: 1/25/13 URL: [Link] RFO-Exhibits [Link] Retreived: 3/1/13 PDF by: @TrocarRogue

Your tax dollars at work, California

RFO Exhibits

Exhibit 0 Response Cover Page

Name of Responding Firm (Legal name as it will appear on the contract)

Mailing Address (Street address, P.O. Box, City, State, Zip Code)

Person authorized to act as the contact for this firm in matters regarding this proposal: Printed Name (First, Last): Title:

Telephone number:

Fax number:

Email address:

Person authorized to obligate this firm in matters regarding this proposal or the resulting contract: Printed Name (First, Last): Title:

Telephone number:

Fax number:

Email address:

(CORPORATIONS ONLY) Name/Title of person authorized by the Board of Directors to sign this bid on behalf of the Board: Printed Name (First, Last): Title:

Signature of Respondent or Authorized Representative

Date:

Exhibit 1 Cost Worksheet (Summary)

Project Category (II): Job Classification / Title Senior Technical Lead IT Consultant Number of Hours 1944 Hourly Rate $ Extended Cost $ Subcategory Letter : A&B

Brief identification of the Tasks, Functions, or Deliverables for the identified classification

Programmer

1944

Application Analyst

1944

Exhibit 1A & 1B Anticipated Labor Costs Subtotal Unanticipated Labor Costs Exhibit 1A & 1B Variable* Variable classifications Variable appearing above and/or within the Respondents Master Agreement with DGS.

$ $ Total cannot exceed 10% of Subtotal of Anticipated Labor Costs. Unanticipated Tasks will be identified and approved by submission of Work Authorizations to DHCS. When only a total cost is projected, include explain how the cost was determined.

Based upon operational needs, DHCS reserves the right to shift the number of labor hours between $ classifications provided Grand Total Labor Costs are Anticipated Labor plus Unanticipated Labor not exceeded. * The hourly wage rate charged for unanticipated costs cannot exceed the hourly rate projected for anticipated labor. If unanticipated tasks are performed by a classification not identified herein, a Work Authorization will identify both the labor rate and classification and reimbursement shall not exceed the labor rates appearing in the Respondents Master Agreement.

Exhibit 1A & 1B Grand Total Labor Costs

Check if multiple Cost Worksheets are used

Exhibit 1A & 1B Cost Worksheet Total $

Name of Responding Firm: Signature Printed Name of Person Signing Date:

This is a sample Cost Worksheet for the Respondents use. Respondents may complete this form or create a computer generated like document that contains the same level of cost data. Complete one worksheet for each Service Category. Include additional sheets if the project covers more than one Service Category and/or if the contracted rates differ for each category/subcategory. Identify multiple worksheet pages as Page 1 of X, 2 of X, etc. Page 1 of 3

Exhibit 1A Cost Worksheet

Project Category (II): Job Classification / Title Senior Technical Lead Programming Number of Hours 972 Hourly Rate $ Extended Cost $ Subcategory Letter: A Programming

Brief identification of the Tasks, Functions, or Deliverables for the identified classification

Programmer

972

Application Analyst

972

Anticipated Labor Costs Subtotal Unanticipated Labor Costs Variable classifications appearing above and/or within the Respondents Master Agreement with DGS. Variable Variable*

$ $ Total cannot exceed 10% of Subtotal of Anticipated Labor Costs. $ Unanticipated Tasks will be identified and approved by submission of Work Authorizations to DHCS. When only a total cost is projected, include explain how the cost was determined.

Grand Total Labor Costs

Anticipated Labor plus Unanticipated Labor

Based upon operational needs, DHCS reserves the right to shift the number of labor hours between classifications provided Grand Total Labor Costs are not exceeded.

* The hourly wage rate charged for unanticipated costs cannot exceed the hourly rate projected for anticipated labor. If unanticipated tasks are performed by a classification not identified herein, a Work Authorization will identify both the labor rate and classification and reimbursement shall not exceed the labor rates appearing in the Respondents Master Agreement.

Check if multiple Cost Worksheets are used Name of Responding Firm: Signature

Cost Worksheet Total $

Printed Name of Person Signing

Date:

This is a sample Cost Worksheet for the Respondents use. Respondents may complete this form or create a computer generated like document that contains the same level of cost data. Complete one worksheet for each Service Category. Include additional sheets if the project covers more than one Service Category and/or if the contracted rates differ for each category/subcategory. Identify multiple worksheet pages as Page 1 of X, 2 of X, etc. Page 2 of 3

Exhibit 1B Cost Worksheet

Project Category (II): Job Classification / Title Senior Technical Lead System Analysis Number of Hours 972 Hourly Rate $ Extended Cost $ Subcategory Letter: B System Analysis

Brief identification of the Tasks, Functions, or Deliverables for the identified classification

Programmer

972

Application Analyst

972

Anticipated Labor Costs Subtotal Unanticipated Labor Costs Variable classifications appearing above and/or within the Respondents Master Agreement with DGS. Variable Variable*

$ $ Total cannot exceed 10% of Subtotal of Anticipated Labor Costs. Unanticipated Tasks will be identified and approved by submission of Work Authorizations to DHCS. When only a total cost is projected, include explain how the cost was determined.

Based upon operational needs, DHCS reserves the right to shift the number of labor hours between $ classifications provided Grand Total Labor Costs are Anticipated Labor plus Unanticipated Labor not exceeded. * The hourly wage rate charged for unanticipated costs cannot exceed the hourly rate projected for anticipated labor. If unanticipated tasks are performed by a classification not identified herein, a Work Authorization will identify both the labor rate and classification and reimbursement shall not exceed the labor rates appearing in the Respondents Master Agreement.

Grand Total Labor Costs

Check if multiple Cost Worksheets are used Name of Responding Firm: Signature

Cost Worksheet Total $

Printed Name of Person Signing

Date:

This is a sample Cost Worksheet for the Respondents use. Respondents may complete this form or create a computer generated like document that contains the same level of cost data. Complete one worksheet for each Service Category. Include additional sheets if the project covers more than one Service Category and/or if the contracted rates differ for each category/subcategory. Identify multiple worksheet pages as Page 1 of X, 2 of X, etc. Page 3 of 3

Exhibit 2 Business Information Sheet

A signature affixed hereon and dated certifies compliance with all solicitation requirements. The signature below authorizes the State to verify the claims made on this form.
Name of Responding Firm: Name of Principal (If not an individual): Street Address / P.O. Box Title: City CA Corp. No. (If applicable) Telephone Number State Federal ID Number Fax Number Zip Code

Type of Business Organization / Ownership (Check all that apply) Ownership Corporation Governmental
Sole Proprietor Partnership Joint venture Association Nonprofit For Profit Private Public City/County, California State Agency, Federal Agency, State (other than California) Other: N/A

Other Type of Entity Public or Municipal Corporation, School or Water District, California State College, University of California, Joint Powers Agency Auxiliary College Foundation Other: Small business NVSA Expiration Date:

California Certified Small Business Status

Certified By DGS Certification No:

Microbusiness

If certified, attach a copy of certification letter. If an application is pending, date submitted to DGS:

Small Business Type (If applicable)

Contractor (Construction Type):

N/A

Services

Non-Manufacturer Contractors License Type:

Manufacturer

Veteran Status of Business Owner

Disabled Veteran Certified by DGS

N/A (not a veteran or not certified by DGS) Certification No. Expiration Date:

If certified, attach a copy of certification letter. If an application is pending, date submitted to DGS:

Disadvantaged Business Enterprise Status:

Certification number issued by Cal Trans: Race/Ethnicity of Primary Business Owner Owners Ethnicity (check one) Asian-Indian Black Hispanic Native American Pacific-Asian Other ______________ Primary Business Owners Gender

N/A

Approved by the Cal Trans, Office of Civil Rights. Expiration Date:

N/A (No single owner possess 51% or more ownership)

Opt not to state

Owners Race (check one) American Indian/Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other _______________ N/A (Not independently owned)

If Asian, Native Hawaiian or Pacific Islander (check one): Asian-Indian Japanese Cambodian Korean Chinese Laotian Filipino Samoan Guamanian Vietnamese Hawaiian Other ___________________ Male Female Lesbian Transgender Gay Bisexual Opt not to state Opt not to state

Sexual Orientation of Prime Business Owner

N/A (Not independently owned)

Indicate possession of required licenses and/or certifications (if applicable): N/A (None required) Contractors State Licensing Board No. PUC License Number Required Licenses/Certifications (If applicable)
CAL-TSignature
Printed/Typed Name Title

Date Signed

Public Records Information

The above information is required for statistical reporting purposes. Completion of this form is mandatory however supplying certain data elements is voluntary and optional. This information will be become public information upon award of the contract and will be supplied to department contract staff, Department of General Services and possibly other public agencies. To access contract related records, contact the Contract Management Unit, 1501 Capitol Avenue, Suite 71.5195, MS 1403, P.O. Box 997413, Sacramento, CA 95899-7413 or call (916) 650-0150.

Exhibit 3 Client References

List 3 clients serviced in the past who can confirm the quality & timeliness of the Respondents services. Preferably list firms with service needs that were similar or related to those sought in this RFO. List the most recent first.

REFERENCE 1
Name of Firm Street address Contact Person Dates of service Brief description of service provided City Telephone number State Zip Code

Value or cost of service

REFERENCE 2
Name of Firm Street address Contact Person Dates of service Brief description of service provided City Telephone number State Zip Code

Value or cost of service

REFERENCE 3
Name of Firm Street address Contact Person Dates of service Brief description of service provided City Telephone number State Zip Code

Value or cost of service

If three references cannot be provided, explain why:

State of CaliforniaDepartment of Health Care Services

Exhibit 4

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9)
STD. 204 (Rev. 5/06)_DHCS

1 2

INSTRUCTIONS: Complete all information on this form. Sign, date, and return to the State agency (department/office) address shown at the bottom of this page. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in this form will be used by State agencies to prepare Information Returns (1099). See reverse side for more information and Privacy Statement. NOTE: Governmental entities, federal, state, and local (including school districts), are not required to submit this form.
PAYEES LEGAL BUSINESS NAME (Type or Print)

SOLE PROPRIETORENTER NAME AS SHOWN ON SSN (Last, First, M.I.)

E-MAIL ADDRESS

MAILING ADDRESS

BUSINESS ADDRESS

CITY, STATE, ZIP CODE

CITY, STATE, ZIP CODE

3
PAYEE ENTITY TYPE

ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):

PARTNERSHIP

CHECK ONE BOX ONLY

ESTATE OR TRUST

CORPORATION: MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.) LEGAL (e.g., attorney services) EXEMPT (nonprofit) ALL OTHERS

NOTE: Payment will not be processed without an accompanying taxpayer I.D. number.

INDIVIDUAL OR SOLE PROPRIETOR ENTER SOCIAL SECURITY NUMBER:

(SSN required by authority of California Revenue and Tax Code Section 18646)

4
PAYEE RESIDENCY TYPE

California residentqualified to do business in California or maintains a permanent place of business in California. California nonresident (see reverse side)Payments to nonresidents for services may be subject to State income tax withholding. No services performed in California. Copy of Franchise Tax Board waiver of State withholding attached. I hereby certify under penalty of perjury that the information provided on this document is true and correct. Should my residency status change, I will promptly notify the State agency below.
AUTHORIZED PAYEE REPRESENTATIVES NAME (Type or Print) TITLE

SIGNATURE

DATE

TELEPHONE

Please return completed form to: Department/Office: Unit/Section: Mailing Address: City/State/ZIP: Telephone: E-Mail Address:

Department of Health Care Services Office of HIPAA Compliance P.O. Box 997413, MS Code 4722 Sacramento, CA 95899-7413

( 916 ) 552-9525
[Link]@[Link]

FAX:

( 916 ) 449-5125

State of CaliforniaDepartment of Health Care Services

Exhibit 4

PAYEE DATA RECORD

STD. 204 (Rev. 5/06)_DHCS (Page 2)

1

Requirement to Complete Payee Data Record, STD. 204

A completed Payee Data Record, STD. 204, is required for payments to all non-governmental entities and will be kept on file at each State agency. Since each State agency with which you do business must have a separate STD. 204 on file, it is possible for a payee to receive this form from various State agencies. Payees who do not wish to complete the STD. 204 may elect to not do business with the State. If the payee does not complete the STD. 204 and the required payee data is not otherwise provided, payment may be reduced for federal backup withholding and nonresident State income tax withholding. Amounts reported on Information Returns (1099) are in accordance with the Internal Revenue Code and the California Revenue and Taxation Code.

Enter the payees legal business name. Sole proprietorships must also include the owners full name. An individual must list his/her full name. The mailing address should be the address at which the payee chooses to receive correspondence. Do not enter payment address or lock box information here. Check the box that corresponds to the payee business type. Check only one box. Corporations must check the box that identifies the type of corporation. The State of California requires that all parties entering into business transactions that may lead to payment(s) from the State provide their Taxpayer Identification Number (TIN). The TIN is required by the California Revenue and Taxation Code Section 18646 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other information returns as required by the Internal Revenue Code Section 6109(a). The TIN for individuals and sole proprietorships is the Social Security Number (SSN). Only partnerships, estates, trusts, and corporations will enter their Federal Employer Identification Number (FEIN).

Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California. A partnership is considered a resident partnership if it has a permanent place of business in California. An estate is a resident if the decedent was a California resident at time of death. A trust is a resident if at least one trustee is a California resident. For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident. Payments to all nonresidents may be subject to withholding. Nonresident payees performing services in California or receiving rent, lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments withheld for State income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the calendar year. For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below: Withholding Services and Compliance Section: For hearing impaired with TDD, call: 1-888-792-4900 1-800-822-6268 E-mail address: [Link]@[Link] Website: [Link]

Provide the name, title, signature, and telephone number of the individual completing this form. Provide the date the form was completed. This section must be completed by the State agency requesting the STD. 204.

Privacy Statement
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, State, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and State law imposes noncompliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the State agency(ies) with which you transact that business. All questions should be referred to the requesting State agency listed on the bottom front of this form.

Exhibit 5 Statement of Work Description [Use of this form and format is optional. These instructions must mirror the Statement of Work description requirements in the RFO.] I. Insert here a brief explanation or description of the overall approaches and/or methods that will be used to accomplish DHCS Scope of Work.

2.

If applicable, explain what is unique, creative, or innovative about the proposed approaches and/or methods.

3.

If the Respondent envisions any major complications or delays at any stage of performance, describe those complications or delays and include a proposed strategy for overcoming those issues. Likewise, indicate if the Respondent does not anticipate any major complications or delays.

4.

If, for any reason, the Statement of Work does not wholly address each DHCS Scope of Work requirement, fully explain each omission. Likewise, indicate if the Statement of Work does not contain any omissions.

5.

Indicate the assumptions that were made in developing the Statement of Work in response to DHCS Scope of Work. For each assumption listed, explain the reasoning or rationale that led you to that assumption.

6.

If applicable, identify the additional Contractor and/or State responsibilities that were included in the Statement of Work that the Respondent believes are necessary to ensure successful performance but were omitted from DHCS Scope of Work.

Page

of

[Like or similar electronic versions of this form may be developed for submission with a response. Use as many pages as are necessary to fully detail the Respondents Statement of Work for the entire contract term.]

Statement of Work Category/Subcategory Designation: Major Functions, Tasks, and Activities

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Analyze X data to determine Y Develop recommendations for the design of a ____. List pros/cons of each, identify preferences and justify chosen design. Develop sample model using ABC design. Make design modifications, required by DHCS. Test ___ to confirm proper working action and document positive/negative results.

SAMPLE

Exhibit 5

Timeline for performance

01/01/XX 3/15/XX By end of 1 quarter of 200X By end of 2 quarter of 200X Week of XX/XX/XX 11/15/XX 12/15/XX.
nd st

Classification of responsible party

Application Analyst Application Analyst Technical Leader Application Analyst Technical Leader

Performance Measure and/or Deliverables and Completion Date

Submit report documenting analytical techniques and findings by 4/30/XX. Submit list of recommendations by 3/31/XX. Submit initial model to DHCS for review and approval no later than 6/30/XX. Re-submit adjusted model for approval no later than ________. Complete tests and submit written results by 12/31/XX.

Page

of

[Like or similar electronic versions of this form may be developed for submission with a response. The above sample is intended to illustrate the type of information that is required. Use as many pages as are necessary to fully detail the Respondents Statement of Work for the entire contract term.]

Exhibit 6 Resume [Name of Staff Person] Resume Completion Instructions To the extent possible, the resume for each contract participant should not be lengthy (i.e., limited to one-two pages in length) and should only include the following types of information. There is no required order in which to present the information.

Persons formal name Educational credentials, highest grade completed, degrees obtained (if applicable) and when obtained (e.g., month and year) Employment history for up to the past five years including employer name, length of employment, position or functional title, from and to dates, and a very brief description of roles and responsibilities. Employment data should be presented with the most recent employment first and should reflect employment by the Respondent unless the person is serving as a subcontractor. Technical, educational, or industry specific certificates (if applicable such as a Project Management Professional (PMP) certificate and relevant to the service to be performed) and/or licenses and when obtained (e.g., month and year)

Data to Exclude from a Personal Resume To the extent possible, resumes should omit facts of a personal nature including, but not limited to:

Home address, home telephone number, home or personal email address, personal cellular telephone number, drivers license number Social security number, Gender, marital status, number of children Age and date of birth, Race or ethnicity, Other personal facts including physical description, identification of spouse, religious affiliation, political affiliation, personal hobbies, description of state of health or medical condition, personal financial information or holdings, etc.

DHCS cannot ensure protection of any personal or confidential information included in a personal resume as all resumes become part of the public contract file.

Exhibit 7 DVBE Participation Confirmation

All certified small business, micro business, or DVBE Contractors, subcontractor or suppliers must meet the commercially useful function requirements, under Government Code Section 14837(d)(4) (for SB) and Military and Veterans Code Section 999(b)(5)(b) (for DVBE). Please answer the following questions, as they apply to each DVBE subcontractor for the goods and services being acquired in this solicitation. Complete one form for each DVBE subcontractor. Name of DVBE (as certified by DGS): Mark all that apply: 1. 2. 3. 4. DVBE Small Business Micro Business Percent of DVBE Use Claimed: Yes Yes Yes Yes No No No No

Will the DVBE subcontractor be responsible for the execution of a distinct element of the services of the resulting contract? Will the DVBE subcontractor be actually performing, managing, or supervising an element of the services of the resulting contract? Will the DVBE subcontractor be performing work or supplying goods on the resulting contract that are normal for its business, services, and functions? Will there be any further subcontracting by the DVBE subcontractor for the resulting contract that is greater than that expected to be subcontracted by normal industry practices?

A No response to questions 1-3, or a response of Yes to question 4 may result in the Respondents proposal being deemed nonresponsive and disqualified. The Respondent must identify below the specific elements of the service description (i.e., tasks, activities, or functions) that will be performed by the DVBE subcontractor identified above. If goods will be obtained, only list the specific goods that will be utilized solely to perform the services sought in this solicitation and identify the service elements, tasks, activities, or functions for which the identified goods will be used. At its option, DHCS reserves the right to request the submission of additional clarifying information.

An entry above imposes an obligation on the Respondent to use the identified DVBE to perform commercially useful functions for the percentage claimed. The budget/cost work sheets, if required, and submitted in an RFO response should include costs for the DVBE identified above. This form may be photocopied or reproduced in a like form for inclusion in an RFO response. Responding firms that choose to render a like copy of this form by computer or other means may do so. This form must be completed by the Respondent.
Responding Firms Name Signature

Printed Name/Title of Person Signing Above

Date Signed

RESPONDENT / BIDDER DECLARATION

1. Prime bidder information (Review the instructions on Page 2 entitled Respondent / Bidder Declaration Instructions prior to completing this form): 1a. Identify current California certification(s): (Check One) MB SB NVSA DVBE or None (If None, go to Item #2) 1b. Will subcontractors be used for this contract? Yes No (If yes, indicate the distinct element of work your firm will perform in this contract e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, identify which solicited services your firm will perform, etc.). Use additional sheets, if necessary.

Exhibit 8

1c. If you are a California certified DVBE:

(1) Are you a broker or agent? Yes No (2) If the contract includes equipment rental, does your company own at least 51% of the equipment provided in this contract (quantity and value)? Yes No N/A

2.

No subcontractors will be used.

Yes. The proposed subcontractors for this contract are listed below. Attach additional pages if necessary.
CA Certification (MB, SB, Work performed or goods provided NVSA, DVBE or None) for this contract Corresponding Good % of bid price Standing? 51% Rental?

Subcontractor Name, Contact Person, Subcontractor Address Phone Number & Fax Number & Email Address

MB SB NVSA DVBE None

Yes No %

N/A
Yes No

MB SB NVSA DVBE None

Yes No %

N/A
Yes No

MB SB NVSA DVBE None

Yes No %

N/A
Yes No

Certification: By signing the price quote / bid response, I certify under penalty of perjury that the information provided is true and correct.
Page 1 of 2

RESPONDENT / BIDDER DECLARATION Instructions

All prime respondents / bidders (entity submitting the price quote / bid) must complete this form. 1.a. Identify all current certifications issued by the State of California. If the prime respondent / bidder has no California certification(s), check the line labeled None and proceed to Item #2. If the prime respondent / bidder possesses one or more of the following certifications, enter the applicable certification(s) on the line: Microbusiness (MB) Small Business (SB) Nonprofit Veteran Service Agency (NVSA) Disabled Veteran Business Enterprise (DVBE) 2. (continued) Column Labels subcontractors.

Exhibit 8

Subcontractor Name, Contact Person, Phone Number & Fax NumberList each element for all

Subcontractor Address & Email AddressEnter the address and if available, an Email address. CA Certification (MB, SB, NVSA, DVBE or None)If a subcontractor possesses a current State of California certification(s) mark the certs possessed & verify on this website ([Link]). Work performed or goods provided for this contractIdentify the distinct element of work contained in

1.b. Mark either Yes or No to identify whether subcontractors will be used for the contract. If the response is No, proceed to Item #1.c. If Yes, enter on the line the distinct element of work contained in the contract to be performed or the goods to be provided by the prime respondent / bidder. Do not include goods or services to be provided by subcontractors. Respondents / Bidders certified as MB, SB, NVSA, and/or DVBE must provide a commercially useful function as defined in Military and Veterans Code Section 999 for DVBEs and Government Code Section 14837(d)(4)(A) for small/microbusinesses. Price Quotes / Bids received from certified firms must indicate that a commercially useful function for the resulting contract will be performed or the response/bid will be deemed non-responsive and rejected by the State. For questions regarding the solicitation, contact the procurement official identified in the solicitation. Note: A subcontractor is any person, firm, corporation, or organization contracting to perform part of the primes contract. 1.c. This item is only to be completed by businesses certified by California as a DVBE. (1) Declare whether the prime respondent / bidder is a broker or agent by marking either Yes or No. The Military and Veterans Code Section 999.2 (b) defines broker or agent as a certified DVBE contractor or subcontractor that does not have title, possession, control, and risk of loss of materials, supplies, services, or equipment provided to an awarding department, unless one or more of the disabled veteran owners has at least 51-percent ownership of the quantity and value of the materials, supplies, services, and of each piece of equipment provided under the contract. (2) If responding to a bid for rental equipment, mark either Yes or No to identify if the prime respondent / bidder owns at least 51% of the equipment provided (quantity and value). If not responding to a bid for rental of equipment, mark N/A for not applicable.

the contract to be performed or the goods to be provided by each subcontractor. Certified subcontractors must provide a commercially useful function for the contract. (See paragraph 1.b above for code citations regarding the definition of commercially useful function.) If a certified subcontractor is further subcontracting a greater portion of the work or goods provided for the resulting contract than would be expected by normal industry practices, attach a separate sheet of paper explaining the situation. Corresponding % of bid priceEnter the corresponding percentage of the total bid price / price quote for the goods and/or services to be provided by each subcontractor. Do not enter a dollar amount. Good Standing?Provide a response for each subcontractor listed. Check either Yes or No to indicate that the respondent has verified that the subcontractor(s) is in good standing for all of the following: Possesses valid license(s) for any license(s) or permits required by the solicitation or by law If a corporation, the company is qualified to do business in California and designated by the State of California Secretary of State to be in good standing Possesses valid State of California certification(s) if claiming MB, SB, NVSA, and/or DVBE status 51% Rental?This pertains only solicitation for equipment rental. Based on the following parameters, enter either N/A (not applicable), Yes or No for each subcontractor listed. Check N/A if the: Subcontractor is NOT a DVBE (regardless of whether or not rental equipment is provided by the subcontractor) or Subcontractor is NOT providing rental equipment (regardless of whether or not subcontractor is a DVBE) Check Yes if the subcontractor providing rental equipment is a California certified DVBE and the subcontractor owns at least 51% of the rental equipment (quantity and value) it will be providing for the contract. Check No if the subcontractor providing rental equipment is a California certified DVBE but the

2. If no subcontractors are proposed, check the No box and do not complete the table. Read the certification at the bottom of the form and complete the pagination indicating Page 1 of 1 on the form.
If subcontractors will be used, check the Yes box and complete the table listing all subcontractors. If necessary, attach additional pages and note the pagination Page __ of __ on each page accordingly.

subcontractor does NOT own at least 51% of the rental equipment (quantity and value) it will be providing.

Read the certification at the bottom of the page and complete the Page ___ of ___ accordingly.

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