Document Cortlandcountyny_doc_113d0791c8

1 2016 CORTLAND COUNTY HIGHWAY DEPARTMENT SPECIFICATIONS AND BID SHEETS BITUMINOUS MATERIALS LIQUID This specification is for contractor supplied materials, personnel, supervision and equipment for applying Liquid Bituminous Materials and surface treatment aggregate on various County roads. This work, shall be performed by the successful bidder, hereinafter referred to as the “Contractor”, and shall consist of supplying all labor, materials and equipment necessary for applying Liquid Bituminous Materials to existing asphalt pavements. The Contractor shall also provide labor and equipment necessary to accurately and uniformly spread surface treatment aggregate supplied and hauled to the site by County forces and trucks. Compaction of the resulting surface treatment surface shall be by County forces and equipment. The Contractor’s application operations shall result in an acceptably safe and driveable highway surface course using liquid bituminous materials meeting the requirements more specifically outlined in the MATERIALS Section of this specification. 1. Bids shall be submitted in a sealed envelope plainly marked “Bid for Bituminous Materials Liquid” and “Cortland County Highway Department” on the outside of the envelope. 2. All bids must be submitted on bidding forms provided by the County Superintendent of Highways, Cortland County, Cortland, New York. 3. The bidder shall comply with current NYS DOT Group Specifications for Commodity Group 31501 - Liquid Bituminous Materials (delivered) and (F.O.B. Storage Facility). 4. All emulsified asphalt materials shall meet New York State Department of Transportation Standard Specifications, dated May 1, 2008 as amended, or the asphalt emulsion requirements listed in these specifications. All materials supplied shall be tested, inspected and approved for use by the supplier. Test results shall be maintained on file at the source for a minimum of two years and available to County Superintendent for review. 5. The department reserves the right to purchase the type or types of materials, grades, temperatures and quantities of materials which, in the judgment of the County Superintendent of Highways, is best suited for the particular requirements of each application and to purchase those types in the quantities deemed necessary by the County Superintendent. 6. If County-owned or controlled trucks and equipment are delayed for more than one hour at the contractor’s plant or at the job site, then the contractor shall be required to pay to the county the agreed upon liquidated damages of $75.00 per hour delay per truck for each delay. The liquidated damages herein prescribed are established as a reasonable approximation at the time of the letting of the contract of the damages, which the County will sustain as a result of the failure to timely use its trucks and equipment. Said liquidated damages sum, in view of the difficulty of accurately ascertaining the loss which the County will suffer by reason of said delay, is hereby fixed and agreed upon by the parties hereto as the liquidated damages that will be ---PAGE BREAK--- 2 suffered by reason of such delay and not as a penalty. The County will deduct and retain out of the monies, which may become due hereunder, the amount of any such liquidated damages, and in case the amount of liquidated damages suffered exceeds the amount of monies which may become due hereunder, the contractor shall be liable to pay the difference upon demand by the County. 7. The successful bidder shall extend the prices bid to any municipality in Cortland County. 8. Method of Measurement: The quantity to be paid for will include the number of gallons measured at a temperature of 60 degrees F and incorporated in the work as directed by the Superintendent of Highways or his authorized representative. 9. Bid prices are to be for material “furnished and delivered”. Material is to be furnished heated and delivered to any road in Cortland County in a truck or trucks as required within two hours after notice by County. Material is to be delivered in varying quantities up to 30,000 gallons per day. Equipment used to deliver material shall be equipped to transfer the load to a distributor or pugmill. The bidders must be prepared to furnish a list of equipment owned by them and have the equipment available for inspection. 10. Asphalt distributors shall meet NYS DOT Section 410-3 specifications for equipment for Bituminous Surface Treatments. Sufficient distributors and transports shall be provided to ensure continuous operation and minimize idle time by municipal forces. 11. The aggregate spreader shall be a self-propelled unit capable of uniformly spreading the aggregate at a rate specified by the Highway Superintendent with an allowable variation not to exceed 0.5 pounds per square yard. The spreader hopper shall have a maximum spread width of 18 feet with gate openings graduated so that the spread widths can be adjusted in 6-inch increments. The spreader shall be equipped with a self- locking hitch with a minimum of 90-degree vertical movement. The machine shall have sufficient power and traction to pull loaded aggregate trucks on any county road. 12. The compaction roller shall be an 8-10 ton pneumatic-tire compaction roller, or equal, which will be available for use during surface treatment operations. 13. Each asphalt distributor, the compaction equipment and the aggregate spreader shall each be supplied with a competent and experienced operator. The operators shall have appropriate experience with the type of work being done and with the equipment that they are operating. The will work in full cooperation with the County Highway Superintendent and his representatives. 14. The Superintendent of Highways or his representative will make necessary field measurements to ascertain volumes actually delivered or applied. The measurement will be made prior to commencing and upon completion, using a calibrated tank stick gauge, which must be carried on each transport or distributor. The bidder’s driver will provide access to tanks by opening the dome to permit measurement by County personnel. 15. The Superintendent of Highways reserves the right to make any investigations or inquires necessary to determine the competence and ability of the bidder to properly perform the work. If after said investigation the Superintendent of Highways is not satisfied that the bidder is properly qualified to meet all requirements contained herein and to perform all work in a satisfactory manner, he may recommend to the Highway ---PAGE BREAK--- 3 Committee that the bidder be rejected as unsatisfactory. 16. Bid price on bid item XIII on the bid sheet will apply to the first 15,000 gallons per project on each workday. There will be no payment for distributing over 15,000 gallons per product per day. 17. The Bidder, at the time of bidding, must own and operate a permanent emulsion manufacturing plant and be listed as a supplier on the NYSDOT APPROVED LIST OF LIQUID ASPHALT EMULSIONS PRIMARY SOURCES and/or SUPPLIERS. All liquid asphalt emulsions supplied shall be obtained from an approved NYSDOT primary source. Each individual finished product storage tank shall be properly numbered, heated and equipped with necessary sampling devices and pumps. The Contractor’s plant must have storage capacity of at least 100,000 gallons. The Contractor’s plant must have a dispatcher on duty form 7 a.m. to 5 p.m. Monday through Friday and have a telephone listed in Contractor’s name. 18. Each load delivered shall have a computer printed, numbered liquid scale ticket for all deliveries and returns meeting NYSOGS Commodity Group 31501 specifications showing date, customer name, gallons, temperature and grade of product. Additionally, a road condition report shall be completed and signed by bidder’s driver and the Superintendent of Highways or his representative, stating road or project name, application rate, weather and surface conditions at the time of application. 19. The bidder shall own, operate and maintain a working laboratory at his plant. The laboratory shall be equipped with all equipment necessary to perform all specified tests on any emulsion sample. The laboratory shall be operated by a full time qualified technician and shall be available for use by County personnel. In addition, the laboratory shall also include sufficient equipment to test aggregates and mixes required by NYS DOT Materials Method 5. In addition, the County Highway Superintendent may have samples tested by a certified independent testing lab. 20. All sampling, testing, inspection, certifying and shipping shall be in accordance with NYS DOT Materials Method 8.1 and 8.2. County Highway Department personnel shall sample each load at the point of delivery. Each transport or distributor shall be properly equipped with sampling devise. The Bidder will also provide the sample containers. 21. The Superintendent of Highways may have samples tested by a certified independent testing laboratory. All laboratory tests performed shall be done at the expense of the Bidder. 22. All samples shall be properly handled, protected from freezing and tested within 30 days of sampling. Failure to meet appropriate specification (NYS DOT and ASTM) is grounds for rejection and non-payment for the delivered material. When materials furnished do not conform to these specifications, or are deemed unsatisfactory by the County Superintendent of Highways, payment due will be withheld and the supplier will be charged for any damage involved. In any case, payment by the County Highway Department for any materials delivered shall not be construed as acceptance thereof. 23. All materials shall be delivered under the direction and supervision of the County Superintendent of Highways or some person authorized by him to direct and superintend the same. 24. Failure of the bidder, after being awarded a contract and thus referenced hereafter as the “contractor”, to supply materials when as needed or as directed by the County Superintendent of Highways will be deemed a ---PAGE BREAK--- 4 declaration on the part of the contractor that he does not intend to perform his contract and the County may then secure the types of material elsewhere and charge all excess cost to the contractor. 25. When material furnished does not conform with specifications or is deemed unsatisfactory by the Superintendent of Highways, material will be purchased from the next lowest competent bidder, and payments due will be withheld and the contractor will be charged for all excess costs and all damage involved. Operator of plant facilities shall have a minimum of two year’s experience in the production of the type of material specified to insure proper mixtures and satisfactory service. 26. The bidder shall supply, with the bid, documentation showing that he has manufactured and supplied all items being bid in at least four successful projects in the previous two years. This documentation will show customer, location, quantities, date of completion and person to contact for verification; also submitting certified test results for each project cited above. Any bid which is not documented as above will be considered unresponsive to this specification and will be rejected. The bidder at the time of bidding shall own the equipment with which he intends to complete the contract, if so awarded. 27. On all work for which the bidder provides labor to operate the bidder’s equipment at the project site, the bidder shall conform to Section 220 of the New York State Labor Law and to the Prevailing Wage Rates for Cortland County as provided by the New York State Department of Labor, as contained in this proposal. The supplier shall maintain appropriate payroll records on each employee and file a certified payroll weekly. Each payroll record must be affirmed as true under the penalties of perjury, which means a notarized signature to that effect. If, during the period of the contract, the low bidder is cited by the NYS Department of Labor for a willful violation of the laws and regulations applicable to the bidding process, pricing policies, or in any way applicable to the services or supplies rendered pursuant to this contract, the County shall have the option to deem the bidder irresponsible and any other work will be awarded to the next low bidder and the original low bidder will be charged for the difference in bid prices. 28. In the event that the specified product does not properly set-up with respect to the highest of standards, the County Superintendent has the right to proceed with the following: 1) Implement the requirements established in this item of the specifications; 2) Obtain the products and services from the second lowest bidder and the low Bidder will be responsible for the cost differential; 3) Conduct an investigation as to the dissatisfaction of the County’s standards; 4) If in its best interest the County declares the low bidder not responsible and contracts with the second lowest bidder, the County shall hold the low bidder responsible to incur any difference in cost. 29. The Highway Committee reserves the right to accept or reject any or all bids in the best interest of Cortland County 30. The Contractor shall provide to Cortland County a qualified technical person for each project, at the County Highway Superintendent’s request, to assist in training County employees on asphalt emulsion applications, calibrating equipment and recommending to the County Highway Superintendent specific expertise on uses of asphalt emulsions. 31. Prior to working on any project, the asphalt emulsion supplier shall provide the Cortland County Highway ---PAGE BREAK--- 5 Superintendent with their recommendations for the project. As a minimum this would include target aggregate gradation and quantity and type of asphalt emulsion to be used. 32. All bidders will submit with their bid a certified check in the amount of $5,000.00. The unsuccessful bidders will have their checks returned after acceptance of the successful bid by the Cortland County Legislature. The successful bidder will have his check returned upon receipt of the required contract. 33. Upon acceptance, Cortland County will require a performance bond to insure the financial responsibility of the bidder in an amount equal to One Hundred Eighty Five Thousand Dollars ($185,000.00). 34. All bids must be accompanied by properly executed non-collusion statement. 35. Due to the uncertainty of the cost of asphalt cement used in the manufacture of emulsified asphalt products, a price adjustment clause is included. Price adjustments shall be based on New York State Department of Transportation methods and shall be based on the September 1, 2015 F.O.B. average terminal price of $521.000 per Short Ton. 36. Guarantee: The bidder shall guarantee that all material and equipment used to fulfill this contract meets the enclosed specifications. A two-year guarantee for defective or inferior bituminous material and/or workmanship shall apply to all bituminous materials supplied and applied under this contract. 38. The County of Cortland reserves the right to reject any item in the bid and to award the bid in whole or in part to one or more bidders. 39. Bid sheet Items I through III shall conform to New York State Department of Transportation Standard Specifications dated January 2, 2002 as amended. 40. Bid sheet Items IV through XII shall conform to the requirements of pages 7 through 9 of these specifications. 41. PREVAILING WAGES AND SUPPLEMENTS The Contractor shall conform to Section 220 of the New York State Prevailing Wage Rates for Cortland County as provided by the New York State Department of Labor, as contained in this proposal. The Prevailing Wage Rate document to be used is available for viewing at the following web link: http://www.cortland-co.org/Highway/index.htm, under link entitled “Material and Service Bids”. The Contractor shall maintain appropriate payroll records on each employee and file a certified payroll weekly. Each payroll record must be affirmed as true under the penalties of perjury, which means a notarized signature to that effect. If during the period of the contract the Contractor is cited by the NYS Department of Labor for a willful violation of the laws and regulations applicable to the bidding process, pricing policies, or in any way applicable to the services or supplies rendered pursuant to this contract, the ---PAGE BREAK--- 6 County shall have the option to deem the Contractor irresponsible and in breach of contract. The County may then award the work to a different contractor. 42. CONTRACT AND INSURANCE If awarded the contract and prior to beginning any work, the Contractor shall be required to execute the County of Cortland’s Standard Contract Agreement and provide the County of Cortland proof of insurance coverage as listed in the Standard Contract Agreement. Notice is hereby given that Cortland County requires said insurance coverage by way of a Certificate of Insurance naming the County of Cortland as an additional insured party. A Sample of the County’s Standard Contract Agreement Form is available at the following web link: http://www.cortland-co.org/Highway/index.htm, under link entitled “Material and Service Bids”. 43. CONTRACT TERM AND EXTENSION OF BID PRICES: The prices quoted here in shall remain in effect from May 1, 2016 through April 30, 2017 and thereafter until 30 days after receipt of written notice of a Contractor’s intent to cancel or until public notice is published by the County of Cortland for the receipt of new bids for items mentioned herein. The County reserves the right to extend this contract, upon mutual agreement with the successful bidder, for three additional one-year periods. 44. MEASUREMENT AND PAYMENT: Bid sheet Item XIV shall be bid on a per gallon basis including the operators and operating supplies as per these specifications. Bid sheet Items XV and XVI shall be bid on a per day basis including the operator and operating supplies. Bid sheet Item XVII and XVIII shall be bid on an hourly basis including the operator and operating supplies. All bid prices shall include all transportation and delivery charges to the job site. ---PAGE BREAK--- 7 TABLE II Asphalt Emulsion Fog Coat (AEFC) MATERIAL DESIGNATION Fog Coat Test Requirements Min. Max. Sieve Test, % - 0.10 Residue by Distillation, % 35 50 Oil Distillate, Volume of Total Emulsion, % - 2 ---PAGE BREAK--- 8 Test on Residue from Distillation: Penetration, 77°F (25°C), 100 g, 5 second 40 100 Suggested Spraying Temperature, °F 75 150 ASPHALT EMULSION SPECIFICATIONS TABLE NOTES All tests shall be run in accordance with ASTM D-244 except as noted. All tests shall be run in accordance with ASTM D-244 except as noted. The emulsion shall remain homogenous and useable for a minimum of 30 days. The supplier will not be held responsible for emulsion testing of samples that have frozen before testing. Material that does not fully comply with these specifications will be rejected. The supplier shall be responsible for the cost and disposal of rejected material. Sand Penetration Test for Dust Palliative Solutions The sand penetration test is intended to evaluate how well a dust palliative solution will penetrate a specified material. Apparatus 1. Small container of known cross-sectional area, approximately 76.2 mm in diameter, 50.8 mm in height (3 inches in diameter, 2 inches in height). A 227 gm (8-oz.) ointment tin is suitable. 2. Reference sand. Special screened silica sand #20326. (This graded sand is available from Unimin Sand Inc., 258 Elm Street, New Canaan, Connecticut 06840. 3. MC-30 Cutback Asphalt conforming to ASTM D2027. 4. Graduated Cylinder. 5. Stop watch, spatula, and ruler. 6. Thermometer, ASTM 83C or equivalent. Procedure 1. Thoroughly mix the reference sand with 1.5 percent water. 2. Place moistened sand into container (minimum material thickness 38 mm/1-1/2 inches) and compact at 7 kg/sq. cm (100 psi) using a round metal disc or plunger smaller in diameter than the container. 3. Using the specified field applied dilution ratio if required, weigh 5 grams of the dust palliative solution into the container of compacted sand and start the stop watch. For comparison purposes, pour the material into the center of the container allowing it to flow from this point of pouring by itself. Pour from a height of about 10 cm. (4 inches). ---PAGE BREAK--- 9 4. Stop the stopwatch when the material has penetrated the compacted sand, and record the time in seconds. 5. If additional applications are specified for field use, reapply as required. 6. Remove a cross-section of the penetrated sand with a spatula. Measure to determine the average depth of penetration in mm (inches). Test Results Run the above test using MC-30 Cutback Asphalt as a reference material. The dust palliative material will pass the Sand Penetration Test if: the time for penetration for each application is less than or equal to 150 seconds, and the average final depth of penetration is equal to or greater than that of MC-30. ASTM D-244 except that the maximum temperature that the material shall be subjected to is 383 F 10 F. ASTM Method D-4957 Condition the ductilometer and samples to be treated at 10C (50F). Prepare the brass plate, mold and briquette specimen in accordance with ASTM D113. The molds shall be of the non-tapered type used for Force Ductility Testing. Keep the specimen at the specified test temperature of 10C (50F) for 85-90 minutes. Immediately after conditioning, place the specimen in the ductilometer and proceed to elongate the sample to 20 cm at a rate of pull of 5 cm/min. After the 20 cm elongation has been reached, stop the ductilometer and hold the sample in its elongated position for 5 minutes. After 5 minutes, clip the sample approximately in half by means of scissors or other suitable cutting device. Let the sample remain in the ductilometer in an undisturbed condition for one hour. At the end of this time period, retract the half sample specimen until the two broken ends touch. At this point, note the elongation in centimeters (cm). Calculate the percent recovery by the following formula: % recovery = 20 - E x 100 20 The polymer shall be added at the time of manufacture of the emulsion. ASTM D244 except that the mixture of stone and asphalt emulsion shall be mixed vigorously for 5 minutes, then allowed to stand for 3 hours, after which the mixture shall be capable of being mixed an additional 5 minutes. The mixture shall be then rinsed twice with approximately it’s own volume of tap water without showing appreciable loss in bituminous film. After the second mixing, the aggregate shall retain 90% of it’s original coating. ASTM D244 except the aggregate shall be silica sand. After weighing 500 grams of the sand into the pan, the sand shall be completely immersed in tap water. Rebalance the pan, sand, and water and add 40 grams of emulsion into the sand and water. Mix the sand under water vigorously for 3 minutes. Pour off the excess water. The sand shall be at least 90% coated. 100 grams of produced mixture shall be heated to 250F in a laboratory oven for 2 hours. Stir and cool to ---PAGE BREAK--- 10 200F. Place the mix in 400 ml of boiling distilled water in a 600 ml glass beaker. Stir with a glass rod at a rate of one revolution per second for 3 minutes. The aggregate shall be at least 90% coated with a bituminous film. END OF SPECIFICATIONS ---PAGE BREAK--- 11 2016 BID SHEET 1 of 2 Item I 702-3102 HFRS-2 * per gal. *The minimum demulsibility shall be 60% when run in accordance with ASTM D244. Item II 702-90 Tack Coat per gal. Item III 702-3301 HFMS-2 $ per gal. Item IV AEPM per gal. Item V AEDC per gal. Item VI AEFC per gal. Item VII HFMS-2ST per gal. Item VIII HFMS-2C per gal. Item IX HFMS-2GH per gal. Item X HFMS-1 per gal. Item XI HFRS-2P per gal. Item XII HFMS-1P gal. Item XIII HFMS-2P gal. Item XIV Distributor (w/operator) gal. Item XV Roller (w/operator) day. Item XVI Self propelled aggregate spreader day. (w/operator) Item XVII 18 wheel Flow Boy hour (w/operator) Item XVIII Ten Wheel Dump Truck hour (w/operator) ---PAGE BREAK--- 12 2016 BITUMINOUS MATERIALS - LIQUID BID SHEET 2 of 2 NAME OF BIDDER: ADDRESS: LOCATION OF PLANT: AUTHORIZED SIGNATURE: NAME & TITLE: DATE: CONTACT PERSON: EMAIL ADDRESS: TELEPHONE: FAX: ---PAGE BREAK--- 13 EXHIBIT A – DRUG FREE WORKPLACE Whenever two or more Bids which are equal with respect to price, quality and service are received by the State or by any political subdivisions for the procurement of commodities or contractual services, a Bid received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. Established procedures for processing the Bids will be followed if none of the tied vendors have a drug free workplace process. In order to have a drug-free workplace program, a business shall: 1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2) Inform employees about the dangers of drug abuse in the workplace, the business’ policy of maintaining a drug free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3) Give each employee engaged in providing the commodities or contractual services that are under Bid a copy of the statement specified in Subsection 4) In the statement specified in Subsection notify that employees, that, as a condition of working of the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employee of any conviction of, or plea of guilty or nolo contendere to, any violation of any controlled substance law in the United States or any state or Cortland County, for a violation occurring in the workplace no later than five days after such conviction. 5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program, if such is available in the employee’s community, by any employee who is so convicted. 6) Make a good faith effort to continue to maintain a drug free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies with the above requirements. Print Name: Date: Signature: ---PAGE BREAK--- 14 EXHIBIT B – ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH STANDARD CLAUSES FOR NEW YORK STATE CONTRACTS (APPENDIX A) I hereby acknowledge that I have read, understand and agree to comply with the terms as outlined in Appendix A – Standard Clauses for New York State Contracts. Failure to comply may result in immediate termination of this agreement with potential legal recourse by the County. Signed: Date: Title: ---PAGE BREAK--- 15 EXHIBIT C - NON COLLUSIVE BILLING CERTIFICATE REQUIRED BY SECTION 139-D OF THE STATE FINANCE LAW Section 139D, Statement of Non-Collusion in bids to the State: By submission of this bid, bidder and each person signing on behalf of bidder certifies, and in the case of joint bid, each party thereto certifies as its own organization, under penalty of perjury, that to the best of his/her knowledge, and belief: 1) The prices of this bid have been arrived at independently, without collusion, consultation, communication, or agreement, for the purposes of restricting competition, as to any matter relating to such prices with any other bidder or with any other competitor; 2) Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the Bidder and will not knowingly be disclosed by the Bidder prior to opening, directly or indirectly, to any other bidder or to any competitor; and 3) No attempt has been made or will be made by the Bidder to induce any other person, partnership or corporation to submit or not to submit a bid for the purpose of restricting completion. A Bid shall not be considered for award nor shall any award be made where 1, 2, 3 above have not been complied with; provided however, that if in any case, the bidder(s) cannot make the foregoing certification, the bidder shall so state and shall furnish below a signed statement which sets forth in detail the reasons therefore: (Affix addendum to this page if space is required for statement.) Subscribed to me under penalty of perjury under the laws of the State of New York, this day of as the act and deed of said corporation of partnership or sole proprietor. If Bidders are a Partnership, complete the Following: Names of Partners or Principals Legal Residence ---PAGE BREAK--- 16 If Bidders are a corporation, complete the following: Name Legal Residence President Secretary Treasurer President Secretary Treasurer Identifying Data: Potential Contractor: Address: Telephone Title: E-Mail Address: If applicable, Responsible Corporate Officer Name: Title: Signature: Joint or combined bids by companies or firms must be certified by each participant. Legal name of person or firm Legal name of person or firm Name Name Title Title Address Address ---PAGE BREAK--- 17 EXHIBIT D - CONFLICT OF INTEREST DISCLOSURE Conflict of Interest Disclosure Form Note: A potential or actual conflict of interest exists when commitments and obligations are likely to be compromised by the nominator(s)’other material interests, or relationships (especially economic), particularly if those interests or commitments are not disclosed. This Conflict of Interest Form should indicate whether the nominator(s) has an economic interest in, or acts as an officer or a director of, any outside entity whose financial interests would reasonably appear to be affected by the addition of the nominated condition to the newborn screening panel. The nominator(s) should also disclose any personal, business, or volunteer affiliations that may give rise to a real or apparent conflict of interest. Relevant Federally and organizationally established regulations and guidelines in financial conflicts must be abided by. Individuals with a conflict of interest should refrain from nominating a condition for screening. Date: Name: Position: Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or circumstances that you believe could contribute to a conflict of interest: I have no conflict of interest to report. I have the following conflict of interest to report (please specify other nonprofit and for- profit boards you (and your spouse) sit on, any for-profit businesses for which you or an immediate family member are an officer or director, or a majority shareholder, and the name of your employer and any businesses you or a family member own): 1. 2. 3. I hereby certify that the information set forth above is true and complete to the best of my knowledge. Signature: Company: Date: ---PAGE BREAK--- 18 EXHIBIT PRIVACY AND SECURITY (HIPAA) The purpose of this clause is to set forth the requirements for privacy and security of protected health information (“PHI”) mandated by 45 CFR Part 164 as they apply to the services provided by CONTRACTOR on behalf of COUNTY. CONTRACTOR understands the importance of the privacy of a patient’s PHI, and agrees to protect that right to the extent necessary under this Agreement and under current federal, state, and local regulations and laws. All PHI will be handled in a private and/or confidential manner. For purposes of this Agreement, PHI is any data or other information as defined by the Department of Health and Human Services in the Code of Federal Regulations, 45 CFR §164.501. Further, CONTRACTOR understands that County’s patients are intended third-party beneficiaries of this Agreement, and have all the rights and privileges of any third-party beneficiary under current law. Uses and disclosures of PHI that are permitted are those necessary in order for CONTRACTOR to: 1. Properly manage and administer its functions. 2. Meet its legal responsibilities. 3. Provide data aggregation services relating to the health care operations of the COUNTY. 4. Make those disclosures required by law such as in situations of abuse, neglect, or domestic violence. The uses and disclosures permitted are limited to the PHI necessary to meet the requirements of the law that compels the use or disclosure. 5. Make disclosures in response to a judicial or administrative proceeding through a lawful process such as a subpoena or discovery request. The uses and disclosures of PHI that are required are those disclosures necessary: 1. For patients to review their PHI. 2. To provide an accounting of disclosures in accordance with 45 CFR §164.528. 3. To allow the Secretary of Health and Human Services to determine County’s compliance with 45 CFR §164.504. CONTRACTOR shall make the following assurances to COUNTY: 1. CONTRACTOR agrees that it shall not use or disclose any patient’s PHI for any purpose not expressly stated in this Agreement. Further, CONTRACTOR shall not use or disclose PHI in any manner or context prohibited by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and subsequent federal, state, and local regulations. If CONTRACTOR ---PAGE BREAK--- 19 does use or disclose PHI for a purpose not expressly stated in this Agreement, it shall immediately cease the unauthorized use or disclosure, and shall notify COUNTY in writing of such use or disclosure. CONTRACTOR agrees to mitigate, to the extent practicable, any harmful effect known to it of a use or disclosure of PHI not allowed under this Agreement. 2. CONTRACTOR further agrees that any sub-contractors or other persons or entities not directly employed by CONTRACTOR who use or disclose PHI obtained from COUNTY, shall abide by terms of this clause of this Agreement. Any sub-contractor or other person or entity not directly employed by CONTRACTOR that has used or disclosed PHI without proper authorization (as defined in HIPAA and subsequent federal, state, and local regulations) shall be considered to have acted as an agent of CONTRACTOR, and have violated the terms of this Agreement. COUNTY may consider this use or disclosure a material breach of this Agreement. 3. By signing this Agreement, CONTRACTOR is assuring COUNTY it has met the minimum safeguards necessary to protect unauthorized use or disclosure of PHI to any person or entity not party to this Agreement. Such safeguards shall include the security safeguards outlined by the 1996 Health Insurance Portability and Accountability Act and subsequent federal regulation, including: physical access to PHI, technical access to PHI, and administrative policies and procedures addressing security of PHI. 4. Provider shall report to COUNTY any instance or circumstance in which PHI has been used or disclosed by an unauthorized person or entity, including accidental disclosure by CONTRACTOR. CONTRACTOR shall notify COUNTY in writing of any steps or procedural changes made to address the unauthorized use or disclosure. 5. Should COUNTY find PHI used or disclosed to CONTRACTOR to be inaccurate or incomplete, CONTRACTOR shall incorporate any amendments or corrections to the PHI at COUNTY’s request. 6. CONTRACTOR will make PHI available to the individual who is the subject of the PHI for amendment. Such requests by the individual for their PHI from CONTRACTOR will be made through County. CONTRACTOR will incorporate any amendments to PHI that have been made by COUNTY by virtue of the individual’s request for amendment. 7. CONTRACTOR will provide a timely accounting to the individual or to COUNTY, if requested by either, of the disclosures of an individual’s PHI. 8. Should CONTRACTOR make any material alterations to the PHI while the PHI is in its possession, CONTRACTOR shall notify COUNTY of such alterations so that COUNTY may inform the patient who is the subject of the PHI. 9. At the termination of this Agreement, CONTRACTOR shall return or destroy to the satisfaction of COUNTY any PHI held or maintained by CONTRACTOR and retain no ---PAGE BREAK--- 20 copies of such information. If COUNTY and CONTRACTOR mutually agree that returning or destroying the PHI is not feasible or permitted under law, the PHI will remain protected after this agreement ends for as long as CONTRACTOR maintains the information. Further uses or disclosures of the PHI will be limited to those purposes that make the return or destruction infeasible. If COUNTY determines CONTRACTOR has violated any of the above assurances, covenants or terms, the CONTRACTOR has committed a material breach of this Agreement. COUNTY may then provide CONTRACTOR with an opportunity to cure the breach or may terminate this Agreement and may report the violations to the Department of Health and Human Services (“HHS”) or other federal or state entity for possible prosecution or sanctions. Both parties to this agreement agree that they will protect the integrity and confidentiality of any PHI being shared electronically. CONTRACTOR hereby gives COUNTY and the Department of Health and Human Services (or an agent acting on behalf of HHS) the express right to inspect any and all internal practices, books, and records relating to the use or disclosure of PHI by CONTRACTOR. If HHS suspects an unauthorized use or disclosure of PHI by CONTRACTOR, HHS is authorized to pursue an investigation into CONTRACTOR’s activities for the purposes of determining whether an unauthorized use or disclosure of PHI has taken place. CONTRACTOR may have policies and procedures relating to privacy and security in place prior to the commencement of this Agreement. If, after reasonable investigation, COUNTY concludes CONTRACTOR’s policies and procedures to be “adequate” protection of a patient’s privacy rights relating to PHI, CONTRATOR may elect to continue to use its own policies and procedures. The term “adequate” in this clause means CONTRACTOR’s policies and procedures meet the minimum privacy and security standards as set forth in COUNTY’s privacy and security policies and procedures. COUNTY, through the appropriate Department will: 1. provide CONTRACTOR with its Privacy Notice; 2. provide CONTRACTOR with any changes in, or revocation of, permission by a patient to use or disclose PHI, if such changes affect CONTRACTOR’s permitted or required uses or disclosures; and 3. notify CONTRACTOR of any restriction to the use or disclosure of PHI to which the COUNTY has agreed. (K.)Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic ---PAGE BREAK--- 21 protected health information (ePHI) that it creates, receives, maintains, or transmits on behalf of Cortland County. Ensure that any agent, including a subcontractor, to whom Contractor provides ePHI agrees to implement reasonable and appropriate safeguards to protect this information. Report to Security Officer of Cortland County any security incidents of which it becomes aware. (A security incident is defined as the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system.) ---PAGE BREAK--- 22 APPENDIX A APPENDIX A APPENDIX A APPENDIX A STANDARD CLAUSES FOR NEW YORK STATE CONTRACTS PLEASE RETAIN THIS DOCUMENT FOR FUTURE REFERENCE. ---PAGE BREAK--- 23 TABLE OF CONTENTS Page 1. Executory Clause 24 2. Non-Assignment Clause 24 3. Comptroller’s Approval 24 4. Workers’ Compensation Benefits 24-25 5. Non-Discrimination Requirements 25 6. Wage and Hours Provisions 25 7. Non-Collusive Bidding Certification 25 8. International Boycott Prohibition 26 9. Set-Off Rights 26 10. Records 26 11. Identifying Information and Privacy Notification 4 12. Equal Employment Opportunities For Minorities and Women 4-5 13. Conflicting Terms 5 14. Governing Law 5 15. Late Payment 5 16. No Arbitration 5 17. Service of Process 5 18. Prohibition on Purchase of Tropical Hardwoods 5-6 19. MacBride Fair Employment Principles 6 20. Omnibus Procurement Act of 1992 6 21. Reciprocity and Sanctions Provisions 6 22. Compliance with New York State Information Security Breach and Notification Act 6 23. Compliance with Consultant Disclosure Law 6 24. Procurement Lobbying 7 25. Certification of Registration to Collect Sales and Compensating Use Tax by Certain 7 State Contractors, Affiliates and Subcontractors 26. Iran Divestment Act 7 ---PAGE BREAK--- 24 STANDARD CLAUSES FOR NYS CONTRACTS The parties to the attached contract, license, lease, amendment or other agreement of any kind (hereinafter, "the contract" or "this contract") agree to be bound by the following clauses which are hereby made a part of the contract (the word "Contractor" herein refers to any party other than the State, whether a contractor, licenser, licensee, lessor, lessee or any other party): 1. EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the State shall have no liability under this contract to the Contractor or to anyone else beyond funds appro- priated and available for this contract. 2. NON-ASSIGNMENT CLAUSE. In accordance with Section 138 of the State Finance Law, this contract may not be assigned by the Contractor or its right, title or interest therein assigned, transferred, conveyed, sublet or otherwise disposed of without the State’s previous written consent, and attempts to do so are null and void. Notwithstanding the foregoing, such prior written consent of an assignment of a contract let pursuant to Article XI of the State Finance Law may be waived at the discretion of the contracting agency and with the concurrence of the State Comptroller where the original contract was subject to the State Comptroller’s approval, where the assignment is due to a reorganization, merger or consolidation of the Contractor’s business entity or enterprise. The State retains its right to approve an assignment and to require that any Contractor demonstrate its responsibility to do business with the State. The Contractor may, however, assign its right to receive payments without the State’s prior written consent unless this contract concerns Certificates of Participation pursuant to Article 5-A of the State Finance Law. 3. COMPTROLLER'S APPROVAL. In accordance with Section 112 of the State Finance Law (or, if this contract is with the State University or City University of New York, Section 355 or Section 6218 of the Education Law), if this contract exceeds $50,000 (or the minimum thresholds agreed to by the Office of the State Comptroller for certain S.U.N.Y. and C.U.N.Y. contracts), or if this is an amendment for any amount to a contract which, as so amended, exceeds said statutory amount, or if, by this contract, the State agrees to give something other than money when the value or reasonably estimated value of such consideration exceeds $10,000, it shall not be valid, effective or binding upon the State until it has been approved by the State Comptroller and filed in his office. Comptroller's approval of contracts let by the Office of General Services is required when such contracts exceed $85,000 (State Finance Law Section 163.6-a). However, such pre-approval shall not be required for any contract established as a centralized contract through the Office of General Services or for a purchase order or other transaction issued under such centralized contract. 4. WORKERS' COMPENSATION BENEFITS. In accordance with Section 142 of the State Finance Law, this contract shall be void and of no force and effect unless the Contractor shall provide and maintain coverage during the life of this contract for the benefit of such employees as are required to be covered by the provisions of the Workers' Compensation Law. 5. NON-DISCRIMINATION REQUIREMENTS. To the extent required by Article 15 of the Executive Law (also known as the Human Rights Law) and all other State and Federal statutory and constitutional non-discrimination provisions, the Contractor will not discriminate against any employee or applicant for employment because of race, creed, color, sex (including gender identity or expression), national origin, sexual orientation, military status, age, disability, predisposing genetic characteristics, marital status or domestic violence victim status. Furthermore, in accordance with Section 220-e of the Labor Law, if this is a contract for the construction, alteration or repair of ---PAGE BREAK--- 25 any public building or public work or for the manufacture, sale or distribution of materials, equipment or supplies, and to the extent that this contract shall be performed within the State of New York, Contractor agrees that neither it nor its subcontractors shall, by reason of race, creed, color, disability, sex, or national origin: discriminate in hiring against any New York State citizen who is qualified and available to perform the work; or discriminate against or intimidate any employee hired for the performance of work under this contract. If this is a building service contract as defined in Section 230 of the Labor Law, then, in accordance with Section 239 thereof, Contractor agrees that neither it nor its subcontractors shall by reason of race, creed, color, national origin, age, sex or disability: discriminate in hiring against any New York State citizen who is qualified and available to perform the work; or discriminate against or intimidate any employee hired for the performance of work under this contract. Contractor is subject to fines of $50.00 per person per day for any violation of Section 220-e or Section 239 as well as possible termination of this contract and forfeiture of all moneys due hereunder for a second or subsequent violation. 6. WAGE AND HOURS PROVISIONS. If this is a public work contract covered by Article 8 of the Labor Law or a building service contract covered by Article 9 thereof, neither Contractor's employees nor the employees of its subcontractors may be required or permitted to work more than the number of hours or days stated in said statutes, except as otherwise provided in the Labor Law and as set forth in prevailing wage and supplement schedules issued by the State Labor Department. Furthermore, Contractor and its subcontractors must pay at least the prevailing wage rate and pay or provide the prevailing supplements, including the premium rates for overtime pay, as determined by the State Labor Department in accordance with the Labor Law. Additionally, effective April 28, 2008, if this is a public work contract covered by Article 8 of the Labor Law, the Contractor understands and agrees that the filing of payrolls in a manner consistent with Subdivision 3-a of Section 220 of the Labor Law shall be a condition precedent to payment by the State of any State approved sums due and owing for work done upon the project. 7. NON-COLLUSIVE BIDDING CERTIFICATION. In accordance with Section 139-d of the State Finance Law, if this contract was awarded based upon the submission of bids, Contractor affirms, under penalty of perjury, that its bid was arrived at independently and without collusion aimed at restricting competition. Contractor further affirms that, at the time Contractor submitted its bid, an authorized and responsible person executed and delivered to the State a non-collusive bidding certification on Contractor's behalf. 8. INTERNATIONAL BOYCOTT PROHIBITION. In accordance with Section 220-f of the Labor Law and Section 139-h of the State Finance Law, if this contract exceeds $5,000, the Contractor agrees, as a material condition of the contract, that neither the Contractor nor any substantially owned or affiliated person, firm, partnership or corporation has participated, is participating, or shall participate in an international boycott in violation of the federal Export Administration Act of 1979 (50 USC App. Sections 2401 et seq.) or regulations thereunder. If such Contractor, or any of the aforesaid affiliates of Contractor, is convicted or is otherwise found to have violated said laws or regulations upon the final determination of the United States Commerce Department or any other appropriate agency of the United States subsequent to the contract's execution, such contract, amendment or modification thereto shall be rendered forfeit and void. The Contractor shall so notify the State Comptroller within five business days of such conviction, determination or disposition of appeal 105.4). 9. SET-OFF RIGHTS. The State shall have all of its common law, equitable and statutory rights of set-off. These rights shall include, but not be limited to, the State's option to withhold for the ---PAGE BREAK--- 26 purposes of set-off any moneys due to the Contractor under this contract up to any amounts due and owing to the State with regard to this contract, any other contract with any State department or agency, including any contract for a term commencing prior to the term of this contract, plus any amounts due and owing to the State for any other reason including, without limitation, tax delinquencies, fee delinquencies or monetary penalties relative thereto. The State shall exercise its set-off rights in accordance with normal State practices including, in cases of set-off pursuant to an audit, the finalization of such audit by the State agency, its representatives, or the State Comptroller. 10. RECORDS. The Contractor shall establish and maintain complete and accurate books, records, documents, accounts and other evidence directly pertinent to performance under this contract (hereinafter, collectively, "the Records"). The Records must be kept for the balance of the calendar year in which they were made and for six additional years thereafter. The State Comptroller, the Attorney General and any other person or entity authorized to conduct an examination, as well as the agency or agencies involved in this contract, shall have access to the Records during normal business hours at an office of the Contractor within the State of New York or, if no such office is available, at a mutually agreeable and reasonable venue within the State, for the term specified above for the purposes of inspection, auditing and copying. The State shall take reasonable steps to protect from public disclosure any of the Records which are exempt from disclosure under Section 87 of the Public Officers Law (the "Statute") provided that: the Contractor shall timely inform an appropriate State official, in writing, that said records should not be disclosed; and (ii) said records shall be sufficiently identified; and (iii) designation of said records as exempt under the Statute is reasonable. Nothing contained herein shall diminish, or in any way adversely affect, the State's right to discovery in any pending or future litigation. 11. IDENTIFYING INFORMATION AND PRIVACY NOTIFICATION. Identification Number(s). Every invoice or New York State Claim for Payment submitted to a New York State agency by a payee, for payment for the sale of goods or services or for transactions leases, easements, licenses, etc.) related to real or personal property must include the payee's identification number. The number is any or all of the following: the payee’s Federal employer identification number, (ii) the payee’s Federal social security number, and/or (iii) the payee’s Vendor Identification Number assigned by the Statewide Financial System. Failure to include such number or numbers may delay payment. Where the payee does not have such number or numbers, the payee, on its invoice or Claim for Payment, must give the reason or reasons why the payee does not have such number or numbers. Privacy Notification. The authority to request the above personal information from a seller of goods or services or a lessor of real or personal property, and the authority to maintain such information, is found in Section 5 of the State Tax Law. Disclosure of this information by the seller or lessor to the State is mandatory. The principal purpose for which the information is collected is to enable the State to identify individuals, businesses and others who have been delinquent in filing tax returns or may have understated their tax liabilities and to generally identify persons affected by the taxes administered by the Commissioner of Taxation and Finance. The information will be used for tax administration purposes and for any other purpose authorized by law. The personal information is requested by the purchasing unit of the agency contracting to purchase the goods or services or lease the real or personal property covered by this contract or lease. The information is maintained in the Statewide Financial System by the Vendor Management Unit within the Bureau of State Expenditures, Office of the State Comptroller, 110 State Street, Albany, New York 12236. ---PAGE BREAK--- 27 12. EQUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN. In accordance with Section 312 of the Executive Law and 5 143, if this contract is: a written agreement or purchase order instrument, providing for a total expenditure in excess of $25,000.00, whereby a contracting agency is committed to expend or does expend funds in return for labor, services, supplies, equipment, materials or any combination of the foregoing, to be performed for, or rendered or furnished to the contracting agency; or (ii) a written agreement in excess of $100,000.00 whereby a contracting agency is committed to expend or does expend funds for the acquisition, construction, demolition, replacement, major repair or renovation of real property and improvements thereon; or (iii) a written agreement in excess of $100,000.00 whereby the owner of a State assisted housing project is committed to expend or does expend funds for the acquisition, construction, demolition, replacement, major repair or renovation of real property and improvements thereon for such project, then the following shall apply and by signing this agreement the Contractor certifies and affirms that it is Contractor’s equal employment opportunity policy that: The Contractor will not discriminate against employees or applicants for employment because of race, creed, color, national origin, sex, age, disability or marital status, shall make and document its conscientious and active efforts to employ and utilize minority group members and women in its work force on State contracts and will undertake or continue existing programs of affirmative action to ensure that minority group members and women are afforded equal employment opportunities without discrimination. Affirmative action shall mean recruitment, employment, job assignment, promotion, upgradings, demotion, transfer, layoff, or termination and rates of pay or other forms of compensation; at the request of the contracting agency, the Contractor shall request each employment agency, labor union, or authorized representative of workers with which it has a collective bargaining or other agreement or understanding, to furnish a written statement that such employment agency, labor union or representative will not discriminate on the basis of race, creed, color, national origin, sex, age, disability or marital status and that such union or representative will affirmatively cooperate in the implementation of the Contractor's obligations herein; and the Contractor shall state, in all solicitations or advertisements for employees, that, in the performance of the State contract, all qualified applicants will be afforded equal employment opportunities without discrimination because of race, creed, color, national origin, sex, age, disability or marital status. Contractor will include the provisions of and above, in every subcontract over $25,000.00 for the construction, demolition, replacement, major repair, renovation, planning or design of real property and improvements thereon (the "Work") except where the Work is for the beneficial use of the Contractor. Section 312 does not apply to: work, goods or services unrelated to this contract; or (ii) employment outside New York State. The State shall consider compliance by a contractor or subcontractor with the requirements of any federal law concerning equal employment opportunity which effectuates the purpose of this section. The contracting agency shall determine whether the imposition of the requirements of the provisions hereof duplicate or conflict with any such federal law and if such duplication or conflict exists, the contracting agency shall waive the applicability of Section 312 to the extent of such duplication or conflict. Contractor will comply with all duly promulgated and lawful rules and regulations of the Department of Economic Development’s Division of Minority and Women's Business Development pertaining hereto. ---PAGE BREAK--- 28 13. CONFLICTING TERMS. In the event of a conflict between the terms of the contract (including any and all attachments thereto and amendments thereof) and the terms of this Appendix A, the terms of this Appendix A shall control. 14. GOVERNING LAW. This contract shall be governed by the laws of the State of New York except where the Federal supremacy clause requires otherwise. 15. LATE PAYMENT. Timeliness of payment and any interest to be paid to Contractor for late payment shall be governed by Article 11-A of the State Finance Law to the extent required by law. 16. NO ARBITRATION. Disputes involving this contract, including the breach or alleged breach thereof, may not be submitted to binding arbitration (except where statutorily authorized), but must, instead, be heard in a court of competent jurisdiction of the State of New York. 17. SERVICE OF PROCESS. In addition to the methods of service allowed by the State Civil Practice Law & Rules ("CPLR"), Contractor hereby consents to service of process upon it by registered or certified mail, return receipt requested. Service hereunder shall be complete upon Contractor's actual receipt of process or upon the State's receipt of the return thereof by the United States Postal Service as refused or undeliverable. Contractor must notify the State, in writing, of each and every change of address to which service of process can be made. Service by the State to the last known address shall be sufficient. Contractor will have thirty (30) calendar days after service hereunder is complete in which to respond. 18. PROHIBITION ON PURCHASE OF TROPICAL HARDWOODS. The Contractor certifies and warrants that all wood products to be used under this contract award will be in accordance with, but not limited to, the specifications and provisions of Section 165 of the State Finance Law, (Use of Tropical Hardwoods) which prohibits purchase and use of tropical hardwoods, unless specifically exempted, by the State or any governmental agency or political subdivision or public benefit corporation. Qualification for an exemption under this law will be the responsibility of the contractor to establish to meet with the approval of the State. In addition, when any portion of this contract involving the use of woods, whether supply or installation, is to be performed by any subcontractor, the prime Contractor will indicate and certify in the submitted bid proposal that the subcontractor has been informed and is in compliance with specifications and provisions regarding use of tropical hardwoods as detailed in §165 State Finance Law. Any such use must meet with the approval of the State; otherwise, the bid may not be considered responsive. Under bidder certifications, proof of qualification for exemption will be the responsibility of the Contractor to meet with the approval of the State. 19. MACBRIDE FAIR EMPLOYMENT PRINCIPLES. In accordance with the MacBride Fair Employment Principles (Chapter 807 of the Laws of 1992), the Contractor hereby stipulates that the Contractor either has no business operations in Northern Ireland, or shall take lawful steps in good faith to conduct any business operations in Northern Ireland in accordance with the MacBride Fair Employment Principles (as described in Section 165 of the New York State Finance Law), and shall permit independent monitoring of compliance with such principles. 20. OMNIBUS PROCUREMENT ACT OF 1992. It is the policy of New York State to maximize opportunities for the participation of New York State business enterprises, including minority and women-owned business enterprises as bidders, subcontractors and suppliers on its procurement contracts. ---PAGE BREAK--- 29 Information on the availability of New York State subcontractors and suppliers is available from: NYS Department of Economic Development Division for Small Business Albany, New York 12245 Telephone: [PHONE REDACTED] Fax: [PHONE REDACTED] email: [EMAIL REDACTED] A directory of certified minority and women-owned business enterprises is available from: NYS Department of Economic Development Division of Minority and Women's Business Development 633 Third Avenue New York, NY 10017 [PHONE REDACTED] email: [EMAIL REDACTED] The Omnibus Procurement Act of 1992 requires that by signing this bid proposal or contract, as applicable, Contractors certify that whenever the total bid amount is greater than $1 million: The Contractor has made reasonable efforts to encourage the participation of New York State Business Enterprises as suppliers and subcontractors, including certified minority and women-owned business enterprises, on this project, and has retained the documentation of these efforts to be provided upon request to the State; The Contractor has complied with the Federal Equal Opportunity Act of 1972 (P.L. 92-261), as amended; The Contractor agrees to make reasonable efforts to provide notification to New York State residents of employment opportunities on this project through listing any such positions with the Job Service Division of the New York State Department of Labor, or providing such notification in such manner as is consistent with existing collective bargaining contracts or agreements. The Contractor agrees to document these efforts and to provide said documentation to the State upon request; and The Contractor acknowledges notice that the State may seek to obtain offset credits from foreign countries as a result of this contract and agrees to cooperate with the State in these efforts. 21. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are hereby notified that if their principal place of business is located in a country, nation, province, state or political subdivision that penalizes New York State vendors, and if the goods or services they offer will be substantially produced or performed outside New York State, the Omnibus Procurement Act 1994 and 2000 amendments (Chapter 684 and Chapter 383, respectively) require that they be denied contracts which they would otherwise obtain. NOTE: As of May 15, 2002, the list of discriminatory jurisdictions subject to this provision includes the states of South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii. Contact NYS Department of Economic Development for a current list of jurisdictions subject to this provision. ---PAGE BREAK--- 30 22. COMPLIANCE WITH NEW YORK STATE INFORMATION SECURITY BREACH AND NOTIFICATION ACT. Contractor shall comply with the provisions of the New York State Information Security Breach and Notification Act (General Business Law Section 899-aa; State Technology Law Section 208). 23. COMPLIANCE WITH CONSULTANT DISCLOSURE LAW. If this is a contract for consulting services, defined for purposes of this requirement to include analysis, evaluation, research, training, data processing, computer programming, engineering, environmental, health, and mental health services, accounting, auditing, paralegal, legal or similar services, then, in accordance with Section 163 (4-g) of the State Finance Law (as amended by Chapter 10 of the Laws of 2006), the Contractor shall timely, accurately and properly comply with the requirement to submit an annual employment report for the contract to the agency that awarded the contract, the Department of Civil Service and the State Comptroller. 24. PROCUREMENT LOBBYING. To the extent this agreement is a "procurement contract" as defined by State Finance Law Sections 139-j and 139-k, by signing this agreement the contractor certifies and affirms that all disclosures made in accordance with State Finance Law Sections 139-j and 139-k are complete, true and accurate. In the event such certification is found to be intentionally false or intentionally incomplete, the State may terminate the agreement by providing written notification to the Contractor in accordance with the terms of the agreement. 25. CERTIFICATION OF REGISTRATION TO COLLECT SALES AND COMPENSATING USE TAX BY CERTAIN STATE CONTRACTORS, AFFILIATES AND SUBCONTRACTORS. To the extent this agreement is a contract as defined by Tax Law Section 5-a, if the contractor fails to make the certification required by Tax Law Section 5-a or if during the term of the contract, the Department of Taxation and Finance or the covered agency, as defined by Tax Law 5-a, discovers that the certification, made under penalty of perjury, is false, then such failure to file or false certification shall be a material breach of this contract and this contract may be terminated, by providing written notification to the Contractor in accordance with the terms of the agreement, if the covered agency determines that such action is in the best interest of the State. 26. IRAN DIVESTMENT ACT. By entering into this Agreement, Contractor certifies in accordance with State Finance Law §165-a that it is not on the “Entities Determined to be Non- Responsive Bidders/Offerers pursuant to the New York State Iran Divestment Act of 2012” (“Prohibited Entities List”) posted at: http://www.ogs.ny.gov/about/regs/docs/ListofEntities.pdf Contractor further certifies that it will not utilize on this Contract any subcontractor that is identified on the Prohibited Entities List. Contractor agrees that should it seek to renew or extend this Contract, it must provide the same certification at the time the Contract is renewed or extended. Contractor also agrees that any proposed Assignee of this Contract will be required to certify that it is not on the Prohibited Entities List before the contract assignment will be approved by the State. During the term of the Contract, should the state agency receive information that a person (as defined in State Finance Law §165-a) is in violation of the above-referenced certifications, the state agency will review such information and offer the person an opportunity to respond. If the person fails to demonstrate that it has ceased its engagement in the investment activity which is in violation of the Act within 90 days after the determination of such violation, then the state agency shall take such ---PAGE BREAK--- 31 action as may be appropriate and provided for by law, rule, or contract, including, but not limited to, imposing sanctions, seeking compliance, recovering damages, or declaring the Contractor in default. The state agency reserves the right to reject any bid, request for assignment, renewal or extension for an entity that appears on the Prohibited Entities List prior to the award, assignment, renewal or extension of a contract, and to pursue a responsibility review with respect to any entity that is awarded a contract and appears on the Prohibited Entities list after contract award. ---PAGE BREAK--- 32 Checklist of documents to be returned with bid or contract: Exhibit A: Drug Free Workplace Exhibit B: Acknowledgement and Agreement to Comply with Standard Clauses for New York State Contracts Exhibit C: Non-Collusive Bidding Certification Required by Section 139-D of the State Finance Law Exhibit D: Conflict of Interest Disclosure Proof of Insurance as required Valid W9 with signature Copy of NYS Certificate of Authority to do Business in New York State Proof that signatory is at least a 50% owner and has the authority to act on behalf of the business