Articulated Dump Truck Proposals 12 04 2018
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BID FORM ARTICULATED DUMP TRUCK LEASE Santa Rosa County Environmental Department 6051 Old Bagdad Highway Suite 301 Milton, Florida 32583 Date: A/4,v. 8, 2018 Dear Sir: The undersigned agrees to furnish the item as requested by you for Santa Rosa County in your Request for Proposal and certifies that the equipment meets or exceeds the specifications called for, except as set out in "Exceptions and Conditions" and attached to this form. Make and Model of Equipment ~''/la,- 730C ~ .£,..-vc/4 Name & Address of Company -z.i~A?f2S"(JA '7ii.cfr2L~- :z:;,,e. 2~7£2 [ef. /J,:,eHtf Rel ,?,,,,tko~ EZ ..i3SSV 48 month/6000hr lease: Articulated DUMP TRUCK $ 1, 87J. •!J, month .z I 4-.( &,,. &1dd Company Representativ~=tS!gnature 8£()- a,s-. atJ~6 Telephone EXCEPTIONS AND CONDITIONS: coMMENTs: Wz,1ew1i; ~✓'/,,~eds 5Peci f'tt:zlM$ .,,. ~tlt/~/.J f()UJt/t'/.et~J 6jdl,ut~s I &:.clu,~~JL ~l!)n,p<:>Aea.fs (ho~e~G-, ~eh, "' ptPtRh Ile-ti .S~/01<:<! bz~ I l,~e 1,,.[lel'!)c .,./ rl~ ~"'' a, ~~/'/Z~ l"t!pe:rr SWORN STATEMENT UNDER SECTION 287.133 (3) (A), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF I. 2. I understand that a "public entity crime" as defined in Paragraph 287 .133(l)(g). Florida Statutes means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods of services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitn1st, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1 )(b), Florida Statutes means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guil~ in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdic~ non jury trial, or entry of a plea of guilty or nolo contrendrc. 4. I understand that an "affiliate" as defined in Paragraph 287.133(1 )(a), Florida Statutes, means: I. A predecessor or successor of a person convicted of a public entity crime; or 2, An entity under tl1e control of any natural person who is active in the management of tl1e entity and who· has been convicted of a public entity crime. The term "affiliate" includes tl1ose officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a poolirrn of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima faca case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of public entity crime. 5. [ understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with legal power to enter into a binding contract and which bids or appeals to bid on contracts for the provision of goods and services let by a public entity, or which otl1erwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in mana,!lement of an entity. 6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Indicate which s~ment applies.) --'~"'--·Neither the entity submitting this sworn statement, nor one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in tnanagement of the entity, nor any affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July I, 1989. ____ The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. ____ The entity submitting tl1is sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who'lli'e active in management of the entity, or an affiliate oftl1e entity has been charged with and convicted of a public entity crime subsequent to July I, 1989. However, tl1ere has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by tl1e Hearing Officers determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (ATTACH A COPY OF THE FINAL ORDER.) Personally known ____________ or Pr~duced identification, P:l M~f \) t~ Notary Public- State of f-L:,(' ~ Jo., &{\\N' J l) \.\<:,tu\~ My commission expires /l)-6~ ,'90J.\ (Type of identification) __________________ (Printed, typed, or stamped commissioned name 0/110/ary public.) BID FORM ARTICULATED DUMP TRUCK LEASE Santa Rosa County Environmental Department 6051 Old Bagdad Highway Suite 301 Milton, Florida 32583 Dear Sir: The undersigned agrees to furnish the item as requested by you for Santa Rosa County in your Request for Proposal and certifies that the equipment meets or exceeds the specifications called for, except as set out in "Exceptions and Conditions" and attached to this form. Make and Model of Equipment JOltAJ Va2G 3/0e f/1>, Name & Address of Company~ OJw'iJ~ tJz!'/Plf' 3BS WJWJJf; /11,41?J., '&11e/v,1 El- 3'J..S3f 48 month/6000hr Lease: Articulated DUMP TRUCK $ 6, 6,%. I,!.. month ~w,'th pay,,,wl- /)/ /lR,(M.e.s $ 5/o01. If! JlfiNHl.-w1~/llwl tip h1JNl- o~ Must Be Specified tk0-20 d°:!15 lkm ~ of DrduL ~~ ~Company Representative ·s· 1gnature $?5o-41{,· 02.11 Telephone EXCEPTIONS AND CONDITIONS: COMMENTS: _______________________ _ SWORN STATEMENT UNDER SECTION 287.133 (3) (AJ. FLORIDA STATUTES. ON PUBLIC ENTITY CRIM ES and (if applicable) its Federal Employer If the entity has no FEIN, include the Social 2. I undcrs1,111d th,11 a "public entity crime" as defined in Paragraph 287.133(1 )(g), Florida Statutes. means a violation of any state or federal law by a person with respect to and directly relmed to the transaction of business with any public entity or with an agency or polit1cal subdivision of any other state or with the U1111ed States, including, but not limited to. any bid or contract for goods of services to be provided to any public entity or an agency or political subdivision of any other state or of the Unit eel States and involving antitrust, fraud. theft. bribery, collusion, racketeering. conspiracy. or material misrepresentation 3 I unclers1,111d that "convicted" or "conv1ct1on" as defined in Paragraph 287 133(1 )(b). Florida Statutes. means a Iinding of guilt or a conviction of a pubhc entity crime. with or without ,111 adJud1cation or guilt. 111 any federal or state trial coun of record relating to charges brought by indictment or information ai'ter July I. 1989. as a result or a jury verdict. nonjury trial. or entry of a plea of guilty or nolo cont rend re. 4. I underst:ind that an ··,11'1iliate'' as defin ed in Paragraph 287. 133( 1)( a). Floricla Statutes, means: I. A predecessor or successor of ,1 person convicted of a public entity cnme: or 2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted or a public entity crime. The tenn ..aniliate .. includes those orticers. directors. executives. panners. shareholders. employees. members, and agents who arc active in the management or an arliliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm 's length agreement. shall be a prima faca case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of public entity cnme. 5. I understand that ,1.. person" as de lined in Paragraph 287.133( I )(el. Florida Statutes. means any natural person or entity orga 111 zed under the laws of any state or of the United Swtes with legal power to enter into a b111d ing contract and which bids or appeals to bid on contr..icts for the provision of goods and services let by a public entity, or wluch otherwise transacts or applies to transact business with a public entity. The tenn "person" includes those oflicers. directors. executives. par1ners. shareholders. employees. members. and agents who are active in management of an entity. 6. Bas · 011 inform,111on tind belief. the statement which I have m,1rked below 1s true in relation to the entity submitting this sworn statement. (Indicate whi atcment applies.) -~~ - Neither the entity submitting this sworn statement. nor one or more of the oflicers.