Request for Proposal

From: Design/Build Contractors

For: Storage Building

Fulton County, Ohio

Board of Commissioners
 TABLE OF CONTENTS

SECTION PAGE
Introduction & Background 3
Scope of Services 5
Project Schedule & Deliverables 8
Proposal Requirements 9
Qualifications for Proposal 10
Proposal Contents 13
Proposal Evaluation & Selection Criteria 18

Attachments:

Notice to Bidders & Schedules

Federal Form W-9
Delinquent Personal Property Tax Statement
Non-Discrimination Affidavit
Non-Collusion Affidavit
Introduction and Background

LEGAL NOTICE

Sealed proposals for design/build for the construction of a 9,000 sq. ft. storage building located at Fulton Soil
and Water Conservation District, Robert Fulton Building, 8770 State Route 108, Suite B, Wauseon, OH 43567.
The building when completed will be utilized by the Fulton Soil and Water Conservation District. Proposals
will be received by the Board of Commissioners, Fulton County, Ohio, until August 4, 2016 at 10:00am, and
opened thereafter. Proposals may be hand delivered or mailed to the Board of Fulton County
Commissioners, 152 S. Fulton Street, Suite 270, Wauseon, Ohio 43567.

Complete set of criteria for the project will be available for examination, Monday through Friday from 8:30
am to 4:30 pm at the office of the Fulton County Commissioners, 152 S. Fulton Street, Suite 270, Wauseon,
Ohio 43567 and on the County website: www.fultoncountyoh.com.

Any proposals may be withdrawn prior to scheduled closing time for the receipt of Proposals, but no
Proposer shall withdraw his bid within 45 days after the actual bid opening thereof. The County reserves the
right to reject any or all Proposals, waive irregularities in any bid, and to accept any bid which is deemed most
favorable to the County.

By Order of Fulton County Commissioners

Paul Barnaby
Jeff Rupp
Bill Rufenacht
Teri Suarez, Clerk

Advertise: July 19 & 26, 2016

The Request for Proposal (RFP) for this project along with all supporting documentation, which are
considered to be part of an extension of the RFP and/or the Project Criteria and Performance Specification
s as if they were physically attached, can be accessed at the following site:

www.fultoncountyoh.com

All future documentation including addenda, response to questions, etc. will be posted on the above site as
no additional mailings will be made for this RFP. Upon receipt of this letter, it is requested that any firm
interested in this project email Vond T. Hall at: [email protected] as confirmation of your receipt
and interest.
Anticipated Storage Building Development Dates

RFP Release: July 15, 2016

Proposals due: August 4, 2016

If your firm is interested, please submit your Proposal to the County no later than 10:00 a.m., on August 4,
2016 as described below. (Hand delivered proposals can be taken to the Board of County Commissioners,
l o c a t e d on the second level of the administration building at 152 South Fulton Street, Wauseon, Ohio
43567.)

If a Proposal is not received by this date and time, it will be considered nonresponsive and will not be
evaluated. No Proposal will be accepted after that time unless the County extends the deadline by a
written addendum. Please deliver or send o n e ( 1) complete proposal to the address l i s t e d a b o v e .
It is required for each firm to submit two (2) separate envelopes, one containing the written proposal
and another with the price proposal and Office of Equal Opportunity forms where price is indicated. Please
identify the project name: County Storage Building Development Program on the outside of the envelopes
and indicate which envelope is the price proposal that also contains the forms.

The County reserves the right to reject any or all proposals or portions of them, to waive irregularities,
informalities, and technicalities, to re-issue or to proceed to obtain the service(s) desired otherwise, at
any time or in any manner considered in the County’s best interests. The Director may, at his/her sole
discretion, modify or amend any provision of this notice or the RFP.
 Scope of Services

General

Project Description: Construct a 9 ,0 0 0 sq . f t . s t o rage b u ild in g wit h co n cre t e f l o o r , (2 )

1 4 ’H x1 6 ’W D o o rs an d (2 ) 1 2 ’ H x1 4 ’ W D o o rs, 3 w al k - in d o o rs an d ro o m f o r a wa l k
in co o le r . The scope of the work to include but, not limited to:

1. Design Work, APE Fees, Local Permits, Testing (soil & concrete), Tap Fees, Edison Fees.

2. Site work, Excavation/backfill, Drainage system, Grading, Stump Removal, Curb Cuts and
taps.

3. Building Construction

4. Landscaping, Replace Topsoil around perimeter of new building. Install correct blend of
grass seed and mulch for conditions. (All trees and bushes, if planted, will be by the Fulton
County Commissioners.)

5. Tree Removal including stumps

6. Concrete work, Fine Grade, Sub Grade, form, pour and finish all flat concrete and curb to
the designed elevation and finish as described on approved/permit drawings. a. Follow all
ACI Best Practices for forming, reinforcing, placement, mix design, finishing, saw cutting,
control joints, expansion joints, cure and sealing.

7. Electrical Work, furnish and install complete electrical service, including 2 lights to be
located on the West and East end of said building. Also provide proper 120 Volt receptacles
for Cooler. All installed equipment/panels/receptacles to be properly NEMA rated for
exterior installation. Construction to include all Toledo Edison Costs.

8. General Conditions, all work to be in compliance with: OBBC Requirements, that may
pertain to spacing, ADA Requirements and electrical service requirements.

9. Barricades, cleanup and all safety related issues that may come up in the responsibility of
the design build/contractor.

10. Bonding & Insurance Requirements A bid must be accompanied by bid security in the
form of either a bid guaranty and contract bond for the full amount of the bid, with security
satisfactory to the Fulton County Commissioners, or by a certified check, cashier's check, or
letter of credit pursuant to Chapter 1305 of the Ohio Revised Code, in the amount of 10% of
the total bid, payable to the Fulton County Board of Commissioners.

Work Done by Owner/Others:

1. Provide survey to design/build contractor for use in developing design.

2.. All above grade signage to be purchased and installed by the owner.

3. Power to Sign

County Role:

The C o u n t y w i l l e x p r e s s t h e i n t e n t o f t h e d e s i g n a n d p r o v i d e a n
a d e q u a t e a n d complete facility design/construction scope and criteria in the RFP.
In addition, the County will:

1. Look to establish the execution requirements (e.g., schedule, operations, and any
constraints on Design/Builder’s work, Design/Builder submittals, permits, special
work acceptance requirements) and identify appropriate requirements in the RFP.

2. Monitor design and construction during the project implementation for

contractual compliance.

3. Endeavor to answer all questions promptly, and provide information that is critical
to the success of the project to avoid impeding the Design/Builder’s schedule.

4. Attempt to render decisions in a timely manner.

5. Not assume responsibility for design adequacy or “approve” design and

construction submittals, except t o approve r e q u e s t e d d e v i a t i o n s from
the contract when acceptable and appropriate. The County’s role changes
from reviewing designs and s u b m i t t a l s for technical accuracy for traditional
design/build projects to reviewing for conformance with the contract on design/build
contract(s).

Design/Builder’s Role

A. It will be the responsibility of the Design/Builder to be fully acquainted with the existing
conditions of the project site by conducting visual inspections before proposal
submission.

B. Professional consulting services for the Project will include the traditional stages of
project design (including schematic design, design development and cost estimates);
construction administration and management and Final construction documents.

C. It is anticipated that the project requirements will most likely include the involvement of,
in varying degrees, surveying, civil engineering, geotechnical, mechanical, electrical
structural, and landscape architectural professionals, as well as information technology
specialists and environmental services. The pertinent professional services will include, at
a minimum, the following:
 1. Project and construction management
2. Integrated schedule for design and construction
3. Extensions of designs
4. Permit preparation and application
5. Cost control
6. Material and equipment acquisition (including incorporation of long-lead items and
identification of possible impact to schedule)
7. Construction
8. Environmental Storm Water Pollution Prevention Plan development
9. Inspection and quality assurance/quality control (including any material testing
required)
10. Value Engineering
11. As-built survey for acceptance and record purposes
12. Training for operation and maintenance
13. Turnover, warranty and record (“as-built”) drawings

D. The Design/Builder must ensure the integrity of all extensions of the design and ensure
that all equipment and materials meet the minimum design criteria requirements. This
function is a significant role reversal from the traditional design/bid/build projects. The
Design/Builder must further develop the design and provide complete and usable storage
in this RFP.

The County reserves the right to modify the scope of services at any time before execution of
a contract to add, delete, or otherwise amend any item(s), as it deems necessary, in its sole
judgment, and in the best interest of the County.
Project Schedule and Deliverables

The project is on a time sensitive schedule and will require availability and dedication of
the selected Design/Builder to complete services on-time. Proposers should carefully
consider their ability to complete all required tasks inclusively within the project schedule
time frame.

Design/Builder shall submit within ten (10) calendar days after the award and/or
execution of the Contract, a Design Schedule for the performance of Design/Builder’s
design services and construction work which shall include allowance for reasonable time
required for the review and/or approval of all authorities having jurisdiction over the
Project.

The project must be completed in all stages by S e p t e m b e r 30, 2016. This is the
mandated final delivery and acceptance date of the project.

The County has established the following list of reports that the Design/Builder will be
required to provide as deliverables. The County reserves the right to modify the list of
deliverables at any time before e x e c u t i o n o f a c o n t r a c t t o a d d , d e l e t e , o r
o t h e r w i s e a m e n d a n y r e p o r t o r other deliverable, as it deems necessary, in
its sole judgment, and in the best interest of the County.

A. Please refer to “Project Requirements and Performance

Specifications” B. The County reserves the right to add related

services as needed.

C. Unless otherwise expressly provided, the term of the Agreement shall begin upon
its date of execution and, unless extended by County or unless sooner canceled
or terminated under the provisions of the Agreement, shall expire when all
required deliverables have been submitted to and approved by the County and
all other Services have been satisfactorily performed and accepted by the County.
Proposal Requirements

A. Submission of Proposal: Each proposer shall submit its proposal(s) in the number,
form, and manner, and by the date and time and at the location required in the
section, Introduction and Background above.

1. Each Proposer shall provide all information requested in this Request for
Proposal. The proposer must organize its proposal package to address
each of the elements in this RFP in the order listed in Proposal Contents
Section. The proposer should carefully read all instructions and
requirements and furnish all information requested. If a P r o p o s a l
d o e s n o t c o m p l y w i t h a l l t e r m s , c o n d it i o n s , a n d requirements
for submittal, the County may consider it unacceptable and may reject it
without further consideration.

2. If you find discrepancies or omissions in this RFP or if the intended meaning

of any part of this RFP is unclear or in doubt, a written request for
clarification or interpretation must be received by Vond T. Hall, preferably
by email at [email protected] by 4:00 local time on August 4,
2016.

B. The County’s Rights and Requirements

1. The County may require any Proposer to augment or supplement its

proposal or to meet with the County’s designated representatives for
interview or presentation to further describe the Proposer’s qualifications
and capabilities. The requested information, interview, meeting, or
presentation shall be submitted or conducted, as appropriate, at a time
and place the County specifies.

2. The County reserves the right, at its sole discretion, to reject any
proposal that is incomplete or unresponsive to the requests or
requirements of this RFP. The County reserves the r i g h t t o r e j e c t
a n y o r a l l p r o p o s a l s a n d t o w a i v e a n d accept any informality or
discrepancy in the proposal or the process as may be in the
County’s best interest.

3. Proposal as a Public Record. Under the laws of the State of Ohio, all
parts of a proposal, other than trade secret or proprietary information
and the fee proposal may be considered a public record which, if
properly requested, the County must make available to the requester for
inspection and copying. Therefore, to protect trade secret or
proprietary information, the Proposer should clearly mark each page,
but only that page, of its proposal that contains that information.
The County will, to the extent reasonably possible under the
circumstances, notify the proposer i f s u c h i n f o r m a t i o n i n
i t s p r o p o s a l i s requested, b u t cannot, however, guarantee
 the confidentiality of any proprietary or otherwise sensitive
information in or with the proposal. Blanket marking of the entire
proposal as “proprietary” or “trade secret” will not protect an entire
proposal and is not acceptable.

4. Term of Proposal’s Effectiveness. By submission of a proposal, the

Proposer agrees that its proposal will remain effective and eligible for
acceptance by the County until the earlier of the execution of a final
contract or 180 calendar days after the proposal submission deadline (the
“Proposal Expiration Date”).

5. Execution of a Contract. The Successful Proposer shall, within 10

business days after r e c e i p t o f a c o n t r a c t p r e p a r e d b y t h e
C o u n t y P r o s e c u t i n g A t t o r n e y , exclusive of Saturdays, Sundays
and holidays, execute and return the contract to the County together
with evidence of proper insurance and intent to conform to all
requirements of the contract attached hereto or which are a part hereof
and all applicable federal, state and local laws and ordinances prior to or
at the time of execution of the contract.

6. “Short-listing”. The County reserves the right to select a limited

number (a “short list”) of Proposers to make an oral presentation of
their qualifications, proposed services, and capabilities. The County will
notify the Proposers selected for oral presentations in writing.
7. Proposer’s Familiarity with RFP; Responsibility for Proposal. By
submission of a RFP, the Proposer acknowledges that it is aware of and
understands all requirements, provisions, and conditions in and of this
RFP and that its failure to become familiar with all the requirements,
provisions, conditions, and information either in this RFP or
disseminated either at a pre-proposal conference or by addendum
issued prior to the proposal submission deadline, and all circumstances
and conditions affecting performance of the services to be rendered
by the successful proposer will not relieve it from responsibility for
all parts of its Proposal and, if selected for contract, its complete
performance of the contract in compliance with its terms. Proposer
acknowledges that t h e C o u n t y h a s n o responsibility for any
conclusions or interpretations made by Proposer on the basis o f
i n f o r m a t i o n m a d e available by t h e C o u n t y . The C o u n t y
d o e s n o t guarantee the accuracy of any information provided and
Proposer expressly waives any right to a claim against the C o u n t y
arising from o r based upon any incorrect, inaccurate, or incomplete
information or information not otherwise conforming to represented
or actual conditions.
C. Interpretation

The County is not responsible for any explanation, clarification, interpretation,

representation or approval made concerning this RFP or a Proposal or given
in any manner, except by written addendum. The County will mail, e-mail, or
otherwise deliver one copy of each addendum issued, if any, to each individual
or firm that requested and received a RFP. Any addendum is a part of and
incorporated in this RFP as fully as if originally written herein.
Qualification for Proposal
A. Each Proposer, regardless of the form of its business entity, must meet the
following requirements. Failure to meet all requirements may be cause for
rejection of a proposal. If Proposer is a partnership or a joint venture, at least one
general partner or constituent member must meet the requirements. Each
Proposer must:

1. Each Design/Build team must provide evidence that it has a minimum of

five (5) continuous years of experience in the last seven (7) years in
performing Design/Build services for public agencies.

2. Teams must possess all applicable licenses, certificates, permits or other

authorizations required by all governmental authorities.

3. Teams must be authorized to conduct business in the State of Ohio,

County
of Fulton.

4. Teams must demonstrate experience in establishing and maintaining

constructive relations with project stakeholders and the community.

B. Insurance: The Successful Proposer, at its expense, shall at all times during the
term of the contract resulting from this RFP, maintain the following insurance
coverage. The insurance company(is) providing the required insurance shall be
authorized by the Ohio Department of Insurance to do business in Ohio and
rated “A” or above by A. M. Best Company or equivalent. The Successful
Proposer, as contractor, shall provide a copy of the p o l i c y o r p o l i c i e s a n d
a n y n e c e s s a r y e ndo rse me nt s , or a s u b s t i t u t e f o r t h e m satisfactory
to and approved by the County Prosecuting Attorney, evidencing the required
insurances upon execution of the contract.

1. The Successful Firm shall, at its expense and at all times during the
performance of Services hereunder, maintain comprehensive general and
professional liability insurance. The policies shall be with companies
authorized to do business in the State of Ohio and rated "A" or above by
A. M. Best Company or its equivalent. The comprehensive general liability
insurance policy shall (I) be occurrence type; (ii) name the County as an
additional insured; (iii) have limits of not less than a combined single limit
of One Million Dollars ($1,000,000.00) for any one incident and have a
deductible of not more than Fifty Thousand Dollars ($50,000.00) per
occurrence and in the aggregate; and (iv) be primary with respect to
Successful Firm’s general liability, notwithstanding a n y o t h e r
insurance co ve rin g County. The insurance policy shall include valuable
papers coverage in the amount of One Hundred Thousand Dollars
($100,000.00).
 2. Business automobile liability insurance to cover each automobile, truck or
other vehicle used in the performance of the contract in an amount not
less
than a combined single limit of One Million Dollars ($1,000,000.00) for
bodily injury (including death at any time occurring) and property damage
per occurrence.
3. Professional liability insurance (including errors and omissions) shall have limits
of not less than One Million Dollars ($1,000,000.00) each occurrence and
subject to a deductible each occurrence of not more than Fifty Thousand
Dollars ($50,000.00) per occurrence and in the aggregate and if not written
on an occurrence basis, shall be maintained for a period of not less than two
(2) years following the completion of the services provided under the contract.

4. Workers’ compensation and employer’s liability insurance as provided under

the laws of the State of Ohio.

5. Statutory unemployment insurance protection for all of its employees.

6. Maintain such other insurance policies as may be reasonably required by the

County.

C. Bond Information

1. Upon execution of the Contract, Design/Build contractor shall furnish to the

County separate performance and payment bonds in the penal sum of 100%
of the Guaranteed Maximum Price (GMP) amount, or the amount of the
Project construction budget if a GMP has not been established as of the date
of execution of the Contract, as a guarantee of good faith that the terms of
the Contract shall be compiled with in every particular. If the GMP established
under the Contract is less than the Project construction budget,
Design/Builder may furnish a rider to adjust the amount of the bonds to
reflect the GMP, and shall reflect the adjusted premium cast appropriately in
the general conditions shown as a part of the GMP.

a. Said p e r f o r m a n c e bond shall b e subject t o the approval of t h e

County’s Prosecuting Attorney.

b. The Surety must be licensed to do business within the State of Ohio.

A "Certificate of Compliance" issued by the Ohio Department of
Insurance shall accompany the performance bond.

c. The Surety must have an agent located within the State of Ohio, and the
agent shall be identified as part of the bond submittal.

d. The Surety shall provide a properly executed power of attorney

evidencing
the authority of the signatory to execute the bond.
 e. The Surety must be listed on the current edition of U.S. Treasury
Circular 570, and the penal amount of the bond shall be within the
limit noted on the circular.

f. The Design/Builder’s performance bond and the Design/Build Team

Surety will be r e l e a s e d o n l y w h e n a l l p r o v i s i o n s o f t h e
c o n t r a c t a n d a l l w a r r a n t y obligations required by the contract
have been fulfilled.

2. Subcontractor Bonds: Each Subcontractor whose Subcontract is

greater than$100,000 shall be required, as a condition of the
Subcontractor, to execute a similar Performance Bond in the full amount of
each Subcontract, naming the Design/Build Team and the County as joint
obligees.
Proposal Contents

Each proposal shall include the following parts in the below order. Please separate and
identify each part by tabs for quick reference. Each proposal should be organized so
as to facilitate its evaluation of the statements of qualifications.

Cover Letter: A letter to identify Proposer and to state other general information
that the Proposer wants to include regarding the business organization. At a
minimum the cover letter must include the name, principal address, federal ID
number, telephone number, facsimile number and email address of the
submitting firm (Proposer).

1. If the Proposer is a corporation, state the full name and title of each
of the corporate officers and their experience. The state of incorporation
is to be included. If the firm is not an Ohio corporation, a statement
advising whether or not t h e f i r m i s q u a l i f i e d t o d o b u s i n e s s i n t h e
S t a t e o f O h i o a s a f o r e i g n corporation. A foreign corporation will be
required to qualify to do business in the State of Ohio prior to the execution
of a contract.

2. If the Proposer is a sole proprietorship state the name of the individual

doing business.

3. If a partnership, state the full name, address and other occupation, if any,
of each partner; whether the partner is active or dormant; whether each
partner is a general or limited partner; each partner’s experience and the
proportionate share of the business owned by each partner. If the
Proposer is not an Ohio partnership, a statement advising whether or not
the Proposer is qualified to do business in the State of Ohio as a foreign
Partnership. A foreign Partnership will be required to qualify to do
business in the State of Ohio prior to the execution of a contract.

4. If a joint venture, state the names of the firms participating in the joint
venture and the principal officers of each firm; each officer’s experience
and the proportionate share of the joint venture owned by each joint
venture partner. If the Proposer is not an Ohio joint venture, a statement
advising whether or not the Proposer is qualified to do business in the
State of Ohio as a foreign joint venture. A foreign joint venture will be
required to qualify to do business in the State of Ohio prior to the
execution of a contract.

A. Executive Summary: The Executive Summary should provide a clear and concise
summary of Proposer’s background, level of expertise, direct relevant experience
and ability to provide and implement a design/build project for the
County Storage Building Development Project –developed to meet the
requirements of this RFP. The executive summary should make the firms case
as the best candidate for the contract. Proposer should structure this section in
 a manner that allows it to serve as a stand-alone summary when separated from
the other sections of the proposal.

B. Exceptions: Proposer shall itemize any exceptions it has to the RFP. If it

has no exceptions to or deviations from any part of this RFP, it shall so state on
an “Exceptions” page. If no deviations or exceptions are identified,
Proposer understands that if the County accepts the Proposer’s proposal, it
must comply with and conform to all of the requirements of the RFP.

C. Qualifications: The qualifications statement is an opportunity for each Proposer

to detail its qualifications, experience and what defines the Proposer and the rest
of the Design/Build Team as industry leaders. Proposers may include as much
information in this section as is needed to differentiate their Design/Build Team
and proposal from the other Proposers. Please include, as a minimum, the
following information:

1. Clearly communicate how you meet or exceed the minimum

qualifications of the following;
a. Minimum qualifications of Design/Builder
b. Minimum qualifications of Architect/Engineer of Record

2. Describe the nature of your business experience in providing and

implementing design/build services for construction projects as
described in this Request for Proposal a n d s t a t e t h e n u m b e r o f
p e r s o n s y o u c u r r e n t l y e m p l o y i n s u c h operations;

3. Describe the nature of your business experience in providing and

implementing Smart Parking Technology for construction projects as
described in this Request for Proposal and state the number of persons
you currently employ in such operations;

4. Describe the nature of your business experience in providing and

implementing Sustainable design and construction for construction
p r o j e c t s as described in this Request for Proposal and state the
number of persons you currently employ in such operations;

5. Clearly state the total number of such programs and their locations that
you have provided and implemented within the last five (5) years;

6. Clearly state your business experience working with County of Fulton and
State of Ohio Building Codes for similar construction p r o j e c t s as
described in this Request for Proposal;

7. Give the name, location and date of all agreements f o r providing

and implementing design/build services that have been terminated or
canceled within the past five (5) years, prior to the expiration of their
 contractual term, and also list any judgment terminating, or any pending
lawsuits or unresolved disputes for the termination of, such agreements
administered by you within the past five (5) years and;

8. Give t h e n a m e s and a d d r e s s e s of a t l e a s t t h r e e (3) r e f e r e n c e s

as t o y o u r professional capability. Include the name of the companies,
addresses, phone numbers, phone number and provide a contact person
and title for the project.

D. Project Approach: Provide a statement discussing your understanding of the

design/build opportunity, including those factors that are critical to making the
opportunity a success. Proposers must provide a detailed discussion of how they
will approach this opportunity to ensure that the County’s goals and objectives
will be realized. The Proposer may include conceptual drawings and renderings
to help define their approach and understanding of these project objectives. The
Proposer must provide a project schedule based on their understanding of
project milestone dates. The Proposal should also identify and discuss key
issues impacting the services as defined in this Request for Proposal as well as
discuss methods/models that would address key issues. The Proposer must
describe the sustainable design and construction features proposed for the project.

E. Key Staff: Proposers should indicate the key staff proposed for this contract,
setting forth the specific responsibilities and availability of each proposed key
staff person. Indicate the proposed Design/Builder Project Manager for the
project, Key Staff of Design Team including Architect and Engineers (Civil,
Structural, Mechanical and Electrical) and Field Construction Manager. Provide
for each proposed key staff person a one- p a g e resume detailing both
general experience and specific experience related to the services as
defined in this Request for Proposal.

F. Management Approach: Provide an organization chart showing all major

component units; where the management of this contract will fall within the
organization and what corporate resources will be available to support this
contract in both primary and secondary or back-up roles. A discussion of cost
control related to the location of work and performing project management
responsibilities, including participating in meetings and completing work at the
A i r p o r t for this contract should also be included. Describe the past
working relationships of the Design/Build Team. Describe roles and
responsibilities of each team member.

G. Work Product Samples: Proposers are to submit a case history for projects
which demonstrate the ability of the Design/Build Team to perform design/build
services. Case histories should include projects relating to: (i) Storage buildings;
Be specific as to how and why the Proposer decided to approach the project a
certain way. Each case history should address the following elements: (I)
concept; (ii) strategy and (iii) supporting tactics (e.g. method for implementation
of project). The samples must have been developed within the past three (3) years.
 In addition, provide examples and discuss in narrative the Proposer’s method for
implementation of the project in written, graphic and pictorial form.

H. EDGE Participation: Proposers are to submit a summary of all EDGE

sub- consultants/subcontractors on their team and the anticipated percentages for
each. Also provide the complete address for the location and contact of each.

I Financial Background Information: The Proposer shall include the following financial
information:

1. Balance sheet and income statement for the last two (2) fiscal years,
audited statements preferred, prepared in accordance with generally accepted
accounting principles, consistently applied reflecting the current financial
condition of the Proposer as of and for the dates thereof and interim financial
statements from the date of the last statement to the date of the proposal.
If a publicly held corporation, the Proposer should provide in lieu of the
foregoing: consolidated financial statements as submitted to the Securities
and Exchange Commission (“SEC”) on Form 10K, the most recent Form 10Q,
and any Forms 8K filed with the SEC in the last twelve (12) months. Owners
of closely held corporations must submit a personal financial statement,
current within three (3) months from date of submittal;

2. Ownership structure of the Proposer (If the Proposer is a corporation and

the outstanding stock of said corporation is held by fewer than ten (10)
individuals, the name and residence address of each stockholder and his/her
shares of outstanding stock must be listed.); and

3. Provide three (3) bank and trade references.

J. Fee Proposal: Proposer shall submit its fee proposal for all its services in a
separately sealed envelope clearly marked on the outside. Proposer shall follow
the itemized breakdown contained in the referenced Fee Proposal Format. Proposer
shall provide its best estimate of expenses including, but not limited to, travel and
associated expenses. No qualification of the financial offer will be accepted. The fee
proposal shall be a firm and final amount including the costs and expenses for all
anticipated services.

K. Proposers Affidavit: Proposer shall submit with its proposal an affidavit

stating that neither it nor its agents, nor any other party acting for it has
paid or agreed to pay, directly or indirectly, any person, firm or corporation
any money or valuable consideration for assistance in procuring or attempting
to procure the contract proposed to result from its proposal, and further
agreeing that no such money or reward will be paid.

L. Supplemental Information:
 1. The County may require a Proposer to further supplement its written
Proposal to obtain additional information regarding its Proposal or to
meet with the County’s designated representatives to further describe
the firm’s qualifications and abilities.

2. The decision regarding which Proposer(s) will be asked to

supplement their Proposal or meet with County representatives is in the
County’s sole discretion.

3. Supplements will be utilized for clarification purposes only and the

Proposer may not substitute material elements of its written Proposal nor
may the Proposer provide previously omitted material. The requested
information or meeting shall be respectively furnished or take place at
the time and place specified by the County.

N. Additional Submittal Requirements: Include any additional information you

would like to submit to support your Proposal.

Firms shall complete, execute and return with its proposal the following
documents, copies of which are attached to this Request for Proposals:

1. Fair Employment Practices Disclosure;

2. Federal Taxpayer Identification;
3. Non-Collusion Statement.
Proposal Evaluation; Selection Criteria

A. Evaluation Methodology. The C o u n t y A d m i n i s t r a t o r w i l l

e v a l u a t e e a c h p r o p o s a l submitted. The County Administrator will
present his recommendations to the County Board of Commissioners (County).
The County may, but shall not be obligated to, entertain formal presentations.
The County may approve one or more contracts to one or more firms. The County
will only consider proposals that are received on or before the proposal
submission deadline, and which meet all the requirements of this RFP.

B. Scoring of Proposals. The County will score each Proposal in each of the
following categories
1. Qualifications/Experience (Rating up to 17 points)
2. Project Approach (Rating up to 30 points)
3. Key Staff (Rating up to 18 points)
4. Management Approach (Rating up to 25 points)
5. Work Product Sample (Rating up to 10 points)

The ratings are not intended to be interpreted as a reflection of a Proposer’s

professional abilities. Instead, they reflect the County’s best attempt to
quantify each Proposer’s ability t o provide the s e r v i c e s s o u g h t by the
County and to meet t h e s p e c i f i c requirements of this RFP, for
comparison purposes.

The technical portions will be reviewed by staff members who will award points
as identified above. Summaries of all staff evaluations will be combined and the
Proposals will be ranked in order of their score, highest to lowest. The lowest
scored Proposal will then be assigned its ranking value of one, the second lowest
will be assigned a ranking value of two, etcetera up to the highest technical team.

The Fee Proposals will be opened and verified for accuracy and likewise ranked
in order of highest to lowest. The highest fee will be assigned a ranking value of
one, the second highest will be assigned a ranking value of two, etcetera up to the
lowest fee.

The two rankings for each firm will be weighted first by 60% for the Proposal
score ranking and then by 40% for the fee ranking. The sum of the two weighted
values will be used to determine the overall ranking of the best submittal for
award.
C. Evaluation Credit: For t h e p u r p o s e o f c o m p a r i n g c o m p e t i n g
Proposals o n l y , t h e County may apply an Evaluation Credit of five percent
(5%) of the total points awarded for a Proposal received from a joint venture with
EDGE Vendor.
D. Procedure: The contracting department may use the total points awarded for a
proposal after applying e v a l u a t i o n c r e d i t to c o m p a r e competing
p r o p o s a l s t o d e t e r m i n e the ranking of the proposals. The application of
evaluation credits shall not alter the amount of a proposal submitted by a
 Proposer or of the contract executed based on the proposal. The County will use
only the actual proposal upon which the County and the Proposer have agreed
for approval and a contract award based on that proposal.

E. Disqualification of a Proposer/Proposal: The County does not intend by this

RFP to prohibit or discourage submission of a proposal that is based upon a
Proposer’s trade experience in relation to the nature or scope of work, services,
or product(s) described in this RFP or to prescribe the manner in which its services
are to be performed or rendered.

The County will not be obligated to accept, however, significant deviations from
the work or services s o u g h t b y t h i s R F P , i n c l u d i n g t e r m s
i n c o n s i s t e n t w i t h o r s u b s t a n t i a l l y varying from the services or the
financial and operational requirements of the RFP, as determined solely by the
County. The County reserves the right to reject any proposal that does not
furnish or is unresponsive to the information required or requested herein. The
County reserves the right to reject any proposal or to waive or to accept
any deviation from this RFP or in any step of the proposal submission or evaluation
process so as to approve the award of the contract considered in the County’s
best interest, as determined in the County’s sole discretion.

Although the County prefers that each Proposer submit only one proposal
including all alternatives to the proposal that the Proposer desires the County
to consider, it will accept proposals from different business entities or
combinations having one or more members in interest in common with another
Proposer. The County may reject one or more proposals if it has reason to believe
that proposers have colluded to conceal the interest of one or more parties in a
proposal, and will not consider a future proposal from a participant in the
collusion. In addition, the County will not accept a proposal from or approve
a contract to any Proposer that is in default as surety or otherwise upon an
obligation to the County or has failed to perform faithfully any previous
agreement with the County, or is currently in default under any agreement with
the County.

The County reserves the right to reject any or all proposals. Failure by a
Proposer to respond thoroughly and completely to all information and document
requests in this RFP may result in rejection of its proposal. Further, the County
reserves the right to independently investigate the financial status,
qualifications, experience, and performance history of a Proposer.

The County reserves the right to cancel the approval or authorization of a

contract award, with or without cause, at any time before its execution of a
contract and to later enter into a contract that varies from the provisions of
this RFP, if agreed to by another Proposer.
ATTACHMENTS
 LEGAL NOTICE

Sealed proposals for design/build for the construction of a 9,000 sq. ft. storage building located at
Fulton Soil and Water Conservation District, Robert Fulton Building, 8770 State Route 108, Suite B,
Wauseon, OH 43567. The building when completed will be utilized by the Fulton Soil and Water
Conservation District. Proposals will be received by the Board of Commissioners, Fulton County,
Ohio, until August 4, 2016 at 10:00am, and opened thereafter. Proposals may be hand delivered
or mailed to the Board of Fulton County Commissioners, 152 S. Fulton Street, Suite 270, Wauseon,
Ohio 43567.

Complete set of criteria for the project will be available for examination, Monday through Friday
from 8:30 am to 4:30 pm at the office of the Fulton County Commissioners, 152 S. Fulton Street,
Suite 270, Wauseon, Ohio 43567 and on the County website: www.fultoncountyoh.com.

Any proposals may be withdrawn prior to scheduled closing time for the receipt of Proposals, but
no Proposer shall withdraw his bid within 45 days after the actual bid opening thereof. The County
reserves the right to reject any or all Proposals, waive irregularities in any bid, and to accept any
bid which is deemed most favorable to the County.

By Order of Fulton County Commissioners

Paul Barnaby
Jeff Rupp
Bill Rufenacht
Teri Suarez, Clerk
Preliminary Project Schedule:
Proposals Received August 4, 2016
Proposals Reviewed & Ranked August 8, 2016
Negotiation & Design Build Contract Awarded August 11, 2016
Preliminary Design Review August 14, 2016
Final Design Review August 19, 2016
Permits August 12-20, 2016
Construction of Building September 1, 2016
Grass/Fence work September 15, 2016
Punch List Complete September 29, 2016
Turn Over to Fulton County SWCD for Use September 30, 2016
 PROPOSAL FORM

1. Design Fee $
2. Preconstruction Services Fee $

3. Site Work
a. Excavation backfill $

b. Drainage System $

c. Grading $

d. Stump Removal $

e. Curb Cuts $

f. Tap Fees & Permits $

g. Inspection Fees $
4. Building Construction $

5. Landscaping $

6. Concrete Work $
7. Electrical Work $

8. General Conditions $

9. Contractor Mark-up $

10. Bond (Performance & Payment) $

11. Contingency $

TOTAL GUARANTEED MAX PRICE (BID) $

PRICE IS GOOD FOR ( ) DAYS COMPLETION DATE

BASED ON AWARD OF AUGUST 2016

SEAL
Authorized Signature

Print

Date
 Form W-9 Request for Taxpayer Give Form to the
requester. Do not
(Rev. December 2011)
Department of the Treasury Identification Number and Certification send to the IRS.
Internal Revenue Service
Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

See Specific Instructions on page 2.

Check appropriate box for federal tax classification:

Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate
Print or type

Exempt payee
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Other (see instructions) ▶

Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line Social security number
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other – –
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
–

Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign Signature of
Here U.S. person ▶ Date ▶

General Instructions Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester’s form if it is substantially similar
Section references are to the Internal Revenue Code unless otherwise to this Form W-9.
noted.
Definition of a U.S. person. For federal tax purposes, you are
Purpose of Form considered a U.S. person if you are:
A person who is required to file an information return with the IRS must • An individual who is a U.S. citizen or U.S. resident alien,
obtain your correct taxpayer identification number (TIN) to report, for • A partnership, corporation, company, or association created or
example, income paid to you, real estate transactions, mortgage interest organized in the United States or under the laws of the United States,
you paid, acquisition or abandonment of secured property, cancellation • An estate (other than a foreign estate), or
of debt, or contributions you made to an IRA.
• A domestic trust (as defined in Regulations section 301.7701-7).
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the Special rules for partnerships. Partnerships that conduct a trade or
requester) and, when applicable, to: business in the United States are generally required to pay a withholding
tax on any foreign partners’ share of income from such business.
1. Certify that the TIN you are giving is correct (or you are waiting for a Further, in certain cases where a Form W-9 has not been received, a
number to be issued), partnership is required to presume that a partner is a foreign person,
2. Certify that you are not subject to backup withholding, or and pay the withholding tax. Therefore, if you are a U.S. person that is a
3. Claim exemption from backup withholding if you are a U.S. exempt partner in a partnership conducting a trade or business in the United
payee. If applicable, you are also certifying that as a U.S. person, your States, provide Form W-9 to the partnership to establish your U.S.
allocable share of any partnership income from a U.S. trade or business status and avoid withholding on your share of partnership income.
is not subject to the withholding tax on foreign partners’ share of
effectively connected income.
Cat. No. 10231X Form W-9 (Rev. 12-2011)
Form W-9 (Rev. 12-2011) Page 2

The person who gives Form W-9 to the partnership for purposes of Certain payees and payments are exempt from backup withholding.
establishing its U.S. status and avoiding withholding on its allocable See the instructions below and the separate Instructions for the
share of net income from the partnership conducting a trade or business Requester of Form W-9.
in the United States is in the following cases: Also see Special rules for partnerships on page 1.
• The U.S. owner of a disregarded entity and not the entity,
Updating Your Information
• The U.S. grantor or other owner of a grantor trust and not the trust,
and You must provide updated information to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
• The U.S. trust (other than a grantor trust) and not the beneficiaries of and anticipate receiving reportable payments in the future from this
the trust. person. For example, you may need to provide updated information if
Foreign person. If you are a foreign person, do not use Form W-9. you are a C corporation that elects to be an S corporation, or if you no
Instead, use the appropriate Form W-8 (see Publication 515, longer are tax exempt. In addition, you must furnish a new Form W-9 if
Withholding of Tax on Nonresident Aliens and Foreign Entities). the name or TIN changes for the account, for example, if the grantor of a
Nonresident alien who becomes a resident alien. Generally, only a grantor trust dies.
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
Penalties
treaties contain a provision known as a “saving clause.” Exceptions Failure to furnish TIN. If you fail to furnish your correct TIN to a
specified in the saving clause may permit an exemption from tax to requester, you are subject to a penalty of $50 for each such failure
continue for certain types of income even after the payee has otherwise unless your failure is due to reasonable cause and not to willful neglect.
become a U.S. resident alien for tax purposes. Civil penalty for false information with respect to withholding. If you
If you are a U.S. resident alien who is relying on an exception make a false statement with no reasonable basis that results in no
contained in the saving clause of a tax treaty to claim an exemption backup withholding, you are subject to a $500 penalty.
from U.S. tax on certain types of income, you must attach a statement
Criminal penalty for falsifying information. Willfully falsifying
to Form W-9 that specifies the following five items:
certifications or affirmations may subject you to criminal penalties
1. The treaty country. Generally, this must be the same treaty under including fines and/or imprisonment.
which you claimed exemption from tax as a nonresident alien.
Misuse of TINs. If the requester discloses or uses TINs in violation of
2. The treaty article addressing the income. federal law, the requester may be subject to civil and criminal penalties.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions. Specific Instructions
4. The type and amount of income that qualifies for the exemption
from tax.
Name
5. Sufficient facts to justify the exemption from tax under the terms of If you are an individual, you must generally enter the name shown on
the treaty article. your income tax return. However, if you have changed your last name,
for instance, due to marriage without informing the Social Security
Example. Article 20 of the U.S.-China income tax treaty allows an Administration of the name change, enter your first name, the last name
exemption from tax for scholarship income received by a Chinese shown on your social security card, and your new last name.
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if his or her stay in If the account is in joint names, list first, and then circle, the name of
the United States exceeds 5 calendar years. However, paragraph 2 of the person or entity whose number you entered in Part I of the form.
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows Sole proprietor. Enter your individual name as shown on your income
the provisions of Article 20 to continue to apply even after the Chinese tax return on the “Name” line. You may enter your business, trade, or
student becomes a resident alien of the United States. A Chinese “doing business as (DBA)” name on the “Business name/disregarded
student who qualifies for this exception (under paragraph 2 of the first entity name” line.
protocol) and is relying on this exception to claim an exemption from tax Partnership, C Corporation, or S Corporation. Enter the entity's name
on his or her scholarship or fellowship income would attach to Form on the “Name” line and any business, trade, or “doing business as
W-9 a statement that includes the information described above to (DBA) name” on the “Business name/disregarded entity name” line.
support that exemption.
Disregarded entity. Enter the owner's name on the “Name” line. The
If you are a nonresident alien or a foreign entity not subject to backup name of the entity entered on the “Name” line should never be a
withholding, give the requester the appropriate completed Form W-8. disregarded entity. The name on the “Name” line must be the name
What is backup withholding? Persons making certain payments to you shown on the income tax return on which the income will be reported.
must under certain conditions withhold and pay to the IRS a percentage For example, if a foreign LLC that is treated as a disregarded entity for
of such payments. This is called “backup withholding.” Payments that U.S. federal tax purposes has a domestic owner, the domestic owner's
may be subject to backup withholding include interest, tax-exempt name is required to be provided on the “Name” line. If the direct owner
interest, dividends, broker and barter exchange transactions, rents, of the entity is also a disregarded entity, enter the first owner that is not
royalties, nonemployee pay, and certain payments from fishing boat disregarded for federal tax purposes. Enter the disregarded entity's
operators. Real estate transactions are not subject to backup name on the “Business name/disregarded entity name” line. If the owner
withholding. of the disregarded entity is a foreign person, you must complete an
You will not be subject to backup withholding on payments you appropriate Form W-8.
receive if you give the requester your correct TIN, make the proper Note. Check the appropriate box for the federal tax classification of the
certifications, and report all your taxable interest and dividends on your person whose name is entered on the “Name” line (Individual/sole
tax return. proprietor, Partnership, C Corporation, S Corporation, Trust/estate).
Payments you receive will be subject to backup Limited Liability Company (LLC). If the person identified on the
withholding if: “Name” line is an LLC, check the “Limited liability company” box only
and enter the appropriate code for the tax classification in the space
1. You do not furnish your TIN to the requester, provided. If you are an LLC that is treated as a partnership for federal
2. You do not certify your TIN when required (see the Part II tax purposes, enter “P” for partnership. If you are an LLC that has filed a
instructions on page 3 for details), Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for
3. The IRS tells the requester that you furnished an incorrect TIN, C corporation or “S” for S corporation. If you are an LLC that is
disregarded as an entity separate from its owner under Regulation
4. The IRS tells you that you are subject to backup withholding section 301.7701-3 (except for employment and excise tax), do not
because you did not report all your interest and dividends on your tax check the LLC box unless the owner of the LLC (required to be
return (for reportable interest and dividends only), or identified on the “Name” line) is another LLC that is not disregarded for
5. You do not certify to the requester that you are not subject to federal tax purposes. If the LLC is disregarded as an entity separate
backup withholding under 4 above (for reportable interest and dividend from its owner, enter the appropriate tax classification of the owner
accounts opened after 1983 only). identified on the “Name” line.
Form W-9 (Rev. 12-2011) Page 3

Other entities. Enter your business name as shown on required federal Part I. Taxpayer Identification Number (TIN)
tax documents on the “Name” line. This name should match the name
shown on the charter or other legal document creating the entity. You Enter your TIN in the appropriate box. If you are a resident alien and
may enter any business, trade, or DBA name on the “Business name/ you do not have and are not eligible to get an SSN, your TIN is your IRS
disregarded entity name” line. individual taxpayer identification number (ITIN). Enter it in the social
security number box. If you do not have an ITIN, see How to get a TIN
Exempt Payee below.
If you are exempt from backup withholding, enter your name as If you are a sole proprietor and you have an EIN, you may enter either
described above and check the appropriate box for your status, then your SSN or EIN. However, the IRS prefers that you use your SSN.
check the “Exempt payee” box in the line following the “Business name/ If you are a single-member LLC that is disregarded as an entity
disregarded entity name,” sign and date the form. separate from its owner (see Limited Liability Company (LLC) on page 2),
Generally, individuals (including sole proprietors) are not exempt from enter the owner’s SSN (or EIN, if the owner has one). Do not enter the
backup withholding. Corporations are exempt from backup withholding disregarded entity’s EIN. If the LLC is classified as a corporation or
for certain payments, such as interest and dividends. partnership, enter the entity’s EIN.
Note. If you are exempt from backup withholding, you should still Note. See the chart on page 4 for further clarification of name and TIN
complete this form to avoid possible erroneous backup withholding. combinations.
The following payees are exempt from backup withholding: How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, get Form SS-5, Application for a Social Security
1. An organization exempt from tax under section 501(a), any IRA, or a Card, from your local Social Security Administration office or get this
custodial account under section 403(b)(7) if the account satisfies the form online at www.ssa.gov. You may also get this form by calling
requirements of section 401(f)(2), 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer
2. The United States or any of its agencies or instrumentalities, Identification Number, to apply for an ITIN, or Form SS-4, Application for
3. A state, the District of Columbia, a possession of the United States, Employer Identification Number, to apply for an EIN. You can apply for
or any of their political subdivisions or instrumentalities, an EIN online by accessing the IRS website at www.irs.gov/businesses
and clicking on Employer Identification Number (EIN) under Starting a
4. A foreign government or any of its political subdivisions, agencies, Business. You can get Forms W-7 and SS-4 from the IRS by visiting
or instrumentalities, or IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).
5. An international organization or any of its agencies or If you are asked to complete Form W-9 but do not have a TIN, write
instrumentalities. “Applied For” in the space for the TIN, sign and date the form, and give
Other payees that may be exempt from backup withholding include: it to the requester. For interest and dividend payments, and certain
6. A corporation, payments made with respect to readily tradable instruments, generally
you will have 60 days to get a TIN and give it to the requester before you
7. A foreign central bank of issue, are subject to backup withholding on payments. The 60-day rule does
8. A dealer in securities or commodities required to register in the not apply to other types of payments. You will be subject to backup
United States, the District of Columbia, or a possession of the United withholding on all such payments until you provide your TIN to the
States, requester.
9. A futures commission merchant registered with the Commodity Note. Entering “Applied For” means that you have already applied for a
Futures Trading Commission, TIN or that you intend to apply for one soon.
10. A real estate investment trust, Caution: A disregarded domestic entity that has a foreign owner must
11. An entity registered at all times during the tax year under the use the appropriate Form W-8.
Investment Company Act of 1940, Part II. Certification
12. A common trust fund operated by a bank under section 584(a),
To establish to the withholding agent that you are a U.S. person, or
13. A financial institution, resident alien, sign Form W-9. You may be requested to sign by the
14. A middleman known in the investment community as a nominee or withholding agent even if item 1, below, and items 4 and 5 on page 4
custodian, or indicate otherwise.
15. A trust exempt from tax under section 664 or described in section For a joint account, only the person whose TIN is shown in Part I
4947. should sign (when required). In the case of a disregarded entity, the
person identified on the “Name” line must sign. Exempt payees, see
The following chart shows types of payments that may be exempt
Exempt Payee on page 3.
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 15. Signature requirements. Complete the certification as indicated in
items 1 through 3, below, and items 4 and 5 on page 4.
IF the payment is for . . . THEN the payment is exempt 1. Interest, dividend, and barter exchange accounts opened
for . . . before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
Interest and dividend payments All exempt payees except certification.
for 9
2. Interest, dividend, broker, and barter exchange accounts
Broker transactions Exempt payees 1 through 5 and 7 opened after 1983 and broker accounts considered inactive during
through 13. Also, C corporations. 1983. You must sign the certification or backup withholding will apply. If
Barter exchange transactions and Exempt payees 1 through 5 you are subject to backup withholding and you are merely providing
patronage dividends your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
Payments over $600 required to be Generally, exempt payees 3. Real estate transactions. You must sign the certification. You may
reported and direct sales over 1 through 7 2 cross out item 2 of the certification.
1
$5,000
1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2
However, the following payments made to a corporation and reportable on Form
1099-MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for
services paid by a federal executive agency.
Form W-9 (Rev. 12-2011) Page 4

4. Other payments. You must give your correct TIN, but you do not Note. If no name is circled when more than one name is listed, the
have to sign the certification unless you have been notified that you number will be considered to be that of the first name listed.
have previously given an incorrect TIN. “Other payments” include
payments made in the course of the requester’s trade or business for Secure Your Tax Records from Identity Theft
rents, royalties, goods (other than bills for merchandise), medical and Identity theft occurs when someone uses your personal information
health care services (including payments to corporations), payments to such as your name, social security number (SSN), or other identifying
a nonemployee for services, payments to certain fishing boat crew information, without your permission, to commit fraud or other crimes.
members and fishermen, and gross proceeds paid to attorneys An identity thief may use your SSN to get a job or may file a tax return
(including payments to corporations). using your SSN to receive a refund.
5. Mortgage interest paid by you, acquisition or abandonment of To reduce your risk:
secured property, cancellation of debt, qualified tuition program
• Protect your SSN,
payments (under section 529), IRA, Coverdell ESA, Archer MSA or
HSA contributions or distributions, and pension distributions. You • Ensure your employer is protecting your SSN, and
must give your correct TIN, but you do not have to sign the certification. • Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a
What Name and Number To Give the Requester notice from the IRS, respond right away to the name and phone number
For this type of account: Give name and SSN of: printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
1. Individual The individual think you are at risk due to a lost or stolen purse or wallet, questionable
2. Two or more individuals (joint The actual owner of the account or, credit card activity or credit report, contact the IRS Identity Theft Hotline
account) if combined funds, the first
1 at 1-800-908-4490 or submit Form 14039.
individual on the account
3. Custodian account of a minor 2 For more information, see Publication 4535, Identity Theft Prevention
The minor
(Uniform Gift to Minors Act) and Victim Assistance.
4. a. The usual revocable savings The grantor-trustee
1
Victims of identity theft who are experiencing economic harm or a
trust (grantor is also trustee) system problem, or are seeking help in resolving tax problems that have
b. So-called trust account that is The actual owner
1
not been resolved through normal channels, may be eligible for
not a legal or valid trust under Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
state law calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
3
5. Sole proprietorship or disregarded The owner 1-800-829-4059.
entity owned by an individual
The grantor*
Protect yourself from suspicious emails or phishing schemes.
6. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Phishing is the creation and use of email and websites designed to
Regulation section 1.671-4(b)(2)(i)(A)) mimic legitimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
For this type of account: Give name and EIN of:
legitimate enterprise in an attempt to scam the user into surrendering
7. Disregarded entity not owned by an The owner private information that will be used for identity theft.
individual
8. A valid trust, estate, or pension trust Legal entity
4 The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
9. Corporation or LLC electing The corporation
corporate status on Form 8832 or
taxpayers for the PIN numbers, passwords, or similar secret access
Form 2553 information for their credit card, bank, or other financial accounts.
10. Association, club, religious, The organization If you receive an unsolicited email claiming to be from the IRS,
charitable, educational, or other forward this message to [email protected]. You may also report misuse
tax-exempt organization of the IRS name, logo, or other IRS property to the Treasury Inspector
11. Partnership or multi-member LLC The partnership General for Tax Administration at 1-800-366-4484. You can forward
12. A broker or registered nominee The broker or nominee suspicious emails to the Federal Trade Commission at: [email protected]
13. Account with the Department of The public entity or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT
Agriculture in the name of a public (1-877-438-4338).
entity (such as a state or local Visit IRS.gov to learn more about identity theft and how to reduce
government, school district, or your risk.
prison) that receives agricultural
program payments
14. Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulation section 1.671-4(b)(2)(i)(B))
1
List first and circle the name of the person whose number you furnish. If only one person on a
joint account has an SSN, that person’s number must be furnished.
2
Circle the minor’s name and furnish the minor’s SSN.
3
You must show your individual name and you may also enter your business or “DBA” name on
the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you
have one), but the IRS encourages you to use your SSN.
4
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the
personal representative or trustee unless the legal entity itself is not designated in the account
title.) Also see Special rules for partnerships on page 1.
*Note. Grantor also must provide a Form W-9 to trustee of trust.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with
the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation
of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS,
reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District
of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies
to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to
file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a
TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.
 DELINQUENT PERSONAL PROPERTY TAX AFFIDAVIT
THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND NOTARIZED

I, ,
Name Title

Affirm that at the time I submitted the bid for

Name of Company

To the Board of Fulton County Commissioners on

Bid Title

, 2015 that
Date Name of Company

WAS/WAS NOT charged with delinquent personal property taxes by the Fulton County Auditor.

(If personal property taxes are delinquent, please complete the following section)

The amount of delinquent personal property taxes due to Fulton County is $

and unpaid penalties and interest are $ .

Signature

Company Name

Date

Sworn to and subscribed before me this day of , 20 .

Notary

SEAL
 NON-DISCRIMINATION AFFIDAVIT

THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND NOTARIZED

STATE OF OHIO )
SS)
COUNTY OF )

being first duly sworn, deposes and says that he/she is the
Name

of the party
Title Company Name
that made the foregoing proposal; that such party does not and shall not discriminate against any
employee or applicant for employment because of race, creed, sex, disability or military status as
defined in section 4112.01 of the Ohio Revised Code, or color as is described and prohibited by Section
153.59 and/or 125.111 of the Ohio Revised Code. Furthermore, if awarded the contract under this
proposal, said party shall indemnify and hold harmless the Fulton County Board of Commissioners for
any violations of Section 153.59 or 125.111 of the Ohio Revised Code made by any contractor,
subcontractor or any person who works on behalf of the party relating to the ensuing contract.

Signature

Affiant (Print)

Company

Address

City/State/Zip

Sworn to and Subscribed before me this day of , 20 .

SEAL
 NON-COLLUSION AFFIDAVIT
THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND NOTARIZED

PROJECT:

State of __________________)
ss.
County of _________________)

I , ,
(Name of party signing affidavit) (Title)

being duly sworn, do depose and say: that

(insert name of individual, co-partnership, or corporation)

its agent, officers or employees have not directly or indirectly entered into any agreement,
participated in any collusion, or otherwise taken any action in restraint of free competitive
bidding in connection with this proposal.

________________________________________
(Signature)

________________________________________
(Title)

Sworn to and subscribed before me this ______ day of __________________

20 ____.

_______________________________
(Notary Public)
(Seal)
____________________ County, Ohio

My commission expires _________________