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CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED) <br />(a) <br />V) _V <br />By checking this box I hereby acknowledge that i am not o pne+qum@iedbiddmr <br />Indiana Secretary ofState's on-line records (ie. Business verification) dated within <br />with the City ofSouth Bend. <br />V0 V <br />By checking this box, |hereby acknowledge that the City reserves the right to <br />existence, current with the Indiana Secretary ofState's Business Entity Report, <br />'naquea1 supplemental infonmsdion, additional verification of any information <br />and eligible for a certificate of good standing. (Not applicable to individuals, sole <br />prumded, and may also conduct random inquiries of my current and prior <br />proprietors orpwrtnmrmhipm). <br />customers. The City reserved the right to utilize all information provided in this <br />List identifying all former business names. <br />submission and all information obtained in inquiries or requests to determine if a <br />Any determinations byacourt mgovernmental agency any violations of federal <br />bidder is responsive and responsible. Additionally, | acknowledge that all <br />state, or local laws including, but not limited to, violations of contracting or antitrust <br />information provided tothe City shall beregarded aapublic records. <br />(iii) v/ <br />By checking this box. | hereby acknowledge that copies of all Applicable <br />Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) <br />apprenticeship certificates or standards for training programs applicable to the <br />years, <br />8ta&*n`mnt about staffing capabilities, including labor sources. This statement <br />work performed on the project may be requested at any time and shall be furnished <br />indicates and ensures | have sufficient employees onstaff hocomplete the work { <br />upon request. <br />(iv) v^ <br />By checking this box, | hereby acknowledge and ensure that l and all sub- <br />Statement that individuals who will perform work *nthe public work project on my <br />contractors, from whom I have accepted a bid andlor intend to hire to perform work <br />behalf will beproperly classifiedamanemployee amwnindependent contractor <br />onthe public work project, are licensed. Furthermore, Yacknowledge my <br />under all applicable state and federal laws and local ordinances. <br />understanding that it is my responsibility to ensure that all sub -contractors have <br />For every pnoject, submit evidence of participation in apprenticeship and training <br />the necessary licenses to undertake the work called for in this hid- If sub- <br />pnognsmm, applicable to the work to be podbnned on the project, which are <br />contractor loses their Umynme at any point. it is the responsibility of that sub- <br />ub~contnaotortoncddytheCdy. <br />approved by and registered with the United States Department of Labor's Office of <br />contractor to notify the City. <br />(b) Attachments: <br />N L <br />Indiana Secretary ofState's on-line records (ie. Business verification) dated within <br />sixty (60) days of the submission of said document showing that business is in <br />existence, current with the Indiana Secretary ofState's Business Entity Report, <br />and eligible for a certificate of good standing. (Not applicable to individuals, sole <br />proprietors orpwrtnmrmhipm). <br />(ii) V <br />List identifying all former business names. <br />(iii) V <br />Any determinations byacourt mgovernmental agency any violations of federal <br />state, or local laws including, but not limited to, violations of contracting or antitrust <br />|awm, tax or licensing laws, environmental laws, Occupational Safety and Health <br />Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) <br />(iv) °/ <br />years, <br />8ta&*n`mnt about staffing capabilities, including labor sources. This statement <br />indicates and ensures | have sufficient employees onstaff hocomplete the work { <br />mmbidding onORoutlines how | intend tomeet the staffing needs ofthe work. <br />(v) v~ <br />Statement that individuals who will perform work *nthe public work project on my <br />behalf will beproperly classifiedamanemployee amwnindependent contractor <br />under all applicable state and federal laws and local ordinances. <br />(xi) v/ <br />For every pnoject, submit evidence of participation in apprenticeship and training <br />pnognsmm, applicable to the work to be podbnned on the project, which are <br />approved by and registered with the United States Department of Labor's Office of <br />organization. <br />(Vii)«/ <br />CApprenticeship,of� n | fu � testhat covers all of my employees <br />who will perform vmzdk on the public work project and meets or exceeds the <br />requirements set forth in IC4-13-18-5or/C4-13-18-8. <br />(viii) »/ <br />Evidence that | am utilizing a surety company which is on the Bureau of Fiscal <br />Service "Department of Treasury's Listing of Approved Sureties" as required in the <br />bid specifications urcontract. <br />Version 02/2312022 General Conditions -13 <br />