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INCORPORATED VILLAGE OF ISLAND PARK
127 LONG BEACH ROAD
ISLAND PARK, NEW YORK
REQUEST FOR PROPOSALS FROM CONTRACTORS
CONTRACT MANAGEMENT SERVICES
FOR
HAZARD MITIGATION GRANT PROGRAM (HMGP) PROJECT
Federal Emergency Management Agency and
New York State Division of Homeland Security and
Emergency Services
Legal Notice, Instructions to Bidders, Deadline Schedule,
Insurance Requirements, Cost Proposal and
Contractor’s Qualification Statement
APRIL 11, 2016
Request for Proposals from Contractors
Contract Management Services
for
Hazard Mitigation Grant Program (HMGP) Project
Federal Emergency Management Agency and
New York State Division of Homeland Security and
Emergency Services
Request for Proposal Issue Date: April 11, 2016
Technical Questions Due: April 15, 2016 (no later than 12:00 noon)
Technical Response Issued: April 19, 2016 (to be posted on the Village website
http://www.kpsearch.com/DF/Villageofislandpark-
n/bid_documents.htm)
Proposal Due Date: April 25, 2016 (no later than 11:00 am)
Contact Information:
Constance L. Conroy, Village Clerk
Tel. 516-431-0600
Fax: 516-431-0436
Email: clconroy@villageofislandpark.com
Table of Contents
LEGAL NOTICE
INSTRUCTIONS TO BIDDERS
I. Introduction and Overview ..................................................................................1
II. Project Description ...............................................................................................2
III. Deadlines and Completion Date .........................................................................3
IV. Scope of Work ......................................................................................................4
V. Submittal Content .................................................................................................5
VI. Selection Process ...................................................................................................9
VII. Specific Legal Obligations ....................................................................................10
VIII. New York Law and Venue ...................................................................................12
SCHEDULE A Deadline Schedule
SCHEDULE B Insurance Requirements
SCHEDULE C Cost Proposal
SCHEDULE D Contractor’s Qualification Statement
APPENDIX A New York State Vendor Responsibility Questionnaire
APPENDIX B DHSES Hazard Mitigation Program Project
Management Handbook
LEGAL NOTICE
INCORPORATED VILLAGE OF ISLAND PARK
PUBLIC NOTICE TO BIDDERS
PLEASE TAKE NOTICE THAT sealed proposals will be received by the Incorporated Village
of Island Park until Monday, April 25, 2016 at 11:00 a.m. prevailing time at the Village Hall,
127 Long Beach Road, Island Park, New York, at which time they will be publicly opened and
read and the contract awarded as soon thereafter as practicable for:
Contract Management Services for the
Hazard Mitigation Grant Program (HMGP) Project
The Village is seeking proposals from firms experienced in providing Contract Management
Services in the State of New York related to the HMGP Project being conducted pertaining to
flood mitigation. The selected firm will assist the Village in coordinating project activities
(including reporting, scheduling and benefit-cost analysis) to ensure compliance with the HMGP
Project requirements established by the Federal Emergency Management Agency (FEMA) and
administered by the New York State Division of Homeland Security and Environmental Services
(DHSES).
The Scope of Work Package will be available at the Office of the Village Clerk at Village Hall,
127 Long Beach Road, on or after Monday, April 11, 2016 between the hours of 9:00 a.m. and
4:30 p.m. prevailing time, Monday through Friday, except on holidays.
All sealed Proposals must be received before opening date and time and can be delivered or
mailed to the Village Clerk, Village of Island Park, 127 Long Beach Road, Island Park, New
York 11558.
The Village encourages Bidders that are certified as a Minority or Women Owned Business
Enterprise to participate in the bidding process.
The Mayor and Board of Trustees reserve the right to reject any and all proposals.
BY ORDER OF THE MAYOR AND BOARD OF TRUSTEES
of the Incorporated Village of Island Park, New York.
Constance L. Conroy
Village Clerk
Dated: April 6, 2016
Island Park, New York
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INSTRUCTIONS TO BIDDERS
***Note that this RFP and any Addenda or Responses to Questions will be posted on the
Village’s website (http://www.kpsearch.com/DF/Villageofislandpark-n/bid_documents.htm).
Potential Bidders are advised to check this website frequently for any updates that may be
posted until the April 25, 2016 submittal deadline.***
I. Introduction and Overview
The Incorporated Village of Island Park (Village) has been awarded Phase I Funding for the
development of a Comprehensive Drainage Study and Plan for the geographic area of the Village
under the guidelines of the Federal Emergency Management Agency’s (FEMA) Hazard Mitigation
Grant Program (HMGP) as administered by the NYS Division of Homeland Security and
Emergency Service (DHSES). Accordingly, Bidders are obligated to comply with applicable
federal and state laws and regulations governing the FEMA/DHSES HMGP Program, as well as
with the Village’s Procurement Policy and Procedures. In addition, Bidders are obligated to
comply with all municipal codes, ordinances, and regulations.
The Village is seeking proposals from firms experienced in providing Contract Management
Services in the State of New York related to the HMGP Project being conducted pertaining to
flood mitigation. The selected firm will assist the Village in coordinating project activities and
preparing project documentation to ensure compliance with the HMGP Project requirements
established by FEMA and administered by DHSES. The Village will provide the Contract
Management firm with direction on the project responsibilities to be performed by the firm and
HMGP Project deadlines. The firm will also work closely with the Engineer retained by the
Village to conduct the engineering work required to complete the HMGP Project.
The Phase I HMGP Project consists of a comprehensive evaluation of the Village’s storm water
drainage system, development and evaluation of alternatives to provide flood protection, and a
benefit-cost analysis of the various alternatives. The Phase I field inventory and data evaluation
is in progress by the Engineering firm retained by the Village. The Phase I drainage improvement
plan will address the widespread flooding resulting from Superstorm Sandy and Hurricane Irene.
The Phase I HMGP project will produce a strategy for drainage infrastructure upgrades to provide
solutions for unmet recovery needs pertaining to flood mitigation and to ensure a more resilient,
flood-protected community. Upon FEMA/DHSES approval of the Phase I recommendations, it is
expected that HMGP funding will be approved to implement Phase II (engineering design and
permitting) and Phase III (construction of approved project improvements).
Information on FEMA’s HMGP Program can be found at http://www.fema.gov/hazard-mitigation-
grant-program.
2
Procurement shall only be conducted with responsible Bidders who have the technical and
financial competence to perform the required Contract Management services as well as an
exemplary record of integrity. Before selecting a firm, the Village intends to review the federal
and state lists of vendors excluded from procurement. Contracts shall not be awarded to debarred,
suspended or ineligible vendors. Accordingly, Bidders’ responses to RFPs must include a
completed NYS Vendor Responsibility Questionnaire and notarized certification, along with
verification that a completed NYS Vendor Responsibility Questionnaire has been filed with the
NYS Office of the State Comptroller (see Appendix A and http://www.osc.state.ny.us/vendrep/
for additional information).
In accordance with New York State General Municipal Law Section 104-b, this Request for
Proposals (RFP) is designed to identify the firm best qualified to provide the Contract Management
services desired by the Village and ensure compliance with HMGP Project requirements
established by FEMA and administered by DHSES.
Firms submitting bids will be reviewed on the basis of their experience and ability to provide
Contract Management services in a manner responsive to specific HMGP Project requirements
and timetables established by the Village and DHSES. The Village will select a firm that employs
adequate appropriate staff and possesses the financial management capacity to be able to focus
immediate attention on this project. The selected Contract Management firm must work closely
with the Village and the Village’s Engineer and shall not hinder progress of the HMGP Project.
A Contract Management firm will be chosen based on the scoring system described herein. The
Village’s Evaluation Team will select the Bidder whose proposal receives the greatest number of
points. The Evaluation Team will only open or evaluate Cost Proposals from those firms that it
has determined are qualified on the basis of Specifications and the Technical Factors listed below.
A detailed description of the scoring system may be found in the “Selection Process” section of
this document.
Bidders will not be reimbursed for costs incurred in the preparation of his/her proposal. Failure to
comply with any of the instructions contained in this RFP shall constitute cause for which bids
may be rejected.
The Village reserves the right to reject any and all proposals either in whole or in part.
II. Project Description
The selected Contract Management firm will assist the Village in coordinating HMGP Project
activities, attending meetings (Village Board meetings and HMGP Project meetings) and other
responsibilities including preparation of documentation to ensure compliance with the HMGP
Project requirements established by FEMA and administered by DHSES. The selected firm will
perform specific HMGP Project tasks as directed by the Village. These tasks include but are not
limited to those outlined in Section IV (Scope of Work).
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Note that other Contract Management services may arise during the course of the HMGP Project
in accordance with DHSES requirements and timetables, therefore the selected firm must be
flexible with respect to scheduling and must respond when requested by the Village.
The Village will provide work space in Village Hall for use by the Contract Management firm
when personnel need access to Village records or need to work with Village staff to facilitate
completion of required HMGP Project tasks.
III. Deadlines and Completion Date
The Technical Proposal and Cost Proposal must be delivered in separate sealed envelopes to the
Village in accordance with the timeline presented in SCHEDULE A. Proposals are due by 11:00
a.m on Monday, April 25, 2016. Any questions relative to the RFP must be received electronically
in written form by the Village no later than 12:00 noon on Friday, April 15, 2016. The Village
will then compile the questions into a single document for the responses and post the responses on
the Village’s website (http://www.kpsearch.com/DF/Villageofislandpark-n/bid_documents.htm)
by the close of business on April 19, 2016. The Village reserves the right to extend receipt of
submissions beyond April 25, 2016.
Sealed Proposals (consisting of the technical project narrative and a separate sealed cost
proposal) will be received by the Village Clerk of the Inc. Village of Island Park, 127 Long
Beach Road, Island Park, NY until 11:00 a.m. on April 25, 2016, at which time the Technical
Proposals shall be publicly opened (Cost Proposals will remain sealed until the Technical
Proposals are evaluated). The Village will review the Proposals in accordance with the Selection
Process described herein. The Contract shall be awarded as soon thereafter as may be
practicable. It is the sole responsibility of the Bidder to see that his/her Proposal is received on
time. Any Proposal received after the scheduled closing time for receipt of Proposals shall be
returned to the Bidder unopened.
Note that this RFP and any Addenda or Responses to Questions will be posted on the Village’s
website (http://www.kpsearch.com/DF/Villageofislandpark-n/bid_documents.htm). Potential
Bidders are advised to check this website frequently for any updates that may be posted until
the April 25, 2016 submittal deadline.
The Bidder whose Proposal is accepted will be required to appear at the Office of the Village
Clerk and execute the Contract within ten (10) days from the date of service of the Notification
of Award, delivered to him in person or mailed to the address given in the Proposal, stating that
the Contract has been awarded to him.
In case of failure to execute the Contract (including the required Insurance, Indemnification/Hold
Harmless Agreement and Contractors Qualification Statement along with the Certificate of
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Contractor’s Qualification Statement) within the time frame stated, the Bidder shall be deemed to
have abandoned the Contract.
IV. Scope of Work
The Village is seeking proposals from firms experienced in providing Contract Management
Services in the State of New York related to the HMGP Project being implemented by the
Village with the objective of improving storm water drainage system infrastructure and
mitigating flooding within the Village. The selected firm will assist the Village in coordinating
project activities and preparing project documentation to ensure compliance with the HMGP
Project requirements established by FEMA and administered by DHSES. A copy of the Hazard
Mitigation Program Project Management Handbook issued by DHSES outlining HMGP Project
requirements is provided in Appendix B.
The scope of work shall include, but is not limited to the following work items which shall be
performed as directed by the Village. Note that the scope of work shall apply to Phase I of the
HMGP Project and the Village may elect to have the selected Contract Management firm provide
these services (as applicable) in the future as the HMGP Project progresses through Phase II
(engineering design and permitting) and Phase III (construction of approved project
improvements).
Reporting and Invoicing
Prepare Quarterly Reports by completing the DHSES Quarterly Report Form (see
Appendix B). Quarterly reports are due by the 15th of the month following the end of
each quarter (i.e., January 15th, April 15th, July 15th, October 15th) and must include
information on the HMGP Project status, relevant activities, schedule updates, budget
status, problems encountered, etc., plus associated supporting documentation.
Prepare Payment/Reimbursement Requests on appropriate DHSES forms (see
Appendix B). Payment requests must detail labor, materials, equipment and
contractual costs for the HMGP Project plus associated supporting documentation.
DHSES prefers quarterly submission of payment requests.
Review Invoices submitted by the Engineer and Contractors retained by the Village
to perform the HMGP Project work (i.e., Phase I work being performed by the
Engineer and Contractors includes field inventory and data collection, storm drainage
system cleaning and CCVT inspection, data evaluation, development and evaluation
of alternatives, summary report preparation).
Review Certified Payrolls submitted with Contractor invoices to verify compliance
with prevailing wage laws.
Coordinate and Track in-kind support provided by Village DPW and Village Hall
staff (force account labor) and usage of Village equipment (force account equipment)
during project implementation.
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Scheduling, Project Tracking and Recordkeeping
Track HMGP Project Schedule and monitor progress of Phase I field work and
engineering evaluation; maintain records of project activities and prepare punch lists
of outstanding HMGP Project tasks if applicable. The selected Contract Management
firm must work closely with the Village and the Village’s Engineer and shall not
hinder progress of the HMGP Project.
Check Disposal Documentation including waste manifests.
Verify Quantities of materials delivered for use in project.
Provide Daily Logs to Village documenting Contract Management activities.
Attend Meetings related to the HMGP Project with the Village, Engineer,
Contractors and/or FEMA/DHSES administrative personnel; attend Village Board
meetings if requested by Village.
Assist Village in Recordkeeping to maintain complete HMGP Project files.
Development and Evaluation of Mitigation Alternatives
Assist Village in Producing Documentation and compiling records required to
support development and evaluation of flood mitigation alternatives for the Phase I
HMGP drainage study report.
Work with Village and Engineer to evaluate drainage system evaluation results and
conceptualize flood mitigation alternatives.
Complete Benefit Cost Analysis (BCA) of alternatives developed for flood mitigation
to be included in Phase I HMGP drainage study report. BCA must be completed in
accordance with FEMA guidance. See http://www.fema.gov/benefit-cost-analysis for
guidance and information on BCA procedures.
Assist Village in HMGP Project Close-out and Project Audit, if applicable.
All work must comply with federal, state and local codes, regulation, laws and ordinances,
including all requirements related to HMGP Project funding.
V. Submittal Content
Bidders must supply one (1) original and five (5) copies of his/her submission to the attention of
Constance L. Conroy, Village Clerk, no later than 11:00 am on April 25, 2016.
Constance L. Conroy
Village Clerk
Inc. Village of Island Park
127 Long Beach Road
Island Park, New York 11558
clconroy@villageofislandpark.com
6
Each Proposal shall be submitted in a Sealed Envelope bearing the Title of the Work and the
Name of the Bidder. The Proposal submittal must contain a narrative Technical Proposal
and a separate sealed Cost Proposal (separate envelope to be clearly marked “Cost
Proposal”).
Proposals must contain the following information and documentation:
Firm. Proposals must describe the Bidding firm’s legal structure, areas of expertise, length
of time in business, number of employees and detailed contact information for the person
authorized to contractually obligate the Bidder and for the person administratively
responsible for preparing the Proposal.
Subcontractors. The Bidder must be capable of performing the work required under this
RFP and shall perform a substantial portion thereof with his/her own resources. If the
Bidder intends to subcontract portions of the Scope of Work, the Proposal must identify
any Subcontractors, including a summary of the Subcontractors’ organization,
qualifications, experience and technical skills. Bidders shall not employ, contract with, or
use the services of any Subcontractor for the work of this Contract (except such third parties
which may be used by the Bidder in the normal course of business, such as couriers,
imaging services, etc.) without obtaining prior written approval from the Village.
Disclosure. Bidders must disclose all allegations or claims of substandard work, unethical
or illegal practices or debarment or suspension from State- or Federally-funded projects,
and provide documentation as to the resolution of these matters. Bidders must not be
suspended or debarred from participation in State- or Federally-funded projects. Proposals
must include completed NYS Vendor Responsibility Questionnaire, with notarized
certification (see Appendix A and http://www.osc.state.ny.us/vendrep/).
Relevant Experience and References. Proposals must describe at least five (5) previous
projects that demonstrate relevant experience and identify public sector clients for whom
Bidder has provided similar work (to the scope of work described in this RFP) in the past
five (5) years. For each project described, provide current contact information for the
individual with whom Bidder worked. In addition, provide contact information for three
(3) references so the Village can verify the quality of your work.
Approach and Methodology. Proposals must indicate the Bidder’s understanding of the
required HMGP Project Contract Management services.
Staffing Plan. Proposals must include documentation that demonstrates the firm is
adequately staffed, skilled and experienced to perform the Contract Management services
required by the Village within the project timeframe established by FEMA/DHSES.
Proposals must identify the individual designated to be the firm’s primary HMGP Project
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Contract Management point of contact with the Village, as well as all other key personnel
that would be involved. Resumes of all key personnel that would be involved in the project
shall be included in the proposal, including their education, years of contract management
experience and functions on this project.
Ability to Conform to HMGP Project Timeline. Proposals must describe the firm’s
workload and its current capacity to perform services on this project, and detail specifically
how the firm will comply with the required schedule set forth in SCHEDULE A.
Insurance. The successful Bidder, prior to the execution of the Contract, will be required
to furnish Workers Compensation, Commercial General Liability, Automobile Insurance,
Umbrella Liability and Indemnification/Hold Harmless Agreement as outlined in
SCHEDULE B (Insurance Requirements).
Commitment to Comply with All Applicable Federal, State, and Local Regulations,
including Minority and Women-Owned Business Enterprise (M/WBE) Participation
Goals and Section 3. Proposals must indicate the firm’s commitment to and present a
plan for complying with all applicable Federal, State, and local regulations, including a
plan for M/WBE participation to meet the Village’s goals and hiring requirements under
Section 3 of the Housing and Community Development Act. This is a factor for firm
selection, and Bidders who demonstrate an active commitment to comply will receive the
most points, as described herein in Section VI (Selection Process).
Iran Divestment Act. Bidder must attach the following signed statement on company
letterhead that is affirmed as true under penalty of perjury:
o "By submission of this bid, each bidder and each person signing on behalf of any
bidder certifies, and in the case of a joint bid each party thereto certifies as to its
own organization, under penalty of perjury, that to the best of its knowledge and
belief that each bidder is not on the list created pursuant to paragraph (b) of
subdivision 3 of section 165-a of the State Finance Law."
Costs. The Cost Proposal presented in SCHEDULE C must be completed and included
in the Proposal submittal in a separate sealed envelope to be labeled “Cost Proposal”.
o Each Bidder shall fill out in ink, in both words and figures, in the spaces provided,
his/her bid pricing for each item in SCHEDULE C – Cost Proposal. If there is
any discrepancy between the prices in words and figures, the prices in words shall
govern.
o The estimated item quantities in SCHEDULE C are approximate only and given
solely to be used as a uniform basis for the comparison of bids. The quantities
actually required to complete the Contract of work might be less or more than so
estimated and, if so, no right to recover damages or loss of profits shall accrue to
the Contractor by reason thereof.
8
o This is a unit-based contract, and the total cost calculated in SCHEDULE C does
not constitute the total cost that the Contractor will be paid. Contractor will be
paid based on the actual unit quantities and unit prices (hourly rates indicated in
SCHEDULE C) for the project.
o No bid will be considered which does not include pricing for all items in the
Proposal.
o Pricing as indicated in SCHEDULE C submitted with your bid will remain in
effect for the term of the Contract.
o Note that a schedule of hourly rates for all personnel (including
administrative personnel) designated to be involved in Contract Management
for the Village’s HMGP Project must be included with each Bidder’s Cost
Proposal.
Contractor’s Qualification Statement. Each Bidder must submit with their Proposal a
Contractor’s Qualification Statement including their organization and financial status
along with a Certificate of Contractor’s Qualification as of the date of their Proposal.
The Required Forms are included in SCHEDULE D.
Conflicts of Interest. The Proposal shall disclose the following information:
o Any material financial relationships that your firm or any employee has that may
create a conflict of interest or the appearance of a conflict of interest in contracting
with or representing the Village.
o Any family relationship that any employee of your firm has with a member,
employee, or official of the Village that may create a conflict of interest or the
appearance of a conflict of interest in contracting with or representing the Village.
o Any other matter that your firm believes may create a conflict of interest or the
appearance of a conflict of interest in contracting with or representing the Village
including, without limitation, any current or past relationship with a member,
employee, official or other representative of the Village.
o Please describe any procedures your firm has, or would adopt, to assure the Village
that a conflict of interest would not exist for your firm in the future.
Attachments. Other material relevant to the technical evaluation may also be attached to
the Proposals (short project descriptions, brochures).
No plea of ignorance or misunderstanding of conditions that exist or that may hereafter exist, or
of conditions or difficulties that may be encountered in the execution of the work under this RFP
as a result of failure to make the necessary examinations and investigations as may be expected
of a responsible Bidder, will be accepted as an excuse for any failure or omission on the part of a
Contractor to fulfill in every detail all of the requirements of this RFP, or will be accepted as a
basis for any claims whatsoever for extra compensation, or an extension of time.
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VI. Selection Process
The Village reserves the right to award a Contract resulting from this solicitation based on the
evaluation criteria set forth in the RFP and to reject any and all bids and to award the Contract to
the Bidder who best serves the interest of the Village.
The Technical Proposals (narrative proposals) responsive to the requirements of this RFP will be
evaluated by the Village’s Evaluation Team and scored based on non-cost elements in accordance
with the Technical Evaluation Criteria. Cost Proposals will remain sealed until the evaluation of
Technical Proposals is completed and will only be considered for the best qualified firms. After
Technical Proposals are evaluated, Cost Proposals will be scored for cost. During or after the
review of Bids, the Village may submit written questions and requests to Bidders for clarification,
and may conduct interviews.
The Village shall evaluate each Proposal in terms of:
Technical Factors Maximum Points
1. Relevant Experience and Qualifications 20
2. Approach and Methodology 20
3. Staffing Plan 20
4. Ability to Conform to HMGP Project Timeline 10
5. Commitment to Comply with all Applicable Federal, State
and Local Regulations including M/WBE and Section 3 10
Total Technical Factors 80
Total Cost Factors 20
Maximum Points 100
Cost points will be awarded as follows:
The lowest priced qualifying Technical Proposal will be awarded the full 20 points. Other
bidders will be awarded as follows: total cost points = (lowest bidder cost/other bidder
cost) x 20.
The Village will weigh the Technical and Cost Proposal evaluation results of each
submittal as two components, which together will have a maximum total score of 100
points.
After evaluation of selected Technical Proposals and Cost Proposals, the Village reserves the right
to award the Contract without delay. The Village will issue a Letter of Intent to Award and a
Notice to Proceed as soon as may be practicable.
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VII. Specific Legal Obligations
a. Procurement
In accordance with Section 104-b(2)(f) and Section 139-j(2)(a), the Village must identify the
individual responsible for purchasing and the individual who is the sole point of contact during the
procurement. Constance L. Conroy, Village Clerk for the Incorporated Village of Island Park, will
be the RFP Coordinator.
In accordance with State Finance Law § 139-j and 139-k, this RFP imposes restrictions on
communications between the Village, DHSES, and Bidders during the procurement. Bidders are
restricted from making contact from the earliest notice of intent to solicit offers through final award
and approval of the contract (the restricted period) with Village staff other than the RFP
Coordinator, unless it is a contact included among expressly provided statutory exceptions set forth
in State Finance Law § 139-j(3)(a).
The Village’s employees also are required to obtain certain information when contacted during the
restricted period and make a determination of responsibility of the Bidders pursuant to these two
statutes. Certain findings of non-responsibility can result in the rejection for contract award and in
the event of two (2) findings within a four-year period such Bidder is debarred from obtaining
governmental procurement contracts.
b. Diversity and Income Requirements
i. Minority and Women Owned Businesses (M/WBE)
The Village is committed to awarding a contract to a firm that will provide high quality services
and that is dedicated to diversity and to containing costs. The Village strongly encourages Bidders
that are certified by New York State, any other city or state, or the federal government, as M/WBE
firms, as well as Bidders that are not yet certified but have applied for certification, to submit
responses to this RFP.
All New York State-certified M/WBE firms submitting proposals to this RFP should be registered as
such with the New York State Department of Economic Development. For M/WBE firms that are
not certified but have applied for certification, Respondents must provide evidence of filing including
filing date.
The Village is required to implement the provisions of New York State Executive Law Article 15-
A and 5 NYCRR Parts 142-144 (M/WBE Regulations) for all New York State funded contracts as
defined therein, with a value in excess of $25,000.
The Village strongly encourages joint ventures of M/WBE firms with majority firms and M/WBE
firms with other M/WBE firms. For purposes of this solicitation, the Village hereby establishes an
11
overall goal of 30% for M/WBE participation, 15% for minority-owned business enterprises (MBE)
and 15% for women-owned business enterprises (WBE).
ii. Section 3
In addition to the above diversity requirements, and pursuant to Section 3 of the Housing &
Community Development Act (HCDA), the Inc. Village of Island Park is committed to ensuring that
employment and other economic opportunities generated by HUD financial assistance shall, to the
greatest extent feasible and consistent with existing federal, state and local laws and regulations, be
directed to Section 3 residents and businesses.
A “Section 3 resident” is: 1) a public housing resident; or 2) a low- or very low-income person residing
in the metropolitan area or non-metropolitan county where the Section 3 covered assistance is
expended. For the purposes of Section 3 of the HCDA, low-income persons are defined as families
(including single persons) whose incomes do not exceed 80% of the median income for the area, and
very low-income persons are defined as families (including single persons) whose incomes do not
exceed 50% of the median income for the area.
A “Section 3 business” is a business that can provide evidence that it meets one of the follow criteria:
1) 51% or more owned by Section 3 residents; or 2) at least 30% of its full time employees include
persons that are currently Section 3 residents, or were Section 3 residents within three years of the
date of first hire; or 3) provides evidence, as required, of a commitment to subcontract in excess of
25% of the dollar award of all subcontracts to business concerns that meet one of the preceding two
qualifications.
In their submittals, Respondents should demonstrate their commitment to advancing the Inc. Village
of Island Park’s Section 3 goals, which include the following: 30% of new hires associated with the
CDBG-DR funded project shall be Section 3 residents, 10% of new construction contracts shall be
awarded to Section 3 businesses, and 3% of non-construction contracts shall be awarded to Section 3
businesses.
c. Iran Divestment Act
Every Proposal made to the Village pursuant to a competitive solicitation must contain the
following statement, signed by the Bidder on company letterhead and affirmed as true under
penalty of perjury:
"By submission of this bid, each bidder and each person signing on behalf of any bidder
certifies, and in the case of a joint bid each party thereto certifies as to its own
organization, under penalty of perjury, that to the best of its knowledge and belief that each
bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of section 165-
a of the State Finance Law."
Responses that fail to certify compliance with this requirement will not be accepted as responsive.
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VIII. New York Law and Venue
This contract shall be construed under the laws of the State of New York. All claims, actions,
proceedings, and lawsuits brought in connection with, arising out of, related to, or seeking
enforcement of this contract shall be brought in the Supreme Court of the State of New York,
Nassau County.
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SCHEDULE A
Deadline Schedule
A. Date for Publication of Notice: April 8, 2016
B. Date RFP Package Available: April 11, 2016
C. Date for Questions from Potential Bidders: April 15, 2016 (12:00 noon)
D. Date for Response to Potential Bidders’ Questions: April 19, 2016
E. Date for Submission of Proposals: April 25, 2016 (11:00 a.m.)
F. Date for Evaluation of Proposals: May 2, 2016 (tentative)
G. Date for Notice of Contract Award with Draft Contract: May 9, 2016 (tentative)
H. Date for Execution of Contract with Notice to Proceed: May 23, 2016 (tentative)
The Incorporated Village of Island Park reserves the right to modify this Timeline as necessary.
Changes to the Timeline will be published at
(http://www.kpsearch.com/DF/Villageofislandpark-n/bid_documents.htm).
All Proposals including all forms and information discussed in this RFP shall be submitted in hard
copy, signed in the original, and received and date stamped by the Village on or before 11:00 a.m.
on April 25, 2016.
Bidder is responsible for meeting all deadlines.
14
SCHEDULE B
Insurance Requirements (Page 1 of 3)
The selected firm shall be required to procure and maintain at a minimum the following
insurance coverages during the course of the Agreement giving evidence of same to the
Incorporated Village of Island Park in the form of Certificates of Insurance, copies of the
General Liability Declaration Page and copies of Additional Insured Endorsements,
providing 30 days notice of cancellation, non-renewal or material change. New York State
licensed carriers are preferred; any non-licensed carriers will be accepted at the Village’s discretion.
The insurance carrier must have an A.M. Best Rating of at least A- IX. All subcontractors must
adhere to the same insurance requirements.
I. Workers Compensation and NYS Disability
Coverage Statutory
Extensions Voluntary Compensation; All States Coverage
Employers Liability - Unlimited
II. Commercial General Liability
Coverage and Limits Occurrence 1988 ISO or equivalent
General Aggregate $2,000,000
Products & Completed Operations $2,000,000
Personal & Advertising Injury $1,000,000
Per Occurrence Limit $1,000,000
Fire Damage $ 50,000
Medical Expense $ 5,000
Additional Insured Inc. Village of Island Park, all elected and
appointed officials, employees and volunteers using
ISO Form CG2010 (B) or equivalent including
Products and Completed Operations.
Extension - Mandatory Aggregate Limits to apply per project.
Contractual Liability to extend to Hold Harmless
Extension – If Possible Endorsement showing that this policy is considered
primary and non-contributory.
Waiver of Subrogation in favor of the additional insured.
15
SCHEDULE B
Insurance Requirements (Page 2 of 3)
III. Automobile Insurance
Limit $1,000,000. Combined Single Limit
Additional Insured Inc. Village of Island Park, all elected and
appointed officials, employees and volunteers.
IV. Umbrella Liability
Coverage Umbrella Form, or Excess Follow Form
Minimum Limit $5,000,000.
Additional Insured Inc. Village of Island Park, all elected and
appointed officials, employees and volunteers.
16
SCHEDULE B
Insurance Requirements (Page 3 of 3)
INDEMNIFICATION/HOLD HARMLESS AGREEMENT
The Vendor/Contractor shall indemnify and hold harmless the Incorporated Village of Island Park,
its officers, employees, and/or agents from any and all liability, damage, loss, claims, demands
and actions of any nature whatsoever, for any reason whatsoever, foreseeable of unforeseeable,
which arises out of or is connected with, or is claimed to arise out of to be connected with, any
undertaking, product, goods, merchandise, products, services sold and/or work supplied, furnished
or performed by the Vendor/Contractor or its subcontractors, agents, servants, or employees,
including without limiting the generality of the forgoing, all liability, damages, loss, claims,
attorneys, court and adjusting fees, demands and actions on account of personal injury, death or
property loss to the Incorporated Village of Island Park its officers, employees, agents or to any
other persons, third parties, or property, but shall not include claims resulting from the gross
negligence or willful misconduct of the Incorporated Village of Island Park. This indemnity and
hold harmless is intended to be as broad as is permitted by law and to include claims of every kind
and nature – for tort, under contract; for strict liability or other liability without fault; under statute,
rule, regulation or order; and otherwise.
IN WITNESS WHEREOF, the undersigned has duly executed this Agreement the ___ day of
_________, 201__.
________________________________
Name of Firm
________________________________
Address
________________________________
Contractor’s Signature
________________________________
Print Name and Title
Witness: _______________________
Signature _______________________
Date _______________________
Print Name ______________________
17
SCHEDULE C
COST PROPOSAL
Page 1 of 3
TO BE SUBMITTED IN A SEPARATE SEALED ENVELOPE
MARKED “COST PROPOSAL”
Bidder:
Date:
The undersigned, as bidder, hereby declares that the only person or persons interested in this
proposal as principal or principals is or are named herein and that no other person than herein
mentioned has any interest in this proposal or in the contract to be entered into; that this proposal
is made without connection with any other person, company or parties making a bid or proposal;
and that it is in all respects fair and in good faith without collusion or fraud. The bidder further
declares that he has examined the site of the work and the contract documents relative thereto, and
has read all special provisions furnished prior to the opening of bids; that he has satisfied himself
relative to the work to be performed.
The Bidder proposes and agrees if this Proposal is accepted to enter into a contract with the
Incorporated Village of Island Park to furnish all necessary materials, equipment, means of
transportation and labor necessary to provide Contract Management Services in full and complete
accordance with the RFP, to the full and entire satisfaction of the Incorporated Village of Island
Park.
The Incorporated Village of Island Park is seeking Contract Management Services for the HMGP
Project being implemented by the Village. Base Bid based on the Hourly Rates and Estimated
Quantities Indicated on Schedule C – Cost Proposal Page 2 of 3:
Dollars ($)
In Words In Figures
18
SCHEDULE C
COST PROPOSAL
Page 2 of 3
Bidder:
Date:
Bidders must complete the table below to provide bid pricing that will be used to compare
Proposals based on cost. The tasks and bid quantities are presented for bid comparison
only and do not represent the actual work to be completed based on this RFP. The total
base bid cost shall be calculated by multiplying the hourly rates by the respective bid
quantities listed in the table. Bidders must not change the bid quantities shown.
Description Hourly Rate Bid Quantity
Total Bid
Prepare Quarterly Reports to
DHSES $_______/hr 60 hrs
Prepare Quarterly
Payment/Reimbursement
Requests to DHSES
$_______/hr 60 hrs
Track HMGP Project Schedule
and Monitor Progress of Phase I
Work
$_______/hr 200 hrs
Assist Village in Producing
Documentation and Compiling
Records Necessary to Develop
and Evaluate Flood Mitigation
Alternatives during Phase I
HMGP Project
$_______/hr 100 hrs
Complete Benefit Cost Analysis
(BCA) of Flood Mitigation
Alternatives in Accordance with
FEMA Guidance
$_______/hr 150 hrs
Administrative Support $_______/hr 80 hrs
Total Base Bid Amount
(Enter this Amount on Page 1 of SCHEDULE C)
Note that a schedule of hourly rates for all personnel (including administrative
personnel) designated to be involved in Contract Management for the Village’s HMGP
Project must be included with each Bidder’s Cost Proposal.
19
SCHEDULE C
COST PROPOSAL
Page 3 of 3
Cost Proposal Signature Page
The undersigned further agrees that in the case of failure on his part to execute the said contract
and the bonds within ten (10) consecutive calendar days after being given written notice of the
award of contract, the certified check, cash or bid bond accompanying this bid shall be paid into
the funds of the Village's account set aside for the project, as liquidated damages for such failure;
otherwise the certified check, cash or bid bond accompanying this proposal shall be returned to
the undersigned.
Respectfully submitted this day by: _______________________________ Date:____________
(Name of firm or corporation making bid)
WITNESS: By: Signature ___________________________ Name: (Proprietorship or Partnership) Print or type Title: _____________________________________ (Owner/Partner/Pres./V.Pres)
Address:
ATTEST:
By: License No. Title: Federal I.D. No.
(Corp. Sec. or Asst. Sec. only)
Email Address:
(CORPORATE SEAL)
20
SCHEDULE D
CONTRACTOR’S QUALIFICATION STATEMENT
Page 1 of 6
The signatory of this questionnaire certifies under oath the truth and correctness of all statements
and all answers to interrogatories made.
SUBMITTED TO: Village Clerk
Village of Island Park, Nassau County, New York
SUBMITTED BY:_____________________________________________________________
PRINCIPAL OFFICE:_________________________________________________________
Name and Addresses of Owners, Corporate Officers, Partners, Etc.
PRINCIPAL OFFICERS
PRESIDENT:
_____________________________________________________________________________
Name Address Background Profession or Trade
VICE PRESIDENT:
_____________________________________________________________________________
Name Address Background Profession or Trade
SECRETARY:
_____________________________________________________________________________
Name Address Background Profession or Trade
TREASURER:
_____________________________________________________________________________
Name Address Background Profession or Trade
The Contractor is (Check one of the following):
_____ Sub-chapter “S” Corporation
_____ Public Corporation
_____ Closely Held Corporation
_____ Individually Owner Business
The Contractor’s Federal Employer Identification Number is:_____________________________
21
SCHEDULE D
CONTRACTOR’S QUALIFICATION STATEMENT
Page 2 of 6
List Stockholders
(Not required if publicly held, however disclosure is required if more than 10% of the
Stock is held by one person.)
NAME ADDRESS
1.
_____________________________________________________________________________
2.
_____________________________________________________________________________
3.
_____________________________________________________________________________
4.
_____________________________________________________________________________
Individual Ownership or Partnership (List all Names and Addresses)
NAME ADDRESSES
1,
_____________________________________________________________________________
2.
_____________________________________________________________________________
3.
_____________________________________________________________________________
4,
_____________________________________________________________________________
NOTE: Failure to supply above information prior to, or at bid opening will cause an
informational bid that will be disqualified.
Persons or firms submitting bids must be engaged in the lines of work required in these
specifications, or shall be able to refer to work of similar character performed by them.
Bidders must present satisfactory evidence of experience, ability and financial standing,
and also a statement as to their plant and machinery.
22
SCHEDULE D
CONTRACTOR’S QUALIFICATION STATEMENT
Page 3 of 6
1. Your organization has been in business as a General Contractor under its present
business name for __________ years.
2. You normally perform __________ % of the work with your forces.
List the Trades below:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. Have you ever failed to complete any work awarded to you?
_____________________________________________________________________________
If so, note where and why.______________________________________________________
_____________________________________________________________________________
4. List the major construction projects your organization has under construction at on
this date.
Contract Percent Scheduled
Project Owner Engineer Amount Complete Completion
A. ______________________________________________________________________
B. ______________________________________________________________________
C. ______________________________________________________________________
D. ______________________________________________________________________
E. ______________________________________________________________________
23
SCHEDULE D
CONTRACTOR’S QUALIFICATION STATEMENT
Page 4 of 6
5. List five major projects your organization has completed in the past five years
(indicate percent of work done by other firms, if applicable).
Contract Date of
Project Owner/Engineer Amount Completion Work Trades
A.___________________________________________________________________________
B. ___________________________________________________________________________
C.__________________________________________________________________________
D.___________________________________________________________________________
E.___________________________________________________________________________
6. List the contract management experience of the principal individual of your
organization (particularly the anticipated Project Supervisor).
Type of work
Individual’s Present Position Years of for which In What
Name or Office Experience Responsible Capacity
A.___________________________________________________________________________
B. ___________________________________________________________________________
C.__________________________________________________________________________
D.__________________________________________________________________________
24
SCHEDULE D
CONTRACTOR’S QUALIFICATION STATEMENT
Page 5 of 6
7. Bank References
A.___________________________________________________________________________
B.___________________________________________________________________________
8. Trade Association Membership
A.___________________________________________________________________________
B.___________________________________________________________________________
C.___________________________________________________________________________
25
SCHEDULE D
CONTRACTOR’S QUALIFICATION STATEMENT
Page 6 of 6
CERTIFICATION OF CONTRACTORS QUALIFICATION STATEMENT
I certify that (our) (my) qualifications statement dated _____________________, as on file
with the Village Clerk, Incorporated Village of Island Park, is current and that it reflects
(our) (my) organization, operations, and financial status as of this
____________________________day of ______________________________;
with the following exceptions:
STATE OF:
COUNTY OF:
M__________________________________ being duly sworn deposes and says that he/she is
the
_________________________of ____________________________ (Contractor) and that
answers to the foregoing and all statements therein contained are true and correct.
Sworn before me this ______________________day of ____________________20________
NOTARY PUBLIC:
MY COMMISSION EXPIRES:
APPENDIX A
New York State Vendor Responsibility Questionnaire
AC 3290-S (Rev. 9/13) NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
You have selected the For-Profit Non-Construction questionnaire which may be printed and completed in this format or, for your convenience, may be completed online using the New York State VendRep System.
COMPLETION & CERTIFICATION
The person(s) completing the questionnaire must be knowledgeable about the vendor’s business and operations. An owner or officer must certify the questionnaire and the signature must be notarized.
NEW YORK STATE VENDOR IDENTIFICATION NUMBER (VENDOR ID)
The Vendor ID is a ten-digit identifier issued by New York State when the vendor is registered on the Statewide Vendor File. This number must now be included on the questionnaire. If the business entity has not obtained a Vendor ID, contact the IT Service Desk at ITServiceDesk@osc.state.ny.us or call 866-370-4672.
DEFINITIONS
All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” found at www.osc.state.ny.us/vendrep/documents/questionnaire/definitions.pdf. These terms may not have their ordinary, common or traditional meanings. Each vendor is strongly encouraged to read the respective definitions for any and all underlined terms. By submitting this questionnaire, the vendor agrees to be bound by the terms as defined in the "New York State Vendor Responsibility Definitions List" existing at the time of certification.
RESPONSES
Every question must be answered. Each response must provide all relevant information which can be obtained within the limits of the law. However, information regarding a determination or finding made in error which was subsequently corrected is not required. Individuals and Sole Proprietors may use a Social Security Number but are encouraged to obtain and use a federal Employer Identification Number (EIN).
REPORTING ENTITY
Each vendor must indicate if the questionnaire is filed on behalf of the entire Legal Business Entity or an Organizational Unit within or operating under the authority of the Legal Business Entity and having the same EIN. Generally, the Organizational Unit option may be appropriate for a vendor that meets the definition of “Reporting Entity” but due to the size and complexity of the Legal Business Entity, is best able to provide the required information for the Organizational Unit, while providing more limited information for other parts of the Legal Business Entity and Associated Entities.
ASSOCIATED ENTITY
An Associated Entity is one that owns or controls the Reporting Entity or any entity owned or controlled by the Reporting Entity. However, the term Associated Entity does not include “sibling organizations” (i.e., entities owned or controlled by a parent company that owns or controls the Reporting Entity), unless such sibling entity has a direct relationship with or impact on the Reporting Entity.
STRUCTURE OF THE QUESTIONNAIRE
The questionnaire is organized into eleven sections. Section I is to be completed for the Legal Business Entity. Section II requires the vendor to specify the Reporting Entity for the questionnaire. Section III refers to the individuals of the Reporting Entity, while Sections IV-VIII require information about the Reporting Entity. Section IX pertains to any Associated Entities, with one question about their Officials/Owners. Section X relates to disclosure under the Freedom of Information Law (FOIL). Section XI requires an authorized contact for the questionnaire information.
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
I. LEGAL BUSINESS ENTITY INFORMATION
Legal Business Entity Name*
EIN
Address of the Principal Place of Business (street, city, state, zip code)
New York State Vendor Identification Number Telephone ext.
Fax
Website
Additional Legal Business Entity Identities: If applicable, list any other DBA, Trade Name, Former Name, Other Identity, or EIN used in the last five (5) years and the status (active or inactive).
Type Name EIN Status
1.0 Legal Business Entity Type – Check appropriate box and provide additional information:
Corporation (including PC) Date of Incorporation
Limited Liability Company (LLC or PLLC) Date of Organization
Partnership (including LLP, LP or General) Date of Registration or Establishment
Sole Proprietor How many years in business?
Other Date Established
If Other, explain:
1.1 Was the Legal Business Entity formed or incorporated in New York State? Yes No
If ‘No,’ indicate jurisdiction where Legal Business Entity was formed or incorporated and attach a Certificate of Good Standing from the applicable jurisdiction or provide an explanation if a Certificate of Good Standing is not available.
United States State
Other Country
Explain, if not available:
1.2 Is the Legal Business Entity publicly traded? Yes No
If “Yes,” provide CIK Code or Ticker Symbol
1.3 Does the Legal Business Entity have a DUNS Number? Yes No
If “Yes,” Enter DUNS Number
*All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” which can be found at www.osc.state.ny.us/vendrep/documents/questionnaire/definitions.pdf.
Page 2 of 10
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
I. LEGAL BUSINESS ENTITY INFORMATION
1.4 If the Legal Business Entity’s Principal Place of Business is not in New York State, does the Legal Business Entity maintain an office in New York State? (Select “N/A,” if Principal Place of Business is in New York State.)
Yes No N/A
If “Yes,” provide the address and telephone number for one office located in New York State.
1.5 Is the Legal Business Entity a New York State certified Minority-Owned Business Enterprise (MBE), Women-Owned Business Enterprise (WBE), New York State Small Business (SB) or a federally certified Disadvantaged Business Enterprise (DBE)? If “Yes,” check all that apply:
New York State certified Minority-Owned Business Enterprise (MBE) New York State certified Women-Owned Business Enterprise (WBE) New York State Small Business (SB) Federally certified Disadvantaged Business Enterprise (DBE)
Yes No
1.6 Identify Officials and Principal Owners, if applicable. For each person, include name, title and percentage of ownership. Attach additional pages if necessary. If applicable, reference to relevant SEC filing(s) containing the required information is optional.
Name
Title
Percentage Ownership (Enter 0% if not applicable)
Page 3 of 10
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
II. REPORTING ENTITY INFORMATION
2.0 The Reporting Entity for this questionnaire is: Note: Select only one.
Legal Business Entity Note: If selecting this option, “Reporting Entity” refers to the entire Legal Business Entity for the remainder of the questionnaire. (SKIP THE REMAINDER OF SECTION II AND PROCEED WITH SECTION III.)
Organizational Unit within and operating under the authority of the Legal Business Entity SEE DEFINITIONS OF “REPORTING ENTITY” AND “ORGANIZATIONAL UNIT” FOR ADDITIONAL INFORMATION ON CRITERIA TO QUALIFY FOR THIS SELECTION. Note: If selecting this option, “Reporting Entity” refers to the Organizational Unit within the Legal Business Entity for the remainder of the questionnaire. (COMPLETE THE REMAINDER OF SECTION II AND ALL REMAINING SECTIONS OF THIS QUESTIONNAIRE.)
IDENTIFYING INFORMATION
a) Reporting Entity Name
Address of the Primary Place of Business (street, city, state, zip code) Telephone
ext.
b) Describe the relationship of the Reporting Entity to the Legal Business Entity
c) Attach an organizational chart
d) Does the Reporting Entity have a DUNS Number? Yes No
If “Yes,” enter DUNS Number e) Identify the designated manager(s) responsible for the business of the Reporting Entity.
For each person, include name and title. Attach additional pages if necessary. Name Title
Page 4 of 10
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
INSTRUCTIONS FOR SECTIONS III THROUGH VII
For each “Yes,” provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). For each “Other,” provide an explanation which provides the basis for not definitively responding “Yes” or “No.” Provide the explanation at the end of the section or attach additional sheets with numbered responses, including the Reporting Entity name at the top of any attached pages.
III. LEADERSHIP INTEGRITY Within the past five (5) years, has any current or former reporting entity official or any individual currently or formerly having the authority to sign, execute or approve bids, proposals, contracts or supporting documentation on behalf of the reporting entity with any government entity been:
3.0 Sanctioned relative to any business or professional permit and/or license? Yes No Other
3.1 Suspended, debarred, or disqualified from any government contracting process? Yes No Other
3.2 The subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation for any business-related conduct?
Yes No Other
3.3 Charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime or subject to a judgment for: a) Any business-related activity; or b) Any crime, whether or not business-related, the underlying conduct of which was related to
truthfulness?
Yes No Other
For each “Yes” or “Other” explain:
IV. INTEGRITY – CONTRACT BIDDING Within the past five (5) years, has the reporting entity:
4.0 Been suspended or debarred from any government contracting process or been disqualified on any government procurement, permit, license, concession, franchise or lease, including, but not limited to, debarment for a violation of New York State Workers’ Compensation or Prevailing Wage laws or New York State Procurement Lobbying Law?
Yes No
4.1 Been subject to a denial or revocation of a government prequalification? Yes No
4.2 Been denied a contract award or had a bid rejected based upon a non-responsibility finding by a government entity?
Yes No
4.3 Had a low bid rejected on a government contract for failure to make good faith efforts on any Minority-Owned Business Enterprise, Women-Owned Business Enterprise or Disadvantaged Business Enterprise goal or statutory affirmative action requirements on a previously held contract?
Yes No
4.4 Agreed to a voluntary exclusion from bidding/contracting with a government entity? Yes No
4.5 Initiated a request to withdraw a bid submitted to a government entity in lieu of responding to an information request or subsequent to a formal request to appear before the government entity?
Yes No
For each “Yes,” explain:
Page 5 of 10
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
V. INTEGRITY – CONTRACT AWARD Within the past five (5) years, has the reporting entity:
5.0 Been suspended, cancelled or terminated for cause on any government contract including, but not limited to, a non-responsibility finding?
Yes No
5.1 Been subject to an administrative proceeding or civil action seeking specific performance or restitution in connection with any government contract?
Yes No
5.2 Entered into a formal monitoring agreement as a condition of a contract award from a government entity? Yes No
For each “Yes,” explain:
VI. CERTIFICATIONS/LICENSES Within the past five (5) years, has the reporting entity:
6.0 Had a revocation, suspension or disbarment of any business or professional permit and/or license? Yes No
6.1 Had a denial, decertification, revocation or forfeiture of New York State certification of Minority-Owned Business Enterprise, Women-Owned Business Enterprise or federal certification of Disadvantaged Business Enterprise status for other than a change of ownership?
Yes No
For each “Yes,” explain:
VII. LEGAL PROCEEDINGS Within the past five (5) years, has the reporting entity:
7.0 Been the subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation?
Yes No
7.1 Been the subject of an indictment, grant of immunity, judgment or conviction (including entering into a plea bargain) for conduct constituting a crime?
Yes No
7.2 Received any OSHA citation and Notification of Penalty containing a violation classified as serious or willful?
Yes No
7.3 Had a government entity find a willful prevailing wage or supplemental payment violation or any other willful violation of New York State Labor Law?
Yes No
7.4 Entered into a consent order with the New York State Department of Environmental Conservation, or received an enforcement determination by any government entity involving a violation of federal, state or local environmental laws?
Yes No
7.5 Other than previously disclosed: a) Been subject to fines or penalties imposed by government entities which in the aggregate total $25,000
or more; or b) Been convicted of a criminal offense pursuant to any administrative and/or regulatory action taken by
any government entity?
Yes No
For each “Yes,” explain:
Page 6 of 10
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
VIII. FINANCIAL AND ORGANIZATIONAL CAPACITY
8.0 Within the past five (5) years, has the Reporting Entity received any formal unsatisfactory performance assessment(s) from any government entity on any contract?
Yes No
If “Yes,” provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.
8.1 Within the past five (5) years, has the Reporting Entity had any liquidated damages assessed over $25,000? Yes No
If “Yes,” provide an explanation of the issue(s), relevant dates, contracting party involved, the amount assessed and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.
8.2 Within the past five (5) years, have any liens or judgments (not including UCC filings) over $25,000 been filed against the Reporting Entity which remain undischarged?
Yes No
If “Yes,” provide an explanation of the issue(s), relevant dates, the Lien holder or Claimant’s name(s), the amount of the lien(s) and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.
8.3 In the last seven (7) years, has the Reporting Entity initiated or been the subject of any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?
Yes No
If “Yes,” provide the bankruptcy chapter number, the court name and the docket number. Indicate the current status of the proceedings as “Initiated,” “Pending” or “Closed.” Provide answer below or attach additional sheets with numbered responses.
8.4 During the past three (3) years, has the Reporting Entity failed to file or pay any tax returns required by federal, state or local tax laws?
Yes No
If “Yes,” provide the taxing jurisdiction, the type of tax, the liability year(s), the tax liability amount the Reporting Entity failed to file/pay and the current status of the tax liability. Provide answer below or attach additional sheets with numbered responses.
8.5 During the past three (3) years, has the Reporting Entity failed to file or pay any New York State unemployment insurance returns?
Yes No
If “Yes,” provide the years the Reporting Entity failed to file/pay the insurance, explain the situation and any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.
8.6 During the past three (3) years, has the Reporting Entity had any government audit(s) completed? Yes No
a) If “Yes,” did any audit of the Reporting Entity identify any reported significant deficiencies in internal control, fraud, illegal acts, significant violations of provisions of contract or grant agreements, significant abuse or any material disallowance?
Yes No
If “Yes” to 8.6 a), provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.
Page 7 of 10
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
IX. ASSOCIATED ENTITIES This section pertains to any entity(ies) that either controls or is controlled by the reporting entity. (See definition of “associated entity” for additional information to complete this section.)
9.0 Does the Reporting Entity have any Associated Entities? Note: All questions in this section must be answered if the Reporting Entity is either: − An Organizational Unit; or − The entire Legal Business Entity which controls, or is controlled by, any other entity(ies). If “No,” SKIP THE REMAINDER OF SECTION IX AND PROCEED WITH SECTION X.
Yes No
9.1 Within the past five (5) years, has any Associated Entity Official or Principal Owner been charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime or subject to a judgment for: a) Any business-related activity; or b) Any crime, whether or not business-related, the underlying conduct of which was related to
truthfulness?
Yes No
If “Yes,” provide an explanation of the issue(s), the individual involved, his/her title and role in the Associated Entity, his/her relationship to the Reporting Entity, relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s).
9.2 Does any Associated Entity have any currently undischarged federal, New York State, New York City or New York local government liens or judgments (not including UCC filings) over $50,000?
Yes No
If “Yes,” provide an explanation of the issue(s), identify the Associated Entity’s name(s), EIN(s), primary business activity, relationship to the Reporting Entity, relevant dates, the Lien holder or Claimant’s name(s), the amount of the lien(s) and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.
9.3 Within the past five (5) years, has any Associated Entity:
a) Been disqualified, suspended or debarred from any federal, New York State, New York City or other New York local government contracting process?
Yes No
b) Been denied a contract award or had a bid rejected based upon a non-responsibility finding by any federal, New York State, New York City, or New York local government entity?
Yes No
c) Been suspended, cancelled or terminated for cause (including for non-responsibility) on any federal, New York State, New York City or New York local government contract?
Yes No
d) Been the subject of an investigation, whether open or closed, by any federal, New York State, New York City, or New York local government entity for a civil or criminal violation with a penalty in excess of $500,000?
Yes No
e) Been the subject of an indictment, grant of immunity, judgment, or conviction (including entering into a plea bargain) for conduct constituting a crime?
Yes No
f) Been convicted of a criminal offense pursuant to any administrative and/or regulatory action taken by any federal, New York State, New York City, or New York local government entity?
Yes No
g) Initiated or been the subject of any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?
Yes No
For each “Yes,” provide an explanation of the issue(s), identify the Associated Entity’s name(s), EIN(s), primary business activity, relationship to the Reporting Entity, relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.
Page 8 of 10
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
X. FREEDOM OF INFORMATION LAW (FOIL)
10. Indicate whether any information supplied herein is believed to be exempt from disclosure under the Freedom of Information Law (FOIL). Note: A determination of whether such information is exempt from FOIL will be made at the time of any request for disclosure under FOIL.
Yes No
If “Yes,” indicate the question number(s) and explain the basis for the claim.
XI. AUTHORIZED CONTACT FOR THIS QUESTIONNAIRE
Name
Telephone Fax ext.
Title
Page 9 of 10
AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
Certification
The undersigned: (1) recognizes that this questionnaire is submitted for the express purpose of assisting New York State government entities (including the Office of the State Comptroller (OSC)) in making responsibility determinations regarding award or approval of a contract or subcontract and that such government entities will rely on information disclosed in the questionnaire in making responsibility determinations; (2) acknowledges that the New York State government entities and OSC may, in their discretion, by means which they may choose, verify the truth and accuracy of all statements made herein; and (3) acknowledges that intentional submission of false or misleading information may result in criminal penalties under State and/or Federal Law, as well as a finding of non-responsibility, contract suspension or contract termination.
The undersigned certifies that he/she:
• is knowledgeable about the submitting Business Entity’s business and operations; • has read and understands all of the questions contained in the questionnaire; • has not altered the content of the questionnaire in any manner; • has reviewed and/or supplied full and complete responses to each question; • to the best of his/her knowledge, information and belief, confirms that the Business Entity’s responses are true,
accurate and complete, including all attachments, if applicable; • understands that New York State government entities will rely on the information disclosed in the questionnaire
when entering into a contract with the Business Entity; and • is under an obligation to update the information provided herein to include any material changes to the Business
Entity’s responses at the time of bid/proposal submission through the contract award notification, and may be required to update the information at the request of the New York State government entities or OSC prior to the award and/or approval of a contract, or during the term of the contract.
Signature of Owner/Official
Printed Name of Signatory
Title
Name of Business
Address
City, State, Zip Sworn to before me this __________ day of _____________________________, 20___; _____________________________________________ Notary Public
Page 10 of 10
APPENDIX B
DHSES Hazard Mitigation Program Project Management Handbook
2/24/2015 Rev.
Hazard Mitigation Programs
Project Management Handbook
Prepared by:
Mitigation Section
New York State Division of Homeland Security and Emergency
Services
2
PROJECT MANAGEMENT HANDBOOK
CONTENTS
I. PROGRAM OVERVIEW………………………….….…….…3
II. PROJECT IMPLEMENTATION……………………………...4
III. TIME EXTENSION/PROJECT MODIFICATION…………...5
IV. COST OVERRUNS AND UNDERRUNS……………...…..…5
V. PROJECT ADMINISTRATION……………..……..…...….…6
VI. AUDIT REQUIREMENTS…………………............................7
VII. ATTACHMENTS
Attachment 1 – Quarterly Report Form
Attachment 2 – Payment Certification Form
Summary of Reimbursement Form
Expenditure Forms
Attachment 3 - Expenditure Forms with Completed Examples
3
I
PROGRAM OVERVIEW
The purpose of this handbook is to serve as a guide for the administration of grants awarded
pursuant to Section 404 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act
(The Stafford Act). The intent of the program is to reduce future disaster damages by providing
financial support to implement cost-effective mitigation measures.
Measures consistent with the State Hazard Mitigation Plan are identified and applied for by
eligible applicants who include: state and local agencies, not-for-profit organizations, and Indian
Tribes or tribal organizations.
Under Hazard Mitigation Programs, the State is designated the “Grantee” and the eligible project
applicants identified above are referred to as the “Subgrantees”. The NYS Division of
Homeland Security and Emergency Services (NYSDHSES) administer Mitigation Programs on
behalf of the State of New York and are answerable to the Federal Emergency Management
Agency (FEMA). This Handbook describes the role of the grantee and subgrantee, and as
appropriate references are made to the role of FEMA as the federal agency that disburses the
funds and has overall oversight on its use.
The State, serving as grantee, has primary responsibility for project management and
accountability of funds as indicated in 44CFR Part 13. The State should implement a record-
keeping and financial management system to meet FEMA’s financial reporting requirements
and to document that program funds have not been used in violation of existing regulations.
The State should maintain files for each project application, correspondence, vouchers,
reports, receipts, and other appropriate documentation. Once project close-out has occurred,
these records should be kept for a minimum of three years for audit purposes.
Subgrantees, in turn, are responsible to the State for funds they receive under the Hazard
Mitigation Programs. Similar, and in some cases more detailed, financial records
documenting all expenditures, should be maintained by subgrantees.
The State and Local Agreement signed by each subgrantee, among other things, includes the
general program and financial requirements to which each subgrantee must adhere.
Additionally, there will be a project implementation agreement between the grantee and the
subgrantee. This agreement is specific to the approved project and outlines the scope of work,
financial management requirements and deadlines. For projects costing $50,000 or more (federal
funding), this agreement must be approved by the Office of the State Comptroller and the State
Attorney General’s office before reimbursement of funds can commence. The following
paragraphs and attachments provide in greater detail specific guidance for implementing
approved hazard mitigation projects and managing the associated grant.
4
II
PROJECT IMPLEMENTATION
Upon receipt of the project approval from the Regional Director of the FEMA Region II,
NYSDHSES Mitigation staff will notify the subgrantee of this decision and schedule a Project
Management Briefing, to explain the administration of the grant. After the briefing, the
subgrantee should commence project implementation as soon as practicable, based on the work
schedule outlined in the project application and all the provisions in the FEMA approval letter.
A copy of the FEMA approval letter will be provided to the subgrantee, informally or formally
as soon as it is received by NYSDHSES. The subgrantee is specifically advised to commence
project implementation rather than waiting for the execution of the project implementation
agreement, as this process could be lengthy. Also, as a reimbursement program, the
understanding is that the subgrantee must expend funds before payments can be made. In an
effort to assist the subgrantee throughout the project, NYSDHSES Mitigation staff will conduct
site visits at the project’s inception, construction and completion in conjunction with monthly
telephone contacts.
While the subgrantee must move diligently to implement the project within the work schedule
specified in the approved application, no work shall be done until all required permits are
obtained, as specified in the applicant’s approval letters. Reimbursement may be denied
for work completed without receipt of required permits. If problems arise that will impede
the progress towards completion of the project within the proposed work schedule,
NYSDHSES’s Hazard Mitigation Branch must be notified immediately. Request for extension
must be made no later then 60 days prior to the approved project completion date. Send
notification and all correspondences to the following address:
Richard M. Lord
Chief of Mitigation Programs
and Agency Preservation Officer
Mitigation Programs
NYS Division of Homeland Security and Security Services
State Office Campus
Building #22, Suite 101
1220 Washington Ave.
Albany, New York 12226-2251
518-292-2304
518-322-4983 (Fax)
5
III
TIME EXTENSION/PROJECT MODIFICATION
If circumstances arise which will result in the project not being completed within the time frame
specified in the approved project application, the subgrantee should notify NYSDHSES in
writing as soon as possible. Request for extension must be made no later then 60 days prior
to the approved project completion date. At a minimum, a request and justification for time
extension must include the following: information on the percentage and description of work
completed to date, copies of any relevant contracts between the subgrantee and a vendor; copies
of relevant permits; expenditures to date; updated budget; an updated project completion
schedule; etc. NYSDHSES will review the request and make a decision if it is authorized to do
so. If NYSDHSES is not authorized to grant a time extension to complete a project,
NYSDHSES will request such extension from FEMA.
The subgrantee is not permitted to modify the scope of the project without first obtaining
written approval from NYSDHSES and FEMA. If a subgrantee determines that a change
in project scope might be preferred to the approved project, the subgrantee must formally
request a change in scope through NYSDHSES.
IV
COST OVERRUNS AND UNDERRUNS
If, during project implementation, it is determined that project costs are exceeding the approved
cost estimates, the subgrantee should notify the State, either by letter or in the quarterly report
which is due immediately following the detection of the overrun. On receipt of such notice, the
State will determine if sufficient funds exist in the grant program to offset the increased project
cost. If such funds exist, the subgrantee will be so advised.
It should be noted that the State, or FEMA, might not be able to provide the federal share of the
funds required to support cost overruns, even if notified in a timely manner. This situation will
likely occur when there are no funds available to offset the cost overruns. The funding in the
Hazard Mitigation Grant Program is finite and is usually completely allocated to eligible
projects. Accordingly, funding to support cost overruns is available only if there are
underruns in other projects.
As with cost overruns, subgrantees are advised to notify NYSDHSES, by letter or in their
quarterly reports, when they anticipate cost underruns. This notification is important as it tells us
whether funds might be available to allocate to other subgrantees that might have experienced
cost overruns.
Subgrantees are not allowed to modify the scope of their projects because of cost overruns
that the State or FEMA is unable to support. The subgrantee is reminded that the Hazard
Mitigation Grant Program allows for the matching of project costs “up to 75%”.
6
Therefore, neither the State nor FEMA accepts the responsibility of providing 75% of project
cost irrespective of the situation. It is understood that the subgrantee will implement the project
as described in the approved application unless permission is sought from and granted by the
State and FEMA to change the project’s scope.
V
PROJECT ADMINISTRATION
Quarterly Reports: During the project implementation process subgrantees are required to
submit quarterly progress reports to the State. These reports are reviewed and approved by the
State before being transmitted to FEMA. Quarterly reports must include project status, relevant
non-construction and construction activities, anticipated completion date, financial information
such as expenditure to date, problems encountered, assistance required, etc... Any problem
affecting completion dates, scope of work or project costs should be described.
The first quarterly report is due to NYSDHSES within fifteen days after the end of the first
full quarter following the notification of project approval. Therefore, the first quarterly
report might include activities extending longer than three months. Whether or not construction
has begun, this first report is still due within the required timeframe. Attachment 1 is a Quarterly
Progress Report Form; it should be completed and submitted to NYSDHSES when the first
quarterly report is due, and for subsequent quarterly reports. Quarterly reports are due by the
15th of the month following the end of every quarter, until the project is completed. Reports are
therefore due by January 15, April 15, July 15 and October 15.
Payments/Reimbursement Requests: Hazard Mitigation Programs are reimbursement
programs. This means, subgrantees are reimbursed for work completed and funds expended.
Reimbursement does not have to await the full completion of approved projects; instead, periodic
reimbursements can be made as the project is being implemented. In instances where the
periodic reimbursement approach is desired, such requests should not be made more
frequently than once every three months. Although the preference is for quarterly submission
of payment requests, exceptions may be made on a case-by-case basis.
Following submission of a payment request, the applicant will be reimbursed up to 75% of
eligible costs incurred on the approved project. On small projects (amounts of $25,000 or less),
applicants may choose to submit one, or at most two reimbursement requests.
7
Payment or reimbursement requests must include the following:
1. A Summary Sheet, detailing expenditure items; e.g. labor, material, equipment,
contractual, etc.,--total costs incurred--and total payment being requested (75% of incurred
expenses). Use the form provided in Attachment 2.
2. Detailed documentation of expenditure items, such as those noted as examples in item 1
above. Use the forms provided in Attachment 3, as appropriate to your project. If necessary, the
subgrantee may add forms and items that support their claims and document their expenditures to
the fullest extent practicable. Subgrantees may also use their own pre-existing forms if they
provide the same information that is included on the sample forms included herein.
3. Certification by the Chief Elected Official, Chief Executive Officer or their designee. This certification (use the form provided in Attachment 4) will attest to the completion of the
work for which payment is being requested. Furthermore, the official signing the Certification,
in doing so, acknowledges that the project must be completed as specified in the application and
FEMA’s approval letter and that failure to do so could result in NYSDHSES and FEMA
requesting that funds previously reimbursed be returned by the subgrantee.
Project Close-out: Final Claim Letter/Final payment: Upon completion of a project, the
subgrantee must submit a letter to the grantee indicating that the project has been completed.
The subgrantee has 90 days from the project completion date to submit documentation of all
eligible expenditures. The State will review the documentation to ensure that all claims and
costs are eligible and that the work performed is in compliance with the approved project
application. Upon approval of the final reimbursement documentation, FEMA will authorize the
State to make final payment. After the final payment has been made and the subgrantee verifies
receipt of this payment, the grantee will transmit a Closeout Form to the subgrantee for
signature. The grantee will then transmit this form to FEMA as verification that the project was
implemented and all payments were made in accordance with the FEMA approval letter and
associated grantee/subgrantee agreements.
VI
AUDIT REQUIREMENTS
The Single Audit Act of 1984 (P.L. 98-502, as amended) requires any subreceipient that expends a total
of $750,000 or more in Federal awards from all sources during it’s fiscal year obtain either a single audit
or a program specific audit for that fiscal year.
A single audit must be conducted if a subreceipent has expended funds of $750,000 or more in a fiscal
year. A program-specific audit may be conducted if a subreceipent has expended funds from only one
Federal program. If a subrecipient has expended less than $750,000 in Federal funds in any fiscal year,
it is exempt for such fiscal year from compliance with Federal audit requirements. However, records,
contracts, etc. must still be kept and be available for audit or review purposes.
Standards for obtaining consistency and uniformity among federal agencies for the audits of non-federal
entities that expend federal funds are found in the U.S. Office of Management and Budget (OMB)
8
circular A-133 and the Government Auditing Standards manual issued by the Comptroller General of the
United States.
An audit performed under the Single Audit Act shall be conducted by a Certified Public Accountant
(CPA) who is licensed by the State of New York. The CPA shall meet all of the general standards
concerning qualifications, independence, due professional care and quality control as required by
Government Auditing Standards (1999 Revision) and any subsequent amendments. When selecting an
independent auditor, the subrecipient should adhere to Federal and State procurement requirements.
The audit report of the independent auditor should be prepared in accordance with generally accepted
government auditing standards. These standards and other guidelines are contained in the latest version
of the following publications:
Government Auditing Standards, Comptroller General of the United States, 1999
OMB Circular A-133, revised June 24, 1997
OMB Circular A-133 Compliance Supplement, March 2003, or subsequent revisions
AICPA’s audit guides for State and Local Governmental Units of Not-for-Profit Organizations
AICPA’s Audit Risk Alerts “State and Local Governmental Development”
AICPA’s Audit Risk Alerts “Not-for Profit Organizations Industry Developments”
Any subrecipient of Federal pass-through funds awarded by NYSDHSES will receive a Single
Audit Certification letter following the close of that subrecipient’s fiscal year. The Single Audit
Certification must be completed by the subrecipient and returned.
If a subrecipient audit contains findings on program(s) awarded through NYSDHSES in the Schedule of
Findings and Questioned Costs, or contains findings on program(s) awarded through NYSDHSES that
are addressed by the auditee in their Summary Schedule of Prior Audit Findings, a copy of the single
audit reporting package must be submitted to NYSDHSES.
If no current or prior findings were noted in the audit for programs awarded through NYSDHSES, the
subrecipient need only to submit a notification of audit in lieu of the single audit reporting package.
Such notification would include the following:
Notice that a single audit was conducted for the fiscal year.
The name, amount, and CFDA number of the Federal awards provided by NYSDHSES.
The Schedule of Findings and Questioned Costs disclosing no audit findings relative to the
Federal awards provided NYSDHSES.
Notice that the Summary Schedule of Prior Audit Findings did not contain any reference to the
Federal awards provided by NYSDHSES.
If required, either a single audit reporting package or a notification of audit must be submitted by
the subrecipient within nine (9) months after the end of the subrecipient’s audited fiscal year.
9
ATTACHMENT 1
QUARTERLY REPORT FORM
12
ATTACHMENT 2
REIMBURSEMENT FORMS
Payment Certification Form
Summary of Reimbursement Form
Force Account Labor Record
Force Account Equipment Record
Rented Equipment Record
Materials Record
Contract Cost Record
13
NYS DIVISION OF HOMELAND SECURITY & EMERGENCY SERVICES
HAZARD MITIGAITON PROGRAMS
PAYMENT CERTIFICATION NUMBER_______
Partial Payment ______ Final Payment______
Date:______________ Applicant:__________________________
FIPS #_____________ County:___________________________
Total Expenses Billed: $_________________
75% of Eligible Expenses = Federal Share: $______________
This is to certify that the Hazard Mitigation Program funding I have requested is for the
reimbursement of funds expended for eligible work completed for approved Project Number
___________.
I understand that all work must be completed as the approved application requires, and that all
documentation to justify this and all remaining work will be maintained and be made available for
review or audit as required. All records will be maintained in accordance with the Hazard
Mitigation Program, Project Management Handbook which was provided with the approved
application notification. (Summary sheets for Force Account Labor, Force Account Equipment,
Rental Equipment, Materials, Contractual and other eligible costs must be certified by the Chief
Executive or his/her agent).
In the event that all work is not completed as specified in the approved application, I acknowledge
that the eligible reimbursement payments may not be made or may be reduced and a request may
be made for the return of payments already received.
By signing this report, I certify to the best of my knowledge and belief that the report is true,
complete, and accurate, and the expenditures, disbursements and cash receipts are for the
purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that
any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me
to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise.
(U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812).
SIGNATURE:__________________________
(Subgrantee’s Chief Executive or Agent)
14
NYS DIVISION OF HOMELAND SECURITY & EMERGENCY SERVICES
HAZARD MITIGATION PROGRAMS
SUMMARY OF REIMBURSEMENT NUMBER ______
Project Number: _________________ Applicant________________________
FIPS # _________________________ County:__________________________
Force Account Labor: $__________________________
Force Account Equipment: $__________________________
Rented Equipment: $__________________________
Materials: $__________________________
Contract Costs: $__________________________
TOTAL Eligible Costs: $__________________________
Partial or Final Payment : $__________________________
(75% of Total Eligible Costs = Federal Share)
15
FORCE ACCOUNT LABOR RECORD for______________________________ (applicant)
Location of Work: _____________________________________________________ Page______of______
Description of Work: _____________________________________________________ Period: ___________to___________20____
PROJECT NUMBER: ________________ DISASTER NUMBER: FEMA ___________
[a] Employee
Name and Title
[b] date/hours worked each day [c]
Total
Hours
[d]
Rate
per hour
[e]
Total
Pay
[f]
Paycheck
Number Date
Reg O/T
Reg
O/T
Reg
O/T
Reg
O/T
Reg
O/T
Reg
O/T
Reg
O/T
Reg
O/T
[g]
Reg Pay _______ x Fringe Benefit Rate _______ = _________(1) Total Hours
Total RP $
(2)
OT Pay _______ x Fringe Benefit Rate _______ = _________(3) Total OT $
(4)
(1) ___________ + (2) ____________ +(3) ____________+ (4) __________ = $___________ Grand Total (this page) I certify that the above information was transcribed from timesheets, payroll records, or other documents which are available for audit.
Certified By:____________________________________Title:______________________________________ Date:_______________________
16
FORCE ACCOUNT EQUIPMENT RECORD for_______________________________ (applicant)
Location of Work: _____________________________________________________ Page______of______
Description of Work: _____________________________________________________ Period: ___________to___________20____
PROJECT NUMBER ________________________ DISASTER NUMBER: FEMA ___________
[A] Type of Equipment Indicate make, model, size,
capacity, and horsepower as
appropriate.
[b] Equipment
Number
Reference
[c] Enter Date and Hours Used [d]
Total
Hours
[e]
Rate
[f]
Cost
Total Hours
(this Page)
Total Cost
(this page)
I certify that the above information was transcribed from daily logs or other documents which are available for audit.
Certified By: ____________________________________________ Title: _________________________________ Date: ___________________
17
RENTED EQUIPMENT RECORD for_______________________________ (applicant)
Location of Work: _____________________________________________________ Page______of______
Description of Work: _____________________________________________________ Period: __________to_________________
PROJECT NUMBER ____________ DISATER NUMBER: FEMA ____________
[a] Type of Equipment Indicate make, model, size,
capacity and horsepower as appropriate
[b] Date &
Hours Used
[c]
Rate per Hour
[d] Total
Cost
[e] Vendor
[f] Invoice
Number
[g] Date
Paid
[h] Check
Number
Total Cost (this page)
I certify that the above information was transcribed from daily logs, vendor invoices, or other documents which are available for audit.
Certified By:____________________________________Title:______________________________________ Date:_______________________
18
MATERIALS RECORD for____________________________ (applicant)
Location of Work: _____________________________________________________ Page______of______
Description of Work: _____________________________________________________ Period: __________to____________20____
PROJECT NUMBER: FEMA ___________ DISASTER NUMBER: FEMA __________
[a]
Vendor
[b]
Description
[c]
Quantity
[d]
Unit
Price
[e]
Total
Cost
[f]
Date
Bought
[g]
Check
Number
[h]
Date
Used
[I]
Source of Information
Invoice Stock
Total Cost (this page)
I certify that the above information was transcribed from daily logs, vendor invoices, stock cards, or other documents which are available for audit.
Certified By:____________________________________Title:______________________________________ Date:_______________________
19
CONTRACT COSTS RECORD for_______________________________ (applicant)
Location of Work: _____________________________________________________ Page______of______
Description of Work: _____________________________________________________ Period: ___________to___________20____
PROJECT NUMBER: ___________ DISASTER NUMBER: FEMA ______________
[a]
Vendor
[b]
Description
[c]
Contract
Number
[d]
Period of
Contract
[e]
Contract
Cost
[f]
Check
Number
Total Cost
(this page)
I certify that the above information was transcribed from daily logs, vendor invoices, stock cards, or other documents which are available for audit.
Certified By:____________________________________Title:____________________________________ Date:_______________________
20
ATTACHMENT 3
COMPLETED SAMPLES OF REIMBURSEMENT FORMS
Force Account Labor Record
Force Account Equipment Record
Rented Equipment Record
Materials Record
Contract Cost Record
21
FORCE ACCOUNT LABOR RECORD for____Village of Plank ________(applicant)
Location of Work: Locket Street__________________________________________ Page__1___of__1___
Description of Work: Drainage Improvement Project___________________________ Period:___8/23____to____8/25___2014__
PROJECT NUMBER: ____2001_____ DISASTER NUMBER: FEMA ___555_____
[a] Employee
Name and Title
[b] date/hours worked each day [c]
Total
Hours
[d]
Rate
per hour
[e]
Total
Pay
[f]
Paycheck
Number Date 8/23 8/24 8/25
Abluc, Allen
Working Supervisor
Reg O/T
8.0
8.0
8.0
4.0
8.0
4.0
24.0
16.0
$30.00
$45.00
$720.00
$720.00
031486
Camp, Bill
Laborer
Reg
O/T
8.0
4.5
8.0
8.0
4.0
--
20.0
12.5
$20.00
$30.00
$400.00
$375.00
031487
Head, Brian
Equipment Operator
Reg
O/T
8.0
0.75
8.0
--
8.0
--
24.0
0.75
$25.00
$37.50
$600.00
$28.13
031488
Reg
O/T
Reg
O/T
Reg
O/T
Reg
O/T
Reg
O/T
[g]
Reg Pay _$1,720.00 x Fringe Benefit Rate _35% = _$602.00__(1) Total Hours
97.25 Total RP $
$1,720.00 (2)
OT Pay _$1,123.13 x Fringe Benefit Rate _15% = _$168.47__(3) Total OT $
$1,123.13 (4)
(1) __$602.00___ + (2) __$1,720.00___ + (3)___$168.47____+(4) __$1,123.13__ = $3,613.60____ Grand Total (this page) I certify that the above information was transcribed from timesheets, payroll records, or other documents which are available for audit.
Certified By:___Signature_________________________Title:__Title of Signature_________________Date:___Date Signed_________________
22
FORCE ACCOUNT EQUIPMENT RECORD for____Village of Plank___________ (applicant)
Location of Work: Locket Street_________________________________________ Page__1___of__1___
Description of Work: Drainage Improvement Project____________________________ Period:___8/23___to___8/25____2014___
PROJECT NUMBER ____2001________________ DISASTER NUMBER: FEMA __555______
[A] Type of Equipment Indicate make, model, size,
capacity, and horsepower as
appropriate.
[b] Equipment
Number
Reference
[c] Enter Date and Hours Used [d]
Total
Hours
[e]
Rate
[f]
Cost
8/23 8/24 8/25
Mack tandem dump truck 610
8
8 8 24 $52.44 $1,258.56
Mack tandem dump truck 612
8 8 8 24 $52.44 $1,258.56
Total Hours
(this Page)
48 Total
Cost
(this
page)
$2,517.12
I certify that the above information was transcribed from daily logs or other documents which are available for audit.
Certified By: _____Signature______________________________ Title: _______Title of Signature________ Date: _____Date Signed_____
23
RENTED EQUIPMENT RECORD for__Village of Plank_____________ (applicant)
Location of Work: Locket Street__________________________________________ Page__1___of__1___
Description of Work: Drainage Improvement Project_____________________________ Period:__8/23_____to___8/25_____2014__
PROJECT NUMBER __2001_____ DISATER NUMBER: FEMA ___555_____
[a] Type of Equipment Indicate make, model, size,
capacity and horsepower as
appropriate
[b] Date &
Hours Used
[c]
Rate per Hour
[d] Total
Cost
[e] Vendor
[f] Invoice
Number
[g] Date
Paid
[h] Check
Number
Bulldozer, D8 325hp
8/23 – 5 hours $75 $375.00 Jerry’s Rental
Construction
2193 8/24 20125
Total Cost (this page)
$375.00
I certify that the above information was transcribed from daily logs, vendor invoices, or other documents which are available for audit.
Certified By:___Signature________________________Title:_____Title of Signature_______________ Date:____Date Signed________
24
MATERIALS RECORD for__Village of Plank________________(applicant)
Location of Work: Locket Street_______________________________ Page__1___of__1___
Description of Work: Drainage Improvement Project_____________________________ Period: ___8/23____to___8/25_____2014__
PROJECT NUMBER: FEMA ___2001____ DISASTER NUMBER: FEMA __555_____
[a]
Vendor
[b]
Description
[c]
Quantity
[d]
Unit Price
[e]
Total
Cost
[f]
Date
Bought
[g]
Check
Number
[h]
Date
Used
[I]
Source of Information
Invoice Stock
Phoenix
Excavators
Concrete box
culvert
1 $30,815.00 $30,815.00 8/23 20123 8/23 X
Chemung Supply
Drainage pipe 240 ft. $17.85 $4,284.00 8/23 20127 8/23 X
Thompson
Materials
Rebar 21,254 lbs. $25.00/
100 lbs.
$5,313.50 8/23 20201 8/23 X
Tilcon
1 ½” stone
Item 4
182.16 ton
51.06 ton
$13.50/ton
$11.85/ton
$2,459.16
$605.06
8/24 20258 8/24 X
Tilcon
1 ½” stone
299.01 ton $13.50/ton
$4,036.64 8/25 20,260 8/25 X
Eastern Concrete
Concrete 104.5 c.y. $99.35/c.y. $10,382.08 8/25 20,275 8/25 X
Total Cost (this page)
$57,895.43
I certify that the above information was transcribed from daily logs, vendor invoices, stock cards, or other documents which are available for audit.
Certified By:__Signature_________________________Title:___Title of Signature_________________ Date:___Date Signed_________
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CONTRACT COSTS RECORD for__Village of Plank___________(applicant)
Location of Work: Locket Street_________________________________________ Page__1___of__1___
Description of Work: Drainage Improvement Project_____________________________ Period: ___8/23____to____8/25____2014__
PROJECT NUMBER: __2001_____ DISASTER NUMBER: FEMA ___555________
[a]
Vendor
[b]
Description
[c]
Contract
Number
[d]
Period of
Contract
[e]
Contract
Cost
[f]
Check
Number
Brooks Engineering
Project Design 1604 8/23 to 8/25 $9,500.00 20104
Fairway Testing
Stone compaction testing 203057 8/23 to 8/24 $1,450.00 20291
Fairway Testing
Concrete testing 203058 8/24 to 8/25 $2,500.00 20292
Total Cost
(this page)
$13,450.00
I certify that the above information was transcribed from daily logs, vendor invoices, stock cards, or other documents which are available for audit.
Certified By:___Signature________________________Title:_____Title of Signature_______________ Date:_____Date Signed_______
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