incorporated village of island park 127 long ... for hmgp...127 long beach road, island park, new...

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: [email protected]

http://www.kpsearch.com/DF/Villageofislandpark-n/bid_documents.htm


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

1

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.


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.


http://www.fema.gov/hazard-mitigation-grant-program

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).

http://www.osc.state.ny.us/vendrep/

3

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



4

Contractor’s Qualification Statement) within the time frame stated, the Bidder shall be deemed to

have abandoned the Contract.

IV. Scope of Work


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.

5

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

[email protected]

http://www.fema.gov/benefit-cost-analysis

mailto:[email protected]

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


7

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.

9

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.

10

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.

13

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


III. Automobile Insurance

Limit $1,000,000. Combined Single Limit


appointed officials, employees and volunteers.

IV. Umbrella Liability

Coverage Umbrella Form, or Excess Follow Form

Minimum Limit $5,000,000.


appointed officials, employees and volunteers.

16

SCHEDULE B


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:

_____________________________________________________________________________


SECRETARY:

_____________________________________________________________________________


TREASURER:

_____________________________________________________________________________


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


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


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


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


Page 5 of 6

7. Bank References

A.___________________________________________________________________________

B.___________________________________________________________________________

8. Trade Association Membership

A.___________________________________________________________________________

B.___________________________________________________________________________

C.___________________________________________________________________________

25

SCHEDULE D


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 [email protected] 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.


mailto:[email protected]

http://www.osc.state.ny.us/vendrep/documents/questionnaire/definitions.pdf

AC 3290-S (Rev. 9/13) NYS Vendor ID: ____________ NEW YORK STATE


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

Email

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

http://www.osc.state.ny.us/vendrep/documents/questionnaire/definitions.pdf



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



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



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



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


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


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


Page 6 of 10



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



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



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

Email

Page 9 of 10



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)



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)


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.


18

MATERIALS RECORD for____________________________ (applicant)


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


I certify that the above information was transcribed from daily logs, vendor invoices, stock cards, or other documents which are available for audit.


19

CONTRACT COSTS RECORD for_______________________________ (applicant)



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)


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


$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


$57,895.43


Certified By:__Signature_________________________Title:___Title of Signature_________________ Date:___Date Signed_________

25

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


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incorporated village of island park 127 long ... for hmgp...127 long beach road, island park, new...

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