view, to me known, who, being by me duly sworn, did depose and say that he/she/they reside(s) in _________________________; that he/she/they is (are) _________________________________

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<p>Group 79008 Bank Card Services</p> <p>Electronic Value Transfer</p> <p>Request for Proposal # 22325</p> <p>BID PROPOSAL COVER SHEET</p> <p>PART I - TECHNICAL QUALIFICATIONS </p> <p>AND </p> <p>SERVICE REQUIREMENTS</p> <p>*** Important - Failure to Furnish All Required Information may render the Bid Non-Responsive ***</p> <p>Bidders Legal Name: ________________________________________________</p> <p>Bidders Federal Identification No.: _____________________________________</p> <p>Name of Preparer: __________________________________________________</p> <p>Telephone Number of Preparer: _______________________________________</p> <p>Signature:____________________________________ </p> <p>Name:_______________________________________ </p> <p>Title:_________________________________________</p> <p>CORPORATE ACKNOWLEDGMENT</p> <p>STATE OF </p> <p> :ss.:</p> <p>COUNTY OF </p> <p> On the _____________ day of ______________________in the year _____ , before me personally came: _______________________________________________________________, to me known, who, being by me duly sworn, did depose and say that he/she/they reside(s) in _________________________; that he/she/they is (are) _____________________________________________ (the President or other officer or director or attorney in fact duly appointed) of ___________________________________________, the corporation described in and which executed the above instrument; and that he/she/they signed his/her/their name(s) thereto by authority of the board of directors of said corporation.</p> <p>________________________________________________</p> <p>Notary Public</p> <p> Bid Submittal Checklist</p> <p>The following checklist must be completed and submitted with each bid. Unless otherwise noted, all submissions are mandatory. Failure to respond or submit required information may render the bid non-responsive.</p> <p>Format of Bid Proposal</p> <p>Check to indicate compliance with each requirement.</p> <p>|_|Proposal is bound.</p> <p>|_|Proposal is submitted in two (2) separately sealed parts: </p> <p>Part I, Technical Qualifications &amp; Service Requirements (i.e., response to Section VI)</p> <p>Part II, Financial Requirements (i.e., response to Section VII)</p> <p>|_|Proposal has a Table of Contents and indexed tabs for Part I, following the order set forth in the RFP.</p> <p>|_|Proposal pages are numbered consecutively from beginning to end.</p> <p>|_|Bidder has enclosed:</p> <p>1. Three written and signed originals of Part I, Technical Qualifications &amp; Service Requirements</p> <p>2. Three written and signed originals of Part II, Financial Requirements</p> <p>3. Five electronic diskette containing Part I, Technical Requirements, labeled with Bidder name, RFP # and Part I</p> <p>4. Five electronic diskette containing Part II, Financial Requirements, labeled with Bidder name, RFP # and Part II</p> <p>|_|Bidder has completed all information and provided original signatures as appropriate on the:</p> <p>1. Request for Proposal Form (page 2)</p> <p>2. Mandatory Contractor Questionnaire (Appendix E)</p> <p> MacBride Certification</p> <p> Non-Collusive Bidding Certification</p> <p> Submitted Documentation Establishing Legal Status</p> <p> Submitted List of Directors, Officers, etc.</p> <p>|_|Bidder has completed and submitted Affirmations for Qualifying Technical Requirements (Appendix E)</p> <p>|_|Bidder has completed and submitted Responses for Technical Requirements (Appendix E)</p> <p>|_| Extraneous Terms are fully detailed in a separate section of the Bid Proposal (Tab #3).</p> <p>Table of Conflicting Association Rules completed</p> <p>Affirmation that all known conflicts between Association Rules &amp; RFP have been included.</p> <p>|_|Bidder agrees to extend use of contract in accordance with RFP, Appendix B, Clause 39 (c )</p> <p>ST-220 - NY State Taxation and Finance Forms</p> <p>|_|ST-220-CA is enclosed</p> <p>|_|ST-220-TD sent to NY State Taxation and Finance Department</p> <p>|_|Bidder will provide within 5 business days of written request by OGS</p> <p>Vendor Responsibility Questionnaire for-profit businesses.</p> <p>|_| Bidder has filed the Vendor Responsibility Questionnaire on-line</p> <p>|_| If Bidder submitted on-line, certification (or recertification) is less than six months old.</p> <p>|_| Bidder has submitted a hard copy of the Vendor Responsibility Questionnaire</p> <p>Workers Compensation Requirements</p> <p>|_| Bidder has submitted current NY State Workers Compensation Insurance and Disability certificates.</p> <p>|_| Bidder has submitted a NY State exemption certificate.</p> <p>|_| Bidder will provide within 10 business days of written request by OGS</p> <p>MANDATORY CONTRACTOR QUESTIONNAIRE</p> <p>[BIDDER MUST ANSWER ALL QUESTIONS]</p> <p>Page 1 of 4</p> <p>1.Are you a New York State resident business?</p> <p>Yes_____ </p> <p>No_____</p> <p>2. Total number of people employed by your firm:</p> <p>3. Total number of people employed by your firm in New York State:</p> <p>4.Is your company independently owned and operated?</p> <p>Yes_____</p> <p>No______</p> <p>5. Place of manufacture or development of Product(s) offered</p> <p>(Please indicate Yes or No for A, B or C):</p> <p>A.All NYS manufacture/development?</p> <p> OR</p> <p>B.All manufactured/developed outside NYS? </p> <p> OR</p> <p>C.Manufactured/developed in NYS and outside NYS?</p> <p>Yes_____</p> <p>Yes _____</p> <p>Yes_____</p> <p>No______</p> <p>No______</p> <p>No______</p> <p>6. Is your firm at least 51% owned and controlled by women, or 51% owned and controlled by minority group members, i.e., Black Hispanic, Asian, Pacific Islander, American Indian, Alaskan Native?</p> <p>If yes, _____Minority Owned ______Women Owned</p> <p>If yes, have you been certified or registered? ____Yes _____No</p> <p>If yes, List certification or registration authority:</p> <p>__________________________________________________</p> <p>Yes_____</p> <p>No______</p> <p>7.Do any of the Products offered herein incorporate recycled materials?</p> <p>Yes_____</p> <p>No____ </p> <p>N/A___</p> <p>8.Do any of the Products offered herein contain remanufactured components?</p> <p>Yes_____</p> <p>No____ </p> <p>N/A ___</p> <p>9.Are any of the Products offered herein Energy Star Compliant?</p> <p>If yes, which Products?__________________________________________</p> <p>Yes_____</p> <p>No____ </p> <p>N/A ___</p> <p>10. BIDDER/OFFERER DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS</p> <p>Pursuant to Procurement Lobbying Law (SFL 139-j)</p> <p>A.Has any Governmental Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into the Procurement Contract in the previous four years?</p> <p>Yes_____</p> <p>No____ </p> <p>N/A ___</p> <p> If yes, please answer the following:question:</p> <p>B.Was the basis for the finding of non-responsibility due to a violation of State Finance Law 139-j?</p> <p>Yes_____</p> <p>No____ </p> <p>N/A ___</p> <p>C.If yes, was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a governmental entity?</p> <p>Yes_____</p> <p>No____ </p> <p>N/A ___</p> <p> If yes, please provide details regarding the finding of non-responsibility:</p> <p>Governmental Entity:</p> <p>________________________</p> <p>Date of Finding of Non-responsibility:</p> <p>________________________</p> <p> Basis of Finding of Non-Responsibility:</p> <p>(add additional pages if necessary)</p> <p>D.Has any governmental agency terminated or withheld a procurement contract with the above-named individual or entity due to the intentional provision of false or incomplete information?</p> <p>Yes_____</p> <p>No______</p> <p>If yes, please provide details:</p> <p>Governmental Entity:</p> <p>_________________________</p> <p>Date of Termination or Withholding of Contract:</p> <p>_________________________</p> <p>Basis of Termination or Withholding:</p> <p>(add additional pages if necessary)</p> <p>_________________________</p> <p>Signature:</p> <p>_________________________</p> <p>Printed Name:</p> <p>_________________________</p> <p>Date:</p> <p>_________________________</p> <p>11.Are prices quoted the same as or lower than those quoted other corporations, institutions and government agencies (including GSA/VA contracts) on similar products, quantities, terms and conditions? </p> <p>See "Best Pricing Offer" in Appendix B, OGS General Specifications.</p> <p>If "NO", please explain on a separate sheet.</p> <p>Yes_____</p> <p>No______</p> <p>A.Do you have a contract with the General Services Administration (GSA) or Veterans Affairs (VA) for products offered? (Check all that apply.)</p> <p> GSA</p> <p>Yes_____</p> <p>No______</p> <p> VA</p> <p>Yes_____</p> <p>No______</p> <p>B.If yes, will you offer New York State your GSA or VA pricing or better?</p> <p> GSA</p> <p>Yes_____</p> <p>No______</p> <p> VA</p> <p>Yes_____</p> <p>No______</p> <p>C.If yes, a copy of the GSA or VA schedule is required. </p> <p>Have you included a copy?</p> <p> GSA</p> <p>Yes_____</p> <p>No______</p> <p> VA</p> <p>Yes_____</p> <p>No______</p> <p>12.Will you offer a Cash Discount for payment within 15 days of delivery and/or receipt of voucher?</p> <p>Yes_____</p> <p>_____ %</p> <p>No______</p> <p>13.Will you offer a Cash Discount for payment within 30 days of delivery and/or receipt of voucher?</p> <p>Yes_____</p> <p>_____ %</p> <p>No______</p> <p>BIDDER IS REQUIRED TO SIGN BOTH SECTIONS BELOW</p> <p>MacBride Certification</p> <p>NON-DISCRIMINATION IN EMPLOYMENT IN NORTHERN IRELAND:</p> <p>MACBRIDE FAIR EMPLOYMENT PRINCIPLES</p> <p>In accordance with Chapter 807 of the Laws of 1992 the bidder, by submission of this bid, certifies that it or any individual or legal entity in which the bidder holds a 10% or greater ownership interest, or any individual or legal entity that holds a 10% or greater ownership interest in the bidder, either: (answer yes or no to one or both of the following, as applicable),</p> <p>(1) have business operations in Northern Ireland,</p> <p>Yes___ or No ___</p> <p>if yes:</p> <p>(2) shall take lawful steps in good faith to conduct any business operations they have in Northern Ireland in accordance with the MacBride Fair Employment Principles relating to nondiscrimination in employment and freedom of workplace opportunity regarding such operations in Northern Ireland, and shall permit independent monitoring of their compliance with such Principles.</p> <p>Yes ___ or No ___</p> <p>____________________________________________________________</p> <p> (Bidders Signature)(Name of Business)</p> <p>Non-Collusive Bidding Certification</p> <p>NON-COLLUSIVE BIDDING CERTIFICATION</p> <p>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 his knowledge and belief:</p> <p>(1) The prices in this bid have been arrived at independently without collusion, consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor;</p> <p>(2) Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to opening, directly or indirectly, to any other bidder or to any competitor; and</p> <p>(3) No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit or not to submit a bid for the purpose of restricting competition.</p> <p>____________________________________________________________</p> <p> (Bidders Signature)(Name of Business)</p> <p>Contact Information (for Contract Administration Purposes)</p> <p>Company Name:</p> <p>Company Headquarters Address:</p> <p>(From first page of Contract)</p> <p>FEDERAL ID #:</p> <p>Type of Company:</p> <p>(Legal entity for </p> <p>contractual purposes)</p> <p> |_| Corporation |_| Partnership |_| Joint Venture |_| Other (explain)</p> <p>If Joint Venture Name of Lead Entity: _______________________________________</p> <p> Provide documentation establishing the legal status of the bidder (see VI.1.A</p> <p> Attach a list of all directors, officers, members, partners, joint venturers, etc. of bidder (see VI.1.A)</p> <p>2. Contract ADMINISTRATION</p> <p>Contract Administrator Name:</p> <p>Title:</p> <p>Mailing Address: </p> <p>Toll Free Phone Number:</p> <p>Telephone Number:</p> <p>E-mail:</p> <p>FAX:</p> <p>3. SALES/BILLING </p> <p>Contact Name:</p> <p>Title:</p> <p>Address: </p> <p>Telephone Number:</p> <p>E-mail:</p> <p>FAX:</p> <p>4. HELP DESK/ SERVICE </p> <p>Contact Name:</p> <p>Title:</p> <p>Address: </p> <p>E-mail:</p> <p>WWW Address:</p> <p>Telephone Number:</p> <p>FAX:</p> <p>Contract Toll Free Support Phone Number:</p> <p>Hours of Availability:</p> <p>Bidders Response to Qualifying Technical Requirements (Pass / Fail)</p> <p>In addition to providing the following affirmations, Bidder must respond to the requirements as specified in this RFP. Responses should follow this document in Tab #1. A Microsoft Word version of this Response Form is available on the OGS website at http://www.ogs.state.ny.us/purchase/Bidcalendarlv.asp</p> <p>Technical Requirements Qualifying Criteria</p> <p>Bidders Affirmation</p> <p>Section III.12, Additional Contract Conditions</p> <p>Bidder agrees to conform to and comply with all local, state and federal statutes and regulations governing Authorized Users and their contractors throughout the contract term.</p> <p>|_|</p> <p>Yes</p> <p>|_|</p> <p>No</p> <p>Section VI.1.A, Qualified Bidder</p> <p>Bidder can provide all Financial Services Processing and Transaction Interface services requested. The Bidder affirms it provides Credit/Charge Card and On-line and Off-line Debit Card processing services. All other services can be provided by prospective subcontractors of the Bidder.</p> <p>|_|</p> <p>Yes</p> <p>|_|</p> <p>No</p> <p>Section VI.1.B.1, Authorized Financial Services Processing Provider</p> <p>Bidder affirms that it meets all applicable PCI DSS standards.</p> <p>|_|</p> <p>Yes</p> <p>|_|</p> <p>No</p> <p>Section VI.1.B.1, Authorized Financial Services Processing Provider</p> <p>Bidder affirms authorization to provide FSP services for Credit/Charge Cards and Debit Cards.</p> <p>|_|</p> <p>Yes</p> <p>|_|</p> <p>No</p> <p>Section VI.1.B.1, Authorized Financial Services Processing Provider</p> <p>Bidder agrees to seek authorization for future payment devices requested by Authorized Users.</p> <p>|_|</p> <p>Yes</p> <p>|_|</p> <p>No</p> <p>Section VI.1.B.2, Authorized Financial Services Processing Provider</p> <p>Bidder affirms that all Transaction Interfaces to be provided under the Contract are certified by the Bidder for FSP processing.</p> <p>|_|</p> <p>Yes</p> <p>|_|</p> <p>No</p> <p>Section VI.1.B.3, Authorized Financial Services Processing Provider</p> <p>Bidder affirms that that they will work with Authorized User and their contractors to develop and maintain interfaces between such entities and the Bidder for the purpose of capturing, processing, reporting and reconciling electronic value transfer transactions.</p> <p>|_|</p> <p>Yes</p> <p>|_|</p> <p>No</p> <p>Section VI.1.B.4,a &amp; b, Financial Services Processing Bank (Member)</p> <p>Bidder affirms that the bank to be utilized for processing electronic payment transactions is a State or Federal Chartered bank with a branch in New York State.</p> <p>|_|</p> <p> Yes</p> <p>|_|</p> <p>No</p> <p>Section VI.1.B.4...</p>