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HomeMy WebLinkAbout2009 10 07 Regular 600 Retirement Plan Specialists, Inc.SUBMITTAL COVER SHEET Submit proposal to: Purchasing Department CITY OF WINTER SPRINGS 1126 East State Road 434 Winter Springs, Florida 32708 407 327 -5959 Proposal Due Date Time: September 16, 2009 3:00 p.m. REQUEST FOR PROPOSAL (RFP) #021/09/JD PENSION PLAN ACTUARIAL SERVICES I hereby certify that the information contained herein is true. I agree and understand that any misstatement or misrepresentation or falsification of facts shall be cause for disqualification of the submittal, immediate cancellation of any contract with the City that might arise from the representations contained herein, and forfeiture of rights for further consideration for work in the City of Winter Springs. VENDOR NAME: j �P Tv'R erc\ pc\�T MAILING ADDRESS: City: wML State: FL_ Zip: 3. Name/Title: Authorized S Email Address: Phone (Y0�) Fax 366 s /s This Form Must Be Completed and Returned With Your Submittal. 4 815 Eyrie Drive, Suite 2 Oviedo, Florida 32765 -8602 September 16, 2009 Board of Commissioners City of Winter Springs 1126 East State Road 434 Winter Springs, Florida 32708 Dear Sirs /Madame: Retirement Plan Specialists, Inc. Employee Benefits Administrators, Actuaries Consultants Visit us at www.webpensionplans.com Re: Pension Plan Actuarial Services Proposal Letter of Interest 407 -365 -3490 (office) 407 366 -5154 (fax) 888 376 -7222 (toll free) This letter is in response to your recent RFP for the actuarial services of the City of Winter Springs, Florida Defined Benefit Plan for its employees. As you are aware, we are the current firm that designed, implemented and performed the actuarial services for the plan since its inception in 1997. Initially, the plan was a floor offset and only covered those individuals who would not be getting a significant enough benefit to retire under the then existing Money Purchase Pension Plan. In 2000, it was decided to consolidate the Money Purchase Pension Plan and the Defined Benefit Plan. As part of the consolidation, the employees were told that their contributions would be 100% vested and available to them as long as their total vested benefit was less than $3,500.00. Part of the services for this plan require maintaining the employee accumulation account with earnings on a quarterly basis. Only terminated participants with less than $3,500.00 in benefit value are eligible for payout. This means comparing the present value of the accrued benefit against the employees mandatory contribution account to ascertain which is higher and whether it is above or below $3,500.00. This was not addressed under the Scope of Services of the RFP. Starting on October, 1, 2000, the benefit formula was 3% per year of service on or after this date and 2% per year of service before this date. Starting in October, 2005, the past service unit was increased in .25% increments until it reached 3% for all years of service with the City effective October 1, 2008. It is at this time we recommended the plan be revalued on a fresh start basis. Preliminary numbers were provided to the City but it is our understanding it was not submitted or approved by the Commissioners. The City also decided in October, 2008 to move its firefighters to Seminole County. In the process, the firefighters were allowed to elect whether to stay in the City's Plan or go to the State of Florida Retirement System. A number of the firefighters elected to stay with the City Plan. Part of the work yet to be performed going forward is the separate calculation for those firefighters in the City plan, continuing to earn service credits under the City plan while working for the County. This portion of the required work to be performed was not listed in your RFP. At the end of each plan year a GASB report is required to be prepared and submitted to the City auditors with subsequent submission to the State for approval. This portion of the work to be performed does not appear to be addressed under the Scope of Services required on the RFP. This is not the same as the actuarial report given to the Commissioners each year which is based on projected costs for budgetary purposes. The GASB is a wrap up of what happened in the prior year(s). We have provided one -on -one consultation with the employees and retirees for the City for nearly ten (10) years. Each year, we have performed five to six on site employee meetings to discuss the participant statements and the Summary Plan Description. In addition, we have met with every retiree and his/her spouse in our Oviedo location to go over in detail their retirement benefits from the City and available options. We have maintained the records of nearly 400 current and former employees of the City for nearly 12 years. We are a local firm with employees living in the City. The funds paid for the work performed go back into the community from which they came, either in purchases from other local businesses or property taxes for those of us who own property in the City itself. We have actively participated and contributed to City events and fundraisers. We are a member of the local Chamber. As we are part of the community, we have a deep affection and respect for the City, its employees and those who are elected to run it. We would be proud and honored to continue our service to the City as the actuaries to the pension plan. Thank you for your consideration of our proposal. Sincerely, Sandra R. Turner, ERPA, CPC, QPA President IRS Circular 230 Notice: To ensure compliance with requirements imposed by the IRS, we inform you that any US pension tax advice contained in this communication (including any attachments) is not intended to be used, and cannot be used, for the purpose of (i) avoiding penalties under the Internal Revenue Code or (ii) promoting, marketing or recommending to another party any transaction or matter addressed herein. Part III Profile of Proposer WHO WE ARE: Retirement Plan Specialists, Inc. (RPS) is a local professional organization providing actuarial, consulting and administrative services in the area of pension and profit sharing plans to employers of all sizes, whether operating as corporations, partnerships, sole proprietorships, governmental entities, or not for profits organizations. Retirement Plan Specialists, Inc. (RPS) is located in Oviedo, Florida on 815 Eyrie Drive Suite 2, 32765. The local numbers are 407 365 -3490 and the fax is 407 366 -5154. Our toll free numbers are 888 376 -7222 and toll free fax at 866 236 -1412. Our website is www.web.pensioLiplans.com RPS was incorporated in Seminole County, Florida on July of 1997 as a Sub Chapter S corporation owned by Sandra R. Turner, CPC, QPA, principal. The Board of Directors consists of Sandra R. Turner, ERPA, CPC, QPA, President, Jeffrey T. Sparks, QPA, CLU, ChFC, FLMI, Vice President and Judy L. Conrad, CFP, CLU, Vice President. RPS is a woman owned enterprise (WBE) as certified by the State of Florida and an approved vendor for Actuarial Services (copy of certification attached). RPS performs work for clients locally and across the country. RPS is a fee for service organization and does not engage in the sale of any products such as investments, insurance, etc. For this reason we are able to offer independent and unbiased expertise in consulting and administration. Programs are individually tailored to suit the unique objectives of our clients to meet short and long term needs in the most cost effective and efficient manner. At RPS, all work is done in -house by our own staff of consultants and actuaries, backed with an in -house network of support service personnel and state -of -the -art computer systems. All of our clients' important information is compiled and analyzed in our office to assure accuracy and confidentiality. We utilize the Datair Software System for our actuarial valuations. This is a nationally known system that has been in existence for over 40 years. The software is housed on a ten station network supported by a Windows 2003 server, Intel based, UPS and Raid -1 disk mirroring. Data is backed up daily and transmitted offsite as part of our disaster recovery procedures. As time goes on, businesses change. Additional employees, changing profit pictures and shifting goals require periodic review and adjustments to the programs. Changes also occur in governmental rules and regulations. The RPS staff continually monitors these changes and prepares alternatives for the specific programs as necessary. TECHNICAL SUPPORT RPS offers technical support in the design, development and administration of the following employee benefit programs: QUALIFIED RETIREMENT PLANS: 401(k) Plans Profit Sharing Plans Cross Tested Plans Money Purchase Pension Plans Defined Benefit Pension Plans ESOP /Stock Bonus Plans Union Plans /Multi employer CAFETERIA PLANS (Section 125): Premium Only Plans Full Flex Programs NOT FOR PROFIT/ GOVERNMENT PLANS Defined Benefit Plans 403(b) and 457 Plans SIMPLIFIED EMPLOYEE PLANS NON QUALIFIED DEFERRED WEB NEWS WHAT WE DO: The professionals at RPS work closely with the accountant, tax attorney and /or financial consultant to develop the employee benefit program best suited to meet the needs of the client. On -going communication assures the expectations of the client are being met. DESIGN: RPS works with you. What are your goals, both as an individual and for your company? Because the "bottom line" of RPS services is to develop and implement a program that will help you achieve these objectives, our design begins by helping you determine a realistic answer to this question. Plan design determines the adequacy of plan benefits, the level of long -term plan costs, the ease or complexity of administration, and compliance with state and federal laws. Objectives should be explicit and the plan designed to meet those objectives. No single plan design will suit all participant groups. Defined benefit, defined contribution, and hybrid plans all play a role. The key is designing and implementing the plans in ways that best serve all interested parties. RPS will prepare illustrations showing cost versus benefit provided and suggestions for plan design and formulas utilizing such plan types as: Defined Benefit and Defined Contribution Plans Deferred Compensation Plans Hybrid Plans Excess Benefit Plans Comparative Studies IMPLEMENTATION: RPS will assist in the development of plan documents for review by an attorney and preparation of data needed for filing the plan with the Internal Revenue Service. Preparation of communication packages for employees and conducting employee meetings, where appropriate, will be provided. ADMINISTRATION: RPS' goal is to provide seamless third -party back office administration of the retirement system. While the plan sponsor retains full control as benefit provider, RPS handles the day -to -day details. Plan sponsors can outsource some or all of the administrative functions necessary for the smooth operation of the retirement system. RPS approaches the task by identifying the system's users, what results they seek, and the required information sources. RPS then designs a plan to produce desired results from the sources available. Services include: Recordkeeping and Administration Benefit Calculations Member Education Member Inquiries ACTUARIAL CONSULTING SERVICES: Actuarial valuations are essential for determining the current financial condition and contribution requirements of a funded benefit plan. We also perform actuarial audits, experience studies, projections, and evaluations of proposed changes in plan design. Annual Actuarial Valuations FASB /GASB /IAS Valuations Actuarial Audits /OPED analysis Actuarial Projections QDRO Actuarial Calculations Plan Termination Assistance Governmental, Current (Florida): Actuaries for the City of Winter Springs Defined Benefit Plan city wide plan including police and fire. RPS design, implement and has maintained this defined benefit plan for over ten years. Actuaries for the Cape Canaveral Volunteer Fire Department Defined Benefit Plan. RPS designed, implement and has maintain this defined benefit plan for seven years. Non Governmental, Current and Past (Florida): Actuaries Services: Leesburg Concrete, Inc., full service Vero Radiology Associates, Inc. full service City of South Pasadena, project based City of Fort Myers, project based only RPS also provides actuarial services for a credit union in Michigan, a union plan in North Carolina and a number of private corporations both in Florida and out -side of Florida. Compliance Testing and Consulting: Gray, Robinson, P.A. Lowndes, Drosdick, Doster, Kantor Reed, P.A. SPURSview Vendor Detail Navigation SPURS Home RETIREMENT PLAN SPECIALISTS, IN Page 1 of 1 Address: 815 EYRIE DRIVE SUITE 2 OVIEDO FL 32765 County: 59 SEMINOLE Registration Status: DMS REGISTERED OSD Classification: M NON MINORITY WOMAN, CERTIFIED Certified: 04/09/2009 04/09/2010 (Current) Business Designation: 1 CORPORATION, PROFESSIONAL ASSOCIATION AND PROFESSIONAL CORP Contact: SANDRA TURNER (407) 365 -3490 Electronic Address: SANDYTURNER(&WEBPENSIONPLANS.COM HTTP: /WWW.WEBPENSIONPLANS.COM Active Status: Active Bid Regions: STATEWIDE Source: MFMP and SPURS Matching Commodities Class Group Item Detail Description Contract 973 -000 000 0000 CONTRACTUAL SERVICES, PROFESSIONAL 973 -020 1000 0000 1 JACTUARIAL SERVICES Displaying rows 1 through 2 of 2. Execution Time: 0.06 seconds For assistance please contact the MyFloridaMarketPlace Customer Service Desk M F 8:00 a.m. 5:30 p.m. EST Phone 1- 866 352 -3776 (toll free) Vendor email assistance: vendorhelp@myfloridamarketplace com Agency email assistance: buyerhelp (a.myfloridamarketplace.com Copyright@ 2000 State Of Florida Privacy Statement http:Hwww.myflorida.com/apps /spurs /SPURS.VENDOR MGT.vendor ?display_str= QV2... 9/16/2009 PART IV SUMMARY OF QUALIFICATIONS DONALD D. CHAPMAN, E.A., M.A.A.A, M.S.P.A. Donald D. Chapman has over thirty years of experience as a consulting actuary and pension consultant in the areas of employer retirement programs and employee benefits. He has a wide spectrum of benefits experience gained from working in a major actuarial consulting firm in Boston for over 10 years and as a consulting actuary and principle of a small actuarial consulting firm for over 13 years. His practice today consists of working as a consulting actuary and pension consultant to pension programs for small and large employers, union trustees' pension plans and government pension plans. Mr. Chapman's experience runs the gamut of working with large multi national corporations down to small closely held corporations. His experience also includes working with professional corporations and sole proprietorships. Areas of specialty include plan design, administration, plan documents, actuarial certifications, employee communications and training in both the defined benefit and defined contribution plan areas. Mr. Chapman is an Enrolled Actuary as designated by the Department of Labor and Department of Treasury to perform actuarial services under ERISA. He is also a member of the American Academy of Actuaries and the American Society of Pension Actuaries. SANDRA R. TURNER, ERPA, CPC, OPA Sandra holds a bachelors degree in Mathematics and Computer Science from Florida Atlantic University. She is a Certified Pension Consultant (CPC) and Qualified Plan Administrator (QPA) holding membership in the American Society of Pension Actuaries. Sandra is an Enrolled Retirement Plan Agent as designated by the Department of Treasury and Department of Labor to practice before the tax courts and the IRS. Sandra is a widely respected expert and acknowledged leader in her field with over 30 years experience. She is a member of the Central Florida Employee Benefits Council and has taught pension courses for both CPC and CEBS programs. She also holds membership a number of business and professional associations and is a frequent speaker. Sandra was recently asked to join a special task force group formed in Washington by the SBA Office of Advocacy to address the concerns and issues facing pension plans today. The pension roundtable meets quarterly and is developing recommendations and suggestions to the White House and Congress for improving pensions for all employees. JEFFREY T. SPARKS, OPA, CLU, ChFC, FLMI For almost 25 years, Jeff has been working with clients in designing and administering retirement plans. He holds the Qualified Plan Administrator (QPA), Chartered Life underwriter (CLU), Chartered Financial Consultant (ChFC) and Fellow, Life Insurance Institute (FLMI) designations. Jeffrey has passed all his qualifications and testing for the Enrolled Retirement Plan Agent designation and is awaiting his certification from the Department of Treasury. Jeff is active locally in the Employee Benefits Council of Central Florida and is an active member of his church, leading the Men's Group ministry. LANNING H. TURNER, DEFINED BENEFIT PLANADMINISTRA TOR Lanning Turner has over 5 years experience in pension administration. He graduated from Southeastern College with a BS in Business and Pastoral Ministries. Mr. Turner is currently enrolled in the graduate actuarial science courses offered at the University of Central Florida taught by Stephen Kellison, past president of the Society of Actuaries and well known author. Mr. Turner is a Defined Benefit Plan Administer and is working towards his Enrolled Actuary designation. Part V Forms as required by the RFP are attached. VENDOR RATE /FEE SCHEDULE Please include a breakdown of the dollar amount of and the basis for your fees as appropriate based on the following categories (generally defined in Scope of Services): Benefits Administration Functions Annual Valuation and SPD Preparation Ad hoc Calculations and General Analysis Total proposed annual fee for base services as per scope of work I D S -CIA 91 Cab 4, ©0o 00 5 000. oC7 ri Fee /Rate Schedule for any additional services (above and beyond that stated in the base scope of services) that may be requested: Cate ory of Emp r. r te. M A9— mo For all additional work, vendor is requested to provide a proposal which shall include a breakdown of the hourly rate which will be applicable, in determining the cost of these services, by major category of employee (actuary, associate, clerical, etc.); for these additional services, billing will be broken down into time per category by major task. These fees will be fixed for the initial period of two years, and negotiated thereafter. Prior to accepting an assignment for additional work, you will be requested to provide a proposed fee for the task on a "not to exceed" basis prior to receiving authority to proceed. This Form Must Be Completed and Returned With Your Submittal. DISPUTES DISCLOSURE FORM Answer the following questions by answering "YES" or "NO If you answer "YES please explain in the space provided, please add a page(s) if additional space is needed. 1. Has your firm, or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regu ation or any other regulatory agency or professional association within the last five (5) years? Alb 2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? 3. Has your firm had filed against it or filed any requests for equitable adjustment, contract claims or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? 4k If yes, the explanation must state the nature of the request for equitable adjustment, contract claim or litigation, a brief description of the case, the outcome or status of suit and the monetary amounts or extended contract time involved. I hereby certify that the statements contained herein are true. I agree and understand that any misstatement or misrepresentation or falsification of facts shall be cause for disqualification of the submittal, immediate cancellation of any contract with the City that might arise from the representations contained herein, and forfeiture of rights for further consideration for work in the City of Winter Springs. Firm: Name Title: �2GL u Authorized Signature This Form Must Be Completed and Returned with your Submittal INSURANCE REQUIREMENTS FORM 1. The vendor shall be required to provide to the Purchasing Coordinator, prior to signing a contract for or commencing any work, a Certificate of Insurance which verifies coverage in compliance with the requirements outlined below. Compliance of said certificate must be acknowledged by the Purchasing Coordinator prior to start of work. Any work initiated without completion of this requirement shall be unauthorized and the City of Winter Springs will not be responsible. 2. The City of Winter Springs reserves the right to require coverage and limits as considered to be in its best interests. Insurance requirements shall be on a case by case basis determined by the project, conditions and exposure. 3. Except for Professional Liability and Workers Compensation Policies, when required, all policies are to be endorsed to include the City of Winter Springs as Additional Insured. In the cancellation clause the number "30" shall be inserted into the blank space provided prior to the words "days prior notice... All vendor policies are to be considered primary to City coverage and shall not contain co- insurance provisions. 4. In the event that the insurance coverage expires prior to the completion of services, a renewal certificate shall be issued 30 days prior to said expiration date. 5. Subvendors or sub contractors retained by the primary vendor are the responsibility of said primary vendor in all respects. 6. Insurance requirements: COVERAGE REQUIRED MINIMUM POLICY LIMITS Workers' Compensation Statutory Commercial General Liability including Contractual Liability, Products and Completed Operations, XCU and Owners and Contractors Protective 1,000,000 Occurrence Comprehensive Auto Liability, CSL, shall include "any auto" 1,000,000 CSL Professional $1,000,000 Occurrence (NOTE: All limits are per occurrence and must include Bodily Injury and Property Damage. Deductibles and self insured retentions must be approved by the City of Winter Springs, and all insurers must have an A.M. Best rating of at least A: VII.) 7. Bonding Required: None This Submittal 8. Vendor will be required to provide a certificate of insurance in compliance with the above, within four (4) days of notification of award with continuing coverage, without a break. 9. 1 hereby certify that the insurance and bonding requirements outlined above shall be met as required, if I am awarded a contract for the services specified herein. Firm: �P ►E\P,rt�N�"T P \O f\ Name Title: Authorized Si This Form Must Be Completed and Returned with your Submittal 9 FLORIDA STATUTES ON PUBLIC ENTITY CRIMES FORM THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. 1. This sworn statement is submitted to the City of Winter Springs by: on behalf of: whose business is: Federal Employer Identification Number (FEIN) 51— 3� 5 0 or Social Security of the person signing this statement: 2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), F.S., means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services, any lease for real property, or any contract for the construction or repair of a public building or public work, involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. 1 understand the "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), F.S., means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilt or nolo contendere. 4. 1 understand that an "affiliate" as defined in Paragraph 287.133(1)(a), F.S., means: A predecessor or successor of a person convicted of a public entity crime or an entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 10 5. 1 understand that a "person" as defined in Paragraph 287.133(1)(e), F.S., means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity. 6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies.) Neither the entity submitting this sworn statement, nor any of its officers, director, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity were charged with and convicted of a public entity crime after July 1, 1989. The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any affiliate of the entity was charged with and convicted of a public entity crime after July 1, 1989. The entity submitting this sworn statement, or one of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any affiliate of the entity was charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I understand that the submission of this form to the City of Winter Springs is for the City of Winter Springs only, and that this from is valid through December 31, 2007. 1 also understand that I am required to inform the City of Winter Springs prior to entering into a contract in excess of $25,000 of any change in the information contained in this form. State of Florida, County of wnole- On this day of 2001, before me, the undersigned Notary Public of the State of Florida, personally appeared: oSandm.. I rncK,., �residv►f o-� f� QS. �cc (Name(s) of individuals who appeared before notary) 11 .nyi iaLui c vaLc whose name(A is /q/e Subscribed to the within instrument, and M /she /thiy acknowledge that hk /she /thVy executed it. Sworn to and subscribed before me this 1 day of t 20 Personally Known Produced Identification: (Type) Did take an Oath Did Not take an Oath J-V� lc� Notary Public My Commission expires: fl -zl- zorl TERRY L. DAWSON Notary Public, State of Florida MY Comm. Expires Nov. 21, 2011 Commission No. DO 732378 This Form Must Be Completed and Returned with your Submittal 12 DRUG -FREE WORK PLACE FORM The undersigned, in accordance with Florida Statute 287.087 hereby certifies that the company named below does: 1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Give each employee engaged in providing the commodities or contractual services that are proposed a copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, by any employee who is so convicted. 6. Make a good faith effort to continue to maintain a drug -free workplace through implementation of this section. Firm Name Title: Authorized Signature I This Form Must Be Completed and Returned with your Submittal 13 CONFLICT OF INTEREST STATEMENT I 1 9 f2c 0'.0'e-40 �t. of eyma -A nN Q deposes and states that Name of Affiant Name of Company the above named entity is submitting a proposal to the City of Winter Springs for the project identified above. 2. The Affiant has made diligent inquiry and provides the information contained in this Affidavit based upon his own knowledge. 3. The Affiant states that only one submittal for the above project is being submitted and that the above named entity has no financial interest in other entities submitting qualifications for the same services. 4. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive pricing in connection with the entity's submittal for the above project. This statement restricts the discussion of pricing data until the completion of negotiations and execution of the Agreement for this project. 5. Neither the entity nor its affiliates, nor anyone associated with them, is presently suspended or otherwise ineligible from participating in contract lettings by any local, state, or federal agency. 6. Neither the entity, nor its affiliates, nor anyone associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for these services. 7. 1 certify that no member of the entity's ownership, management, or staff has a vested interest in any aspect of or department of the City of Winter Springs. 8. 1 certify that no member of the entity's ownership or management is presently applying for an employee position or actively seeking an elected position with City of Winter Springs. 9. In the event that a conflict of interest is identified in the provision of services, 1, on behalf of the above rcntged eXty, will imnWgiately_notify the City of Winter Springs in writing. XOMPE MOMS r MWIM State of Florida, County of Title Typed or Printed Name of Affiant noIF- On this I 1 1� day of 4�et 2001, before me, the undersigned Notary Public of the State of Florida, personally appeared t� p�Qr►dro�. n ur n ex.� Pri 'prr,5;JeA and 14 (Name(s) of individuals who appeared before notary) whose name() is /ah subscribed to the within instrument, and P(e/she /th /y acknowledge that I e /she /t /ey executed it. WITNESS my hand and official seal. NOTARY PUBLIC, STATE OF FLORIDA NOTARY PUBLIC TERRY L. DAWSON Notary Public, State of Florida SEAL OF OFFICE: My Comm. Expires Nov. 21, 2011 Commission No. DD 732378 (Name of Notary Public: Print, Stamp, or Type as Commissioned.) This Form Must Be Completed and Returned with your Submittal 15 CERTIFICATION OF NON SEGREGATED FACILITIES FORM By affixing his signature to this form, the consultant certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The consultant certifies further that he will not maintain or provide for his employees any segregated facilities at any location under his control where segregated facilities are maintained. The consultant agrees that a breach of this certification will be a violation of the Equal Opportunity clause in any contract resulting from acceptance of this Bid. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms and other storage and dressing areas, parking lots, drinking fountains, recreation or entertainment area, transportation and housing facilities provided for employees which are segregated by explicit directive, or are in fact segregated on the basis of race, color, religious disability or national origin, because of habit, local custom, or otherwise. The consultant agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, and that he will retain such certifications in his files. The nondiscriminatory guidelines as promulgated in Section 202, Executive Order 11246, and as amended by Executive Order 11375 and as amended, relative to Equal Opportunity for all persons and implementations of rules and regulations prescribed by the United States Secretary of Labor are incorporated herein. NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.O. 1001. Print Name Official Address: Title Late L 6 This Form Must Be Completed and Returned with your Submittal 16 PUBLIC RECORDS FORM All proposals are subject to the Florida Public Records Act, F.S. 119. The submission of a proposal authorizes release of your firm's credit data to the City of Winter Springs. Responsive proposals are "public records" and shall be subject to public disclosure consistent with Chapter 119.07(3) (o), Florida Statutes. Vendors must invoke any exemptions to disclosure provided by law in the response to the proposal, and must identify the data or other materials to be protected, and must state the applicable statutory exemption for exclusion from public disclosure. Please list below any exemptions to disclosure as provided by law and sign and date the form where indicated.: If you are not claiming any Public Records Exemptions, please check the box below and sign and date the form where indicated. We are claiming no exemptions L aA 107 Vendor Signat re /Date This Form Must Be Completed and Returned with your Submittal 17