AGREEMENT FOR PROFESSIONAL SERVICES - RFQ 34-23 (35) DocuSign Envelope ID:59A00936-87C94C5D-9511-E2133D2308E1
Agreement
For
Professional Services
RFQ#34-2
This AGREEMENT is made and entered into on the 20=r �
of July 20 y and
between the City of Clearwater, Florida(CITY) s$ QgONSUL.T T) with an
effective date August 1, 2021
WITNESSETH:
WHEREAS, the CITY desires to engage the CONSULTANT to perforra certain professional
services pertinent to such work in accordance with this Agreement; and
WHEREAS,the CONSULTANT T desires to provide such professio • i services in accordance with
thisAgreement; and
WHEREAS,in accordance with the competitive selection process described in Section 287.055 o
the Florida Statutes, the CITY selected the CONSULTANT NT based on Request for(qualifications
(" F ")#34-23 and responses by the CONSULTANT to RFQ#34-23.
NOW, E EFC} E, in consideration of the mutual promises contained herein and ether good
and valuable consideration,the Parties agree that the above terms, recitals, and representations are
true and accurate and are incorporated herein by reference,and the Parties further agree as follows:
1. S T
The relationship of the CONSULTANT to the CITY will be that of a professional
consultant, and the CONSULTANT will provide the professional and technical services
required under this Agreement in accordance with acceptable engineering practices, by
exercising the skill and ability ordinarily required of engineers performing the same or
similar services, under the same or similar circumstances, in the State of Florida, and
ethical standards.
® C° CL SIC:
2.1 It shall be the responsibility of the CONSULTANT to work with and for the CITY to
perform an array of services for the City as set forth in RFQ #3423, Scope of Services,
2.2 The CONSULTANT'S services under this Agreement will be provided under a project
specific Work Order(s), Each Work Order will include the services for a single project,
phase, task or assignment, and will contain a mutually agreed-upon detailed scope of
services, project goals, fee and schedule of performance in accordance with applicable
fiscal and budgetary constraints. Work Orders will be incorporated by reference and
attached hereto this Agreement.
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Total compensation for all services shall not exceed $_100,000.00 unless
specifically authorized by the City Council.
See Work Order Template attached hereto as Exhibit A.
2.3 The CONSULTANT shall maintain an adequate and competent staff of professionally
qualified personnel available to the CITY for the purpose of rendering the required
engineering and/or consultant services hereunder and shall diligently execute the work to
meet the completion time established in the Work Orders.The CONSULTANT shall notify
the CITY by U.S.Mail addressed to the City Engineer of any changes in company contact
information, including but not limited to contact phone, address, project manager, email
addresses, etc.
2.4 The CITY reserves the right to enter into contracts with other engineering and/or architect
firms for similar services. The CONSULTANT will, when directed to do so by the CITY,
coordinate and work with other engineering and/or architectural firms retained by the
CITY.
2.5 The CITY reserves the right to remove any and all projects, phases, tasks, or assignments
related to this Agreement. The CITY further reserves the right to enter into contracts with
other engineering firms for services related to such projects,phases,tasks, or assignments.
The CONSULTANT will,when directed to do so by the CITY, coordinate and work with
other firms retained by the CITY.
3.0 PER1OftAff_S_XRVLCM
3.1 The CONSULTANT shall begin work promptly after receipt of a fully executed Work
Order. Receipt of a fully executed Work Order shall constitute written notice to proceed.
3.2 If the CONSULTANT'S services are delayed for reasons beyond the CONSULTANT'S
control, the time of performance shall be adjusted as appropriate.
3.3 It is the intent of the parties hereto that this Agreement continue in force for a period not
to exceed four 4 years effective August 1, 2023, subject to the provisions for termination
contained herein. Assigninents that are in progress at the Termination Date shall be
completed by the CONSULTANT unless specifically terminated by the CITY. Should the
CONSULTANT be in the progress of completing work under this Agreement at the
Termination Date,this Agreement shall continue with all terms,conditions and obligations
being in full force and effect until such time as the work is completed. All provisions
expressly intended to survive termination shall do so.
N: S
r, S I
4.0 FRO-M I � �'s
NEGOTIATION ACT ALChLAJ
Professional Services provided under this Agreement are within the scope of the practice
of architecture, landscape architecture, professional engineering, or registered land
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surveying and mapping, as defined by the laws of the State of Florida. Provisions of F.S.
287.055 apply.
5.0 C
..ENERA. LQNSA DERA11QNS
S.I. All documents including field books, drawings, specifications, calculations, geotechnical
investigation reports, etc., used in the preparation of the work shall be supplied by the
CONSULTANT and shall become the property of the CITY. The CITY acknowledges that
such documents are not intended or represented to be suitable for use by the CITY or others
for purposes other than those for which the documents are prepared. Any reuse of these
documents without written verification or adaptation by the CONSULTANT for the
specific purpose intended will be at the CITY's sole risk without liability or legal exposure
to the CONSULTANT.
51 The CONSULTANT shall prepare preliminary construction cost estimates with each
design submittal to verify the proposed design is within the City project budgets, The
CONSULTANT' shall prepare a final estimate of probable construction costs, following
CITY approval of the bid documents and other pre-bid activities, The CITY hereby
acknowledges that estimates of probable construction costs cannot be guaranteed, and such
estimates are not to be construed as a promise that designed facilities will not exceed a cost
limitation.
5.3 The CONSULTANT will provide expert witnesses, if required, to testify in connection
with any suit at law. A supplemental agreement will be negotiated between the CITY and
the CONSULTANT describing the services desired arid providing a basis for compensation
to the CONSULTANT.
5.4 Upon the CONSULTANT'S written request,the CITY will furnish or cause to be furnished
such reports, studies, instruments, documents, and other information as the
CONSULTANT'aced CITY mutually deem necessary,
5.5 The CITY and the CONSULTANT each bind themselves and their successors, legal
representatives, and assigns to the other party to this Agreement and to the partners,
successors, legal representatives and assigns of each other party, in respect to all covenants
of this Agree ent- and, neither the CITY nor the CONSULTANT will assign or transfer
its interest in this Agreement without written consent of the other,
5.6 To the fullest extent permitted by law, the CONSULTANT agrees to indemnify and hold
harmless the CITY, and its officers and employees, from liabilities, darnagges, losses, and
costs, including, but not limited to, reasonable attorneys' fees, to the extent caused by the
negligence, recklessness, or intentionally wrongful conduct of the CONSULTANT and
other persons employed or utilized by the CONSULTANT in the performance of this
CONSULTANT under this AGREEMENT Notwithstanding any provision herein to the
contrary,this paragraph shall not be construed as a waiver of any immunity to which CITY
is entitled or the extent of any limitation of liability pursuant to § 768.28, Florida Statutes.
Furthermore, this provision is riot intended to nor shall it be interpreted as limiting or in
any way affecting any defense CITY may have under § 768.28, Florida Statutes or as
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consent to be sued by third parties. The obligations under this paragraph shall expressly
survive termination or expiration of this Agreement.
5.7 The CONSULTANT agrees not to engage the services of any person or persons in the
employ of the CITY to an allied capacity, on either a fall or part-time basis, on the date of
the signing of this Agreement, or during its term.
5.8 Key personnel assigned to CITY projects by the CONSULTANT shall not be removed
from the projects until alternate personnel acceptable to the CITY are approved in writing
by the CITY. Key personnel are identified as: Project Manager and technical experts.
5.9 The CONSULTANT shall attach a brief status report on the projects with each requestfor
payment.
5.10 Unless otherwise required by law or judicial order,the CONSULTANT agrees that it shall
make no statements, press releases or other public communication concerning this
Agreement or its subject matter or otherwise disclose or permit to be disclosed any of the
data,technical processes,business affairs or other information obtained or furnished in the
conduct of work under this Agreement without first notifying the CITY and securing its
consent in writing. The CONSULTANT also agrees that it shall not publish copyright or
patent any of the site-specific data or reports furnished for or resulting from work under
this Agreement. This does not include materials previously or concurrently developed by
the CONSULTANT for "In House" use. Only data and reports generated by the
CONSULTANT under this Agreement shall be the property of the CITY.
5.11 Public Records. The CONSULTANT will be required to comply with Section 119.0701,
Florida Statutes, as may be amended from time to time, specifically to:
IF THE CONSULTANT HAS QUESTIONS REGARDING THE
APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE
CONSULTANT'S DUTY TO PROVIDE PUBLIC RECORDS RELATING
TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC
RECORDS AT: 727-562-4092, Rosemarle.Call@myclearwater.com, 600
Cleveland Street, Suite 600, Clearwater, FL 33755.
CONSULTANT shall comply with the following:
a) Keep and maintain public records required by the City of Clearwater(hereinafter
"public agency") to perform the service being provided by the contractor
hereunder.
b) Upon request from the public agency's custodian of public records, provide the
public agency with a copy of the requested records or allow the records to be
inspected or copied within a reasonable time at a cost that does not exceed the
cost provided for in Chapter 119, Florida Statutes, as may be amended from time
to time, or as otherwise provided by law,
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C) Ensure that the public records that are exempt or confidential and exempt from
public records disclosure requirements are not disclosed except as authorized by
law for the duration of the contract term and following completion of the contract
if the contractor does not transfer the records to the public agency.
d) Upon completion of the contract,transfer,at no cost,to the public agency all public
records in possession of the contractor or keep and maintain public records
required by the public agency to perform the service. If the contractor transfers all
public records to the public agency upon completion of the contract,the contractor
shall destroy any duplicate public records that are exempt or confidential and
exempt from public records disclosure requirements. If the contractor keeps and
maintains public records upon completion of the contract,the contractor shall meet
all applicable requirements for retaining public records. All records stored
electronically must be provided to the public agency,upon request from the public
agency's custodian of public records, in a format that is compatible with the
information technology systems of the public agency.
e) A request to inspect or copy public records relating to a public agency's contract
for services must be made directly to the public agency. If the public agency does
not possess the requested records, the public agency shall immediately notify the
contractor of the request and the contractor must provide the records to the public
agency or allow the records to be inspected or copied within a reasonable time.
f) The contractor hereby acknowledges and agrees that if the contractor does not
comply with the public agency's request for records, the public agency shall
enforce the contract provisions in accordance with the contract.
g) A contractor who fails to provide the public records to the public agency within a
reasonable time may be subject to penalties under Section 119.1 a,Florida Statutes.
h) If a civil action is filed against a contractor to compel production of public records
relating to a public agency's contract for services,the court shall assess and award
against the contractor the reasonable costs of enforcement, including reasonable
attorney fees, if:
1. The court determines that the contractor unlawfully refused to comply with the
public records request within a reasonable time; and
2. At least 8 business days before filing the action, the plaintiff provided written
notice of the public records request, including a statement that the contractor has
not complied with the request,to the public agency and to the contractor.
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i) A notice complies with subparagraph (h)2. if it is sent to the public agency's
custodian of public records and to the contractor at the contractors address listed
on its contract with the public agency or to the contractor's registered agent.
Such notices must be seat by common carrier delivery service or by registered,
Global Express Guaranteed, or certified mail, with postage or shipping paid by
the sender and with evidence of delivery,which may be rn. an electronic format.
A contractor who complies with a public records request within 8 business
lots after the notice is sent is not liable for the reasonable costs €f
enforce e t,
6.0 C Ctr ANSA °I N
6.1 The CONSULTANT shall be compensated for services rendered under this Agreement
in accordance with the provisions of each Work Order, upon presentation of
CONSULTANT'S IT'S invoice and as provided in this Agreement (attached as Exhibit ).
.2 Compensation for services shall be invoiced by the CONSULTANT TANT and paid by the
CITY in accordance with the Florida Local Government Prompt Payment Act, §21 x.70,
Florida Statutes.
.3 The CONSULTANT agrees to allow null and open inspection of payroll records and
expenditures in connection with hourly rate and cost-plus fixed fee work assignments
upon request of the CITY.
7.0 PROHIBITION AGAINST CONTINGENT FEES
The CONSULTANT warrants that it has not employed or retained any company or
person,otherthan a bona fide employee working solely for the CC N St.ILTANT to solicit
or secure this Agreernent and that it has not paid or agreed to pay any person, corrrpany,
corporation, individual, or firm, other than a bona fide employee working for the
CONSULTANT any fee, commission, percentage, gift, or any other consideration,
contingent upon orresulting from the award or making of this Agreement.
,0 TERMINATION FO CAUSE
This Agreement may be terminated by either party with seven (7) days prior written
notice, in the event of substantial failure to perform in accordance with the terms hereof
by the other party through no fault of the terminating party. If this Agreement is
terminated, the CONSULTANT ANT shall be paid in accordance with the provisions of
outstanding Work Orders for all work performed up to the date ofterrmilation.
.0 SUSPENSION, CANCELLATIONNT
If the project described in any Work Order is suspended, canceled, or abandoned by the
C fTY,without affecting any other Work Order or this Agreement, the CONSULTANT
shall be given five (5) days prior written notice of such action and shall be compensated
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for professional services provided up to the date of suspension, cancellation, or
abandonment.
10.0 GOVERNING LAW
This Agreement shall be administered and interpreted under the laws of the State of
Florida. The exclusive venue for any proceeding or suit in law or equity arising from or
incident to this Agreement will be in Pinellas County Florida.
11.0 TERMINATION FOR CONVENIENCE
Either the CITY or the CONSULTANT may terminate the Agreement at any time by
giving written notice to the other of such termination and specifying the effective date
of such termination at least thirty (30) days before said termination date. If the
Agreement is terminated by the CITY as provided herein, the CONSULTANT will be
paid for services rendered through the date of termination.
12.0 PUBLIC ENTITY CRIMES
Pursuant to Florida Statute § 287.132-133, the City of Clearwater, as a public entity,
may not accept any proposal from, award any contract to, or transact any business in
excess of the threshold amount provided in§ 287.017,F.S.,for Category Two(currently
$35,000) with any person or affiliate on the convicted vendor list for a period of 36
months from the date that person or affiliate was placed on the convicted vendor list
unless that person of affiliate has been removed from the list pursuant to § 287.133
(3)(f), F.S. By submitting a proposal, CONSULTANT is certifying that Florida Statute
287.132 and 287.133 does not restrict submission.
13.0 SCRUTINIZED COMPANIES AND BUSINESS OPERATIONS
The CONSULTANT will be required to comply with Section 287.135,Florida Statues,
specifically by executing the forms provided(attached as Exhibit Q.
14.0 RFO#34-23, TERMS AND CONDITIONS
All terms and conditions as set forth in RFQ #34-23, Terms of Conditions
are incorporated by reference (attached as Exhibit D).
15.0 ORDER OF PRECEDENCE
Any inconsistency in documents relating to this Agreement shall be resolved by giving
precedence in the following order: (i)this Agreement and subsequent Amendments; (ii)
RFQ#34-23, Terms and Conditions; and (iii)Work Orders.
16.0 INSURANCE REQUIREMENTS
Insurance Requirements are set forth in Exhibit E, which is incorporated by
reference (attached as Exhibit E).
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17.0 TERMINATION FOR LACK OF FUNDING
The CITY'S performance and obligation to pay under this Agreement is contingent
upon an annual appropriation by the Clearwater City Council. In the event the
Clearwater City Council does not appropriate funds for CITY to perform its obligations
hereunder, CITY may terminate this Agreement upon thirty (30) days written notice to
CONSULTANT.
18.0 E-VERIFY
CONSULTANT and its Subcontractors shall register with and use the E-Verify system
to verify the work authorization status of all newly hired employees. CONSULTANT
will not enter into a contract with any Subcontractor unless each party to the contract
registers with and uses the E-Verify system. Subcontractor must provide
CONSULTANT with an affidavit stating that Subcontractor does not employ, contract
with, or subcontract with an unauthorized alien. CONSULTANT shall maintain a copy
of such affidavit.
The CITY may terminate this Agreement on the good faith belief that CONSULTANT
or its Subcontractors knowingly violated Florida Statutes 448.09(1)or 448.095(2)(c). If
this Agreement is terminated pursuant to Florida Statute 448.095(2)(c),
CONSULTANT may not be awarded a public contract for at least I year after the date
of which this Agreement was terminated. CONSULTANT is liable for any additional
costs incurred by the CITY as a result of the termination of this Agreement.
See Section 448.095, Florida Statutes (2020).
[Remainder of Page Intentionally Left Blank]
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IN WITNESS WHEREOF,the parties hereto have made and executed this Agreement on the
date and year first above written.
Terracon Consultants, INC.
(Consultant's..........
By:
... ............. ............
Print Name:
Title
WITNESS:
By:
Print Name:
7
, L
Countersigned. CITY OF CLE ATE
DocuSigned by: DocuSigned by:
49
BNOD427– —------ �4AQ�, -- -- I'll 1 —111-1-1-- --
E EwO*TBviur
C
Brian Aungst Sr. Jenni eTwirrier
Mayor City Manager
DS
Approved as to form: Attest:
DocuSigned by: DocuSigned by-
D8CN46D 20DD5FEC)FF
Jerrod Simpson Rosemarie r1all
Sr. Assistant City Attorney City Clerk
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Exhibit '13
PROVISION OF PAYMENT
ENGINEER OF RECORD.
BASIS FOR PAYMENT
The owner shall pay ENGINEER and ENGINEER agrees to accept as full
compensation for its services (as established by Work Order) compensation as
computed by one of the following methods:
Method "A" -Hourly Rate-
Compensation in the form of burdened hourly rates.
Burdened (direct+indirect)Hourly Rate+ Subconsultant Cost+Other Direct Costs,
Direct cost includes labor hourly rate. Indirect costs include fringe benefit rate,
overhead, operating margin and profit.
Subconsultant Costs are actual costs incurred times a factor of 1.00. Actual costs
shall be based on billing rates for required labor classifications.
Other Direct Costs are actual costs incurred for travel outside of Tampa Bay area,
printing,copying, long distance telephone calls, etc.
Method "B" -1� � S�um -
Compensation in the form of"lump sum" for all work associated with a Work Order or
task and shall be determined by mutual agreement between the ENGINEER and the
City. The lump sum amount shall be negotiated based upon the Work Order scope of
services and approved by both the City and the ENGINEER.
Hourly Rates -
The estimated hourly rates below represent 2023 costs and categories. Periodic changes are
anticipated, and modifications may be made annually in writing to the City for review and
approval.
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CITY OF CLEAR AT ENGINEER OF RECORD 8/1/23
to 7/31/27
ENGINEER OF RECORD: Terracon Consultants, Inc
Please fill out the chart below with job classification and hourly rate.
Job Classification Burdened Hourly-Rate
Senior Vice President $284 . 55
VP/officer-in-Charge $248 . 54
Senior Project Manager/Group Manager $227. 51
Project Manager/Associate Principal $226. 08
Pr
Senior Engineer/Senior Scientist $186. 69
Engineer/Scientist (III-IV) $168 . 04
T............$141. 72' " ' ......----------------
----------------------------------- ..............
Engineer/Scientist (I-III)
Senior Inspector $115 . 92
Inspector F$100 . 67
-------------
C Operator $125 . 69
Project Scientist $75 . 83
---------------------- .........................................._.....a
Field Technician $72 . 94
Admin/Clerical $67 . 54
-------------------
------------- -------------------------
- —------------------------------------ "'__1�------'--'--------------------
-----------------------------------------------
...................
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RF Q 34-23, Exhibit C—Forms
TRUTH-IN-NEGOTIATION CERTIFICATE
In compliance with the Consultants' Competitive Negotiation Act,
Section 287.055, Florida, Statutes, and The Truth in Negotiations Act (TINA),
certifies
Contractor
that wage rates, fringe rates and other factual unit costs supporting the compensation
for the services of
to be provided under this Agreement, concerning
are accurate, complete and current as of the time of contracting.
The hereby undersigned representative submits this certification that they are an
authorized representative of the proposer who may, legally hi I the proposer attest to
the accuracy of the information: 1,11, , I/; 11/ / 1�
7
A/V
...........................
N Authorized Signature
...... ... 1A
Printed Name
........................ -I.........................
Title
STATE OF -jjb6_dQ,,, Name of Entity/Corporation
COUNTY OF GN"
The foregoing instrument was acl nowledgcd before me by means ofkysical presence or 0
online notarization on, thisr day of , 20,,20,22)
.......... (n, of person whose signature is being notarized)as
the (title)of ........... (name
of corporation/entity),personally known or produced
(type of identification) as identification, and who did/did not ta
( y stephani Deitch --
NOTARYPUBLIC —--------..........—---- ............ ................
STATE OF FLORIDA Notary J)l1c
X1. comrn#GG980135
_tw Expires 4120/2024
Printed Name
My Commission Expires:
NOTARY SEAL ABOVE
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RFQ 34-23, Exhibit C FO[mNs
VERIFICATION OF EMPLOYMENT ELIGIBILITY FORM
PER FLORIDA STATUTE 448.095, CONTRACTORS AND SUBCONTRACTORS MUST REGISTER
WITH AND USE THE E-VERIFY SYSTEM TO VERIFY THE WORK AUTHORIZATION STATUS OF
ALL NEWLY HIRED EMPLOYEES.
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE BIDIPROpOSAL. FA&URETO
SUBMIT THIS FORM AS REQUIRED MAY DEEM YOUR SUBMITTAL NONRESPONSIVE.
The ofhant, by virtue of the signature ba|ow, certifies that
1. The Contractor and its Subcontractors are aware of the requirements of Florida Statute 448.095.
2. The Contractor and its Subcontractors are registered with and using the E'Verifysystem toverify the
work authorization status ofnewly hired employees.
3. The Contractor will not anter into a contract with any Subcontractor unless each party to the contract
registers with and uses the E-Verifyeyob*m.
4. The Subcontractor will provide the Contractor with an affidavit stating that the Subcontractor does not
emp|ny, contract with, orsubcontract with unauthorized alien.
S. The Contractor must maintain acopy nfsuch affidavit.
0. The Qh/may terminate this Contract on the gond faith belief that the Contractor or its Subcontractors
knowingly violated Florida Statutes 448.OA(1)or448.O&5(2)(o).
7. If this Contract is terminated pursuant to Florida Statute 448095(2)(o). the Contractor may not be
awarded a public contract for at least 1 year after the date on which this Contract was terminated.
8. The Contractor ioliable for any additional cost incurred bythe City oa a resultofthe termination of this
Contract.
Printed N
ame
Title
'
Name of Entity/Corporation
STATE O
COUNTY OF
The foregoing instrument was acknowledgld before me bypnyoe online
notarization on, this _���!/uv dmy of . 2nA��` by
(name of person w��na eignotune is being notarized) ee the
(tide) ~ of
oorpnretinnlend!y)' personally known or produced (type
identification)anide ifiwho did/did not take anoath.
Stephan, C9 ~
NOTARY PUBLIC
STATF OF FLORIDA
1-11 nA
Expires 412012024 �. MAn 1 .
Printed-Name I
MyCommission Expires:
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RF[] 34-23. Exhibit
SCRUTINIZED COMPANIES THAT BOYCOTT ISRAEL LIST CERTIFICATION FORM
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE BIDIPROPOSAL.FAILURE TO
SUBMIT THIS FORM AS REQUIRED.MAY DEEM YOUR SUBMITTAL NONRESPONSIVE.
The affiant, byvirtue ofthe signature below, certifies that:
1. The vendor, company, individual, principal, subsidiary, affiliate, or owner is aware of the requirements
ufsection 287.136' Florida Statutes, regarding companies on the Scrutinized Companies that Boycott
Israel List, orengaged inaboycott mfIsrael; and
2. The vendor, oompany, ind|vidue|, principa[, auboidiary, affi|iahe, orowner ieeligible to participate in this
solicitation and is not listed on the Scrutinized Companies that Boycott |mnae| Liat, or engaged in a
boycott ufIsrael; and
3. "Boycott |aroe|^ or"boycott of|enae|^ means refusing to dea|, bann|nebng business mctivitiao, or taking
other actions 10 limit commercial relations with |onme|, or persons or entities doing business in |snom| or
in Israel!-controlled tarriburiao, in a discriminatory manner. A statement by a company that it in
participating in a boycott of Israel, or that it has initiated a boycott in response to a request for a boycott
of Israel or in compliance with, or in furtherance of, calls for a boycott of Israel, may be considered as
evidence that acompany ieparticipating inaboycott ufIsrael; and
4. If awarded the Contract(or Agreement),the vendor,company, individual, principal, subsidiary,affiliate,
orowner will immediately notify the City ofClearwater in writing, no later than five (5) calendar days
after any ofits principals are placed onthe Scrutinized
inaboycott ufIsrael.
Aulhbrized Signature
Printe,O Name-
Name of Entity/Corporation
STATE OF
COUNTY OF
The foregoing instrument a ed before me by njeans of ical presence or O online
notarization on. th|a _�(�i�= day of 2049. by
(name of person whis being notarized) as the
(title) o (name of
ourpomationAanthy), parmono|k/ knmwn or produced (type of
|dentificawho did/did not take an oath.
NOTARY PUBLIC
C/ 00980135 —Notary Public
'
Expires 4/20/2M Printed Name
My Commission Expires:
NOTARY SEAL ABOVE
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RF{] 34-23. Exhibit
SCRUTINIZED COMPANIES AND BUSINESS OPERATIONS WITH CUBA AND SYRIA
CERTIFICATION FORM
IF YOUR BIDIPROPOSAL/S$1,000,000 OR MORE, THIS FORM MUST BE COMPLETED AND
SUBMITTED WITH THEBIDIPROPOSAL. FAILURE TO SUBMIT THIS FORMAS REQUIRED MAY
DEEM YOUR SUBMITTAL NONRESPONSIVE.
The affiant, byvirtue ofthe signature below,certifies that:
1. The vendor, company, individual, principal, subsidiary, affiliate, or owner is aware of the requirements
ofsection 287.135, Florida Statutes,regarding companies onthe Scrutinized Companies with Activities
in Sudan List, the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector Liot, or
engaging inbusiness operations inCuba and Syria; and
2. The vendor,company, individual, principal, subsidiary, affiliate, or owner is eligible to participate in this
solicitation and is not listed on either the Scrutinized Companies with Activities in Sudan List. the
Scrutinized Companies with Activities in the }ren Petroleum Sector Liot, or engaged in business
operations inCuba and Syria; and
3. Business Operations means,for purposes specifically related to Cuba or Syria, engaging in commerce
inany form in Cuba urSyria, |nu|uding, but not limited to, acquiring, deve|oping, maintoining, mwning,
selling, possessing, leasing oroperating equipment, faoi|itiea, personnel, producto, servicea, personal
property, real property, military equipment, or any other apparatus of business or commerce; and
4. |fawarded the Contract(or AQn*ement).the vendor, company, individum|, prinoipa|, nubm|diary, affi|iote,
orowner will immediately notify the City ofClearwater in writing, no later than five (5) calendar days
after any ofits principals are placed on the Scrutinized C i ih Aptivities in Sudan List, the
Scrutinized Companies with Activities in the Iran Petrol,eonl, S.99tor, or engaged in business
operations inCuba and Syria. '
Printed Narnb,-�,
1-1--lajw Name of Entity/Corporation
STATE OF
COUNTY OF
The foregoing instrument dged before meby me, s W25hysical presence online
notarization this day of . 20'?a by
(name of person
�hn
signature is being notarized) as the
(title) �
corpuroUo�entity). personally known �� or produced
(type of
identification) aaidentification,and who did/did not take anoath.
Stephani Deitch
NOTARY PUBLIC
STATE OF FLORIDA _
Cmnyr&GG980135 Notary Public
Expires 4/20/2024Printed Name
K8yCommission Expires:
NOTARY SEAL ABOVE