Request for Proposal

The County Broadband Infrastructure Development

RFP Issue Date: August 2, 2022

Intent to Respond: September 2, 2002
Pre-Bid Meeting: August 15, 2022
Question Submittal Deadline: August 22, 2022
Answers/Addendum Response: August 29, 2022
Sealed Proposal Deadline: 1:00 p.m. EST on September 30, 2022
Sealed Proposal Opening: 1:15 p.m. EST on September 30, 2022

Submit Sealed Proposals to: Clinton County Administration

Attn: Penny Goerge, Executive Assistant
100 E. State Street, Suite 2100
St. Johns, MI 48879

Tentative Date for Award: November 30, 2022

Table of Contents
Request for Proposal .................................................................................................................................... 1
The County Broadband Infrastructure Development ............................................................................. 1
1. Statement of Purpose and General Instructions ................................................................................. 3
1.1 Proposal Schedule (subject to change)........................................................................................ 4
1.2 During Award Period .................................................................................................................... 4
1.3 Upon Award Completion ............................................................................................................. 5
1.4 Disposition of Proposals............................................................................................................... 5
1.5 Compliance with Law ................................................................................................................... 5
1.6 Federal Funding Considerations .................................................................................................. 7
2. Payment Terms..................................................................................................................................... 7
2.1 Distribution of Funds .................................................................................................................... 7
3. Provider and Project Information ........................................................................................................ 8
APPENDIX A: SERVICE AREAS ..................................................................................................................... 10
APPENDIX B: SCORING RUBRIC .................................................................................................................. 12
APPENDIX C: CERTIFICATIONS AND ASSURANCES .................................................................................... 15
APPENDIX D: SIGNATURE PAGE ................................................................................................................. 18

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1. Statement of Purpose and General Instructions

The County Board of Commissioners has authorized the procurement of services to supply
fiber-to-the-home broadband internet infrastructure in selected areas, see Appendix A. The
County does not seek to own, operate, or maintain any infrastructure supported by the
funding awarded within this application. The County’s purpose in issuing this Request For
Proposals (RFP) is to facilitate projects that will successfully accomplish getting fiber-to-the-
home broadband internet to the unserved and underserved residents of the County. The
service areas defined in Appendix A are subject to change based on yet to be published maps
provided by the Michigan Highspeed Internet Office (MIHI). As such, Providers are
encouraged to develop their submitted plans to cover every home in the designated service
area, or in portions of the designated service area as applicable.

• Providers must deliver service to the home utilizing technologies that deliver a
minimum 100Mbps download and 20Mbps upload service upon project completion,
expandable to 100Mbps symmetric service.

• Broadband speeds must be certified by a professional engineer within the application.

• Providers should demonstrate the ability to construct, own and operate funded
projects in the defined areas of service to be eligible for consideration of funding.

• Providers shall indicate the expiration date for pricing in any proposal submitted. The
expiration date shall not be less than 180 days from the Proposal Due Date

• Providers will agree to provide their proposed service area to the County as a .kmz or
shapefile file format, showing specific locations that are to be served. If a portion of
the proposed area or homes will be unserved within the Provider’s proposal, the
Provider should document any rational within the response.

• It is the County’s practice to seek and purchase suitable available products and
services at the lowest overall costs. While cost is a factor in any contract award, it is
not the only factor and may not be the determining factor.

• Providers shall analyze and respond to all sections of the RFP, from Section 2 through
the appendices and attachments, and provide sufficient information and product
prototypes (if necessary) to allow the County to evaluate the proposal. A written
response is required. If the Provider is unable to fulfill any section in the RFP, please
indicate on a separate piece of paper an explanation for the sections that are either
non-compliant or not applicable.

• Providers shall also furnish all information as requested and complete all forms
according to this RFP.

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 • Any deviations or exceptions to the County requirements are to be clearly noted in
the Provider’s response. Incomplete proposals, or proposals which do not comply
with the County’s requirements, may be eliminated from the purchase decision at the
County’s discretion.

• The County shall incur no obligation or liability whatsoever to anyone by reason of

issuance of the RFP or action by anyone relative thereto.

• Providers, by submitting a proposal, agree that any costs incurred by the Provider in
responding to this RFP, or in support of activities associated with this RFP, are to be
borne by Provider and shall not be billed to the County.

1.1 Proposal Schedule (subject to change)

1.1.1 Providers must advise the County by September 2, 2022 of Provider’s intention to
submit a proposal.

1.1.2 Mandatory pre-bid meeting, to take place onsite (100 E State St, St Johns, MI
48879) at 10:00 am EST on August 15, 2022 in the Board of Commissioners Room.

1.1.3 Questions regarding the RFP shall be received no later than 2:00 pm EST on August
22, 2022 and submitted via email goergep@clinton-county.org.

1.1.4 Proposal Due Date: All sealed proposals are due no later than 1:00 p.m. EST on
Friday, September 30, 2022. The proposals shall be clearly marked – “Clinton County
Broadband Project” and be delivered to: Clinton County Administration, Attn: Penny
Goerge, Executive Assistant, 100 E. State Street, Suite 2100, St. Johns, MI 48879.

It is the responsibility of the Provider that the sealed proposal submitted is received in a
timely and proper manner. Late proposals will not be considered. Provider has an
obligation to explain and clarify any and all conditions imposed on or included in their
responses to the RFP. Responses shall be sealed and submitted in six (6) copies. One copy
of the proposal shall be clearly marked “Master Copy”. If the proposal is accepted, the
Master Copy will provide the basis for resolving any discrepancies.

Proposals will be opened at 1:15 p.m. EST on Friday, September 30, 2022.

1.1.5 The County may interview any or all Providers prior to making an award as to a
proposal. The County may designate a backup proposal in case the successful proposal does
not result in a contract.

1.2 During Award Period

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 1.2.1 Provide bi-monthly report/update to the County to include disclosure of any
known potential delay-causing issues along with their potential impact and the Provider’s
proposed workarounds.

1.2.2 Providers must be willing to participate in surveys, questionnaires, and

information gathering from the County as needed to contribute to the overall success of
the program.

1.3 Upon Award Completion

1.3.1 Provide a geographic information systems (GIS) map of the service area to the
County in .kmz or shapefile file format. The file must show the specific locations passed,
built and/or served as points and lines and should include a polygon giving the outline of
the funded service area.

1.3.2 Provide a closeout report/documentation to demonstrate successful project

completion to include:

1.3.2.1 Data about the technology used and services provided, such as available speeds,
technology in use, advertised speeds, average subscriber speeds, pricing of advertised
speeds and Affordable Connectivity Program signups.

1.3.2.2 Final report on the completed cost of the project, Provider financial contribution
and a listing of new residential, commercial and government subscribers to services.

1.3.2.3 Provide information from a technical perspective to guarantee the buildout meets
industry standards.

1.4 Disposition of Proposals

All information submitted in response to this RFP will become the property of the County
and may be returned only at the option of the County and at the expense of the Provider.
In any case, one copy shall be retained by the County for official files. Successful and
unsuccessful Providers will be notified by email. The County is not obligated to detail any
of the results of the evaluation.

The County reserves the right to accept or reject any or all proposals, to accept more than
one proposal, and also the right to waive any formal or informal defects in proposals when
deemed in the best interest of the County. The County reserves the right to accept a
proposal higher in price than the lowest price proposal and to negotiate with any Provider
concerning matters which the County determines require clarification or changes.

1.5 Compliance with Law

All goods or equipment shall comply with all applicable Federal, State, and local laws
relative thereto including all safety related items as required by the Federal Occupational

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 Safety and Health Act (OSHA). The Provider shall defend actions or claims brought and
hold harmless the County from loss, cost, or damage by reason of actual or alleged
violations of Federal, State, or local law in the design or manufacturing of equipment
and/or material. This Project is funded, in whole or in part, by funds received through a
federal grant requiring compliance with the Federal Uniform Guidance rules. 2 CFR Part
200. The Provider shall warrant and certify that, in the performance of the resultant
agreement, it has complied with or will comply with all applicable statutes, rules,
regulations and orders of the United States, including laws and regulations pertaining to
labor, wages, hours and other conditions of employment. Contract requirements include,
but are not limited to, the following:

1.5.1 Assignment of Contract . The selected Provider shall not assign, convey, sublet or
otherwise dispose of any contract resulting from this RFP, or any right, title or interest in
therein, without previous consent in writing from the County endorsed on or attached to
the contract.

1.5.2 Contract Performance and Payment Bond. If a construction contract that exceeds
$50,000 is awarded, the following bonds or security will be required and shall become
binding on the parties upon the execution of the contract:

a. Performance bond satisfactory to the County executed by a surety company

authorized to do business in the State of Michigan or otherwise secured in a manner
satisfactory to the County, in an amount equal to 100% of the price specified in the
contract; and

b. A payment bond satisfactory to the County, executed by a surety company

authorized to do business in the State of Michigan or otherwise secured in a manner
satisfactory to the County, for the protection of all persons supplying labor and material
to the contractor or its subcontractors for the performance of the work provided for in
the contract. The bonds shall be an amount equal to 100% of the price specified in the
contract.

Nothing herein shall prevent the requirement of such bonds on construction contracts
under $50,000 when the circumstances warrant.

1.5.3 Default Provision. If the Provider defaults, the County may procure the products
or services from other sources and hold the Provider responsible for any excess costs
incurred by the County.

1.5.4 Non-Collusion Affidavit, Non-Discrimination Clause and Hold Harmless Statement.

All Providers are required to complete Appendix C (includes the signature page for
Appendix D). The person signing the Appendix shall be an authorized party.

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 1.5.5 Davis Bacon/Prevailing Wage Rates. Treasury states in the frequently asked questions
document that the Davis-Bacon Act requirements do not apply to projects solely funded with
CSLFRF, except for projects undertaken by the District of Columbia. Recipients’ projects may be
subject to requirements of Davis-Bacon if a construction project is funded with funds from another
federal program that requires the enforcement of Davis-Bacon Act. Corollary state prevailing-wage-
in-construction laws may also apply to projects. Treasury encourages recipients to ensure that
water, sewer, and broadband projects use strong labor standards, including project labor
agreements and community benefits agreements that offer wage at or above the prevailing rate
and include local hire provisions. However, for projects with capital expenditures over $10 million,
recipients are required to report on wages and labor standards - these requirements can be met
with certifications that the project complies with Davis-Bacon Act.

1.6 Federal Funding Considerations

1.6.1 American Rescue Plan Act Funding.

On March 11, 2021, the President of the United States signed the American Rescue Plan Act
of 2021 (“ARPA”) into law. Section 9901 of ARPA amended Title VI of the Social Security Act
to add section 603, which establishes the Coronavirus Local Fiscal Recovery Fund. The
County has been allocated $15,460,396 in Local Fiscal Recovery Fund (“LFRF”) dollars under
ARPA.

The United States Department of Treasury has issued a final rule, and other guidance for
qualified uses of LFRF. Those qualified uses include responding to the COVID-19 public
health by making necessary investments in infrastructure including broadband.

The County has determined that this grant program is a qualified use of LFRF funds pursuant
to the interim rule and other applicable Department of Treasury guidance. On July 26, 2022,
the Board of Commissioners of Grantor approved up to $3,000,000 in LFRF funds to support
broadband infrastructure expansion within the County.

2. Payment Terms

Payment to support the development of infrastructure will be contingent on the award of

grant funding to the County. Any contact is subject to the condition, and each contract shall
include the condition, that the County receive grant funding in amounts acceptable to the
County, and the County may cancel any contract without liability, if such funding is not
received by the County. Providers are strongly encouraged to provide a minimum of 25
percent of funding to support the proposal area. All Providers must attach a summary of
audited financials to demonstrate ability to fund at the above levels. In-kind purchases that
support a proposal buildout may be considered as part of any matching requirement and
must be disclosed as part of this submission.

2.1 Distribution of Funds

2.1.1 Funding will be distributed pursuant to the final contract.

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3. Provider and Project Information: Please provide the following as part of your proposal.

3.1 Provider Name:

3.2 Proposal for which Service Area(s)

3.3 Provider Narrative.

Please provide, in narrative format, a description of Provider’s history and experience.
Include the following as part of your response:

• Provider number of years in business

• Organizational mission statement
• Overview of Provider’s current infrastructure
• Demonstrate previous experience constructing, operating, and providing
consumer services with track record and outcomes.
• Any examples of digital equity programs and community partnerships the Provider
has operated in the past.
• Explain how the Provider was affected by the Covid-19 pandemic
• Team members and roles

3.4 Project Narrative. Please provide, in narrative format, an overview of the proposed
infrastructure the Provider is seeking funding to construct. Include the following as part
of the Provider’s response:

• Overview of proposed infrastructure

• Provider’s community involvement and previous efforts to provide services within
the County
• Providers must submit the number of households & businesses to be served and
the square miles to be served
• Please provide projected consumer pricing and range of service offerings that
consumers will select from as part of this proposal.
• Relevant plans for digital equity programming
• Is the Provider participating in the Affordable Connectivity Program (ACP)? If yes,
please provide an outline of the implementation of the ACP. If no, please provide
a plan for implementation of the ACP.

3.5 Map of proposed build out (.kmz or shapefile file format). Please also indicate:
• Any existing infrastructure that Provider already owns and maintains
• All domiciles to be serviced
• Community facilities to be serviced (defined as law enforcement, fire stations,
emergency operations centers, healthcare, military, library, state, or local
government) as a result of proposed build out.

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 3.6 Project Schedule.
Assuming an award date of November 30, 2022 (subject to change), please provide a
project schedule aligned with the proposed budget and narrative. If Provider is applying
for multiple service areas, please submit separate project schedules in respect to each
service area.

3.7 Project Budget.

Please provide a projected budget. If Provider is applying for multiple service areas, please
submit separate budgets in respect to each service area. The budget should have:

• Sources that indicate ARPA grant dollars requested and supporting contributions
from Provider.
• Uses that includes administrative, site and right-of-way acquisition costs,
architectural and engineering fees, construction costs, contingencies, and other
categories as appropriate.
• Either sectioned into or separate from the main budget, indicate the cost to build
out the Initial Pass of infrastructure installation and the Road-To-Home
connection.

3.8 Environmental Narrative.

Please provide in a narrative format, a description of the environmental impact of the
proposed project. Projects must comply with all applicable Local, State and Federal laws
to include the Natural Resources and Environmental Protection Act (Act 451 of 1994), the
National Environmental Policy Act, the National Historic Preservation Act and the
Endangered Species Act.

3.9 Is the Provider registered on SAM.GOV?

3.10 Has the Provider, at any time, been disbarred from doing business with the US
Government?

3.11 Has the Provider received federal funding to supply broadband internet services in the
past? Please list coverage areas and status of each.

3.12 Has the Provider been subject to discipline, investigation, or other actions by the
Federal Communications Commission (FCC)? If yes, please explain.

Please provide recent audited financial statements covering FY 2019, 2020, and 2021 that
include summary-level historical revenue, expenditure, and net asset financial information
based on the detailed financial statements for the last three years. If not available at the time
of submission, please explain.

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 APPENDIX A: SERVICE AREAS

1.1 General Information

The proposal service areas are provided as a guide for Providers and are subject to change.
The proposal areas are contained to several census tracts, it is up to the Providers to
determine the serviceable domiciles within each defined service area. The State of Michigan
is mapping currently available services across the state, a process that will narrow the areas
that will be eligible to receive funding as part of this RFP. If a portion of the proposed area or
homes within will be unserved within the Provider’s proposal, the Provider should document
any rationale within the response. Providers may respond to any or all three service areas.

1.2 Service Areas

1.2.1 West Service Area
Townships: Lebanon, Essex, Greenbush, Duplain,
Dallas, Bengal, Westphalia, and Eagle
Census Tract (GEOID): 26037010400,
26037010500, 26037010600, 26037010701,
26037010702

1.2.2 Central Service Area

Townships: Riley and Olive
Census Tract (GEOID): 26037010902

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1.2.3 East Service Area
Townships: Ovid, Victor and Bath (North of I-69)
Census Tract (GEOID): 26037011001,
26037011002, 26037011101

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 APPENDIX B: SCORING RUBRIC

If applying for multiple Service Areas, service area-specific responses will be scored independently of each other.

1. Minimum Service Performance of the Offered Service (20 points maximum)

Any subscriber of broadband funded under this initiative should be able to receive no less than 100 Mbps download and 20 Mbps
upload during peak hours, accounting for expected usage of other customers on the network.

Points will be awarded for speeds beyond the minimum. The Provider may offer consumer services below this threshold, but the
broadband must be capable of 100/20 upon project completion for similar market rates.

The technology installed must be expandable into the future. A certification from a licensed Professional Engineer must declare
that the proposed system will deliver these speeds to every premise in the proposed funded service area.

The included certification form must be signed by a Professional Engineer.

Points are assigned as follows for services available upon project completion:

100 Mbps Download x 20 Mbps Upload = 0 points, application qualifies for the program

100 Mbps Download x 100 Mbps Upload = 5 points

250 Mbps Download x 250 Mbps Upload = 10 points

500 Mbps Download x 500 Mbps Upload = 15 points

1,000 Mbps Download x 1,000 Mbps Upload = 20 points

2. Financial Support / % of Funding by Provider (25 points maximum)

Applicants are strongly encouraged to provide a minimum of 25 percent funding. Applicants will receive 1 point for every
percentage point beyond 25%. All applicants must attach a summary of audited financials to demonstrate ability to fund at the
above levels.

Note: Any project proposing less than a 25% applicant match must clearly explain (in the above narrative) the extenuating
circumstances for consideration that directly reference the financial position of the applicant firm. Projects with extenuating
circumstances will not be penalized on the scoring system.

Points are assigned as follows:

Applicant with greater than 25% funding will receive 1 point for every percentage point beyond 25%, up to 25 points.

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 3. Community Facilities (5 points maximum).

For every community facility served (defined as law enforcement, fire stations, emergency operations centers,
healthcare, military, library, state, or local government), one point will be awarded up to a maximum of 5 points.

Community Facilities

Community Facility Address City

Community Facility Address City

Community Facility Address City

Community Facility Address City

Community Facility Address City

Points are assigned as follows:

Example: 1 x 5 community facilities = 5 points

4. Project Timelines (15 points)

For applications where the project will be completed by December 31, 2023, 15 points will be awarded. Projects that will be
completed by December 31, 2024 will be awarded 10 points. Projects that will be completed by December 31, 2025 will be
awarded 5 points. The mandatory completion date for all projects is December 31, 2026.

Points are assigned as follows:

Project completed by December 31, 2023 = 15 points

Project completed by December 31, 2024 = 10 points

Project completed by December 31, 2025 = 5 points

5. Digital Equity (15 points)

Providers who have registered to participate in the Affordable Connectivity Program (ACP) will be awarded 5 points. Providers
who demonstrate significant outreach and success in signing up users for the ACP, or the previous Emergency Broadband Benefit
program, will be awarded an additional 5 points. Providers who currently have programs, or can demonstrate a plan to provide a
program, that offers qualified users a device to access broadband services will be awarded an additional 5 points.

Points are assigned as follows:

Provider registered for the ACP = 5 points
Demonstrated history of signups for the ACP or EBB = 5 points
Provider device access program = 5 points

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 6. Project Plan (20 points)

Provider has clearly explained how it will accomplish the project(s) by providing a description of how all the required
elements of the project will be met as requested in the narratives.

4 points = Only meets some of the basic requirements

8 points = Meets Basic Requirements but limited in one or more areas

12 points = Meets Basic Requirements

16 points = Meets Requirements & Exceeds Community Integration

20 points = Exceeds Requirements, Community Integration & Demonstrates Innovation

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 APPENDIX C: CERTIFICATIONS AND ASSURANCES

Firm Name:
The Provider makes the following statement of assurances as a required element of the bid to
which it is attached, understanding that the truthfulness of the facts affirmed here and the
continuing compliance with these requirements are conditions precedent to the award or
continuation of the related contract(s):

1. The prices and/or data have been determined independently, without

consultation, communication, or agreement with other bidders for the purpose of restricting
competition. However, Provider may freely join with other persons or organizations for the
purpose of presenting a single bid.

2. The attached bid is a firm offer for a period of one hundred eighty (180) days from
the proposal due date, and it may be accepted by the County without further negotiation (except
where obviously required by lack of certainty in key terms) at any time within the one hundred
eighty (180) day period.

3. The Provider understands that the County will not reimburse Provider for any
costs incurred in the preparation of this bid. All bids become the property of the County, and
Provider claim no proprietary right to the ideas, writings, items, or samples, unless so stated in
this bid.

4. Unless otherwise required by law, the prices and/or cost data which have been
submitted have not been knowingly disclosed by the bidder and will not knowingly be disclosed
by him/her prior to opening, either directly or indirectly to any other bidder or to any competitor.

5. No attempt has been made or will be made by the bidder to induce any other
person or firm to submit or not to submit a bid for the purpose of restricting competition.

6. The Provider agrees that submission of the attached bid constitutes acceptance of
the solicitation contents.

7. The Provider acknowledges communication of any kind regarding the RFP directed
to parties other than the identified contact person may result in disqualification of Provider’s
proposal.

8. The Provider warrants that no conflict of interest knowingly exists for any member
of the project team that contributed to this bid or prospective contract.

9. The Provider shall procure and maintain Workers’ Compensation Insurance,

including Employer’s Liability Coverage, in accordance with all applicable statutes of the State of
Michigan during the duration of this prospective contract.

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 10. The Provider shall procure and maintain Professional Liability Insurance (errors
and omissions) shall be maintained during the life of this contract with limits of liability of not
less than $1,000,000 per claim.

11. The Provider shall procure and maintain Comprehensive General Liability
Insurance on an “Occurrence Basis” with limits of liability not less than $1,000,000 per occurrence
and/or aggregate combined single limit. Coverage shall include the following: a) Contractual
Liability; b) products and completed operations; c) Independent Providers Coverage; d) Broad
Form General Liability Endorsement or Equivalent.

12. The Provider shall procure Additional Insured Commercial General Liability
Insurance, as described above, shall include an endorsement stating the following shall be
“Additional Insureds”. The County, all elected and appointed officials, all employees and
volunteers, all boards, commissions and/or authorities and board members, including employees
and volunteers thereof.

13. Cancellation Notice- All insurances described above shall include an endorsement
stating the following: “It is understood and agreed that thirty (30) days advanced written notice
of cancellations, non-renewal, reduction and/or material change shall be sent to the County
Administrative Services, Attention Penny Goerge, 100 E State Street Suite 2100, St. Johns, MI
48879”

14. The Provider shall provide to the County at the time the contracts are returned by
it for execution, two (2) copies of certificates of insurance for each of the policies mentioned
above. If so requested, certified copies of all policies will be furnished.

15. The Provider shall, as required by law, and/or the Equal Opportunity Employment
and Non-Discrimination Policy of the County, shall not discriminate against an employee or
applicant for employment with respect to hire, tenure, terms, conditions or privilege of
employment, or a matter directly or indirectly related to employment because of race, color,
religion, sex, sexual orientation, gender identity, national origin, disability, height, weight, marital
status, age or political affiliation (except where age, sex or lack of disability constitutes a bona
fide occupational qualification.) Provider shall adhere to all applicable Federal, State and local
laws, ordinances, rules and regulations prohibiting discrimination, including, but not limited to,
the following:

• The Elliott-Larsen Civil Rights Act, 1976 PA 453, as amended.

• The Persons with Disabilities Civil Rights Act, 1976 PA 220, as amended.
• Section 504 of the Federal Rehabilitation Act of 1973, P.L. 93-112, 87 Stat. 394, as
amended, and regulations promulgated there under.
• The Americans with Disabilities Act of 1990, P.L. 101-336, 104 Stat 328 (42 USCA §12101
et seq), as amended, and regulations promulgated there under.

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 16. The Provider who is selected shall, at its own expense, protect, defend, indemnify,
save and hold harmless the County and its elected and appointed officers, employees, servants
and agents from all claims, damages, lawsuits, costs and expenses including, but not limited to,
all costs from administrative proceedings, court costs and attorney fees that the County and its
elected and appointed officers, employees, servants and agents may incur as a result of the acts,
omissions or negligence of the Provider or its employees, servants, agents or subcontractors that
may arise out of the agreement.

The Provider’s indemnification responsibility under this section shall include the sum of
damages, costs and expenses which are in excess of the sum of damages, costs and expenses
which are paid out on behalf of or reimbursed to the County, its officers, employees, servants
and gents by the insurance coverage obtained and/or maintained by the Provider.

17. The Provider who is selected shall be an independent contractor. The employees,
servants and agents of the Provider shall not be deemed to be and shall not hold themselves out
as employees, servants, or agents of the County and shall not be entitled to any fringe benefits
received by the County’s personnel, such as, but not limited to, health and accident insurance,
life insurance, longevity or paid sick or vacation leave. The Provider shall be responsible for paying
all compensation to its personnel for services they have performed under this Contract and for
withholding and payment of all applicable taxes to the proper Federal, State and local
governments.

18. The Provider must certify to the County that neither it nor any of its successors,
parent companies, subsidiaries, or companies under common ownership or control of the
Provider, are an “Iran linked business” engaged in investment activities of $20,000,000.00 or
more with the energy sector of Iran, within the meaning of the Iran Economic Sanctions Act,
Michigan Public Act 517 of 2012 (MCL 129.311 et seq.). The Provider shall not become an “Iran
linked business” during the term of the contract.

NOTE: IF A PERSON OR ENTITY FALSELY CERTIFIES THAT IT IS NOT AN IRAN LINKED

BUSINESS AS DEFINED BY PUBLIC ACT 517 OF 2012, IT WILL BE RESPONSIBLE FOR CIVIL PENALTIES
OF NOT MORE THAN $250,000.00 OR TWO TIMES THE AMOUNT OF THE CONTRACT FOR WHICH
THE FALSE CERTIFICATION WAS MADE, WHICHEVER IS GREATER, PLUS COSTS OF INVESTIGATION
AND REASONABLE ATTORNEY FEES INCURRED, AS MORE FULLY SET FORTH IN SECTION 5 OF ACT
NO. 517, PUBLIC ACTS OF 2012.

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 APPENDIX D: SIGNATURE PAGE

Provider represents and certifies as part of the proposal that he/she is authorized to act as an
agent for the company responsible for this proposal.

Legal name and address of firm submitting the Request for Proposal:

_________________________________
Signature of Approving Authority Title

_________________________________
Printed Name

_________________________________
Date

THIS FORM SHALL BE COMPLETED AND RETURNED WITH YOUR BID. FAILURE TO SUBMIT THIS
COMPLETED FORM MAY RESULT IN DISQUALIFICATION.

6475580

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