RFQ-4

RFP ____________________

Contractors Full Legal Name _________________________________

METROPOLITAN TRANSPORTATION AUTHORITY

CONTRACTOR RESPONSIBILITY FORM
INSTRUCTIONS1

1. Who should complete and sign the Contractor Responsibility Form? This form must be
completed by all proposers. The person who completes the Contractor Responsibility
Form on behalf of the submitting proposer must provide his/her title, telephone/fax
number and e-mail address in Part II of the questionnaire. The person who signs the
questionnaire on behalf of the submitting proposer should be either Chief Executive,
Executive Director, Chief Administrator, President, Vice President, Treasurer, Secretary,
Chair of the Board of Directors, or the principal owner or officer responsible for
administering the submitting proposers contract.
2. For purposes of this questionnaire, the terms Contractor, bidder, and
bidder/proposer refer to both a bidder/proposer.
3. For all questions, matters on appeal must be disclosed.
4. Unless otherwise noted, all questions relate to the previous ten (10) years.
5. All questions on this questionnaire must be answered; do not leave blanks. Where
appropriate, state None or Not Applicable (N/A).
6. If additional space is required to fully respond to any question, please add sheets to this
questionnaire and reference the question/answer appropriately.
7. This form includes:
a. Contractor representations and obligations (Part III) which (a) apply to Contractor's
bid/proposal. If any representation is not accurate and complete at the time Contractor
signs this form, Contractor must, as part of its proposal, identify the provision and
explain the reason in detail on a separate sheet, as provided in Part III; and

1
PERSONAL PRIVACY PROTECTION LAW NOTIFICATION
The information the Contractor is providing on this application, including information about Key People, is
requested pursuant to the New York State Public Authorities Law for the purposes of determining the Applicant
Firms responsibility for a contract award. Failure to provide the specified information and authorization requested
may, in the sole discretion of the MTA, prevent your firms award of a contract by the MTA and/or its agencies.
The information will be kept in a file maintained by MTA and its agencies or other files maintained under the
authority of MTA and its agencies. Information which, because of any name, number, symbol, mark or other
identifier, can be used to identify a person, shall be received, maintained and used by the MTA and its agencies
solely for the above-stated purposes and will be protected from public disclosure to the fullest extent permitted by
law.
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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
1
 b. Questions which Contractor must answer as part of its bid/proposal (Parts III.C., IV, and
V).
8. The Authority reserves the right to inquire further with respect to Contractor's responses;
and Contractor consents to such further inquiry and agrees to furnish all relevant
documents and information as requested by the Authority. Any response to this document
prior or subsequent to Contractor's proposal which is or may be construed as unfavorable to
Contractor will not necessarily automatically result in a negative finding on the question of
Contractors responsibility or a decision to terminate the Contract if it is awarded to
Contractor.
9. Definitions:
a. Affiliate: An entity in which the parent of the submitting contractor owns more than
fifty (50) % of the voting stock and/or an entity in which a group of principal owners
or officers that owns more than fifty (50) % of the submitting contractor also owns
more than fifty (50) % of the voting stock.
b. Authority: refers to the MTA and/or MTA subsidiary or affiliate to which the
Contractor is submitting its bid or proposal and/or which is awarding the contract
sought.
c. Control: The submitting contractor is controlled by another entity when: (1) the other
entity holds ten (10) % or more of the voting stock of the submitting contractor; or (2)
the other entity directs or has the right to direct daily operations. The submitting
contractor controls another entity when: (1) it holds ten (10) % or more of the voting
stock of the other entity; or (2) it directs or has the right to direct daily operations.
d. Government agency(ies): include city, state, federal public agencies, quasi-public
agencies, authorities and corporations, public development corporations, public
benefit corporations and local development corporations.
e. Integrity Monitor: includes an Independent Private Sector Inspector General
(IPSIG), or any independent private sector firm with legal, audit, investigative and
loss prevention skills, employed by an organization or government entity, either
voluntarily or by compulsory process, to monitor an entitys business activities to
ensure compliance with relevant laws and regulations, as well as to uncover and
report unethical or illegal conduct within and against the entity.
f. Joint Venture: a business undertaking by two or more persons, corporations or other
legal entities engaged in a single defined project. The necessary elements are: (1) an
express or implied agreement; (2) a common purpose the group intends to carry out;
and (3) shared profits and losses.
g. Managerial employees or managerial capacity: Employees in a supervisory capacity
who, either by virtue of their title or their duties, operate with discretion over
solicitation, letting, or management of contracts with public agencies.
h. Metropolitan Transportation Authority (MTA) subsidiary or affiliate includes:
New York City Transit Authority (NYCT), Manhattan and Bronx Surface Transit
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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
2
 Operating Authority (MaBSTOA), Staten Island Rapid Transit Operating Authority
(SIRTOA), Triborough Bridge and Tunnel Authority (TBTA), Metro-North
Commuter Railroad Company (MNCR), Long Island Rail Road (LIRR),
Metropolitan Suburban Bus Authority (MSBA), MTA Bus Company (MTA BC),
MTA Capital Construction (MTACC) and First Mutual Transportation Assurance
Company (FMTAC).
i. Officer: Any individual who serves as or performs the functions of chief executive
officer, chief financial officer, or chief operating officer of the submitting contractor,
without regard to such individuals title. president, vice president, secretary, treasurer,
board chairperson, trustee (individual or entity who administers a trust) or their
equivalents.
j. Parent: Any entity including, but not limited to any individual, partnership, joint
venture or corporation which owns (50) % or more of the voting stock of another
entity.
k. Principal Owner: An individual, partnership, joint venture or corporation that holds a
ten (10) % or greater ownership interest in a submitting contractor or subcontractor.
l. Share: To have space, staff, equipment, expenses, or use such items, in common with
one or more other entities.
m. Significant Adverse Information: includes but is not limited to an unsatisfactory final
performance evaluation on a contract with any MTA agency within the immediate
prior three (3) years, an uncured interim unsatisfactory rating on a contract with any
MTA agency, or an answer of yes to any question in Part IV herein.
n. Subcontract: An agreement between an individual or entity that is a party to a
contract and another individual or entity which is for the provision of goods, services
or construction pursuant to that contract, and has a value that when aggregated with
the values of all other such agreements with the same individual or entity and
subcontractor during the immediately preceding twelve (12) month period is valued at
one million dollars ($1,000,000) or more, and in special circumstances involving
agreements of $100,000 or more.
o. Submitting Contractor: The entity submitting the Contractor Responsibility Form.
p. Subsidiary: An entity in which the majority of the voting stock is owned by a parent.

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
3
 PART I. IDENTITY OF CONTRACTOR:

A. Contractors full legal name:

B. Tax ID Number (TIN), Employer Identification Number (EIN) and Social

Security Number (SSN), as applicable:

C. Contractors form of legal entity (corporation, joint venture, sole proprietorship, etc.):

If the Contractor is a Joint Venture, or Partnership, please list all partner firms and/or
parties to the Joint Venture below. All partners and/or parties listed are also required
to individually complete a separate Contractor Responsibility Form.

(1) Partner/Party name:

TIN, EIN, or SSN:
Percentage of Ownership:

(2) Partner/Party Name:

TIN, EIN, or SSN:
Percentage of Ownership:

D. State or country under whose laws Contractor is organized and year organized:
___________________________________________________________________

E. Does the Contractor now use or, in the past ten (10) years has it used, TIN, EIN,
doing business as or DBA, name, trade name or abbreviation other than the
Contractors name or TIN, or EIN number listed in Part I.B. above?
________________

F. Contractors mailing address:

G. Contractors street address (complete only if different than F):

___________________________________________________________________
___________________________________________________________________

H. Has contractor changed its address in the past five (5) years and, if so, what was the
firms prior address(es)?

I. Contractors telephone number: Fax number:

Email address:

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
4
 PART II. IDENTITY OF PERSON COMPLETING THIS QUESTIONNAIRE:

A. Name:

B. Employer/Title:

C. Telephone number: Fax number:

D. Email address: Mobile number:

PART III. CONTRACTOR REPRESENTATIONS: If for any reason a representation on this

questionnaire is not accurate and complete as of the time Contractor signs this form, Contractor
must identify the provision and explain the reason in detail on a separate sheet. Absent such an
explanation, Contractor represents that the following statements are complete and accurate:
Please check this box if a separate sheet is attached: :

A. Statement of non-collusion as required by Section 2878 of the Public Authorities Law:

(1) By submission of this bid, each bidder and each person signing on behalf of any bidder
certifies, and in the case of a joint bid each party thereto certifies as to its own
organization, under penalty of perjury, that to the best of his knowledge and belief:

a. The prices in this bid have been arrived at independently without collusion,
consultation, communication, or agreement, for the purpose of restricting
competition, as to any matter relating to such prices with any other bidder or with
any competitor;

b. Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not knowingly be
disclosed by the bidder prior to opening, directly or indirectly, to any other bidder or
to any competitor; and

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

(2) A bid shall not be considered for award nor shall any award be made where (1) (a), (b),
and (c) above have not been complied with; provided however, that if in any case the
bidder cannot make the foregoing certification, the bidder shall so state and shall furnish
with the bid a signed statement which sets forth in detail the reasons therefor. Where (1)
(a), (b), and (c) above have not been complied with, the bid shall not be considered for
award nor shall any award be made unless the Chief Procurement Officer of the
Authority, or designee, determines that such disclosure was not made for the purpose of
restricting competition.
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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
5
 The fact that a bidder (a) has published price lists, rates, or tariffs covering items being
procured, (b) has informed prospective customers of proposed or pending publication of
new or revised price lists for such items, or (c) has sold the same items to other
customers at the same prices being bid, does not constitute, without more, a disclosure
within the meaning of paragraph 1(a) herein.

B. Statement of no-conflict of interest:

(1) No appointed or elected official, member or other officer or employee of the City or
State of New York, or of the Metropolitan Transportation Authority ("MTA"), or MTA's
affiliates and subsidiaries: i) is interested, directly or indirectly, in any manner
whatsoever in or in the performance of the Contract or in the supplies, work, or business
to which it relates or in any portion of the profits thereof; or ii) has been or will be
offered or given any tangible or intangible consideration in connection with this
bid/proposal/Contract.

(2) Contractor covenants that neither Contractor nor, to the best of Contractor's knowledge
after diligent inquiry, any director, officer, owner or employee of Contractor or any
person or entity with a 10% or more interest in Contractor has any interest nor shall
they acquire any interest, directly or indirectly, which would conflict in any manner or
degree with the faithful performance of the Contract hereunder.

(3) In the event Contractor has no prior knowledge of a conflict of interest as set forth in "1"
and "2" above and hereafter acquires information which indicates that there may be an
actual or apparent violation of any of the above, Contractor shall promptly bring such
information to the attention of the Authority's Chief Procurement Officer. Contractor
shall thereafter cooperate with the Authority's review and investigation of such
information, and comply with any instructions it receives from the Chief Procurement
Officer in regard to remedying the situation.

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
6
 C. The following questions apply to any bid, proposal, or contract between Contractor
and the City or State of New York, any other state, any public authority or other public
entity, the United States government, the MTA, and MTA affiliates and subsidiaries.
(If the answer to any question is YES, Contractor must provide all relevant
information on a separate sheet annexed hereto). Please check this box if a separate
sheet is attached:

The following questions apply to: i) Contractor, Contractor's parent, subsidiaries

and affiliates of Contractor (if any); ii) any joint venture (including its individual
members) and any other form of partnership (including its individual members)
which includes Contractor or Contractor's parent, subsidiaries, or affiliates of
Contractor, iii) Contractor's directors, officers, principals, managerial employees,
and any person or entity with a 10% or more interest in Contractor; iv) any legal
entity controlled, or 10% or more of which is owned, by Contractor, or by any
director, officer, principal, managerial employee of Contractor, or by any person or
entity with a 10% or more interest in Contractor.

(1) Within the past five (5) years, has Contractor been NO YES
declared not responsible?

(2) Has Contractor been debarred, suspended, or otherwise NO YES

disqualified from bidding, proposing, or contracting?

(3) Is there a proceeding pending relating to Contractors NO YES

responsibility, debarment, suspension, or qualification to
receive a public contract?

(4) Within the past five (5) years, has Contractor defaulted NO YES
on a contract or been terminated for cause?

(5) Has a government agency or other public entity NO YES

requested or required enforcement of any of its rights
under a surety agreement on the basis of the
Contractors default or in lieu of declaring Contractor in
default?

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
7
 (6) Within the past five (5) years, has the Contractor been NO YES
required to engage the services of an Integrity Monitor
in connection with the award of or in order to complete,
any public or private contract?

(7) Within the past five (5) years, have Contractors safety NO YES
practices/procedures been evaluated and ruled as less
than satisfactory by the City or State of New York, any
other state, any public authority or any public entity, the
United States government, the MTA, MTA affiliates or
subsidiaries?

(8) Has Contractors Workers Compensation Experience NO YES

Rating been 1.2 or greater at any time in the last five (5)
years? If yes, please explain.

D. Consent to the jurisdiction of New York courts and to service of process:

(1) If Contractor is not organized under the laws of the State of New York, Contractor
consents to the jurisdiction of the Courts of the State of New York and to the jurisdiction
of any federal court located within the City of New York, with respect to any matter
pertaining to Contractor's bid/proposal and, if the Contract is awarded to Contractor, to
the Contract.

(2) Contractor agrees that service of process in any judicial or administrative action may be
made upon it by certified mail, return receipt requested, sent to the mailing address for
Contractor specified above.

(3) Contractor agrees that any judicial or administrative action or proceeding commenced
by Contractor against the Authority shall only be commenced in a state or federal court
or agency located within the City of New York.

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
8
 PART IV. QUESTIONS WHICH MUST BE ANSWERED BY "YES" or "NO": (In the
event of a "YES," Contractor must provide all relevant information on a separate sheet
annexed hereto, and the Authority reserves the right to inquire further with respect
thereto.)

To the best of your knowledge after diligent inquiry, in connection with the business of
Contractor or any other firm which is related to Contractor by any degree of common
ownership, control, or otherwise, do any of the following statements apply to: i)
Contractor, Contractor's parent, subsidiaries and affiliates of Contractor (if any); ii) any
joint venture (including its individual members) and any other form of partnership
(including its individual members) which includes Contractor or Contractor's parent,
subsidiaries, or affiliates of Contractor; iii) Contractor's directors, officers, principals,
managerial employees, and any person or entity with a 10% or more interest in
Contractor; iv) any legal entity controlled, or 10% or more of which is owned, by
Contractor, or by any director, officer, principal, managerial employee of Contractor, or
by any person or entity with a 10% or more interest in Contractor.

A. Within the past ten (10) years, has been convicted of or

pleaded nolo contendre to (1) any felony or (2) a
NO YES
misdemeanor related to truthfulness in connection with
business conduct.

B. Has pending before any state or federal grand jury or court

an indictment or information of the commission of a crime NO YES
which has not been favorably terminated.

C. Is the subject of a pending investigation by any grand jury,

commission, committee or other entity or agency or
authority of any local, state, or the federal government in NO YES
connection with the commission or alleged commission of a
crime.

D. Is currently disqualified from selling or submitting

bids/proposals to or receiving awards from or entering into
NO YES
any contract with any federal, state or local government
agency, any public authority or any other public entity.

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
9
 E. Within the past five (5) years, has refused to testify or to
answer any question concerning a bid or contract with any
federal, state, or local government agency, any public
authority or any other public entity when called before a grand
jury or other committee, agency or forum which is
NO YES
empowered to compel the attendance of witnesses and
examine them under oath, upon being advised that neither the
person's statement nor any information or evidence derived
from such statement will be used against that person in any
subsequent criminal proceeding.

F. Is currently disqualified from selling or submitting a bid to, or

receiving an award from, or entering into any contract with
any public entity or public authority within the State of New
York because, within the past five (5) years, such entity or
person refused to testify or to answer any relevant question
concerning a transaction or contract with the State of New
York, any political subdivision of the State of New York, or a
public authority or a public department, agency or official of
NO YES
the State of New York or of a political subdivision of the State
of New York, when called before a grand jury or other state or
local department, commission or agency which is empowered
to compel the attendance of witnesses and examine them
under oath, upon being advised that neither that person's
statement nor any information or evidence derived from such
statement will be used against that person in any subsequent
criminal proceeding.

G. Has within a ten (10) year period preceding this Bid/Proposal

been convicted of or had a civil judgment rendered against it
for or in relation to: (i) commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or
performing a public (federal, state or local) transaction or
contract under a public transaction; (ii) collusion with another
NO YES
person or entity in connection with the submission of
bid/proposals; (iii) violation of federal or state antitrust
statutes or False Claims Acts; or (iv) commission of
embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statement(s) or receiving
stolen property.

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
10
 PART V. ADDITIONAL QUESTIONS: In the event of a Yes, Contractor must provide all
relevant information on a separate sheet annexed hereto, and the Authority reserves the right
to inquire further with respect thereto.

A. List the name, title, and home and business address of each person or legal entity which
has a 10% or more ownership or control interest in Contractor:

Name:
Title:
Home address:

Business address:

B. List the name, title, and home and business address of each director and principal officer
of Contractor:

Name:
Title:
Home address:

Business address:

C. In the past ten (10) years, has Contractor entered into a

NO YES
consent decree, deferred prosecution agreement, or a non-
prosecution agreement?

D. In the past three (3) years, has Contractor been a

subcontractor on any contract with the Authority? NO YES

E. In the past seven (7) years, have any bankruptcy proceedings

been initiated by or against the Contractor (whether or not
closed) or is any bankruptcy proceeding pending by or against NO YES
the Contractor regardless of the date of filing?

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
11
 F. In the past five (5) years, have there been any judgments,
injunctions, or liens of $100,000 or more, including but not
limited to, judgments based on taxes owed, fines and NO YES
penalties assessed by a government agency against Contractor
at any time?

G. Are there any judgments, injunctions, or liens for $100,000 or

more each against Contractor that remain open, unsatisfied or in NO YES
effect today?

H. During the past five (5) years, has the Contractor failed to file
NO YES
any applicable federal, state or local tax return?

I. Does the Contractor own or rent office space? Please provide

NO YES
details.

J. Does any principal owner or officer of the Contractor, or any

member of his/her immediate family, have an ownership
NO YES
interest in any entity that holds the title or lease to any real
property used by the Contractor?

K. Does Contractor share office space, staff, equipment, or NO YES

expenses with any other entities? If YES, please provide
details.

L. Contractor is required to provide a list of contracts as requested in (1) and (2) below.
For each of the contracts listed in (1) and (2) below, Contractor shall provide a brief
description of the work performed, the contract number, the dollar amount at award and
at completion, date completed, and the name and telephone number of the owners
representative:

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
12
 (1) List all contracts completed during the last three (3) years. If more than three (3)
contracts have been completed in the past three (3) years, list the last three (3)
contracts completed.

a. Brief description of work performed:

Contract number:
Dollar amount of award:
Date completed:
Name/Telephone number of company and owners representative:

Dollar amount at completion:

b. Brief description of work performed:

Contract number:
Dollar amount of award:
Date completed:
Name/Telephone number of company and owners representative:

Dollar amount at completion:

c. Brief description of work performed:

Contract number:
Dollar amount of award:
Date completed:
Name/Telephone number of company and owners representative:

Dollar amount at completion:

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
13
 (2) List each contract completed by Contractor during the last three (3) years for which
liquidated damages or penalty provisions were assessed against Contractor for failure
to complete the work on time or for any other reason. Contractor is required to
provide an explanation of the circumstances for each contract.

a. Brief description of work performed:

Contract number:
Dollar amount of award:
Date completed:
Name/Telephone number of company and owners representative:

Dollar amount at completion:

b. Brief description of work performed:

Contract number:
Dollar amount of award:
Date completed:
Name/Telephone number of company and owners representative:

Dollar amount at completion:

c. Brief description of work performed:

Contract number:
Dollar amount of award:
Date completed:
Name/Telephone number of company and owners representative:

Dollar amount at completion:

M. Furnish the following information for each contract for which, during the last three (3)
years, the Contractor was:
(1) Terminated for default; or
(2) Sued to compel performance; or
(3) Sued to recover damages, including, without limitation, upon an alleged breach of
contract, misfeasance, error or omission or other alleged failure on Contractors
part to perform as required by the contract; or
(4) Called upon a surety to perform the work; or
(5) Required to engage the services of an Integrity Monitor in connection with the
award of or in order to complete, any public or private contract; or
(6) Required to draw on a letter of credit in lieu of a performance bond.
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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
14
 a. Brief description of work performed:

Contract number:
Dollar amount of award:
Date completed:
Name/Telephone number of company and owners representative:

If none of the above situations occurred during the last three (3) years, state NONE here:
______________
N. List all Contractor employees: (Attach additional sheets as needed)
(1) Who are currently employees of MTA or any MTA subsidiary or affiliate:
Name:_________________________________________________________
Currently employed by: (check as appropriate)
MTA NYCT MaBSTOA SIRTOA MNCR

LIRR MSBA TBTA MTACC MTA BC

Name:_________________________________________________________
Currently employed by:
MTA NYCT MaBSTOA SIRTOA MNCR

LIRR MSBA TBTA MTACC MTA BC

Name:_________________________________________________________
Currently employed by:
MTA NYCT MaBSTOA SIRTOA MNCR

LIRR MSBA TBTA MTACC MTA BC

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
15
 (2) Who within the past two (2) years have been MTA or any MTA subsidiary or
affiliate employees who were involved on behalf of Contractor with the preparation
of this bid/proposal or would be involved in the performance of the contract if it is
awarded to Contractor.

Name:_________________________________________________________
Currently employed by:
MTA NYCT MaBSTOA SIRTOA MNCR

LIRR MSBA TBTA MTACC MTA BC

Name:_________________________________________________________
Currently employed by:
MTA NYCT MaBSTOA SIRTOA MNCR

LIRR MSBA TBTA MTACC MTA BC

O. Omitted

P. Does Contractor have a subsidiary or affiliate? NO YES

Q. Is Contractor a subsidiary of another entity? NO YES

R. Within the past five (5) years or currently, does Contractor, any
director, officer, principal, managerial employee of Contractor,
or any person or entity with a 10% or more interest in NO YES
Contractor have an interest of 10% or more in any other firm or
legal entity?

S. If the answer to P, Q or R is YES, would Contractors

answers pertaining to Part V Questions A through M above
be the same for each such parent, subsidiary, affiliate, firm or NO YES
legal entity? If not, please provide a full explanation on a
separate sheet of paper.

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
16
 T. Omitted

U. Does your firm comply with New York State Education

Law Section 7209 with respect to the firm's
authorization to practice engineering in the State of New NO YES
York. (Check "Yes" or "No", as appropriate.)

Contractor must sign here:

Authorized Signature

Date:

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
17
 METROPOLITAN TRANSPORTATION AUTHORITY
CONTRACTOR RESPONSIBILITY FORM

AFFIDAVIT AND ACKNOWLEDGEMENT

(Complete and submit this Affidavit and Acknowledgement Form unless

the Affidavit of No Change applies.)

STATE OF ________________)
) SS:
COUNTY OF______________)

On the ____ day of ___________201__, before me personally came and appeared

______________________ by me known to be said person, who swore under oath as follows:

1. I am _______________________ of _________________________________.
(Print name and title) (Print name of firm)

2. I am duly authorized to sign this questionnaire on behalf of said firm and duly signed
this document pursuant to said authorization.

3. The answers to the questions set forth in the Metropolitan Transportation Authority
Contractor Responsibility Form and, except as set forth in the stated exceptions in Part
III, the representations set forth in this questionnaire, are true, accurate and complete. I
authorize the MTA to verify any such information and to conduct any background
checks it deems appropriate.

4. I acknowledge and understand that the questionnaire includes provisions which are
deemed included in the contract if awarded to the firm.

Signature

Sworn to and subscribed to before me

this ____ day of ____________, 201_.

______________________________

Notary Public ____________ County

My commission expires: __________

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
18
 METROPOLITAN TRANSPORTATION AUTHORITY
CONTRACTOR RESPONSIBILITY FORM

AFFIDAVIT OF NO CHANGE AND ACKNOWLEDGEMENT

STATE OF ________________)
) SS:
COUNTY OF______________)

On the ____ day of ___________201__, before me personally came and appeared

______________________ by me known to be said person, who swore under oath as follows:

1. I am _______________________ of __________________________________.
(Print name and title) (Print name of firm)
2. I am duly authorized to sign this Affidavit of No Change on behalf of said firm and
duly signed this document pursuant to said authorization.

3. The Contractor previously submitted a Metropolitan Transportation Authority

Contractor Responsibility Form within six (6) months prior to the date hereof to the
Metropolitan Transportation Authority or an MTA subsidiary or affiliate.

4. Attached is an accurate and true copy of such previously submitted MTA Contractor
Responsibility Form.

5. I hereby certify that there has been no material change in the information specified on
such attached Contractor Responsibility Form except as follows:

6. I acknowledge and understand that the previously submitted MTA Contractor

Responsibility Form includes provisions which are deemed included in the contract if
awarded to the firm.

Signature
Sworn to and subscribed to before me
this ____ day of ____________, 201_
______________________________

Notary Public ____________ County

My commission expires: __________

------------------------------------------------------------------------------------------------------------------------
No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
19
 RFQ-4; Supplement A

RFP____________________________

ATTESTATION REGARDING CONFLICTS ON

AUTHORITY PROCUREMENTS

The Authority has established the following guidelines for your information and use if you elect to
participate in our procurement process either as a prime consultant or any tier subconsultant. Such
guidelines are required to be reviewed. Your signature on this supplement affirms that you agree and attest
that you have read these requirements and that you will abide with these requirements.
Scoping consultants are not precluded from proposing on the design of any project as long as the
documentation produced for the scope of that project is part of the RFP or made available to all
proposers under the design contract.
Scoping consultants are not precluded from proposing on the Construction Administration and
Inspection (CA&I) contract for a particular project as long as they have not participated in the
associated design (except as described in the guideline below) phase of the project.
Design consultants are precluded from proposing on the CA&I contract of the same project. The
exception to this guideline is as follows: a firm that participated in the design up to the 10% stage of
the project as a subconsultant and who desires to propose on the CA&I contract shall be required to
contract with an entity to inspect that portion of the design in which they were involved. In this
instance, the former subconsultant who intends to participate as the primary firm must request a
waiver of this guideline as part of its Expression of Interest (EOI) submission.
Consultants performing a Study or Investigation are not precluded from proposing on the design
phase of the project as long as the documentation produced under that (study, investigation, etc.)
contract is part of the design RFP or made available to all proposers during the design solicitation
process.
Consultants performing a Study or Investigation phase of a project are not precluded from proposing
on a CA&I contract as long as the documentation produced under that contract (study or
investigation) is part of the CA&I RFP or made available to all proposers during the CA&I
solicitation.
Consultants performing Design Review (DR) services for a project are no precluded from pro9posing
on a CA&I contract for any project for which the consultant performed a DR as long as the
documentation produced under the DR is made a part of the CA&I RFP or made available to all
proposers during the CA&I solicitation process. A DR as discussed herein refers to the various reviews
to include Biddability, Constructability and Operability Review (BCOR), Value Engineering Review,
Constructability Review, Peer Review or other similar Review that might be performed on a project
design to ensure that the project is buildable while being cost effective, biddable and maintainable.
Note: A Consultant shall not perform DR services on a project where it has provided design services.

Proposers signature ______________________________________

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
20
 RFQ-4; Supplement B (Lobby Law)

RFP____________________________

NEW YORK STATE LOBBYING LAW OF 2005

Chapter 1 of the Laws of 2005, as amended by Chapter 596 of the Laws of 2005 (collectively
referred to as the Lobbying Law) makes major changes to the development of procurement
contracts with government entities, including the Authority. The Lobbying Law amends the
New York State Legislative Law and the New York State Finance Law relative to lobbying
and/or other contacts with government agencies on behalf of bidders or proposers (collectively
referred to as offerers) concerning government procurement initiatives. Specifically, the
Lobbying Law created two new sections in the State Finance Law (the New State Finance
Law): Section 139-j, which restricts the types of contacts that offerers may make to a
governmental entity during the procurement process; and Section 139-k, which requires that
offerers disclose prior findings of non-responsibility based either upon violations of Section 139-
j of the State Finance Law or for having provided false or incomplete information to a
governmental entity.

RFQ-4; Supplement (Lobby Law), COMPLIANCE WITH NEW YORK STATE

FINANCE LAW SECTIONS 139-j AND 139-k, Disclosure of Prior Non-Responsibility
Determinations Form and Bidders/Proposers Affirmation and Certifcation, is attached and
made part of this solicitation package in compliance with the requirements of the New State
Finance Law. The proposer shall complete RFQ-4; Supplement (Lobby Law) forms and submit
them with your proposal. Failure to complete and submit both forms shall result in a
determination of non-responsiveness and may disqualify the proposal, thereby precluding the
Authority from awarding the contract to the proposer.

For additional information, all offerers are urged to contact the New York State Office of
General Services at (518) 474-5607, or via their website at:
http://ogs.state.ny.us/aboutOgs/regulations/defaultAdvisoryCouncil.asp.

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
21
 COMPLIANCE WITH NEW YORK STATE FINANCE LAW
SECTIONS 139-j and 139-k

NEW YORK STATE FINANCE LAW SECTION 139-j RESTRICTIONS ON

CONTACTS DURING THE PROCUREMENT PROCESS

Effective January 1, 2006, all procurements by the Authority in excess of $15,000 annually, are
subject to the requirements of Sections 139-j and 139-k of the New York State Finance Law.

Section 139-j of the State Finance Law restricts the extent and nature of contacts that
bidders/proposers (a/k/a offerers) may make or initiate with the Authority concerning a
procurement while that procurement is pending. Section 139-j, subdivision 3 of the State
Finance Law requires that offerers shall make only permissible contacts (defined as oral, written
or electronic communications with the Authority intended to influence an procurement) with the
Authority concerning a procurement, by contacting the designated point of contact only, except
in certain designated cases including the submission of written proposals in response to a
solicitation, submission of written questions to the designated contact person when all such
written questions and responses thereto are to disseminated to all other offerers who have
expressed interest in the procurement, or communications related to contract negotiations after
being notified of the tentative award of a procurement.

Section 139-j, subdivision 6 of the State Finance Law requires that the Authority incorporate a
summary of the policy concerning permissible contacts during procurements into all solicitations
of proposals or bid documents or specifications for procurement contracts subject to the
requirements of Sections 139-j and 139-k of the State Finance Law. Further, the Authority is
required to obtain written affirmations from all offerers that they understand and agree to comply
with the policy relative to permissible contacts during a governmental procurement.

Section 139-j, subdivision 8 of the State Finance Law requires that members, officers and
employees of the Authority report violations of the policy regarding permissible contacts by
offerers to the appropriate official responsible for reviewing or investigating such matters. A
finding that an offerer knowingly and willingly violated the requirements of Section 139-j may
result in a determination of non-responsibility, thereby making the offerer and its subsidiaries,
affiliates and related entities ineligible for award of the contract. Subsequent determinations of
non-responsibility based upon a violation of Section 139-j of the State Finance Law will result in
the offerer being ineligible to submit a bid or proposal on any future procurement contract for a
period of four (4) years. Finally, the Authority is required to notify the New York State Office of
General Services (OGS) of any determinations of non-responsibility or debarments due to
violations of Section 139-j of the State Finance Law which, in turn, will be listed by OGS.

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
22
 NEW YORK STATE FINANCE LAW SECTION 139-k

DISCLOSURE OF CONTACTS AND PRIOR NON-REPONSIBILITY

DETERMINATIONS

Section 139-k, subdivision 2 of the State Finance Law requires that the Authority obtain specific
information from offerers concerning prior non-responsibility determinations due to either (a) a
violation of the requirements of State Finance Law Section 139-j or (b) an offerers having
intentionally provided false or incomplete information to a governmental entity. Section 139-k,
subdivision 3 of the State Finance Law further requires that, in determining the responsibility of
an offerer, the Authority must consider whether that offerer has failed to disclose accurate or
complete information concerning prior non-responsibility determinations as required by Section
139-k, subdivision 2 of the State Finance Law. Further, except under certain circumstances, the
Authority may not award any procurement contract to any offerer that fails to timely disclose
accurate or complete information as required under Section 139-k, subdivision 2 of the State
Finance Law.

THE REQUISITE BIDDERS/PROPOSERS AFFIRMATION AND CERTIFICATION OF

COMPLIANCE WITH THE POLICY REGARDING PERMISSIBLE CONTACTS AND
DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS ARE ANNEXED

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
23
 DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS
Name of Bidder/Proposer:
Address:

Name and Title of Person Submitting this Form: ___________________________________

(Please circle)
Has any governmental entity* made a finding of non-responsibility
regarding the Bidder/Proposer in the previous four years? No Yes

If yes: Was the basis for the finding of the Bidders/Proposers

non-responsibility due to a violation of State Finance Law 139-j? No Yes

Was the basis for the finding of Bidders/Proposers non-responsibility

due to the intentional provision of false or incomplete information to
a governmental entity? No Yes

If yes, please provide details regarding the finding of non-responsibility below.

Governmental Entity:

Year of Finding of Non-responsibility:

Basis of Finding of Non-Responsibility:

(Add additional pages as necessary)

Has any governmental entity terminated a procurement contract with the

Bidder/Proposer due to the intentional provision of false or incomplete
information? No Yes

* A government entity is: (1) any department, board, bureau, commission, division, office,
council, committee or officer of New York State, whether permanent or temporary; (2) each
house of the New York State Legislature; (3) the unified court system; (4) any public authority,
public benefit corporation or commission created by or existing pursuant to the public authorities
law; (5) any public authority or public benefit corporation, at least one of whose members is
appointed by the governor or who serves as a member by virtue of holding a civil office of the
state; (6) a municipal agency, as that term is defined in paragraph (ii) of subdivision (s) of
section one-c of the Legislative Law; or (7) a subsidiary or affiliate of such a public authority.
(SFL 139-j, paragraph 1.a.)

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No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
24
 BIDDERS/PROPOSERS AFFIRMATION AND CERTIFICATION

By signing below, the Bidder/Proposer:

a) Affirms that the Bidder/Proposer Understands and agrees to comply with the
policy regarding permissible contacts in accordance with State Finance Law
Sections 139-j and 139-k of New York State.

b) Certified that all information provided to the Authority with respect to State Finance Law 139-j and 139-k is complete,
true and accurate.

By:
(Signature of Person Certifying)

Date:

Print Name:

Print Title:

Bidder/Proposer or
Contractor/Consultant:
(Full Legal Name)

Address:

Business
Telephone Number:

THE AUTHORITYS RIGHT TO TERMINATE

The Authority reserves the right to terminate a Contract in the event it is found that the
certification filed by the Contractor/Consultant, as Bidder/Proposer, in accordance with
New York State Finance Law 139-k was intentionally false or intentionally incomplete.
Upon such finding, the Authority may exercise its termination right by providing written
notification to the Contractor/Consultant in accordance with the written notification terms
of the Contract.

------------------------------------------------------------------------------------------------------------------------
No alterations, changes, modifications, substitutions of any kind, in whole or in part shall be made to this document by
Consultant including, but not limited to, white-outs, cross-outs, reformatting, paraphrasing, summarizing, or deleting.

Form C-040
(Rev. 8-22-12)
25