Residential Home Bidder Proof of Responsibility
CITY OF LA CROSSE| PLANNING AND DEVELOPMENT DEPARTMENT
Dawn Reinhart, Neighborhood Housing Development Associate
BIDDERS REQUIREMENTS
This form shall be submitted no later than 2:30pm Wednesday, October 5, 2016 in a sealed envelope
addressed to City Planning & Development, Bidder Proof of Responsibility, 400 La Crosse St, La Crosse, WI
54601. The City will notify the bidders of their pre-qualification within two business days.
Prequalification of bidders is required in order to comply with provisions of Section 66.0901(2)(3) of the
Wisconsin Statutes. For bids conducted by the City of La Crosse Replacement Housing Program, contract awards
are made to contractors that meet the criteria of lowest, responsive, and responsible bidder. The proof of
responsiveness will be established both by the bid document and the information contained in this
questionnaire.
A responsible bidder is a bidder who has the experience, integrity, perseverance, reliability, capacity, and credit
which will assure good faith performance. The bidder responsibility determinations are conducted by City of La
Crosse Replacement Housing staff, as an agent of the Housing Rehabilitation Committee, and those decisions are
final in our sole discretion. In determining if a bidder is responsible, while no single factor will be controlling,
consideration will be given, but not limited to the following:
1. Bidder has completed at least five new residential homes and/or substantial residential
rehab (greater than $40,000) projects in the last five years.
2. Receives no unsatisfactory performance ratings from previous clients.
3. Positive past performance on previous City of La Crosse contracts, if any.
4. Can provided the services promptly within the time specified, without delay.
5. Experience and training in residential construction.
6. Financial stability or conditions, access to cash or cash credit.
All contents of this statement shall be confidential and shall not be disclosed except upon the written order of
the person furnishing the statement. Once qualified, the Contractor shall be considered qualified by the
Replacement Housing Program for a period of one year.
An equal opportunity, affirmative action employer. Accommodations for people with disabilities provided upon request.
City of La Crosse Planning & Development: Bidder Proof of Responsibility
A. ORGANIZATION SUMMARY
1. Business Entity/Organization
Name:
Address:
City:
Zip:
Website:
Contact Person:
Title:
Phone:
Fax:
Email:
EIN Number:
Is the organization a:
Corporation
Partnership
If incorporated, state date and where incorporated:
Sole Trader
LLC
B. EXPERIENCE
1. How many single family, detached residential homes have you built or rehabbed within the last five years?
(If you have completed less than 5 new residential homes and/or substantial residential rehab (greater than $40,000) projects in the last 5
years, you will be unqualified to bid on this project).
2. List the 5 most recent residential new construction or substantial rehab projects completed, where you
served as the general contractor. City staff may contact these clients. If work was found unsatisfactory by a
client, bidder may be deemed unqualified to bid.
Address of Residential
Home Built
Date
Started
Date
Completed
Total Cost
Client/Owner Name
Client’s Phone
Number
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City of La Crosse Planning & Development: Bidder Proof of Responsibility
3. Summarize the construction experience, training, and background of the principal project manager who will
be the City of La Crosse's Primary Contact (no more than 5 sentences long)
4. Have you ever failed to complete work awarded to you or defaulted, cancelled, or terminated for cause on
any contract?
Yes
No
If so where and why, attach a statement of explanation, including all pertinent facts.
5. In the past five (5) years, has this company, business entity, affiliate, or predecessor company, or entity:
a. Been suspended or debarred from any government contracting process or been disqualified on any
government procurement?
Yes
No
b. Been subject to any administrative proceeding, arbitration award, or civil action seeking specific
performance, restitution, or other monetary award or settlement?
Yes
No
c. Experienced a revocation or suspension of any business or professionally permit and/or license?
Yes
No
d. Been the subject of a criminal investigation, whether open or closed, or an indictment for any businessrelated conduct constituting a crime under local, state or federal law?
Yes
No
e. Received any OSHA citation or Notification of Penalty containing a violation classified as serious or
willful?
Yes
No
f.
Been the subject of any other federal, state or local citations, notices, violation orders, administrative
hearings, arbitration proceedings, or determinations of a violation of any labor law or regulation?
Yes
No
g. Had any liens, claims or judgments filed against the Business Entity that remain undischarged or were
unsatisfied for more than 90 days?
Yes
No
h. Has the Business or any Affiliate been a party to any civil litigation?
Yes
No
i.
Has the Business or any Affiliates had any liquidated damages assessed?
Yes
No
j.
Has the Business or any Affiliates initiated or been the subject of any bankruptcy proceedings, whether
or not closed, regardless of the date of filing, or is any bankruptcy proceeding pending?
Yes
No
For each “yes” answer above, provide an explanation of the issue(s) on a separate sheet, include all
pertinent facts.
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City of La Crosse Planning & Development: Bidder Proof of Responsibility
C. FINANCIAL ABILITY
To be filled out by submitter of bids. If financial statement is prepared by C.P.A. or by registered accountant,
attach certified copy in lieu of completing section 2 below:
1. Cash Credit Available. Reimbursements will be made upon satisfactory completion of work only. List
available cash credit to pay for costs associated with this project.
Type of Line of Credit
(Merchant Credit, Loan )
Name of Financial
Institution or
Merchant
Current Available Cash
Credit
$
$
$
2. Financial statement. Condition at close of business on date: Click here to enter text., 20____________.
ASSETS:
a. Cash:
$
b. Accounts Receivable:
$
c. Real Estate Equity:
$
d. Construction Equipment, Book Value
$
e. Materials in Stock
$
f. Other Assets
$
g. TOTAL ASSETS:
$
LIABILITIES:
a. Accounts, Notes and Interest Payable Within 2 Years of Date of Financial Statement
$
b.
Accounts, Notes Payable 2 or More Years after Date of Financial Statement
$
c. Other Liabilities
$
d. TOTAL LIABILITIES
$
e. NET WORTH
$
3. What is the Business Entities Bonding Capacity? (Supporting evidence may be required upon request)
Single Project: $
Aggregate (all projects): $
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City of La Crosse Planning & Development: Bidder Proof of Responsibility
4. Do you currently possess the following insurance and liabilities or are you willing to obtain them?
a) Commercial General Liability Insurance of not less than $1,000,000.00 per occurrence for bodily
injury, personal injury and property damage;
Yes
No
b) Umbrella Liability Insurance of not less than $1,000,000.00 per occurrence for bodily injury, personal
injury and property damage in excess of coverage carried for commercial general liability and
automobile liability;
Yes
No
c) Workers’ Compensation and Employees’ Liability Insurance with Wisconsin statutory limits.
Yes
No
Section 3 Requirements.
Bidders are encouraged to use Section 3 and Minority Business Enterprises/Women Business Enterprises
(MBE/WBE) contractors. Preference will be given to bids that include certify they can meet one of the
criteria for Section 3 and/or MBE/WBE Contractors. If they receive the bid and claim this preference, the
bidder will need to submit certification forms.
WARNING: If you claim Section 3 preference and cannot prove Section 3 eligibility, you risk having your bid
rejected or your contract terminated. Proving eligibility will require having employees or subcontractors
complete income eligibility forms.
To be considered a Section 3 business concern, you must meet one of the following criteria:
1. Is your business owned, 51% or more, by someone who is classified as "low-income" by HUD
(definition for low-income below in La Crosse County)?
2. Do you employ individuals for at least 30% of your full-time, permanent staff who meet Section
3 guidelines?
3. Do you commit to subcontracting at least 25% of the dollar amount of the contract to Section 3
eligible business or individuals, i.e. businesses that meet the qualifications for in items 1 or 2
above?
An individual, who is considered a Section 3 resident or low-income in La Crosse County, falls
within the below guidelines:
Definition for Low Income/Section 3, La Crosse County
INCOME LIMIT
HOUSEHOLD SIZE
$37,950
1
$43,350
2
$48,750
3
$54,150
4
$58,500
5
$62,850
6
$67,150
7
$71,500
8+
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City of La Crosse Planning & Development: Bidder Proof of Responsibility
WBE/MBE Definitions
All HUD programs must try to use small, women and minority-owned business firms. For a contractor to
receive points for the WBE/MBE preference, they must be prepared to certify and provide evidence that
they themselves as the general contractor are WBE/MBE or one or 25% of their sub-contracted work goes
to business that meet the following criteria:
Minority Business Enterprise: "Minority business enterprise" is a business in which minority group
members own 51 percent or more of the company; or, in the case of a publicly-owned business, one in
which minority group members own at least 51 percent of its voting stock and control management and
daily business operations. For this purpose, minority group members are those groups of U.S. citizens found
to be disadvantaged by the Small Business Administration pursuant to Section 8(d) of the Small Business
Act. Such groups include, but are not limited to, Black Americans, Hispanic Americans, Native Americans,
Indian tribes, Asian Pacific Americans, Native Hawaiian Organizations, and other minorities.
Women Business Enterprise: A women-owned small business concern is a small business that is at least
51% owned by one or more women. In the case of publicly owned businesses, at least 51% of the stock is
owned by one or more women and the management and daily operations of the business are controlled by
one or more women.
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City of La Crosse Planning & Development: Bidder Proof of Responsibility
Conflict of Interest. The UNDERSIGNED hereby declares that any person(s) employed by the City of La Crosse,
who has direct or indirect personal or financial interest in the RFP, application, or in any portion of the profits
that may be derived there from, has been identified and the interest disclosed below. (Please include in your
disclosure any interest which you know of. An example of a direct interest would be a City of La Crosse
employee, City of La Crosse Council member, City of La Crosse Community development Block Grant Committee,
who would be paid to perform services under this proposal. An example of indirect interest would be a City of La
Crosse employee who is related to any officers, employees, principal or shareholders of your firm or to you. If in
doubt as to status or interest, please disclose to the extent known).
Declaration of any Conflict of Interest with the City of La Crosse:
The undersigned certified that he/she:
1) Is knowledgeable about the submitting Business Entity’s business and operations and has full authority to make
these statements;
2) Has reviewed and/or supplied full and complete responses to each question;
3) To the best of his/her knowledge, information and belief, confirms that the Business Entity’s responses are true,
accurate and complete, including all attachments, if applicable;
4) Recognizes that this questionnaire is submitted for the express purpose of assisting the City of La Crosse in
making responsible determinations and that the City of La Crosse will rely on the information disclosed regarding
an award of a contract or approval of a contract;
5) Acknowledges that the City of La Crosse may, in its sole discretion, by whichever means it may choose, verify the
truth and accuracy of all statements made herein;
6) Acknowledges that intentional submission of false or misleading information may disqualify this business entity
from entering into this or future contracts with the City of La Crosse.
Dated this
day of
, 20
.
Name of Business/Organization: _________________________________________________________________
Signature of Authorized Officer: _______________________________________ DATE: ___________________
Print Name & Title: ____________________________________________________________________________
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