Disabled Veteran Business Enterprise

Cal. Form PUR-004

California Superior Local Rules

ATTACHMENT SDSC PUR-004 (Rev. 1/16) DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) Mil. & Vet. Code § 999 & 999.2 Mandatory Form STATUS DECLARATION SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) STATUS DECLARATION Complete this form only if Bidder wishes to claim the DVBE incentive associated wi th this solicitation. Review the DVBE Status Declaration Instructions (SDSC Fo rm #PUR-004A) prior to completing this form. If Bidder submits incomplete or inaccurate information, it will not receive the DVBE incentive. Each DVBE and each DVBE Subcontractor must complete a separate form.

SECTION A. MUST BE COMPLETED BY ALL DVBEs DVBE Name: DVBE Certification ID Number:

SECTION B. MUST BE COMPLETED BY ALL DVBEs Check only one box in

Section B and provide original signatures of all disabled veteran (DV) owners and managers of the DVBE. I (we) declare that the DVBE is not a broker or agent, as defined in M il. & Vet. Code § 999. 2(b), of the goods and/or services provided by the DVBE in connection with the solicitation identified above. Pursuant to Mil. & Vet.

Code § 999. 2(f), I (we) declare that the DVBE is a broker or agent for the following principal. (attach additional sheets if more than two principals) Principal Name: Telephone Number: A d d r e s s : Principal Name: Telephone Number: A d d r e s s : Disabled veteran owners and managers of the DVBE: (attach additional sheets if necessary) I, the official named below, declare under penalty of perjury under the laws of the state of California that the information provided on this form is true and correct.

Date: Type or print name Signature of DV Owner/Manager Date: Type or print name Signature of DV Owner/Manager Date: Type or print name Signature of DV Owner/Manager ATTACHMENT SDSC PUR-004 (Rev. 1/16) DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) Mil. & Vet. Code § 999 & 999.2 Mandatory Form STATUS DECLARATION

SECTION C. MUST BE COMPLETED BY DVBEs THAT PROVIDE RENTAL EQUIPMENT AND ARE NOT BROKERS/AGENTS Check applicable boxes in

Section C and provide original signatures of all DV owners and managers of the DVBE. Pursuant to Mil. & Vet. Code § 999.2 (c), (

d) and (g), I am (we are) the DV(

s) with at least 51% ownership of the DVBE, or DV manager(

s) of the DVBE. The DVBE maintains certification require ments in accordance with Mil. & Vet. Code § 999 et seq. The undersigned owner(

s) own(

s) at least 51% of the quantity and value of each piece of equipment that will be rented in connection with this solicitation. I (we), t he DV owner(

s) of the equipment, have submitted to the Department of General Services my (our) personal federal tax return(

s) at time of certification and annually thereafter as defined in Mil. & Vet. Code § 999.2 (

c) and (g). Disabled veteran owners of the DVBE: (attach additional sheets if necessary) I, the official named below, declare under penalty of perjury under the laws of the state of California that the information provided on this form is true and correct.

N a m e o f D V O w n e r : T a x I D N u m b e r : Address: Telephone Number: Date: ____________________________________ Signature of DV Owner N a m e o f D V O w n e r : T a x I D N u m b e r : Address: Telephone Number: Date: ____________________________________ Signature of DV Owner Disabled veteran managers of the DVBE: (attach additional sheets if necessary) Date: Type or print name Signature of DV Manager Date: Type or print name Signature of DV Manager ATTACHMENT SDSC PUR-004A (Rev. 1/16) DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) Mil. & Vet.

Code § 999.2 Informational Form STATUS DECLARATION INSTRUCTIONS SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) STATUS DECLARATION INSTRUCTIONS General Instructions In this form, “Bidder” refers to a person or entity that submit s a response to a competitive solicitation issued by the court, including Request for Quotations (RFQs), Inquiry for Bids (I FBs), and Request for Proposals (RFPs; and “bid” refers to a response to a competitive solicitation issued by the court, including RFQs, IFBs, and RFPs.

If Bidder wishes to claim the DVBE incentiv e in a solicitation where a DVBE incentiv e is offered, it must submit a DVBE Status Declaration (SDSC Form #PUR -004) completed by each DVBE that w ill provide goods and/or services in connection with its bid. If Bidder is itself a DVBE, it must complete the DVBE Status Declarat ion itself. If Bidder will use one or more DVBE subcontractors, each DVBE subcontractor must complete a DVBE Status Declaration. If Bidder does not wish to claim the DVBE in centive, Bidder should not submit a DVBE Status Declar ation.

In addition, if Bidder wishes to claim the DVBE incentiv e using a DVBE Business Utilization Plan (BUP ) on file with the Department of General Services (DGS), Bidder should not submit a DVBE St atus Declaration. Note t hat a BUP cannot be used to qualify for the DVBE incentive in a non-IT services solicitation. The court will determine whether Bidder is eligible to receive the DVBE incent ive based on information provided in the DVBE Status Declaration. The court may, but is not obligated to , verify or seek clarification of any information set forth in the DVBE Status Declaration.

If Bidder submits incomplete or inaccurate info rmation, it will not receive the DVBE incentive.

Section A Instructions Provide the full legal name of the DVBE, and the DVBE’s Su pplier ID number. This number is in the DVBE’s DGS Supplier Profile, accessible at https://caleprocure.ca.gov/pages/PublicSearch/supplier-search.aspx.

Section B Instructions Check only one box. If the DVBE is not a broker or agent, check the first box. If the DVBE is a broker or agent, check the second box and provide the name, address, and phone number of the principal for which the DVBE is an agent or broker. Mil. & Vet. Code § 999.2(

b) defines “broker” or “agent” as an individual or entity that does not have title, possession, control, and risk of loss of materials, supplies, services, or equipment provided to [a court], unless one or more of the disabled veteran owners has at least 51% ownership of the quantity and value of the materials, supplies, services, and of each piece of equipment provided under the contract. All disabled veteran (DV) owners and managers of the DVBE must sign and dat e

Section B. If there are insufficient signature lines for all DV owners and managers to sign, attach additional sheets.

Section C Instructions The DVBE must complete

Section C only if both of the fo llowing are true: the DVBE will provide rental equipment in connection with the contract, and the DVBE checked the first box in

Section B, indicating that it is not a broker or agent. If the DVBE will not provide rental equipm ent in connection wi th the contract, or the DVBE checked the se cond box in

Section B, indicating that it is a broker or agent, the DVBE should skip

Section C. Check each box in

Section C for which the corresponding statements are true. All DV owners of the DVBE must sign and dat e

Section C. Each DV owner of t he DVBE must also provide his or her federal tax ID number, address, and telephone number. If ther e are insufficient lines provided for all DV owners, attach additional sheets. All DV managers of the DVBE must sign and date

Section C. If there are insufficient lines pr ovided for all DV managers, attach additional sheets.

Document details

Collection	California Superior Local Rules
Citation	Cal. Form PUR-004
Type	court_rule
Language	en
Format	pdf
Source	CA_LOCAL
Identifier	ca72a57c79c310e2f3c176cfff1f960b7924432d

Source file is stored in the law ingest library (pdf).