Supplier Representations and Certifications

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1 Instructions: Please fill out the form in its entirety and return to W.W. Williams. A copy of your certificate of insurance should be sent to Supplier Representations and Certifications I represent that the following information is true and accurate and may be relied upon by The W.W. Williams Company in making submissions to the United States Government. Supplier Name: Address (including nine digit zip code and congressional district): CCR Cage code (if available): DUNS Number: To obtain a DUNS number, go to Primary Place of Performance: (If different from above) Address (including nine digit zip code and congressional district): Contact Name: Telephone: Signature: Title: Date: North American Industrial Classification System (NAICS) Code(s): To find NAICS codes, see 1. Acceptance of Terms of Conditions Offer accepts W.W. Williams Terms and Conditions found reference/ 2. Common Parent: Common parent, as used in this provision, means that corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which the offeror is a member. Offeror is not owned or controlled by a common parent as defined in this provision. Offeror is owned or controlled by a common parent as defined in this provision. Name and DUNS number of common parent: Name DUNS Number 1

2 *****PLEASE CHECK ALL THAT APPLY***** 3. Business Size. Please check any of the applicable business class definitions that describes your company, the Supplier: Large Business Small Business a small business concern is "one that is independently owned and operated and which is not dominant in its field of operation." To identify the appropriate small business size standard, visit and enter your primary NAICS Code to determine small business status according to U.S. SBA guidelines. Women Owned Small Business a small business concern that is at least 51 percent owned by one or more women; or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and whose management and daily business operations are controlled by one or more women. Service Disabled Veteran Owned Small Business A small business concern owned and controlled by servicedisabled veterans o The term service disabled veteran means a veteran with a disability that is service connected (as defined in section 101 (16) of title 38, United States Code); o The term small business concern owned and controlled by service disabled veterans means a small business concern not less than 51 percent or which is owned by one or more service disabled veterans or, in the case any publicly owned business, not less than 51 percent or the stock of which is owned by one or more service disabled veterans; and o The management and daily business operations of which are controlled by one or more service disabled veterans or, in the case of a veteran with permanent and severe disability, the spouse or permanent caregiver of such a veteran. Small Disadvantaged Business ( SDB ) A small business that is at least 51 percent owned and controlled by one or more socially and economically disadvantaged individual(s); or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more socially and economically disadvantaged individuals; and, whose management and daily business operations are controlled by one or more such individuals. Supplier must be registered as a SDB with the U.S. Small Business Administration ( SBA ) and forward a copy of its SBA SDB certification along with this form. Historically Underutilized Business Zone ( HUBZone ) a small business that appears on the list of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration. Supplier must forward a copy of its HUBZone Certification from the SBA along with this form. Veteran Owned Small Business small business concern that is at least 51 percent owned by one or more veterans (as defined at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more veterans; and the management and daily business operations of which are controlled by one or more veterans. Alaskan Native or Indian Tribe Alaska Native Corporation (ANC) means any Regional Corporation, Village Corporation, Urban Corporation or Group Corporation organized under the laws of the State of Alaska in accordance with the Alaska Native Claims Settlement Act, as amended (43 U.S.C.A. 1601, et seq.) and which is considered a minority and economically disadvantaged concern under the criteria at 43 U.S.C. 1626(e)(1). Indian tribe means any Indian tribe, band, group, pueblo, or community, including native villages and native groups (including corporations organized by Kenai, Juneau, Sitka, and Kodiak) as defined in the Alaska Native Claims Settlement Act (43 U.S.C.A et seq.), that is recognized by the Federal Government as eligible for services from the Bureau of Indian Affairs in accordance with 25 U.S.C. 1452(c). Under 15 U.S.C. 645 (d), any person who misrepresents a firm s status as a small, small disadvantaged, women owned small business or HUBZone, in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal Law that specifically references section 8(d) for a definition of program eligibility, shall be punished by imposition and debarment; and ineligible for participation in programs conducted under the authority of the Act. 2

3 4. Certification Regarding Responsibility Matters (Derived from FAR Apr 2010) (a) (1) The Offeror certifies, to the best of its knowledge and belief, that (i) The Offeror and/or any of its Principals (A) Are are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency; (B) Have have not, within a three year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) contract or subcontract; violation of Federal or State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiving stolen property (if offeror checks have, the offeror shall also see , if included in this solicitation); and (C) Are are not presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in paragraph (a)(1)(i)(b) of this provision; and (D) Have, have not, within a three year period preceding this offer, been notified of any delinquent Federal taxes in an amount that exceeds $3,000 for which the liability remains unsatisfied. (1) Federal taxes are considered delinquent if both of the following criteria apply: (2) Examples. (i) The tax liability is finally determined. The liability is finally determined if it has been assessed. A liability is not finally determined if there is a pending administrative or judicial challenge. In the case of a judicial challenge to the liability, the liability is not finally determined until all judicial appeal rights have been exhausted. (ii) The taxpayer is delinquent in making payment. A taxpayer is delinquent if the taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded. (i) The taxpayer has received a statutory notice of deficiency, under I.R.C. 6212, which entitles the taxpayer to seek Tax Court review of a proposed tax deficiency. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek Tax Court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights. (ii) The IRS has filed a notice of Federal tax lien with respect to an assessed tax liability, and the taxpayer has been issued a notice under I.R.C entitling the taxpayer to request a hearing with the IRS Office of Appeals contesting the lien filing, and to further appeal to the Tax Court if the IRS determines to sustain the lien filing. In the course of the hearing, the taxpayer is entitled to contest the underlying tax liability because the taxpayer has had no prior opportunity to contest the liability. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek tax court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights. (iii) The taxpayer has entered into an installment agreement pursuant to I.R.C The taxpayer is making timely payments and is in full compliance with the agreement terms. The taxpayer is not delinquent because the taxpayer is not currently required to make full payment. 3

4 (iv) The taxpayer has filed for bankruptcy protection. The taxpayer is not delinquent because enforced collection action is stayed under 11 U.S.C. 362 (the Bankruptcy Code). (ii) The Offeror has has not, within a three year period preceding this offer, had one or more contracts terminated for default by any Federal agency. (2) Principal, for the purposes of this certification, means an officer; director; owner; partner; or a person having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a division or business segment; and similar positions). This Certification Concerns a Matter Within the Jurisdiction of an Agency of the United States and the Making of a False, Fictitious, or Fraudulent Certification May Render the Maker Subject to Prosecution Under Section 1001, Title 18, United States Code. (b) The Offeror shall provide immediate written notice to the Contracting Officer if, at any time prior to contract award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. (c) A certification that any of the items in paragraph (a) of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Offeror s responsibility. Failure of the Offeror to furnish a certification or provide such additional information as requested by the Contracting Officer may render the Offeror nonresponsible. (d) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of an Offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. (e) The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Offeror knowingly rendered an erroneous certification, in addition to other remedies available to the Government, the Contracting Officer may terminate the contract resulting from this solicitation for default. 5. FAR Previous Contracts and Compliance Reports (Feb 1999) The offeror represents that (a) It has, has not had contracts with FAR clause included in it ( (b) It has filed, has not filed, is not required to file, form EEO 1 with the government ( and, (c) Representations indicating submission of required compliance reports, signed by proposed subcontractors, will be obtained before subcontract awards. For all orders over $100,000: Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions. (Sep 2007) (a) Definitions. As used in this provision Lobbying contact has the meaning provided at 2 U.S.C. 1602(8). The terms agency, influencing or attempting to influence, officer or employee of an agency, person, reasonable compensation, and regularly employed are defined in the FAR clause of this solicitation entitled Limitation on Payments to Influence Certain Federal Transactions ( ). (b) Prohibition. The prohibition and exceptions contained in the FAR clause of this solicitation entitled Limitation on Payments to Influence Certain Federal Transactions ( ) are hereby incorporated by reference it his provision. (c) Certification. The offeror, by signing its offer, hereby certifies to the best of its knowledge and belief that no Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or 4

5 employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on its behalf in connection with the awarding of this contract. (d) Disclosure. If any registrants under the Lobbying Disclosure Act of 1995 have made a lobbying contact on behalf of the offeror with respect to this contract, the offeror shall complete and submit, with its offer, OMB Standard Form LLL, Disclosure of Lobbying Activities, to provide the name of the registrants. The offeror need not report regularly employed officers or employees of the offeror to whom payments of reasonable compensation were made. (e) Penalty. Submission of this certification and disclosure is a prerequisite for making or entering into this contract imposed by 31 U.S.C Any person who makes an expenditure prohibited under this provision or who fails to file or amend the disclosure required to be filed or amended by this provision, shall be subject to a civil penalty of not less than $10,000, for each such failure. For all first tier vendors/subcontractors (Fill out if directed by W.W. Williams): 7. Executive Compensation (As required by FAR ): Section 2(d) of the Federal Funding Accountability and Transparency Act of 2006 (Pub. L. No ), as amended by section 6202 of the Government Funding Transparency Act of 2008 (Pub. L ), requires the Prime Contractor to report information on first tier subcontract awards. The following information as well as other information found at the end of this form will be reported at and will available to the public. a) In your business or organization's preceding completed fiscal year, did your business or organization (the legal entity to which this specific record, represented by a DUNS number, belongs) receive (1) 80 percent or more of your annual gross revenues in U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements; and (2) $25,000,000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements? Yes No (If No, stop and return this form to W.W. Williams. If Yes, continue) b) Does the public have access to information about the compensation of the executives in your business or organization (the legal entity to which this specific record, represented by a DUNS number, belongs) through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? Yes No (If Yes, stop and return this form to W.W. Williams. If No, continue) c) Provide the following information for the five (5) most highly compensated executives in your business or organization (the legal entity to which this specific record, represented by a DUNS number, belongs): Name: Position Title Total Compensation Amount for the Entity's last complete fiscal year

6 Definitions: Executive means officers, managing partners, or any other employees in management positions. First tier subcontract means a subcontract awarded directly by a Contractor to furnish supplies or services (including construction) for performance of a prime contract, but excludes supplier agreements with vendors, such as long term arrangements for materials or supplies that would normally be applied to a Contractor s general and administrative expenses or indirect cost. Total compensation means the case and noncash dollar value earned by the executive during the Contractor s preceding fiscal year and includes the following (for more information see 17 CFR (c)(2)): 1. Salary and bonus. 2. Awards of stock, stock options, and stock appreciation rights. Use the dollar amount recognized for financial statement reporting purposes with respect to the fiscal year in accordance with the Statement of Financial Accounting Standards No. 123 (Revised 2004) (FAS 123R), Shared Based Payments. 3. Earnings for services under non equity incentive plans. This does not include group live, health, hospitalization or medical reimbursement plans that do not discriminate in favor of executives, and are available generally to all salaried employees. 4. Change in pension value. This is the change in present value of defined benefit and actuarial pension plans. 5. Above market earnings on deferred compensation which is not tax qualified. 6. Other compensation, if the aggregate value of all such other compensation (e.g., severance, termination payments, value of life insurance paid on behalf of the employee, perquisites or property) for the executive exceeds $10,000. Other Subcontractor information reported at 1. Unique identifier (DUNS Number) for the subcontractor receiving the award and for the subcontractor s parent company, if the subcontractor has a parent company. 2. Name of the subcontractor. 3. Amount of the subcontract award. 4. Date of the subcontract award. 5. A description of the products or services (including construction) being provided under the subcontract, including the overall purpose and expected outcomes or results of the subcontract. 6. Subcontract number (the subcontract number assigned by the Contractor). 7. Subcontractor s physical address including street address, city, state, and country. Also include the nine digit zip code and congressional district. 8. Subcontractor s primary performance location including street address, city, state, and country. Also include the nine digit zip code and congressional district. 9. The prime contract number, and order number if applicable. 10. Awarding agency name and code. 11. Funding agency name and code. 12. Government contracting office code. 13. The applicable North American Industry Classification System code (NAICS). 6

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