2

Omnibus Sworn Statement

REPUBLIC OF THE PHILIPPINES ) CITY/MUNICIPALITY OF ______ ) S.S.

AFFIDAVIT

I, [Name of Affiant], of legal age, [Civil Status], [Nationality], and residing at [Address of Affiant], after having been duly sworn in accordance with law, do hereby depose and state that: 1. Select one, delete the other: If a sole proprietorship: I am the sole proprietor of [Name of Bidder] with office address at [address of Bidder]; If a partnership, corporation, cooperative, or joint venture: I am the duly authorized and designated representative of [Name of Bidder] with office address at [address of Bidder]; 2. Select one, delete the other: If a sole proprietorship: As the owner and sole proprietor of [Name of Bidder], I have full power and authority to do, execute and perform any and all acts necessary to represent it in the bidding for [Name of the Project] of the [Name of the Procuring Entity]; If a partnership, corporation, cooperative, or joint venture: I am granted full power and authority to do, execute and perform any and all acts necessary and/or to represent the [Name of Bidder] in the bidding as shown in the attached [state title of attached document showing proof of authorization (e.g., duly notarized Secretarys Certificate issued by the corporation or the members of the joint venture)]; 3. [Name of Bidder] is not blacklisted or barred from bidding by the Government of the Philippines or any of its agencies, offices, corporations, or Local Government Units, foreign government/foreign or international financing institution whose blacklisting rules have been recognized by the Government Procurement Policy Board; 4. Each of the documents submitted in satisfaction of the bidding requirements is an authentic copy of the original, complete, and all statements and information provided therein are true and correct; 5. [Name of Bidder] is authorizing the Head of the Procuring Entity or its duly authorized representative(s) to verify all the documents submitted; Page 1 of 2

6. Select one, delete the rest: If a sole proprietorship: I am not related to the Head of the Procuring Entity, members of the Bids and Awards Committee (BAC), the Technical Working Group, and the BAC Secretariat, the head of the Project Management Office or the end-user unit, and the project consultants by consanguinity or affinity up to the third civil degree; If a partnership or cooperative: None of the officers and members of [Name of Bidder] is related to the Head of the Procuring Entity, members of the Bids and Awards Committee (BAC), the Technical Working Group, and the BAC Secretariat, the head of the Project Management Office or the end-user unit, and the project consultants by consanguinity or affinity up to the third civil degree; If a corporation or joint venture: None of the officers, directors, and controlling stockholders of [Name of Bidder] is related to the Head of the Procuring Entity, members of the Bids and Awards Committee (BAC), the Technical Working Group, and the BAC Secretariat, the head of the Project Management Office or the end-user unit, and the project consultants by consanguinity or affinity up to the third civil degree; 7. [Name of Bidder] complies with existing labor laws and standards; and 8. [Name of Bidder] is aware of and has undertaken the following responsibilities as a Bidder: a) Carefully examine all of the Bidding Documents; b) Acknowledge all conditions, local or otherwise, affecting the implementation of the Contract; c) Made an estimate of the facilities available and needed for the contract to be bid, if any; and d) Inquire or secure Supplemental/Bid Bulletin(s) issued for the [Name of the Project].

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ___, 20__ at ____________, Philippines.

_____________________________________ Bidders Representative/Authorized Signatory

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Name of the Procuring Entity Standard Form Number: SF-GOOD-13a Revised on: July 28, 2004

Project Reference Number Name of the Project Location of the Project

Statement / List of all Ongoing Government & Private Contracts including contracts awarded but not yet started
Business Name Business Address : ___________________________________________________ : ___________________________________________________
a. b. c. Owners Name Address Telephone Nos. Bidders Role Nature of Work Description % a. b. c. Date Awarded Date Started Date of Completion % of Accomplishment Planned Actual Value of Outstanding Works / Undelivered Portion

Name of Contract/ Project Cost

Government

Private

Note: This statement shall be supported with: 1 2 Contract or Purchase Order Notice of Award or Notice to Proceed issued by the owner

Total Cost

Submitted by Designation Date

: ___________________________________________________
(Printed Name & Signature)

: ___________________________________________________ : ___________________________________________________

One of the Eligibility documents required to be in the Eligibility Envelope of a prospective bidder is a list of all its on-going, completed, and awarded but not yet started contracts.

Name of the Procuring Entity Standard Form Number: SF-GOOD-13b Revised on: July 28, 2004

Project Reference Number Name of the Project Location of the Project

Statement / List of all Government & Private Contracts completed which are similar in nature
Business Name Business Address : ___________________________________________________ : ___________________________________________________
a. b. c. Owners Name Address Telephone Nos. Bidders Role Nature of Work Description % a. Amount at Award b. Amount at Completion c. Duration a. Date Awarded b. Contract Effectivity c. Date Completed

Name of Contract

Government

Private

Note: This statement shall be supported with: 1 Contract or Purchase Order; and 2 Certificate of Acceptance or Official Receipt(s) of Last Payment

Submitted by Designation Date

: ___________________________________________________
(Printed Name & Signature)

: ___________________________________________________ : ___________________________________________________

One of the Elgibility documents required to be in the Eligibility Envelope of a prospective bidder is a list of all contracts which are similar in nature and complexity to the contract to be bid. This statement will show that the value of the prospective bidders largest single completed contract, adjusted to current prices using the National Statistics Office (NSO) consumer price indices available at the G-EPS website, and similar to the contract to be bid, must be at least fifty percent (50%) of the approved budget for the contract to be bid.

Sample BID FORM

Date: To: BASES CONVERSION AND DEVELOPMENT AUTHORITY Gentlemen and/or Ladies:

Having examined the Bidding Documents including Bid Bulletin Numbers [insert numbers], the receipt of which is hereby duly acknowledged, we, the undersigned, offer to [supply/deliver/perform] [description of the GOODS or SERVICES] in conformity with the said Bidding Documents for the sum of

(Cite bid amount in Total Cost both in words and figures.)

(inclusive of all incidental charges and monthly interests under a one (1) year Lease-to-Own Agreement/Contract) We undertake, if our Bid is accepted, to deliver the goods in accordance with the delivery schedule specified in the Schedule of Requirements. If our Bid is accepted, we undertake to provide a performance security in the form, amounts, and within the times specified in the Bidding Documents. We agree to abide by this Bid for the Bid Validity Period specified in BDS provision for ITB Clause 22.2 and it shall remain binding upon us and may be accepted at any time before the expiration of that period. Commissions or gratuities, if any, paid or to be paid by us to agents relating to this Bid, and to contract execution if we are awarded the contract, are listed below: 1 Name and address of agent Amount and Currency Purpose of Commission or gratuity

(if none, state None) Until a formal Contract is prepared and executed, this Bid, together with your written acceptance thereof and your Notice of Award, shall be binding upon us. We understand that you are not bound to accept the lowest or any Bid you may receive. We certify/confirm that we comply with the eligibility requirements as per ITB of the Bidding Documents. Dated this _____________ day of ________________________ 20__. [signature] [in the capacity of] ____________________________

Duly authorized to sign Bid for and on behalf of

1 Applicable only if the Funding Source is the ADB, JBIC or WB.

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9
Bill of Quantities
Refer to Section 3 and 4 of the TERMS OF REFERENCE (Tab H of the Bid Documents)

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