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Slate of Callfornla—De rtment of General Servke; Procurement Divlslon 64049 <br />Pa Solidtation Number <br />GSPD-05-105 (REV. 08/09) <br />BIDDER DECLARATION <br />1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form): <br />t,l <br />a. Identify current California certification(s)(MB, SB, NVSA, DVBE): or None Iv (If"None;gotoltem#2) <br />b. Will subcontractors be used for this contract? Yes ✓❑Non(if yes, indicate the distinct element of work your firm will perform in this contract <br />e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, <br />identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary. <br />Grant oversight & Fiscal Agent coordination with.au1a.cQnjraQtQr5 and partners. c anagement asse sment training OJTM/FX <br />and support services. II�� <br />c. If you area California certified DVBE: (1) Are you a broker or agent? Yes Ll No ✓0 <br />(2) If the contract includes equipment rental, does r�Ourcorn any at least 51% of the equipment <br />provided in this contract (quantity and value)? Yes LJ No LI N/A ✓ <br />2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary): <br />Subcontractor Name, Contact Person, <br />Subcontractor Address <br />CA Certification (MR, <br />Work performed or goods provided <br />Corresponding <br />Good <br />51% <br />Phone Number&Fax Number- <br />&Email Address <br />NVSA, OVBEor None) <br />for this contract <br />%of bid price <br />Standing? <br />Rental? <br />City of Anaheim <br />201 S. Anaheim Blvd, <br />Suite 1001 <br />None <br />Coordination of Services - CaseLuz <br />25% <br />❑ <br />714 71ores 65-4341 <br />Management, Assessment, <br />Fax 714765-4356 <br />Anahelm CA 92805 <br />Training, OJT and support <br />IRores@anahelm.net <br />services <br />County of Orange <br />Carma Lacy <br />1300 S. Grand Ave <br />Bldg. B, 3rd FI. <br />None <br />Coordination of services - Case <br />Management, Assessment, <br />20% <br />❑ <br />714-480-6420 <br />Santa Ana CA 92705 <br />Training, OJT, and support <br />Fax 714-834-7132 <br />carma.lacy@occr.ocgov.com <br />services <br />0 <br />Working Wardrobes <br />Jerri Rosen <br />1851 Kettering St <br />Irvine, CA 92614 <br />None <br />Case Management, workforce <br />15% <br />❑ <br />714-210-2460 <br />jerri@workingwardrobes.org <br />readiness training, soft skills, job <br />development and placement, <br />Fax 714-434-2870 <br />Interview/work wardrobe <br />131 <br />CERTIFICATION: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct. <br />Pag�1 of 2 <br />