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State of Californla—Department of General SeW us, Procurement Division <br />GSPD-05-1 05 (REV 08/09) <br />BIDDER DECLARATION <br />Solicitation Number 84049 <br />1. Prime bidder information (Review attached Bidder Declaration Instructions prior tocompletion ofthis form): <br />a. Identify current California certification(s)(MB,S%NVSA,DVBE): erNone i• lIi (If"None9gotoItem #2) <br />b. Will subcontractors be used for this contract? Yes 21 No El (if yes, indicate the distinct element of work Lour 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 sub contractors and partnem. gase management „-ay5eggme t training,O iTANEX <br />and support services. <br />c. If you area California certified DVBE: (1) Are you a broker or agent? Yes J_I NO ✓Q <br />(2) If the contract includes equipment rental, does o rco{{f�nyow,��,,at least 51% of the equipment <br />provided in this contract (quantity and value)? Yes No NIA MV <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,Cootau Person, <br />SubconaactorAddress- <br />CACertificatiun(M8,56, <br />Worliperformed orgoods provided <br />Corresponding <br />Good <br />- 51% <br />Phone Number&Fax Number <br />&Frail Address <br />NYSA,DVBE of None) <br />I for this contract <br />%ofloldirrice <br />Standing? <br />Rental? <br />City of Anaheim <br />Flores <br />201 S. Anaheim Blvd, <br />Suite 1m <br />None <br />Coordination of Services - CaseLuz <br />25% <br />❑ <br />714 765-4341 <br />Management, Assessment, <br />Fax 714-765-4356 <br />Andheim CA 92805 <br />Training, OJT and support <br />Mores@anaheim.net <br />services <br />County of Orange <br />Carma Lacy <br />1300 S. Grand Ave <br />Bldg, B, 3rd Fl. <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 />Rosen <br />1851 Kettering St <br />Irvine, CA 92614 <br />None <br />Case Management, workforce <br />readiness training, soft skills, job <br />15% <br />El <br />714-210-2460 <br />jerri@workingwardrobes.org <br />development and placement, <br />Fax 714-434-2870 <br />Interviewlv✓ork wardrobe <br />0 <br />CERTIFICATION: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct. <br />Page a of 2 <br />