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					     ATTACHMENT “C”
  QUALIFICATION APPLICATION FORMS




  EQUAL EMPLOYMENT OPPORTUNITY &
   AFFIRMATIVE ACTION PLAN FORMS




CONTRACTOR COMPLIANCE CERTIFICATION
             FORMS




        ANTI-LOBBYING FORM


   SAMPLE INSURANCE CERTIFICATE




                                      1
           PHILADELPHIA HOUSING DEVELOPMENT CORPORATION

                   WEATHERIZATION ASSISTANCE PROGRAM

                        QUALIFICATION APPLICATION FORMS

                                       2009-2010

NAME OF ORGANIZATION:_________________________________________

NAMES & TITLES
OF PRINCIPAL OFFICERS:
_______________________________________________________

________________________________________________________________


ADDRESS: _______________________________________________________

________________________________________________________________

TELEPHONE/CELL NUMBERS: ______________________________________

________________________________________________________________

FAX NUMBER: ____________________________________________________

EMAIL: __________________________________________________________

DATE SUBMITTED: _______________________________________________


Please select area(s) of Weatherization services(s) your company proposes to provide:

Air Sealing/Carpentry      ______________

Standard Heating           ______________

CRISIS Heating             ______________

Insulation                 ______________

Baseload                   ______________


                                                                                        2
                    CONTRACTOR BACKGROUND & QUALIFICATIONS

SECTION 2:
Type of business:

      Sole Proprietor ship               _________________
      Partnership                        _________________
      Corporation                        _________________


Is business certified by the Minority Business Enterprise Council as:

      (Please provide MBEC Certification number)

      African-American owned             _________________
      Female owned                       _________________
      Minority owned                     _________________
      Disabled/Handicapped owned         _________________

IDENTIFICATION:

             1.     Federal I.D. Number                ____________
             2.     Business Privilege
                    License No.                        ____________

             3.      Contractor’s License No.          ____________
             4.     Date of Formation or
                    Incorporation                      ____________

INSURANCE:

             1.     Company                            ____________________
             2.     Agent                              ____________________
             3.     Address                            ____________________
             4.     Coverage                           ____________________
             5.      Bonding
                     Amount                            ____________________




                                                                              3
1.    Describe your business and its purpose, providing a brief historical sketch.


      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________


2.    Provide a list of licenses you hold:

      License Type                           License No.     Date of First Issue


      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________


(Attach additional sheets if necessary)




                                                                                     4
3.   Give the names of employees and helpers you regularly employ and their skill level.
     For all subcontracted work, please list on the EEO documents in this section.

     Employee Name                     License Type                License

     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________




4.   List your major customers from 2008-2009. Include public and private and
     estimate dollar value of work performed:

     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________


5.   Summarize all other planned business activities for the period of this contract 2009-
     2010.

     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________




                                                                                             5
6.   Identify all experience in blower door use, insulation work, and general construction,
     building shell heat loss reduction treatments, heater work, energy education,
     whichever applies to your qualifications for services. Be as specific as possible in
     describing job locations, clients, and volume of work in value. Include experience with
     government housing programs.

     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________



7.   Identify all specialty equipment your company or your subcontractors own
     Which will help you to perform weatherization services.

     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________




                                                                                           6
8. Describe how you will assure quality control in your delivery of services.

       a.     Describe how your work is supervised:
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________


       b.     Describe your system for resolving client complaints and PHDC punch list
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________

       c.     Describe how you determine field staff competence:

              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________
              _______________________________________________________________



                                                                                         7
9.   Describe your invoicing process for PHDC

     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________




                                                                   8
                                        SUBCONTRACTORS
SECTION 3

(You must complete this section if you intend to use subcontractors in this project).

1.     List the name, address, telephone number and license numbers, of all subcontractors
       you intend to use. Be sure to include copies of there insurance certificates and trade
       licenses in the “Attachment Section”.

       Name                 Address    Telephone       License
                                       Number           Type/No.
       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________

2.     List each subcontractor’s major customers in 2008-2009. Include public   and
       private customers and estimated dollar value of work performed. (Use additional
       paper if needed):

       Customer Name               No. Jobs                    Estimated $ Value

       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________

3.     Describe the subcontractor(s) experience in providing services for which you intend to
       use them.
       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________
       ____________________________________________________________________




                                                                                                9
4.   Describe how you will control the turnaround speed of work from your subcontractors:

     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________

5.   Describe how you will control the quality of work from your subcontractors:

     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________


                                                                                       10
      SECTION 4

PRODUCTION LEVEL PROJECTIONS

Schedule your proposed work productions by month for both Weatherization
and all other concurrent activity. Assume PHDC will have funding to weatherize
2,500 units, all of which will receive air-sealing work; roughly 2,000 of which
will receive insulation; and roughly 1,750 of which receive heating work.




2009                                    2010
Aug Sep       Oct   Nov   Dec           Jan Feb      Mar    Apr    May    Jun

___   ___     ___   ___   ___           ___    ___   ___    ___    ___    ___


Total Weatherization Units: ____

Other Units

___   ___     ___   ___   ___           ___    ___   ___    ___    ___    ____


Total Weatherization Units: ___




Identify the number of crews, mechanics, subcontractors, etc., committed to
Weatherization production shown above.

                    No. of Crews               ___________

                    No. of Mechanics           ___________

                    No. of Subcontractors      ___________




                                                                                  11
Assume an average cost per unit of $2,500 for air seal/carpentry, $1,600 for
Heating $1,500 for base load and $900 for insulation. Considering the trade
You are proposing to provide and your production schedule, complete the
projected expenditures charts:



PROJECTED EXPENDITURES

Aug          Sep           Oct          Nov           Dec          Jan

_____        _____         _____        _____         _____        _____


Feb          Mar           April        May           June         July

_____        _____         _____        _____         _____        _____

Aug          Sept

_____        _____



Show amount of two highest consecutive months:

$______________________

$______________________




                                                                               12
FISCAL ABILITY

Provide evidence of either adequate cash on hand or credit to cover up to sixty
days peak production (60) days peak production (per the prior Production Le vel
Form). List the following and attach supporting correspondence from creditor:
Without supporting documentation, the listed credit will not be included in
PHDC’s analysis for your capacity.


BANK CREDIT:

Bank(s)      ________________________________________________
Amount       $_______________

             ________________________________________________
             $________________

             ________________________________________________
             $________________

             ________________________________________________
             $________________

             ________________________________________________
             $________________


VENDOR CREDIT:

Vendors:     ________________________________________________
Amount       $_________________

             _________________________________________________
             $_________________

             _________________________________________________
             $_________________

             __________________________________________________
             $_________________

             __________________________________________________
             $_________________

Cash on Hand $___________________________________
(Average Bank Balance)



                                                                                  13
        EQUAL EMPLOYMENT OPPORTUNITY
           AFFIRMATIVE ACTION PLAN
                   FORMS




 NOTE: Please contact the Office of Housing and
Community Development’s (OHCD) Compliance
Department for questions about the forms in this
section at 215-683-3001.




                                                   14
     CONTRACTOR'S CERTIFICATION OF COMPLIANCE                             CITY OF PHILADELPHIA
                   SECTION 3
                                                              OFFICE OF HOUSING AND COMMUNITY DEVELOPMENT
       HOUSING & URBAN DEVELOPMENT ACT OF 1988



CITY OF PHILADELPHIA'S CERTIFICATION OF COMPLIANCE WITH REGULATIONS TO SECTION 3 OF

THE HOUSING AND URBAN DEVELOPMENT ACT OF 1968 AS REQUIRED FOR PARTICIPATION IN
THE FEDERALLY FUNDED COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM, PURSUANT TO
THE HOUSING AND COMMUNITY ACT OF 1974, PI-93-383.

PURPOSE, AUTHORITY AND RESPONSIBILITY
Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 11701U (hereinafter
Section 3) requires that to the greatest extent feasible, opportunities for training and employment in a Section 3
covered project to be given to lower Income residents of the project area and that contracts for work In
connection with the project be awarded to business concerns which are located in, or owned in substantial part
by persons residing In the area of the project.


                                                                              (Hereinafter called the Contractor),
                     NAME OF CONTRACTOR


Upon being awarded a contract for                                                                  in the amount
                                                   NAME OF PROJECT


of                                                                                     ($                     ) in

the City of Philadelphia, to the extent feasible, will make a good faith effort to train and employ lower income
residents and shall make a good faith effort to utilize the services of businesses located in or substantially
owned by persons who live within the project boundaries.

The Contractor has been informed by the City, that the project area boundaries for the Community
Development Project will include the immediate zip codes, adjacent zip code and the municipal limits of
the City.

The City has determined that there are approximately 223,703 Lower income persons within the City limits
based on the 1990 Census.

To complete the project it is estimated that the Contractor's work force needs will be as reflected in the Table
of Manpower. Utilization Training and Work Force Needs.

To complete the project it is also- estimated that the Contractor will be subcontracting for supplies and
services for which certain business concerns eligible under Section 3 could provide. In order to comply
with the regulations for Utilization of businesses under Section 3. The contractor will adopt an Affirmative
Action Plan. The contractor will also require each subcontractor, if any, to adopt an affirmative action plan.



          NAME OF CONTRACTOR                                           NAME AND TITLE OF CONTRACTOR




          ADDRESS AND ZIP CODE                                                TELEPHONE



                                                                                                                     15
                 DATE                                                  AUTHORIZED SIGNATURE
Workforce Needs / Manpower Utilization                                                      City of Philadelphia
                               Section 3                                     Office of Housing and Community Development
Contractor                                                                  Contract

Occu-                     Number of skilled employees                                             Number of Trainees
 pation                   Presently               To Be Hired                              Presently               To Be Hired
                 Required on Payroll Total       Philadelphia Residents      Required      on Payroll     Total      Philadelphia Residents
                                               Low Income       Minority                                           Low Income       Minority




OCCUPATIONAL CATEGORY CODES
1-Asbestos Workers        5-Electricians                    9-Lathers                    13-Plasterers            17-Tile Setters
2-Brick Layers            6-Elevator Construcors            10-Machinists                14-Plumbers              18-Others (Specify)
3-Carpenters              7-Glaziers                        11-Operating Engineers       15-Roofers
4-Cement Masons           8-Iron Workers                    12-Painters                  16-Sheet Metal
                                                         Contractor's Certifications
A. The Contractor hereby certifies that the above tables represent the approximate number of employee/trainee positions
required in the execution of the contract designated and also represents the number of lower income residents of the City
of aPhiladelphia that the Contractor proposes to utilize in filling employee/trainee positions pursuant to a Federal or State
Department of Labor approveed training plan.

B. The Contractor certifies that it will make a good faith effort to fulfull the number of lower income trainees stated above
by utilizing such community based organizations as Negro Trade Union Leadership Council, Philadelphia Urban League,
Bureau of Employment Security and Opportunities Industrialization Center (OIC), and Building Trade Unions.

C. The Contractor certifies that apprentices/trainees to be utilized on this project in no event will be less than the number of
apprentices/trainees determined by the Secretary of Labor for each building construction occupation.

D. The Contractor, prior to subcontraction any portion of the work covered by this contract will require a Manpower
Utilization Table to be prepared and certifications similar to paragraphs A, B and C to be executed.

REPORTING: The Contractor will report to the City on a regular basis (monthly or quarterly) the results of employee and
trainee employment of lower income residents of the City. The Contractor reports will include not only his efforts, but the
efforts of subcontractors, if any.
                          *************************************************************************
The Contractor will, to the greatest extent feasible, abide by the requirements to Section 3 of the Housing and
Urban Development Act of 1968, 12, U.S.C. 1701u. in carrying out its contract.

Name of the Contractor                                      Contractor's Authorized Signature and Title           Date



                                       Authorized Signature and Title                                             Date
       Approval by
   City of Philadelphia




                                                                                                                                          16
     Contractor's Section 3 Affirmative Action Plan                           City of Philadelphia
                   for business utilization                    Office of Housing and Community Development
The Contractor shall utilize, to the maximum extent feasible, eligible Section 3 business concerns located in
Philadelphia, Pennsylvania, in contracting for work to be performed in connection with the completion of the
contract. Elegible Section 3 businesses are those which qualify as "small" under the Small Business
Administration size standards and which are socially and economically disadvantaged.

Section 3 requires a minimum goal of 10% of the total contract amount which it expects to be awarded to
eligible Section 3 business concerns. Table 1, Business Utilization Table, sets forth the classification of
subcontracts, the estimate of each subcontractor dollar amount, whether a Section 3 business is intended to
be utilized, and the dollar amount of proposed subcontracts to Section 3 businesses.

Name of Project _______________________________________ Contract Amount

                                         BUSINESS UTILIZATION
                                      Proposed $ Amount of                                       Sec
Proposed Subcontracts/Suppliers       Proposed Subcontract    Description of Work                 3 WBE MBE




To Achieve the goal specified above, the Contractor shall:

1. Make full use of minority business listings made available by HUD Area Office, Small Business
Administration, the Minority Business Enterprise Council, the Pennsylvania Department of Commerce, (and
other applicable resources). If an interested eligible business neeeds help in preparing bid documentation or
meeting bonding requirements, they will be referred to an appropriate agency.

2. Take steps to insure that subcontracts which are typically let on a negotiated rather than a bid basis are
also let on a negotiated bases, whenver feasible.

3. Where competitive bids are solicited, include as part of the bid documents the contractor's goals for
Section 3 as it relates to the work for which bids are being solicited, require each bidder to submit their
Utilization Goals and Affirmative Action Plan for achieving Section 3 Business Utilization.

4. Insert the Section 3 contract language required by 24 CFR 135.20(b) in all subcontracts, and require to be
executed by the subcontractor a certification of compliance with Section 3, similar to the Contractor's
Certification of Compliance, (20-D-395), and an Affirmative Action Plan for Business Utilization, (20-D-397).

The Contractor will report to the City on a regular basis (monthly) the results of the Affirmative efforts and
undertakings per paragraphs 1, 2, and 3 above, inluding the efforts of its subcontractors.

                                      Authorized Signature and Title                             Date
Contractor's Signature
     Approval by       Authorized Signature                                                      Date
 City of Philadelphia




                                                                                                                 17
                         SOLICITATION AND COMMITMENT FORM (BID)                                                                           DEPARTMENT OF FINANCE
          DISADVANTAGED MINORITY (M-DBE) WOMEN (W-DBE) AND DISABLED (DS-DBE) OWNED BUSINESS ENTERPRISES                          MINORITY BUSINESS ENTERPRISE COUNCIL (MBEC)
NUMBER                                   NAME OF BIDDER                                                                               DATE OF BID OPENING


        List below ALL M-DBE, W-DBE, DS-DBEs that were solicited regardless of whether a commitment resulted.                              Photocopy this form as necessary
                                                                                Date Solicited     Commitment Made                                   Give Reasons
    M-DBE      W-DBE     DS-DBE             Type of work or material        By Phone      By Mail if Yes, give Date No                            If No Commitment
Company Name

Address                                                                                  Quote Received       Amount Committed
                                                                                       Yes          No           Dollar Amount
Contact Person                           Phone

MBEC Cert Number, plus expiration date                                                                      Percentage of Total Bid


                                                                                         Date Solicited      Commitment Made                         Give Reasons
    M-DBE        W-DBE        DS-DBE                      Type of work or material   By Phone     By Mail   if Yes, give Date No                  If No Commitment
Company Name


Address                                                                                  Quote Received       Amount Committed
                                                                                       Yes          No           Dollar Amount
Contact Person                           Phone


MBEC Cert Number, plus expiration date                                                                      Percentage of Total Bid


                                                                                         Date Solicited     Commitment Made                          Give Reasons
    M-DBE        W-DBE        DS-DBE                      Type of work or material   By Phone     By Mail               No
                                                                                                            if Yes, give Date                     If No Commitment
Company Name


Address                                                                                  Quote Received       Amount Committed
                                                                                       Yes          No           Dollar Amount
Contact Person                           Phone


MBEC Cert Number, plus expiration date                                                                      Percentage of Total Bid


                                                                                         Date Solicited     Commitment Made                          Give Reasons
    M-DBE        W-DBE        DS-DBE                      Type of work or material   By Phone     By Mail               No
                                                                                                            if Yes, give Date                     If No Commitment
Company Name


Address                                                                                  Quote Received       Amount Committed
                                                                                       Yes          No           Dollar Amount
Contact Person                           Phone


MBEC Cert Number, plus expiration date                                                                      Percentage of Total Bid




                                                                                                                                                                18
                     SECTION 3 CERTIFICATION
TRAINING EMPLOYMENT, AND CONTRACTING OPPORTUNITIES FOR BUSINESS
                  AND LOWER INCOME PERSONS


A.   The project to be assisted under this Request is subject to the requirements of Section
     3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.-C.
     1701u. Section 3 requires that to the greatest extend feasible, opportunities for
     training and employment be given lower income residents of the project area and
     contracts for work in connection with the project be awarded to business concerns
     which are located in or owned in substantial part by persons residing in the area of the
     project.

B.   Notwithstanding any other provision of this Req2uiest, the applicant shall carry out the
     provisions of said Section 3 and the regulations issued pursuant thereto by the
     Secretary set forth in 24 CFR Part 135 (published in 38 Federal Register 29220,
     October 23, 1973) and all applicable rules and orders of, the Secretary issued
     thereunder prior to the execution of a Redeveloper’s Agreement. The requirement of
     said regulations include but are not limited to development and implementation of an
     affirmative action plan for business concerns located within or owned in substantial
     part by persons residing in the area of the project; the making of a good faith effort, as
     defined by the regulations, to provide training, employment, and business
     opportunities required by Section 3; and incorporation of the Section 3 clause
     specified by Section 135, 20(b) of the regulation in all contracts for work in connection
     with the project. The applicant certifies and agrees that it is under no contractual or
     other disability which would prevent it form complying with these requirements.

C.   Compliance with the provisions of Section 3. the regulations set forth in 24 CFR Part
     135, and all applicable rules and orders of the Secretary issued thereunder prior to
     approval by the Government of the application for this (agreement) (contract) shall be
     a condition of the Federal financial assistance provided to the project, binding upon
     the applicant, its successors and assigns. Failure to fulfill these requirements shall
     subject applicant, its contractors and subcontractors, its successors, and assigns to
     the sanctions specified by the Redevelopment Agreement and to such sanctions as
     are specified by 24 CFR Section 135.


_________________________                             __________________________
DATE                                                  SIGNATURE

                                                      _____________________________
                                                      NAME (TYPE OR PRINT)

                                                      _____________________________
                                                      TITLE



                                                                                             19
                         EXECUTIVE ORDER 2-95 CERTIFICATION
                          NEIGHBORHOOD BENEFIT STRATEGY


A.     Pursuant to Executive Order 2-95 issued by the Mayor of Philadelphia on January 31,
       1995, each project sponsor, developer, or builder working on housing or community
       development project that is funded by PHDC or DOC or their designee, whether such
       project is financed in part by HUD funds, certified and covenants.

B.     That to the greatest extent feasible, contracts for work to be performed pursuant to
       such projects shall be awarded to business concerns including individuals or firms
       doing business in the field of design, architectures, including building construction,
       rehabilitation, maintenance, or repair, that are owned by, employ or otherwise provide
       economic opportunities to low or very low persons income residing in the areas of
       such projects:

Furthermore:

       1.      Project sponsors, developers, or builders receiving PHDC or DOC funds for
               housing and community development projects are encouraged to establish a
               goal of employing low and very low income neighborhood area residents at fifty
               percent (50%) or more of the aggregate number hires associated with these
               projects.

       2.      Project sponsors, developers, or builders are encouraged to establish a goal of
               awarding fifty percent (50%) more of the aggregate value of all construction
               contracts and service contracts associated with these projects to neighborhood
               area businesses.

These goals should not be construed are requirements, quotas, set-asides, or a cap on hiring
or contracting with low and very low income individuals and businesses. However, the goals,
if met, constitutes as a safe harbor for project sponsors, developers, and builders on the
issue of compliance with this order.

Neighborhood Benefits Strategy certification is required by all project sponsors, developers
or builders submitting proposals in response to the Request. The respondent certifies and
agrees that it is under no contractual or other disability which would prevent it from complying
with these requirements.
_______________________________                           ______________________________
DATE                                                      SIGNATURE

                                                        ______________________________
                                                        NAME (TYPE OR PRINT)

                                                        ______________________________
                                                        TITLE



                                                                                             20
                           TAX STATUS CERTIFICATION REQUEST


Taxpayer Name:                                                           Date:

Taxpayer Trading As:

Home Address:

Business Address:




1.       Are you a Registered Taxpayer?                                  Yes            No    []
         If so, Philadelphia A/C #
         Social Security Number
              I



2.       Are you presently delinquent in any City of                     Yes     []     No    []
         Philadelphia School District Taxes?

         If so, what tax and amount owed:


3.       Are you presently delinquent in Water and                       Yes     []     No    []
         Sewer Charges?

         If so, amount owed:

4.
         Have you ever been sued by the City of                          Yes     []     No    []
         Philadelphia?                                                            [
                                                                                 ]
         If so, list nature of law suit:


5.       Are you involved in any other business activity?                Yes     []     No    []

         If so, list company name and account number:


 6.      Do you own real estate?                                         Yes     []     No    []
         If so, list address(es) here or back of this form.                                   ]



 I hereby affirm that the information provided above is true and correct to the best of my
 knowledge, information and belief; said affirmation being made subject to the penalties
 prescribed.by 18 Pa. C. S. A. Sec. 4904 relating to unsworn falsifications to authorities.
 Name:                                                                                             21
 Signature:                                                      Date:
    ANTI –LOBBYING
         FORM




I
                     22
                     ANTI-LOBBYING CERTIFICATION




I, _____________________________________, (Contractor) hereby certify that no
Federally-appropriated funds have been paid or will be paid, by or on behalf of myself
to any person for influencing or attempting to influence an employee or a Member of
Congress in connection with a Federal contract, grant, loan or cooperative agreement.

I will provide immediate written notification to PHDC if I learn that the above certification
was erroneous when submitted or has become erroneous because of changed
circumstances.

I also certify that I have required this same certification from my contractors.




______________________________                    ___________________________
           Witness                                           Contractor




                                                                                                23
  SAMPLE INSURANCE
     CERTIFICATE




       REMINDER:

THE CITY OF PHILADELPHIA AND
  PHDC MUST BE LISTED AS
 ADDITIONAL INSURED ON THE
   INSURANCE CERTIFICATE




                               24
                                                                                                              Issue Date (MM/DD/YY)
                   CERTIFICATE OF INSURANCE
PRODUCER                                    This certificate is issued as a matter of information only and confers no rights upon
                                            the certificate holder. This certificate does not amend, extend or alter the coverage
                                            afforded by the policies below.
                 Broker
                                                                    COMPANIES AFFORDING COVERAGE
                                            Company Letter A           Name of Contractor
INSURED                                     Company Letter B
                                                                                    B,C & D filled out only if there
                                            Company Letter C                        is more than one insurance
             Contractor                     Company Letter D                        company
                                            Company Letter E

This is to certify that policies of insurance listed below have been issued to the insured named above for the policy period indicated,
notwithstanding any requirement, term or conditions of any contract or other document with respect to which this certificat my be issued or may
pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions, and conditions of such policies.


                                                           Pol. Effective   Pol.Expire Date
                                                           Date             (MM/DD/YY)
 Type of Insurance                Policy Number            (MM/DD/YY)                                                Limits
General Liability                                                                             General Aggregate                    $2,000,000
X Commercial Gen Lia                                                                          Prod-Comps/Ops Aggregate             $1,000,000
X Occurence                          ABC XXX               XX/XX/2008 XX/XX/2009 Personal & Advertising Injury                     $1,000,000
   Claims Made                                                                                Each Occurrence                      $1,000,000
   Owner's Protective                                                                         Fire Damage (Any one fire)              $50,000
                                                                                              Medical (Any one person)                 $5,000
Auto Liability                                                                                CSL                                  $1,000,000
  Any auto                                                                                    Bodily Injury
X All owned autos                                                                                Per Person
  Hired autos                                                                                 Bodily Injury
X Non-owned autos                                                                               Per Accident
                                                                                              Property Damage
Excess Liability                                                                              Each Occurrence
                                                                                              Aggregate
Worker's Comp                                                                                 Each Accident                          $100,000
and                                                                                           Disease-Policy Limit                   $500,000
Employer's Liability                                                                          Disease-Each Employee                  $100,000
Professional                                                                                  Individuals and professional corporations:
Liability                                                  XX/XX/2008 XX/XX/2009 $1,000,000, with at deductible not to
                                                                                              exceed $50,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
   PHDC and the City of Philadelphia are included as additional insureds
CERTIFICATE HOLDER                                                          CANCELLATION
Philadelphia Housing Development Corp.                        Should any of the above described policies be cancelled before the expiration date
                                                              thereof, the issuing company will endeavor to mail ___ days notice to the
1234 Market Street
                                                              certificate holder named to the left, but failure to mail such notice shall impose no
17th Floor                                                    obligation or liability of any kind upon the company, its agents or representatives.
Philadelphia, PA 19107

Attention: Compliance Department                                            Authorized Representative:




                                                                                                                                                  25
                                       Instructions
                  Contractor Compliance Certification Form
                         Individual Employee Form


Overview:
This form is designed for individual employees to self-certify their household income as
either ''less than'' or ''greater than'' 80% of the Area Median Income. This -information is
required by The Philadelphia Code, which states that on City-funded construction
contracts of more than $150,000, at least 40% of employees must earn less than 80% of
Area Median Income. Employees that have been hired within three years and who now
make greater than 80%, but at the time of hiring made less than 80%, are. also counted as
part of the 40% requirement.
The Individual Employee Form is designed to determine whether an individual employee
may be counted against the.Employer's 40% goal. Each employee should complete one
of these forms and return it to the employer.
Area Median Income is measured by Gross Income by Household Size. Household
Includes all persons living as part of your household (for example, spouse and minor
children). Current Annual Gross Income includes income from all sources, including
earned.income, disability income, etc., of any and all members of the household.
Section One:

This section of the form deterrnines whether the employee's current household income is
less than 8 0% of the Area Median Income, or greater than 8 0% of the Area Median
Income. The employee should locate the line which reflects his or her Household Size
(Number. of Persons) and determine whether the Current Annual Gross Income of all
those persons is less than, or greater than, the amount listed on the. line.

Check the appropriate box on the line, indicating whether the total annual gross income is
less than or greater than the amount on that line. Only one check mark should appear, on
only one line.

If the income is less than the amount listed, proceed to Section Three. It is not necessary
to complete Section Two. If the income is greater than the amount listed, the employee
may still qualify based on income at hiring, if such hiring occurred within the last three
years. This qualification is made in Section Two.
Section Two:

Section Two is designed to determine whether employees whose household income is
currently over 80% of Area Median Income, may qualify for the 40% requirement based

                                                                                               26
                                                                                                             .


    on household income prior to being hired by this company or employer. Such hiring
    must have occurred within the last three years. This section should only be completed by
    employees whose household income in Section One. was determined to be greater than
     80% of Area Median.
                                          I


     Line I is the Date of Hire by this Employer.

     Line 2 tests whether the Employee was hired within the last three
     years.
     Line 3 tests whether the Employee's Household Income was less than or greater than the
     80% figure for the date of hiring. In determining the answer to this question, the following table
     should be used:


          Table of Pdor.Year 80% Income               Maximum Household Income
                    Maximums

                                                           Date of Hiring   by This Employer                     .

                                                    Mar. 9, 2000-      Apr. 6, 2001-        Jan. 31, 2002-
        Household Size (Number of Persons)-          Apr. 5, 2001      Jan. 30, 2002         Feb. 26, 2003

                         1                             32,350               33,650             35,450

                         2                             37,000               38,450              40,500

                         3                             41,600                43,250            45,600

                         4                             46,250               48,100              50,650

                         5                             49,950               51,950              54,700
.
                         6                             53,650               55,750              58,750

                         7                             57,350               59,600              62,800

                         8                             61,050               63,450              66,850

                         9                             64,750               67,298             70,902

                         10                            68,450               71,146              74,954

                         11                            72,150               74,994              79,006

                         12                            75,850               78,842              83,058


     The Table above works very much like the Table in Section One of the Employee Form .

     For example, if the Employee was hired on August 15, 2001, and at the time of hiring had
     a household of five persons and a Total Gross Household Income for these persons of
     $48,000, the Employee's Household Income at hiring was less than 80% of median
     income. In this example, the Employee would locate the line for a Household of Five
     Persons and locate the column for the Hiring Date of August 15, 2001. The maximum
                                                                                                                     27
income for that household size and date was $51,950. The Employee’s Household
Income was $48,000, which is less than $51,950. The Employee should check “Yes” on
Line 3.

Line 4 verifies the answers to both lines 2 and 3 is Yes. If the answer on both lines is
Yes, the Employee is qualified as Less than 80% and should enter this information in the
appropriate place in Section Three.


Section Three:

This Section combines information from Sections One and Two to determine whether the
Employee is Qualified as Less than 80% by either Section. If the Employee’s Current
Household Income (as determined in Section One) is Less than 80%, or if the
Employee’s Income at Hiring was Less than 80% (as determined by Section Two), Circle
the answer Yes. If neither of these means of qualifying is met, Circle the answer No.


Certification:

Read, sign and date the self-certification form indicating that the information provided is
accurate to the best of the employee’s knowledge.




                                                                                              28
                                                                                   .
                                                                                   .
                                                                                   .

                            Contractor Compliance Certification Form
                                      Employer Summary Form.
        Project Name
        Employer/Company Name

                                                   Check ONE box per employee. - This information is
                                                   gathered from Section 3 of the Individual Employee
                                                                           Form
        Employee Name                                   Less than 80%?             Greater than 80%?
   1
   2
   3
   4
   5
   6
  -7
   8
   9
  10
  11.
  12
 13
 14
 15
 16
.17
 18
 19
20
                Total Number this Page
              Use additional sheets if necessary


1 Total Number of Employees on Project
2 Number of Employees Less than 80%
3 Number of Employees Greater than 80%
4 Percentage Less than 80%

    Certification:

   I certify that the summary information provided here is based on certifications. provided by
   individual employees.



                           Authorized signature:

                          Title
                          :
                          Date:                                                                         29
                  Contractor Compliance Certification Form
                    Individual Employee Form - - Page One

   Project Name
   Employer/Company Name

   Employee Name
  Qualification Date

   Note: Employees may be qualified to meet the 40% goal., either based on current
  income (Section One) or on income prior to. being hired to the current job, if hired.,
  within the last three years (Section Two).
  Section One   - Current Household Income Test                   (effective 2/26/2003)

        Employee's Household Income Data
              (Check ONE box only)                        Current Gross Household Income
                                                                    2003 annual
                                                                  maximum (80%
       Household Size (Number of Persons)            less than      of median)          greater than

                            1                                          38,200

                        2                                              43,650

                        3                                             49,100

                        4                                             54,55.0

                        5                                             58,900

                        6                                             63,300

                        7                                             67"1650

                        8                                             72,000

                        9                                             76,364

                       10                                             80,728

                       11                                             85,092

                       12                                             89,456


                                                                                                       30
If Current Household Income is less than 80% of median, go directly to Section Three.
                                                                                                       ...




                                                     ...
                        Individual Employee Form -Page Two
  Section Two - Income at Hiring Test

1 . Date of Hire by this Employer

                                                                          Yes                No
2 . Is Date of Hire Less than 3 years from
    today's date?
3 . Was Employee's Household Income at
   hiring less than 80% -of median income
   on date hired? (See Yearly Tables)
                             ...
4 .Is the answer to BOTH questions 2 & 3 Yes?

         ff answers to BOTH questions is YES,employee is-qualifled as Les than BO%.
                          .


 Section Three - Qualffication as Less than 80% of Median Income
                   I




     Is Employee Qualified as Less than 80% by either Section One OR Section
     Two?
                                       Circle
                                       one


    Yes - Less Than 80%                                    No - More than 80%


    Employer: Enter Qualification on Summary Sheet by Employee's Name.



 Certification:
I certify that the above information related to my household's annual gross income is accurate
to the best of my knowledge.


                       Employee Signature
                       Date


                                                                                                  31
32
             PHDC WEATHERIZATION PROGRAM PROPOSAL
                                   APPENDIX CHECKLIST

The following attachments, as applicable to your business, must be included as part of your proposal.
Missing documents will be interpreted as failure to conform to proposal requirements. Use this form
as a checklist to indicate attachments you have included in your proposal.

Forms supplied by PHDC to be completed by ALL respondents:

       1.      Contractor’s Certification of Compliance (Section 3)                       [ ]
       2.      Workforce Needs/Manpower Utilization (Section 3)                           [ ]
       3.      Contractor’s Section 3 Affirmative Action Plan for
               Business Utilization                                                       [ ]
       4.      Solicitation for Participation and Commitment Form                         [ ]
       5.      Section 3 Certification                                                    [ ]
       6.      Executed Order 2-95 Certification                                          [ ]
       7.      Tax Status Certification                                                   [ ]
       8.      Anti- Lobbying Certification                                               [ ]
       9.      Employee Income Forms (Employee and Contractor)                            [ ]
Supporting documents to be provided by all respondents:

       10.     Insurance certificate general liability, auto liability, and worker’s      [ ]
               Compensation. PHDC and the City of Philadelphia must be named
               As additional insured on the certificate.
       11. ** Articles of Incorporation and Bylaws                                        [ ]
       12.     Current Trade License and/or Home Repair License                           [ ]
       13. ** Resumes (Owners and Key Staff)                                              [ ]
       14.     Subcontractor qualifications (insurance certificate, trade license,        [ ]
               Experience statement and Tax Status Certification for each).
       15.     2008 Federal Tax Return (or F.T. Return) or Accountant’s                   [ ]
               (Review or Audit) (less than one year old)
       16.     Letters of Credit or bank statements showing adequate cash on hand         [ ]
               (Letters of Credit must be typed on company letterhead)

** These items are unnecessary for contractors currently under contract in the Weatherization
   Program.



                                                                                                    33

				
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