HomeMy Public PortalAboutFY2017 Consultant Selection Process Documents_0Metropolitan St. Louis Sewer District
FY17 Consultant Selection Process Documents
Consultant Selection Policy
RFQ and RFP Scoring Sheets
Minority and Women Workforce
Utilization Program Procedure
Multiplier Calculation Worksheet
ENGINEERING
GENERAL MANAGEMENT POLICY/PROCEDURE
NUMBER E-1
PAGE 1 OF S
ISSUED 01/22/14
APPROVED BY
EXECUTIVE DIRECTOR
TOPIC: Consultant Selection
Procedure for Selection of
Engineering, Surveying,
Architectural and
Construction Management
Consultants
SUPERSEDES
PREVIOUS ISSUE DATED
12/12/03 & 3/1/11
PURPOSE
To identify procedures for procurement of engineering, architectural, and survey consultants interested in providing
professional services for the District.
POLICY
I. Prequalification Requirements
A. Must have a full-time office within the District boundary. The office shall have the capabilities and
staff to produce an architectural, surveying, or engineering product, such as construction drawings,
easement plats, surveys, reports and other related work. The office must be open and manned during
normal company work hours and serve as a self-sufficient office for the company.
B. Must have at least one engineer/architect/surveyor registered in the State of Missouri on staff to be
responsible for and seal all work.
C. Must be qualified and experienced in architecture, surveying, civil, or environmental engineering
work. To be considered qualified, a consulting firm must provide verifiable documentation of
experience in the area of expertise necessary for the size and discipline of the proposed project to be
considered. This will generally consist of the design of sanitary sewers, sewage treatment facilities,
pump stations, infrastructure rehabilitation, and storm drainage facilities such as sewers, culverts,
channels, detention basins, overflow structures, and land or topographic surveys.
D. Poor past performance may result in the District rescinding or denying prequalification.
II. Prequalification Process
A. Must submit Qualification Form (see Engineering Department for Engineering Service
Questionnaire) and Insurance Certificate, which is to be updated annually. The insurance certificate
shall indicate compliance with all the District's current insurance requirements, including
professional liability limits. The annual qualification forms will be used to formulate a pre -
qualification list of consultants to be used for consideration in the selection of firms to provide
professional services as required.
ENGINEERING
III. Consultant Procurement Process
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A. For projects that are less than $500,000 in estimated fees, usually two projects will be selected for
proposals from three consultants on the current pre -qualified list. Those consultants that can meet
all the District's insurance requirements, including the required professional liability/errors and
omissions coverages and annual aggregate requirements and who have expressed an interest in a
particular set of projects will be considered for an applicable selection list;
or
For projects that exceed $500,000 in estimated fees, the District will send out requests for
qualifications (RFQs) and will solicit pre -qualified consultants that have interest in being considered
for any/or all projects.
B. A Short List Committee consisting of the Director of Engineering, an Assistant Director of
Engineering or Operations, the Director of Operations, and the Director of Human Resources shall
prepare a short list of at least three (3) consultants from a list of pre -qualified consultants for projects
less than $500,000. For projects over $500,000, a short list of at least three consultants will be
developed from the consultants that have submitted a Request for Qualifications for an identified
project. If a project receives proposals from less than three qualified consultants, other consultants
may be asked to submit on the project based on the consultant's general qualifications.
Consideration will be given to project team and key members, personnel availability/workload, past
performance/project experience, and backlog of all team members. For projects over $500,000 that
require a Request for Qualifications, a diversity multiplier will be applied to the final score
consisting of the following: WBE prime or African American, Asian American, Native American
MBE prime — 10%; ability of prime to meet minority and women local office workforce goals —
10%; and ability of prime to meet half of both minority and woman local office workforce goals —
5 %. Prime may utilize local office workforce of a sub -consultant towards a total maximum 10%
workforce multiplier. (See Attachment A — Diversity Multiplier Worksheet.)
C. Request for Proposals (RFP) shall be sent to the short listed firms.
D. All proposals will be date stamped upon receipt by the District. Proposals not submitted on time will
not be eligible for consideration.
E. The composition of the Selection Committee shall not include any members of the Short List
Committee unless it is deemed necessary by the Executive Director. The Selection Committee will
consist of at least five individuals. It shall consist of two Assistant Directors of Engineering, and
three Assistant Directors or management personnel from the Engineering or the Operations
Department as appropriate. The Manager of Diversity Programs will oversee compliance with
District diversity goals.
ENGINEERING
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ISSUED 01/22/14
F. Using a point system, all proposals shall be individually evaluated by each Committee member for
each consultant's understanding of the project technical approach, project manager and team,
personnel availability, project design schedule, related project experience/past performance, and
backlog for the entire team. On projects less than $500,000, only prime backlog will be considered.
On all proposals, a diversity multiplier will be applied to the fmal score consisting of the following:
WBE prime or African American, Asian American, Native American MBE prime — 10%; ability of
prime to meet minority and women local office workforce goals — 10%; and ability of prime to meet
half of both minority and woman local office workforce goals — 5%. Prime may utilize local office
workforce of a sub -consultant towards a total maximum 10% workforce multiplier. (See Attachment
A — Diversity Multiplier Worksheet.) The selection of consultants shall be based on the highest
number of first place selections by the Selection Committee. In case of a tie, the total number of
points shall decide the consultant to be awarded the project. The District has the right to reject any
or all proposals if, in the District's opinion, the proposal does not demonstrate sufficient ability to
perform the work. The recommended Iists of selected consultants shall be forwarded to the
Executive Director for final approval.
G. The District will request a fee proposal from the selected consultants. The proposals shall include a
re -statement of the definition of the project scope, technical and management approaches, project
manager and staffing, schedule and MWBE subcontractors. Fees shall be submitted on a lump sum
or cost plus fixed fee basis as directed by the District. Contracts shall be negotiated to ensure the
best and fairest rates are obtained by the District for the services required.
H. If a reasonable contract cannot be negotiated, for a project, the District will repeat this process with
the next acceptable consultant. If no contract can be negotiated, then the procurement process will
be repeated with all new consultants.
L The Fee Proposal will become part of the approved contract for each project.
J. The Notice to Proceed with the services shall be sent with the signedcontracts only after District
Board approval and verification of proper and current insurance requirements by the Office of
General Counsel. During each project's work period a suspense file of all insurance certificates and
their expiration dates will be maintained so that the consultant may be notified by the District to
submit new certificates in a timely manner, preventing a lapse of coverages. These certificates also
will be verified by the Office of General Counsel.
K. In special cases, for unusual or unique projects, negotiations with qualified consultants, who do not
have offices in St. Louis, as defined in Paragraphs I.A. through I.D., will be undertaken only after
written justification by the Director of Engineering and the approval of the Executive Director.
L. Upon project completion the District will prepare a performance evaluation on the quality of the
design services completed to include the consultant's ability to meet all schedules, and design the
project within budget requirements. The consultant shall be briefed and the evaluations shall be
filed for use in future selection processes.
ENGINEERING
IV Watershed Consultant Procurement Process
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ISSUED 01/22/14
A. The Watershed Consultant Procurement Process shall be used for those contracts specifically offered
to address issues over a large geographical area that are grouped by watersheds and/or specific areas
of expertise. This process is planned to be used to address many issues identified in the District's
consent decree with the Federal Government.
B. The District will send out requests for qualifications (RFQs) and will solicit pre -qualified
consultants that have interest in being considered for any/or all projects.
C. A Short List Committee consisting of the Director of Engineering, an Assistant Director of
Engineering or Operations, the Director of Operations, and the Director of Human Resources shall
prepare a short list of at least three consultants developed from the consultants that have submitted a
Request for Qualifications for an identified project. If a project receives proposals from less than
three qualified consultants, other consultants may be asked to submit on the project based on the
consultant's general qualifications. Consideration will be given to project team and key members,
personnel availability/workload, past performance/project experience, and backlog of all team
members. A diversity multiplier will be applied to the final score consisting of the following: WBE
prime or African American, Asian American, Native American MBE prime — 10%; ability of prime
to meet minority and women local office workforce goals — 10%; and ability of prime to meet half of
both minority and woman local office workforce goals — 5%. Prime may utilize local office
workforce of a sub -consultant towards a total maximum 10% workforce multiplier. (See Attachment
A — Diversity Multiplier Worksheet.)
D. Request for Proposals (RFP) shall be sent to the short listed firms.
E. All proposals will be date stamped upon receipt by the District. Proposals not submitted on time will
not be eligible for consideration.
F. The composition of the Selection Committee shall not include any members of the Short List
Committee unless it is deemed necessary by the Executive Director. The Selection Committee will
consist of at least five individuals. It shall consist of three Assistant Directors of Engineering or
Operations, and two management personnel from the Engineering or the Operations Department as
appropriate. Additional non -voting members may be added to provide technical input. The
Manager of Diversity Programs will oversee compliance with District diversity goals.
ENGINEERING
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ISSUED 01/22/14
G. Using a point system, all proposals shall be individually evaluated by each Committee member for
each consultant's understanding of the project and technical approach, the demonstrated skills and
availability of the project team, related project experience/past performance, backlog of all team
members, and the quality of the teams' oral presentation. A diversity multiplier will be applied to
the final score consisting of the following: WBE prime or African American, Asian American,
Native American MBE prime — 10%; ability of prime to meet minority and women local office
workforce goals — 10%; and ability of prime to meet half of both minority and woman local office
workforce goals — 5%. Prime may utilize local office workforce of a sub -consultant towards a total
maximum 10% workforce multiplier. (See Attachment A — Diversity Multiplier Worksheet.) The
selection of consultants shall be based on the highest number of first place selections by the
Selection Committee. In case of a tie, the total number of points shall decide the consultant to be
awarded the project. The District has the right to reject any or all proposals if, in the District's
opinion, the proposal does not demonstrate sufficient ability to perform the work. The
recommended lists of selected consultants shall be forwarded to the Executive Director for final
approval.
H. The District will request a project rate structure and an annual fee proposal from the selected
consultants. The proposals shall include a re -statement of the definition of the project scope,
technical and management approaches, project manager and staffing, schedule and MWBE
subcontractors. Fees shall be submitted on a cost plus fixed fee basis as directed by the District.
Contracts shall be negotiated to ensure the best and fairest rates are obtained by the District for the
services required.
I. If a reasonable contract cannot be negotiated, the District will repeat this process with the next
acceptable consultant. If no contract can be negotiated, then the procurement process will be
repeated with all new consultants.
J. The Fee Proposal will become part of the approved contract for each project.
K. The Notice to Proceed with the services shall be sent with the signed contracts only after District
Board approval and verification of proper and current insurance requirements by the Office of
General Counsel. During each project's work period a suspense file of all insurance certificates and
their expiration dates will be maintained so that the consultant may be notified by the District to
submit new certificates in a timely manner, preventing a lapse of coverages. These certificates also
will be verified by the Office of General Counsel.
L. In special cases, negotiations with qualified consultants, who do not have offices in St. Louis, will be
undertaken only after written justification by the Director of Engineering and the approval of the
Executive Director.
M. The District will prepare an annual performance evaluation on the quality of the design services
completed to include the consultant's ability to meet all schedules, and design the project within
budget requirements. The consultant shall be briefed and the evaluations shall be filed for future
use.
ENGINEERING
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ISSUED 01/22/14
ATTACHMENT A
METROPOLITAN ST. LOUIS SEWER DISTRICT
ENGINEERING PROFESSIONAL SERVICES DIVERSITY
MULTIPLIER CALCULATION WORKSHEET FOR SELECTIONS ONLY
Starting multiplier 1.000
Vendor Diversity (only one category allowed)
Is prime firm a WBE or Asian -American MBE? If yes, enter 0.100
Is prime firm an MBE other than Asian or Hispanic -American? If yes enter 0.100 -
PRIME CONTRACTOR VENDOR MULTIPLIER SUB -TOTAL (1.000 to 1.100)
ENTER THE TOTAL ON LINE 1 OF LAST SHEET
Workforce Diversity — Prime Consultant Minority Women may count as either Women or
Minorities at the proposer's discretion, but not both. Count all full time personnel working in
your office for this calculation regardless of job duties. Full time personnel shall have worked for
the company for the past three months and during that period must average at least 30 hours of
work per week. COUNT FULL-TIME PERSONNEL.ONLY!
a. Total Local Office Workforce -
b. Women in Local Office Workforce -
c. Minorities in Local Office Workforce -
d. "b" divided by "a" (drop all decimals/fractions) -%
e. "c" divided by "a" (drop all decimals/fractions) -_%
f. If "d" is 32% or greater, ENTER 0.025 ON LINES 2 AND 3 OF LAST SHEET
g. If "d" is 16% or greater, ENTER 0.025 ON LINE 3 OF LAST SHEET UNLESS THERE IS
ALREADY A VALUE ENTERED
h. If "e" is 18% or greater, ENTER 0.025 ON LINES 4 AND 5 OF LAST SHEET
i. If "e" is 9% or greater, ENTER 0.025 ON LINE 5 OF LAST SHEET UNLESS THERE IS ALREADY
A VALUE ENTERED
Sub -consultant workforce scoring: Use only if a minimum of 25% of the annual value of work is
sub -contracted. Minority Women may count as either Women or Minorities at the proposer's
discretion, but not both. Count all full time personnel working in your office for this calculation
regardless of job duties. Full time personnel shall have worked for the company for the past
three months and during that period averaged 30 hours of work per week. COUNT FULL-TIME
PERSONNEL ONLY!
ENGINEERING
NUMBER E-1
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ISSUED 01/22/14
Names of sub -consultants performing at least 25% of total contract included in calculation (add
more lines if needed)
Name of Sub -consultant Signature of Representative
j. Combined Total Local Office Workforce of all listed sub -consultants
k. Women in Combined Total Local Office Workforce -
I. Minorities in Combined Total Local Office Workforce -
m. "k" divided by "j" (drop all decimals/fractions) -
n. "I" divided by' j" (drop all decimals/fractions) - %
o. If "m" is 32% or greater, ENTER 0.025 ON LINES 2 AND 3 OF LAST SHEET UNLESS A VALUE IS
ALREADY ENTERED
p. If "m" is 16% or greater, ENTER 0.025 ON LINE 3 OF LAST SHEET UNLESS THERE IS ALREADY
A VALUE ENTERED
q. If "n" is 18% or greater, ENTER 0.025 ON LINES 4 AND 5 OF LAST SHEET UNLESS A VALUE IS
ALREADY ENTERED
r. If "n" is 9% or greater, ENTER 0.025 ON LINE 5 OF LAST SHEET UNLESS THERE IS ALREADY A
VALUE ENTERED
FINAL MULTIPLIER TABULATION
1. PRIME CONTRACTOR VENDOR MULTIPLIER
2. WOMAN WORKFORCE 32% OR GREATER
3. WOMAN WORKFORCE 16% OR GREATER
4. MINORITY WORKFORCE 18% OR GREATER
5. MINORITY WORKFORCE 9% OR GREATER
6. FINAL MULTIPLIER (TOTAL OF 1 THRU 5) (1.000 thru 1.200)
ENGINEERING
NUMBER E-1
PAGE S OF S
ISSUED 01/22/14
The undersigned certifies on behalf of the entity submitting this Report that the above information
is true and accurate as of the date set forth below:
Name of Entity
Signature of Authorized Representative
RATING SCALE CONSULTANT RFQ SHORTLIST RATING FORM Date:
RATE 0-3; 3 is the highest.
(May use 0.5 increments)
PROJECT NAME:
CONSULTANT
x .35 =0.00 x .35 =0.00 x .35 =0.00 x .35 =0.00 x .35 =0.00
35%PROJECT TEAM
& KEY MEMBERS
x .15 =0.00 x .15 =0.00 x .15 =0.00 x .15 =0.00 x .15 =0.00
15%
PERSONNEL
AVAILABILITY/
WORKLOAD
x .35 =0.00 x .35 =0.00 x .35 =0.00 x .35 =0.00 x .35 =0.00
35%
PAST
PERFORMANCE
/ PROJECT
EXPERIENCE
x .15 =0.00 x .15 =0.00 x .15 =0.00 x .15 =0.00 x .15 =0.00
15%BACKLOG
100%Subtotal Points
Diversity Multiplier
Total Points
Ranking
Revision Date: January 16, 2014 Do Not Alter Form without prior approval of the Director of Engineering Rater:
RATING SCALECONSULTANT RFP RATING FORMRATE 0-3; 3 is the highest.(May use 0.5 increments)PROJECT NAME:DATE:CONSULTANTx .30 =0.00x .30 =0.00x .30 =0.0030%UNDERSTANDING OF THE PROJECT AND TECHNICAL APPROACHx .30 =0.00x .30 =0.00x .30 =0.0030%PROJECT MANAGER & PROJECT TEAMx .05 =0.00x .05 =0.00x .05 =0.005%PERSONNEL AVAILABLILITY x .10 =0.00x .10 =0.00x .10 =0.0010%PROJECT DESIGN SCHEDULEx .10 =0.00x .10 =0.00x .10 =0.0010%RELATED PROJECT EXPERIENCE / PAST PERFORMANCEx .15 =0.00x .15 =0.00x .15 =0.0015%BACKLOG *100% Subtotal PointsDiversity MultiplierTotal PointsRankingRater:______________________________________* For projects less than $500,000 only Prime Backlog will be considered.Revision Date: January 16, 2014Do Not Alter Form without prior approval of the Director of Engineering
Engineering Professional Services Page 1 of 5
rev 02/19/15
METROPOLITAN ST. LOUIS SEWER DISTRICT
BUSINESS DIVERSITY
Minority and Women Workforce Utilization Program
Engineering Professional Service Projects
Effective February, 2015
PURPOSE
The Metropolitan Sewer District (MSD or District) has established workforce goals for
businesses in compliance with efforts to increase utilization of underutilized class, and
provide meaningful and representative opportunities.
The purpose of this procedure is to set guidelines and establish procedures for minority
and women workforce participation by applicable consultants, bidders, contractors,
service providers and any person, corporation, business, or other entity doing business
with the District on Engineering Professional Service Projects.
PROCEDURE
A. Minority and Women Workforce Requirements
1. The Metropolitan St. Louis Sewer District (District or MSD) has established
minority workforce goals of 18% and woman workforce goals of 32% on all
engineering professional service contracts in the amount of $500,000 or more.
Minority is a male or female African American, Asian American, Hispanic
American or Native American employed in the consultant’s local office.
Female is defined as a Caucasian female employed in the consultant’s local
office.
2. Prime firms who fall under this requirement and demonstrate on an annual
basis, with the first report occurring after the first 30 days of the contract, that
the workforce make-up of their local office registered with the District meets
this requirement will have been considered to have met these goals.
3. Prime firms who fall under this requirement and are unable to demonstrate on
an annual basis, with the first report occurring after the first 30 days of the
agreement, that they can meet these goals will be required to perform the
following good faith activities on an annual basis:
a. Report the actual current workforce make-up of the local office registered
with the District. In the rare occasion that there is no local office, then
workforce goals will be measured by the numbers of employees working
on MSD’s project. Provide the District with Employment Data to include
Engineering Professional Services Page 2 of 5
rev 02/19/15
the make-up of professional staff by specified categories including
management, technical, ethnic background, and gender.
b. Submit a workforce plan for review and approval by the District
regarding efforts to be taken during the next annual contract period to
increase the workforce make-up of the local office. These efforts should
consist of but not be limited to the following:
1. Include Equal Employment Opportunity (EEO) policy statement in all
policy manuals, and publicize on company’s website and newsletters,
annual reports, etc.
2. Develop and implement targeted recruitment, outreach, and
marketing strategies through collaboration with;
Local Universities
Slate
NSBE
Stem Program and Mentoring Programs
Minority and Women Internship Program
Business and Local Community
Advocacy Groups
Underutilized subcontractors
3. Implement a training needs assessment, internal promotion and
retention program;
4. Provide sufficient resources and efforts to enable the organization to
continue diversity goals;
Management commitment
Financial support
Manpower
c. Submit a quarterly Workforce Report by month to MSD;
d. Submit documentation of status of previous year workforce plan.
B. Non-Compliance
In the event the prime fails to comply with the requirements of the Program, the
prime firm must furnish to the District, in writing, the reasons for non-compliance.
If, in the sole judgment of the District , there have not been sufficient good faith
efforts taken on the part of the prime firm to meet their originally stated obligations,
Engineering Professional Services Page 3 of 5
rev 02/19/15
the District will advise the prime firm, in writing, of corrective actions to be
initiated. If the prime fails to fully initiate the corrective actions in a timely manner
the District may institute appropriate actions pursuant to the provisions
incorporated into the Prime Consultant’s contract. This can include sanctions on
doing future work with the District and up to and including a complete prohibition
from performing work on District projects for a time period to be determined solely
by the District.
C. Proposal Credit Opportunity for MWBE
In an effort to promote a more diverse workforce on all Engineering Professional
Service contracts. Firms have the option to complete the attached Multiplier
Calculation Worksheet where a multiplier will be applied to the RFP evaluation
scoring process to receive credit for minority and women workforce participation.
Engineering Professional Services Page 4 of 5
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ENGINEERING PROFESSIONAL SERVICES DIVERSITY MULTIPLIER CALCULATION SHEET
Starting multiplier- 1.000
Vendor Diversity (only one category allowed)
Is prime firm a WBE or Asian-American MBE? If yes, enter 0.100- ____
Is prime firm an MBE other than Asian or Hispanic-American? If yes enter 0.100- ____
PRIME CONTRACTOR VENDOR MULTIPLIER SUB-TOTAL (1.000 to 1.100) ____
ENTER THIS VALUE ON LINE 1 OF LAST SHEET
Workforce Diversity- Prime Consultant (Minority Women may count as either Women or
Minorities at the proposer’s discretion, but not both). Count all full time personnel working in
your office for this calculation regardless of job duties. Full time personnel shall have worked
for the company for the past three months and during that period averaged 30 hours of work
per week. COUNT FULL-TIME PERSONNEL ONLY!
a. Total Local Office Workforce- ___
b. Women in Local Office Workforce- ___
c. Minorities in Local Office Workforce- ___
d. “b” divided by “a” (drop all decimals/fractions)- ___%
e. “c” divided by “a” (drop all decimals/fractions)- ___%
f. If “d” is 32% or greater, ENTER 0.025 ON LINES 2 AND 3 OF LAST SHEET
g. If “d” is 16% or greater, ENTER 0.025 ON LINE 3 OF LAST SHEET UNLESS THERE IS
ALREADY A VALUE ENTERED
h. If “e” is 18% or greater, ENTER 0.025 ON LINES 4 AND 5 OF LAST SHEET
i. If “e” is 9% or greater, ENTER 0.025 ON LINE 5 OF LAST SHEET UNLESS THERE IS
ALREADY A VALUE ENTERED
Sub-consultant workforce scoring: Use only if a minimum of 25% of work is sub-contracted.
Minority Women may count as either Women or Minorities at the proposer’s discretion, but
not both). Count all full time personnel working in your office for this calculation regardless
of job duties. Full time personnel shall have worked for th e company for the past three
months and during that period averaged 30 hours of work per week. COUNT FULL -TIME
PERSONNEL ONLY!
Engineering Professional Services Page 5 of 5
rev 02/19/15
Names of sub-consultants performing at least 25% of total contract included in calculation
(add more lines if needed)
Name of Sub-Consultant(s)____ Authorized Signature of Sub-Consultant
_______________________________ ________________________________
_______________________________ ________________________________
j. Combined Total Local Office Workforce of all listed sub-consultants- ____
k. Women in Combined Total Local Office Workforce- ____
l. Minorities in Combined Total Local Office Workforce- ____
m. “k” divided by “j” (drop all decimals/fractions)- ____%
n. “l” divided by “j” (drop all decimals/fractions)- ____%
o. If “m” is 32% or greater, ENTER 0.025 ON LINES 2 AND 3 OF LAST SHEET UNLESS A
VALUE IS ALREADY ENTERED
p. If “m” is 16% or greater, ENTER 0.025 ON LINE 3 OF LAST SHEET UNLESS THERE IS
ALREADY A VALUE ENTERED
q. If “n” is 18% or greater, ENTER 0.025 ON LINES 4 AND 5 OF LAST SHEET UNLESS A VALUE
IS ALREADY ENTERED
r. If “n” is 9% or greater, ENTER 0.025 ON LINE 5 OF LAST SHEET UNLESS THERE IS
ALREADY A VALUE ENTERED
FINAL MULTIPLIER TABULATION
1. PRIME CONTRACTOR VENDOR MULTIPLIER ____
2. WOMAN WORKFORCE 32% OR GREATER ____
3. WOMAN WORKFORCE 16% OR GREATER ____
4. MINORITY WORKFORCE 18% 0R GREATER ____
5. MINORITY WORKFORCE 9% OR GREATER ____
6. FINAL MULTIPLIER (TOTAL OF 1 THRU 5) (1.000 thru 1.200) ____
The undersigned certifies on behalf of the entity submitting this Report that the above information
is true and accurate as of the date set forth below:
__________________________________ ________________________________
Prime Firm Name Date
__________________________________ ________________________________
Authorized Representative Name Representative Title
__________________________________
Authorized Representative Signature