Project Information

Bid Title

RFQ #03-24-26 Investment Consulting Services

Issuing Agency

Shawnee State University

Location

Ohio

Published Date

Mar 9, 2026

Closing Date

Mar 27, 2026

Government Level

State & Local

Status

Closed

Original Source

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Bid Documents

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Project Description

Investment Consulting Services

• RFQ #03-24-26 Investment Consulting Services (DOCX)

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RISK MANAGEMENT AND CONTRACT SERVICES

Request for Quote

Date Issued: March 10, 2026 Due Date/Time: March 27, 2026, 3 p.m. EST

Sealed Quotes must be received at Contract Services, located in the Administration Building, Room 188, Shawnee State University, Portsmouth, OH, 45662, by the date and time specified above, and opened immediately thereafter for the same Request for Quote above. Quotes received after that date and time will be returned to the vendor unopened, upon request.

Quotes are to be submitted in accordance with the enclosed Response Instructions and Specifications. There will not be a formal Quote opening.

Questions pertaining to any specifications contained herein should be directed to Joe VanDeusen at 740.351.3310.

Contract Services shall at all times reserve the right to reject any or all quotes, award partial quotes, waive any quote informalities or irregularities, and request new quotes if doing so is deemed to be in the best interests of Shawnee State University.

SHAWNEE STATE UNIVERSITY CONTRACTS SERVICES

Joe VanDeusen

Director, Risk Management and Contract Services

PLEASE READ THE INFORMATION BELOW:

By signing this document, I am agreeing, on behalf of my firm, to the specifications of this RFQ and accepting, without exception or amendment, Shawnee State University’s Standard RFQ Agreement Terms as set forth in Appendix A. All Purchase Orders resulting from this RFQ shall be subject to these instructions, terms, and requirements that shall be incorporated therein.1

SUBMITTED BY

(Company Name)

AUTHORIZED SIGNATURE DATE

(Printed Name and Title)

1 Should a respondent take exception to the University’s Standard RFQ Agreement Terms (Appendix A cited within) the respondent must submit such exceptions and/or amendments in writing to the contact above within five (5) business days prior to the Quote Closing Date. The University reserves the right to reject some, all, or none of the proposed exceptions and/or amendments and assert its Standard RFQ Agreement Terms as described in Appendix A.

REQUEST FOR QUOTE #03-24-2026

INVESTMENT CONSULTING SERVICES

March 10, 2026

TABLE OF CONTENTS

SECTION I Definitions 3

SECTION II RFQ Summary and Agreement Terms 4

SECTION III RFQ Response Instructions 5

SECTION IV Request for Quote Specifications 7

SECTION V Quote Requirements and Selection Criteria 10

ATTACHMENT A RFQ Response and Certification Form 12

ATTACHMENT B Pricing Schedule 13

ATTACHMENT C Credit Card Acceptance Form 14

ATTACHMENT D Declaration of Material Assistance Instructions and Form 15

APPENDIX A Standard RFQ Agreement Terms and Conditions 18

APPENDIX B Directions to Shawnee State University 27

EXHIBIT 1 The Shawnee State University Investment Policy 28

EXHIBIT 2 The Shawnee State University Foundation

Investment Policy 33

EXHIBIT 3 ORC 3345.16 and 3345.05 38

SECTION I: Definitions

Relative to this document, and any addenda incorporated herein, the following definitions apply:

Addendum(a): Written instruments, issued solely by Shawnee State University Contract Services (SSUCS), that detail amendments, changes, modifications, or clarifications to the specifications or terms and conditions of this Request for Quote (RFQ). Such written instruments shall be the sole method employed by SSUCS to amend, change, modify, or clarify this RFQ, and any claims (from whatever source) that verbal amendments, changes, modifications, or clarifications have been made shall be summarily rejected by SSUCS.

Agreement, Contract, Purchase Order: Formal award resulting from the Request for Quote or Request for Quotation.

Design Services: Engineering and/or architectural services which include the conceptual development, proposed design, and/or actual plan drawings, blueprints, and/or other schematics to produce a scope of services and work.

FOB: “Free on Board”; without charge to the purchaser for delivery on board or into a carrier at a specified point or location.

SSU: “Shawnee State University”

SSUCS: “Shawnee State University Contract Services”

SSUF: “Shawnee State University Foundation”

The University: “Shawnee State University”

May, Should: Indicates something that is requested but not mandatory. If the Bidder fails to provide information, SSUCS may, at its sole option, either request that the Bidder provide the information or evaluate the Quote without the information.

Quote Closing Date: The date and time specified in the RFQ by which a sealed quote must be received by SSUCS. Quotes received after the stated date and time will not be considered.

Quote Issue Date: The date and time the RFQ process is opened for submission by prospective vendors.

Quote, Quotation: Response provided by proposer.

Proposer, Vendor, Supplier: Respondent to the RFP or RFQ.

RFP: Request for Proposal

RFQ: Request for Quotation

Shall, Must, Will: Indicates a mandatory requirement. Failure to meet mandatory requirements will invalidate the quote or result in the rejection of a quote as non-responsive.

University Website: (See comment on bottom of page 5 regarding possible mention of website in RFQ

SECTION II: RFQ Summary and Agreement Terms

Introduction

Shawnee State University (SSU) and the Shawnee State University Foundation (SSUF) seek quotes from Investment Consultants/Advisors qualified to provide investment consulting services to the respective investment committees.

This RFQ is part of a competitive procurement process which helps to serve the University’s best interests. It also provides qualified firms with a formal and unrestrictive opportunity for their services to be considered. The process of competitive negotiation being used in this case should not be confused with the process of competitive sealed bidding. The latter process is usually used where the goods and services being procured can be precisely described and price is generally the determinative factor. With an RFQ and competitive negotiation, however, price is not required to be the determinative factor, although it may be, and the University has the flexibility to negotiate with one or more contractors to arrive at a mutually agreeable relationship. Check your quote carefully for it may not be corrected after the quote has been opened

To be given the fullest consideration, organizations are to submit an electronic copy of their quote to Shawnee State University, Contract Services, located in the Administration Building, Room 188 (mailing address is 940 Second Street, Portsmouth, OH 45662-4344), by 3 p.m., Tuesday, March 27, 2026.

Background

“We prepare today’s students to succeed in tomorrow’s world.”

Shawnee State University Mission Statement (Adopted by SSU Board of Trustees, 2021)

The University is dedicated to achieving the goals in the above mission statement and in the goals, priorities, and vision statements that emanate from it. The University’s investments are made in compliance with an investment policy (see Exhibit 1). The University utilizes an investment committee that consists of Board-appointed representatives, the Chief Financial Officer or delegate and chaired by a member of the Board of Trustees. The University investment assets are managed separately from the assets of The Shawnee State University Foundation.

State funds and tuition alone do little more than provide the necessities inherent in a university education. The availability of private financial support has a direct impact on the quality of services that Shawnee State University offers its students. These private funds, whether in the form of unrestricted gifts, endowments, or gifts for specific purposes, allow the University to provide a higher degree of enrichment and opportunity to the campus population. Thus, the University encouraged the formation of the Shawnee State University Foundation, which has the sole mission of making friends and creating funds and support for Shawnee State University. These funds are used in a number of ways. They provide scholarships and faculty development, supply classroom resources, upgrade facilities, and otherwise enhance the campus and student life beyond the basics provided by the University’s general operating budget.

The SSUF investments are made in compliance with a distinct investment policy utilizing the SSUF Finance Committee as an advisory group for investment purposes and to assure compliance with its separate investment policy (see Exhibit 2). This committee is made up of representatives from the Foundation, Board-appointed representatives, the Executive Director for Development, and the University’s Chief Financial Officer in the capacity of Treasurer.

Additional documents included in this RFQ:

Exhibit 1 – The Shawnee State University Investment Policy

Exhibit 2 – The Shawnee State University Foundation Investment Policy

Exhibit 3 – ORC 3345.16 and 3345.05

RFQ Agreement Terms

Respondents are cautioned to read this entire document carefully and to prepare and submit their response providing all requested information in accordance with the terms and conditions set forth herein. To be considered, Respondents must submit a complete response to this RFQ in the format detailed by the specifications. Quotes must be dated, signed by an official authorized to bind the Respondent to the terms of their quote, and submitted to the University in accordance with the instructions, terms, and conditions of this RFQ.

The University reserves the right to:

• Reject any or all quotes received in response to this RFQ;

• Request clarification from any Respondent on any or all aspects of its quote;

• Cancel and/or reissue this RFQ at any time;

• Retain all quotes submitted in response to this RFQ; and,

• Invite some, all, or none of the Respondent(s) for interviews and further negotiations/discussion. The University reserves the right to negotiate the pricing and all terms and conditions associated with this RFQ process with the selected vendor(s).

See Appendix A for the entire Agreement Terms and Conditions (pages 18 – 26).

SECTION III: RFQ Response Instructions

PROJECT SUMMARY: Shawnee State University (SSU) and the Shawnee State University Foundation (SSUF) are seeking quotes for investment committee consulting services, as described herein. Respondents should include information that will demonstrate their ability to meet the requirements of this RFQ.

1. RFQ SCHEDULE OF EVENTS

The University will make every effort to adhere to the schedule detailed below:

RFQ Issued via the University’s website March 10, 2026

Deadline for submitting written questions March 17, 2026 at 3 p.m. EST

Addendum posted to procurement website March 19, 2026 by 5 p.m. EST

RFQ Quote Closing Date March 27, 2026 at 3 p.m. EST

Interviews (if needed) April 8, 2026

Anticipated Award Date April 15, 2026

The Selection Committee intends to conduct respondent interviews on April 8, 2026. Those firms chosen for an interview will be contacted to schedule their interview time. The University will allow respondents 30 minutes to introduce their staff, to highlight what differentiates their firm from others, and to explain why their firm is the best selection for SSU/SSUF. The University has also allotted an additional 15 minutes for questions from the Selection Committee.

Interviews will be conducted on the Shawnee State University campus or virtually (via Microsoft Teams). Directions to the interview location or a Teams invitation will be provided to the firms selected to participate.

2. RFQ INSTRUCTIONS

Respondents shall submit the following:

The following items are to be included in the quote response package by the quote due date and time. Failure to do so may invalidate the quote response.

• Signed and dated RFQ cover sheet

• Attachment A – RFQ Response and Certification Form - (completed and signed)

• Attachment B – Pricing Schedule (completed and signed)

• Attachment C – Credit Card Acceptance Form (completed and signed)

• Attachment D – Declaration of Materials Assistance Form (completed and signed)

• References — Include 1) a complete list of current clients, and 2) a current client list — with names, telephone numbers, and email addresses — for all public universities and foundations under $ 60 million. If none are under $ 60 million, provide the same information for the five (5) clients with the smallest asset value.

• Other applicable Attachments that may assist the University’s evaluation

The University reserves the right to request, at its sole discretion, from some or all of the respondents, any further information or documentation that it deems necessary for the issuance of an agreement.

3. QUESTIONS REGARDING THE RFQ

Respondents must submit written questions regarding this RFQ by 3 p.m., EST, on March 17, 2026. All questions should be submitted via email as indicated below. Answers to questions submitted by the deadline will be issued via an addendum posted to the University’s website no later than 5 p.m. EST, March 19, 2026.

Questions pertaining to this RFQ must be directed solely to:

Joe VanDeusen, Director, Risk Management and Contract Services

Shawnee State University

940 Second Street

Portsmouth, OH 45662-4344

Email: jvandeusen@shawnee.edu

During the University’s competitive selection process, up to and including the issuance of a final letter of award, under no circumstances may a respondent contact other individuals at the University to discuss any aspect of this inquiry or attempt to influence the process. Failure of a Respondent to comply with this protocol may invalidate their response to the Request for Quote.

4. RFQ QUOTE CLOSING DATE AND LOCATION

Responses to this RFQ must be received by 3 p.m., EST on March 27, 2026.

The University accepts no responsibility for delays in the university mail system, the U.S. Postal Service, or any commercial mail carrier. It is the responsibility of the respondent to ensure that its quote is delivered to the proper place by the proper time. Any quotes received after the stated date and time will be disqualified.

Quotes will be received at:

Email Address: jvandeusen@shawnee.edu

Mailing Address: Shawnee State University

Contract Services

940 Second Street

Portsmouth, Ohio 45662-4344

Delivery Address: Shawnee State University

Contract Services

Administration Building, First Floor, Room 188

Portsmouth, Ohio 45662

Bid envelopes shall be sealed and clearly marked:

RFQ #03-24-26

Investment Committee Consulting Services

Shawnee State University

Bid envelopes must include:

One (1) electronic copy of the Respondent’s quote.

SECTION IV: Request for Quote Specifications

1. STATEMENT OF WORK

Shawnee State University and the Shawnee State University Foundation seek quotes from firms qualified to provide investment committee consulting services.

The scope of duties the consulting firm will be required to participate in or provide expert advice on include but are not limited to:

• Assistance with investment policy review and modification and development of new policies, procedures, and provisions as warranted

• Assistance with review and formulation of the role and charge of committees

• Advice on committee best practices drawn from studies of or experiences with similarly sized institutions

• Analysis of performance and benchmarking reports that are submitted to SSU and SSUF by designated investment managers

• Development of straightforward process for the selection and ongoing assessment of investment managers and fund management when applicable

• Assistance/advice to promote the development of the effectiveness of the investment committees

• Advice on range of available investment management options

• Other consulting services as may be identified and applicable within the scope of the agreement

The consultant is expected to report in person to the Investment Committee as requested, not to exceed 3 times annually, and to assist with investment manager searches.

2. ORGANIZATIONAL INFORMATION

Quotes must clearly address each point listed below. Please reference our item number (in the order in which they appear) on your answers to each question, so we may quickly identify your response.

A. Firm’s History

1. Please provide a history of your firm and your parent organization going back to inception. Has your organization experienced any significant developments, within the past three years, such as changes in ownership, restructuring, or personnel reorganizations? Do you anticipate future significant changes in your organization?

B. Firm’s Ownership

1) Provide ownership structure of your organization, including details of your parent and any affiliated companies. If ownership is private, list owners and the percent of ownership.

C. Firm’s Organization

1) Is your firm a registered investment advisor with the SEC under the Investment Advisors Act of 1940? If not, what is your fiduciary classification? Please include Form ADV Parts I and II.

2) Has your organization or an officer or principal been involved in any business litigation or other legal proceedings relating to your consulting activities? If so, provide an explanation and indicate the current status or disposition.

3) Firm’s Independence — Do any investment consulting officers or employees receive direct or indirect compensation from investment managers? If so, describe in detail. What other sources of income does your firm have other than client fees for investment consulting?

4) Does your firm, its parent or affiliate sell information or any other services to investment managers? If so, describe in detail.

5) Does your firm have any affiliation with a brokerage firm? If so, please describe.

6) Provide your firm’s policy on conflict of interest.

D. Firm’s Employees

1) Provide biographies of the key individuals within each functional area, including investment experience and education.

2) Explain how the consultant(s) dedicated to SSU and SSUF would function, including the lead person, back-up, quality control procedures, and support services. List how many other clients these individuals would have if you are the selected firm.

3) The consultant(s) you intend to assign to the SSU/SSUF account must be a participant in the interview. During the interview, the selection committee wishes to hear what sets your firm apart from other firms that offer similar services. Please explain why your firm should be selected.

4) List professional staff departures over the last three years and the reasons for any termination.

5) Describe the compensation arrangement for professional staff. How does this arrangement encourage the retention of key individuals?

3. CONSULTING ACTIVITIES

A. Investment Policy Analysis and Research

1) Outline your approach to the development of an investment policy and provide a sample policy.

2) Describe your firm’s typical involvement in preparing guidelines for the effective interaction between investment committees and investment managers.

3) Discuss the asset allocation models for non-profit organizations you have experience with and how you would evaluate asset class assumptions and/or philosophies of investment management firms.

4) Outline your process for maintaining and providing a continuous review of investment policy, asset allocation, and portfolio structures.

5) What is your experience and philosophy regarding the use of alternative investment approaches? Please provide detail concerning your experience in this area, including compliance with typical university auditing requirements.

B. Investment Manager Search

1) Do you provide first-party investment management services?

2) Do you have an in-house database of investment managers and if not, from where does your database come? How many managers are contained in the database? What asset classes are covered?

3) Do you or your vendor sources charge direct or indirect fees for investment managers to be included in your firm’s database? If you have an in-house database, do you sell it to third parties?

4) Do you have individuals dedicated to manager research within your firm and do they help in the manager search process? Will you help SSU/SSUF find a custodian should this be required? Please explain if there are any extra fees for this service.

5) Give an overview of your firm’s approach and criteria for placing a manager on a watch list. Under what conditions, would the manager be removed from the watch list? How many managers are on the watch list?

6) What methods and sources of data do you use in calculating investment performance of a client’s portfolio? Do you reconcile your calculated performance with investment managers?

7) What benchmarks do you use and how is performance compared? How do you rate or rank managers? Can you rank managers by performance percentile? What comparison universe do you use?

8) How often are performance reports produced and delivered? Please list the various types of reports that are available, what delivery methods are provided, and any fees associated with each report. Are you able to deliver customized reports? If so, please provide details of the scope of customization your offer. Are any fees associated with customized reports? If so, please provide a detailed fee schedule. Are you able to provide secure access to your system so clients are able to create or run reports on demand? If so, please provide details of this feature and any associated fees or requirements. Include a sample performance evaluation report and other reports you feel would be beneficial to Shawnee State University and the Shawnee State University Foundation.

9) Discuss the portfolio analytics your firm is capable of providing. How is risk evaluated in your approach to performance measurement?

C. Firm’s Clients

1) Provide a list of your major current clients, including university, foundation, and non-profit accounts. Please detail the university, foundation, and non-profit account experience of the individuals identified in question 2, under Section IV, 2.D (Firm’s Employees).

2) Please provide the names of all clients who have terminated your firm’s services in the last three years and the reasons for termination.

3) Please provide the names of all new client relationships gained in the last three years.

D. Fee Quote

1) Please provide all services you propose and their associated fees. Indicate whether your quote is a fixed annual retainer fee, a fee calculated as a percentage of assets, or a set of itemized fees for specific services. As an illustration, please use the asset amounts of $ 50 million, $ 60 million and $ 75 million for examples and provide a clear description of all associated costs for each asset amount.

2) Please indicate if any of your fees will be satisfied through a “soft dollar” arrangement.

3) Shawnee State University and the Shawnee State University Foundation expect the assigned consultant to report in person as requested but not to exceed three times per year. In addition, the assigned consultant should be easily accessible via other means. Please detail what other communication alternatives you make available. Are there any fees associated with the in-person reporting requirement or the communication alternatives?

4) Please fully disclose any other fees, rebates, or means of compensation not previously described that the firm may realize as a result of being selected as the SSU/SSUF Investment Committee Consultant.

SECTION V: Quote Requirements and Selection Criteria

1. RESPONSE FORMAT

In order to receive consideration, firms responding to this Request for Quote are required to submit one (1) electronic version of their quote in an email, sealed envelope or package clearly indicating the contents, before and no later than the date and time specified on the RFQ. All aspects of the quote must be clearly explained; the respondent should not assume an opportunity to add further information will exist after submission.

• Each copy of the quote should be bound in a single volume and marked either “original” or “copy.” All documentation submitted with the quote should be bound in that single document. Quotes should follow the format of the RFQ, and each response should reference the number and headings as listed in the RFQ.

• All prices must be clearly set forth. Respondents are cautioned to write all descriptions and prices clearly so there is no doubt as to the intent and scope of the quote. Erasures and other changes in the quote must bear the signature or initials of the respondent. In the event of a price discrepancy, unit prices will prevail.

Signatures required: The RFQ cover sheet and Attachments A, B, C, and D (if applicable) must be completed and signed by the person authorized by the respondent to sign such documents on their behalf. Quotes in the amount of $100,000 or more must include a completed and signed Declaration of Material Assistance (Attachment D). Failure to sign the quote or submit the required signed forms may disqualify the quote. Any quote that does not include prices, terms, the RFQ number, date, and a realistic delivery promise may be considered an incomplete quote.

• Respondents may submit any number of quotes, but if more than one quote is submitted, they should be included in the same document. For each distinct alternate quote, add an appendix containing only those sections that differ from the main quote. For each such instance, include an identifier such as Appendix A at the center top of the page.

2. SELECTION CRITERIA

SSU/SSUF will select the Investment Consultant it believes offers the quote that is in the best overall interest of the SSU/SSUF. SSU/SSUF also reserves the right to accept none of the quotes received.

SSU/SSUF will award this contract according to criteria shown below and reserve the right to award to a single Investment Consultant that may not be the lowest in fees charged.

In determining the successful Investment Consultant, the University will consider, but not be limited to, the following selection criteria:

• Overall quality of the service being offered

• Costs (commissions, fees, expenses, etc. to be charged)

• Reputation of the Investment Consultant

• Ability of the Investment Consultant to provide the service requested

• Information received on reference checks

• Quality and satisfaction of any previous services performed

• Overall financial position of the Investment Consultant

• Number and scope of any conditions included in the Investment Consultant’s quote

• Accessibility of the Investment Consultant’s staff to SSU/SSUF staff

• Documented experience providing similar services to clients similar to Shawnee State University and the Shawnee State University Foundation

• Ability to execute the contract in a timely manner

• Personnel assigned to the project. Please include their resumes.

• Any other relevant information submitted

It is requested that those firms who do not wish to submit a quote indicate the same by submitting a “No Quote” to Shawnee State University, Contract Services, at the address listed on page 7 of this RFQ.

ATTACHMENT A

REQUEST FOR QUOTE RESPONSE AND CERTIFICATION FORM

This form must be completed and signed or your bid will be judged non-compliant and disqualified as non-responsive.

By signing below, Contractor warrants that it is not subject to an unresolved finding for recovery under ORC 9.24. If the warranty is false on the date the parties sign an Agreement resulting from this RFQ, such and any future Agreement is void ab initio, and the Contractor must immediately repay to the State any funds paid under any such Agreement.

Company Name:

Address:

Authorized Signature:

Printed Name and Title:

Date:       Bidder is an individual, the sole shareholder of a

corporation, or the sole member of a limited liability

Telephone:       company.

Fax:       Bidder is NOT an individual, the sole shareholder of

a corporation, or the sole member of a limited liability

Email:       company.

Federal Tax ID or Social Security Number:

All bids submitted are taken by the University as offers to sell by the bidder and acceptance shall occur only by the issuance of a University Purchase Order or Procurement Card or where appropriate, upon the execution of a written contract.

ELECTRONIC INVOICING AND PAYMENT CAPABILITY

All bidders must complete the following information:

1. Does your company offer electronic invoicing? Yes No

If yes, please specify method:

2. Is your company capable of receiving payment via ACH transfer? Yes No

BUY OHIO

Economic preference shall be awarded to Ohio Bidders and Bidders from “Border” states (Indiana, Kentucky, Michigan, New York, Pennsylvania, and West Virginia), provided those states do not impose economic restraints on products produced or mined in Ohio. An “Ohio Bidder” describes one who offers Ohio products (defined to mean products which are mined, excavated, produced, manufactured, raised, or grown in the state by a person where the input of Ohio products, labor, skill or other services constitutes no less than 25 percent of the manufactured cost) or a Bidder who demonstrates significant Ohio economic presence (defined to mean business organization that: have sales offices, divisions, sales outlets or manufacturing facilities in Ohio or facilities demonstrate a significant capital investment in Ohio; pay required taxes to the state of Ohio; and are registered and licensed to do business in the state of Ohio with the office of Secretary of State).

ATTACHMENT B

PRICING SCHEDULE

This form must be completed and signed or your bid will be judged non-compliant and disqualified as non-responsive.

Quote of:

Company Name

To: Shawnee State University

Ref: RFQ #03-24-26

Having carefully examined all the specifications and requirements of this RFQ and any attachments thereto, the under-signed proposes to furnish the contracted services as required pursuant to the aforementioned documents at the terms quoted below.

Pricing Schedule

Respondent shall provide a pricing schedule based on a commitment to the entire project, according to the requirements listed in this RFQ. Price quotations shall include the provision of all goods and services necessary or proper for the completion of the work. Shawnee State University and the Shawnee State University Foundation will not be liable for any costs beyond those proposed herein and awarded. Time and materials quotes are unacceptable.

Payment Terms

The following payment term options and discounts are quoted (the University’s suggested payment terms are NET 30). Bidder may offer additional payment term options and discounts for the University to consider.

Addenda Checklist

Receipt is hereby acknowledged of the following addenda to this RFQ.

(Initial if applicable) No. 1       No. 2       No. 3      No. 4

Respectfully submitted, By:

Authorized Signature

Date:

ATTACHMENT C

CREDIT CARD ACCEPTANCE FORM

This form must be completed and signed or your bid may be judged non-compliant and disqualified as non-responsive.

Will your company accept credit cards? Yes No

If yes, what is the maximum dollar limit per transaction, if any? $

Does your company charge a fee for the use of credit cards? Yes No

If yes, under what circumstances?

(Indicating “yes” will be viewed as an extra charge. Companies are strongly discouraged from charging credit card transaction fees.)

If yes, what is the percentage charged for each transaction?       %

COMPANY

AUTHORIZED SIGNATURE DATE

PRINT NAME       TITLE

ATTACHMENT D

DECLARATION OF MATERIAL ASSISTANCE

Quotes totaling $100,000 or more must include this completed, dated, and signed form.

*************************** FOR INSTRUCTIONAL USE ONLY ***************************

READ BEFORE COMPLETING YOUR DMA FORM

Forms not conforming to the specifications listed below or not submitted to the appropriate agency or office will not be processed.

• To complete this form, you will need a copy of the Terrorist Exclusion List for reference. The Terrorist Exclusion List can be found on the Ohio Homeland Security Web site at the following address:

http://www.homelandsecurity.ohio.gov/dma.asp

• Be sure you have the correct DMA form. If you are applying for a state issued license, permit, certification or registration, the “State Issued License” DMA form must be completed (HLS 0036). If you are applying for employment with a government entity, the “Public Employment” DMA form must be completed (HLS 0037). If you are obtaining a contract to conduct business with or receive funding from a government entity, the “Government Business and Funding Contracts” DMA form must be completed (HLS 0038). The Pre-certification form (HLS 0035) should only be completed if you are specifically instructed to do so by the agency or office requesting the form.

• Your DMA form is to be submitted to the issuing agency or entity. “Issuing agency or entity” means the government agency or office that has requested the form from you or the government agency or office to which you are applying for a license, employment or a business contract. For example, if you are seeking a business contract with the Ohio Department of Commerce’s Division of Financial Institutions, then the form needs to be submitted to the Department of Commerce’s Division of Financial Institutions. Do NOT send the form to the Ohio Department of Public Safety UNLESS you are seeking a license from or employment or business contract with one of its eight divisions listed below.

• Department of Public Safety Divisions:

Administration Ohio Homeland Security*

Ohio Bureau of Motor Vehicles Ohio Investigative Unit

Ohio Emergency Management Agency Ohio Criminal Justice Services

Ohio Emergency Medical Services Ohio State Highway Patrol

• DO NOT SEND THE FORM TO OHIO HOMELAND SECURITY UNLESS OTHERWISE DIRECTED. FORMS SENT TO THE WRONG AGENCY OR ENTITY WILL NOT BE PROCESSED.

*************************** FOR INSTRUCTIONAL USE ONLY ***************************

(Continued on next page)

Ohio Department of Public Safety

DIVISION OF HOMELAND SECURITY

http://www.homelandsecurity.ohio.gov

GOVERNMENT BUSINESS AND FUNDING CONTRACTS

In accordance with section 2909.33 of the Ohio Revised Code

DECLARATION REGARDING MATERIAL ASSISTANCE/NO ASSISTANCE TO A TERRORIST ORGANIZATION

This form serves as a declaration of the provision of material assistance to a terrorist organization or organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List (see the Ohio Homeland Security Division Web site for reference copy of the Terrorist Exclusion List).

Any answer of “yes” to any question, or the failure to answer “no” to any question on this declaration shall serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided. Failure to disclose the provision of material assistance to such an organization or knowingly making false statements regarding material assistance to such an organization is a felony of the fifth degree.

For the purposes of this declaration, “material support or resources” means currency, payment instruments, other financial securities, funds, transfer of funds, and financial services that are in excess of one hundred dollars, as well as communications, lodging, training, safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials.

COMPLETE THIS SECTION ONLY IF YOU ARE AN INDEPENDENT CONTRACTOR
LAST NAME	FIRST NAME	MI
HOME ADDRESS
CITY	STATE	ZIP	COUNTY
HOME PHONE	WORK PHONE
COMPLETE THIS SECTION ONLY IF YOU ARE A COMPANY, BUSINESS OR ORGANIZATION
LAST NAME	FIRST NAME	MI
BUSINESS/ORGANIZATION NAME	PHONE
BUSINESS ADDRESS
CITY	STATE	ZIP	COUNTY

DECLARATION

In accordance with section 2909.32 (A)(2)(b) of the Ohio Revised Code

For each question, indicate either “yes” or “no” in the space provided. Responses must be truthful to the best of your knowledge.

1. Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List? Yes No

2. Have you used any position of prominence you have with any country to persuade others to an organization Yes No

on the U.S. Department of State Terrorist Exclusion List?

3. Have you knowingly solicited funds or other things of value for an organization on the U.S. Department of State Yes No

Terrorist Exclusion List?

4. Have you solicited any individual for membership in an organization on the U.S. Department of State Terrorist Yes No

Exclusion List?

5. Have you committed an act that you know, or reasonably should have known, affords “material or resources” Yes No

to an organization on the U.S. Department of State Terrorist Exclusion List?

6. Have you hired or compensated a person you knew to be a member of an organization on the Department of Yes No

State Terrorist Exclusion List, or a person you knew to be engaged in planning, assisting, or carrying out an

act of terrorism?

HLS 0038 8/06 Page 2 of form

In the event of a denial of a government contract or government funding due to a positive indication that material assistance has been provided to a terrorist organization, or an organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List, a review of the denial may be requested. The request must be sent to the Ohio Department of Public Safety’s Division of Homeland Security. The request forms and instructions for filing can be found on the Ohio Homeland Security Division Web site.

CERTIFICATION

I hereby certify that the answers I have made to all of the questions on this declaration are true to the best of my knowledge. I understand that if this declaration is not completed in its entirety, it will not be processed and I will be automatically disqualified. I understand that I am responsible for the correctness of this declaration. I understand that failure to disclose the provision of material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List, or knowingly making false statements regarding material assistance to such an organization is a felony of the fifth degree. I understand that any answer of “yes” to any question, or the failure to answer “no” to any question on this declaration shall serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided by myself or my organization. If I am signing this on behalf of a company, business or organization, I hereby acknowledge that I have the authority to make this certification on behalf of the company, business or organization referenced on page 1 of this declaration.

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Commodity Codes

• NAICS 541611Administrative Management and General Management Consulting Services
• NAICS 541618Other Management Consulting Services

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