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6.D. - Page 109 of 170 Request for Qualifications: General Park Building Construction, Retrofit, Maintenance, and/or Repairs FORM H IRAN CONTRACTING ACT OF 2010 COMPLIANCE AFFIDAVIT (California Public Contract Code Sections 2200-2208) The California Legislature adopted the Iran Contracting Act of 2010 to respond to policies of Iran in a uniform fashion (PCC § 2201(q)). The Iran Contracting Act prohibits bidders engaged in investment activities in Iran from bidding on, submitting responses for, or entering in to or renewing contracts with public entities for goods and services of One Million Dollars ($1,000,000.00) or more (PCC § 2203(a)). A bidder who "engages in investment activities in Iran" is defined as either: 1. A bidder providing goods or services of Twenty Million Dollars ($20,000,000.00) or more in the energy sector of Iran, including provision of oil or liquefied natural gas tankers, or products used to constructor maintain pipelines used to transport oil or liquefied natural gas, for the energy sector of Iran; or 2. A bidder that is a financial institution (as that term is defined in 50U.S.C. § 1701) that extends Twenty Million Dollars ($20,000,000.00) or more in credit to another person, for forty-five (45) days or more, if that person will use the credit to provide goods or services in the energy sector in Iran and is identified on a list created by the California Department of General Services (DGS) pursuant to PCC § 2203(b) as a person engaging in the investment activities in Iran. The bidder shall certify that at the time of submitting a bid for new contract or renewal of an existing contract, the bidder is not identified on the DGS list of ineligible businesses or persons and that the bidder is not engaged in investment activities in Iran in violation of the Iran Contracting Act of 2010. California law establishes penalties for providing false certifications, including civil penalties equal to the greater of Two Hundred Fifty Thousand Dollars ($250,000.00) or twice the amount of the contract for which the false certification was made; contract termination; and three-year ineligibility to bid on contracts (PCC § 2205). To comply with the Iran Contracting Act of 2010, the bidder shall provide its vendor or financial institution name, and City Business Tax Registration Certificate (BRTC) if available, in completing ONE (1) of the options shown below. OPTION #1: CERTIFICATION I, the official named below, certify that I am duly authorized to execute this certification on behalf of the bidder or financial institution identified below, and that the bidder or financial institution identified below is not on the current DGS list of persons engaged in investment activities in Iran and is not a financial institution extending Twenty Million Dollars ($20,000,000.00) or more in credit to another person or vendor, for forty-five (45) days or more, if that other person or vendor will use the credit to provide goods or services in the energy sector in Iran and is identified on the current DSG list of persons engaged in investment activities in Iran. Vendor Nmue/FivancialInstitution (printed) sW PUBLIC E5 0o MPAN BTRC(on✓a) 0 � � �, 941 �( By (A on zed StgnaI ) Print Name and Title ofPersou Signin 694ARLES E, KA( FYY) N PRESIDeNj DaleExecuted, City Approval(Signature) (Print Name)L1PPU-5 C - U F M AN OPTION #2: EXEMPTION Pursuant to PCC § 2203(c) and (d), a public entity may permit a bidder or financial institution engaged in investment activities in Iran, on a case-by- case basis, to be eligible for, or to bid on, submit a response for, or enter into, or renew, a contract for goods and services. If the bidder or financial institution identified below has obtained an exemption from the certification requirement under the Iran Contracting Act of 2010, the bidder or financial institution shall complete and sign below and attach documentation demonstrating the exemption approval. Vendor Nanre/Fiaanctallnslilu6on(printed) BTRC(orn/a) By (Authorized Signature) Print Name and Title of Person Signing Dale Executed City Approval (Signature) (Print Name) IMPORTANT — RESPONDERS MUST SUBMIT ALL REQUIRED FORMS (COMPLETELY FILLED OUT) BY RFQ SUBMITTAL DEADLINE. Page 102 of 103 192