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Date:

Firm:

FTA BUS TESTING CERTIFICATION

I. NEW BUS MODEL TO BE TESTED

In accordance with 49 CFR Part 665, “Bus Testing Program,” the Proposer certifies that the bus
model being proposed for this Contract is a new bus model or a bus model with a major change in
configuration or components (as described in Subpart A of the interim rule). Bidder, at its own
expense, will arrange for the required testing at the FTA Bus Testing Facility at Altoona,
Pennsylvania prior to the Authority's acceptance of the first vehicle in a manner that the Time for
Performance outlined in the Contract Specifications will not be impacted. Contractor will provide a
copy of the Test Report prepared for this bus model prior to acceptance.

OR

I. BUS MODEL ALREADY TESTED

In accordance with 49 CFR Part 665, “Bus Testing Program,” the Proposer certifies that the bus
model being proposed for this Contract is not a new bus model and does not incorporate a major
change in configuration or components (as described in Subpart A of the interim rule). The
Contractor will provide, upon request of the Authority, a copy of the Test Report prepared for the
bus model accepted under this Contract.

(CHECK ONE BOX ONLY)

Signature:

Title:

CERTIFICATE OF
TVM DBE

COMPLIANCE

(TO BE FILLED OUT BY MANUFACTURER'S OF ROLLING STOCK ONLY)

In connection with the contract to be awarded as a result of the invitation to bid issued by the Nashua Transit
System:

| hereby certify that the (name of company) has complied with
the requirements of 49 CFR 26, participation by Disadvantage Business in DOT Programs, and that our goals
have not been disapproved by the Federal Transit Administration.

Name of Company

Signature of Authorized Official

Name and Title of Authorized Official

Date

CHAMPION’

A -GROUP

BUY AMERICA
DOMESTIC CONTENT WORKSHEET

NASHUA, NH

More than 855 of the material cost of tve Champion bes is U.S. domestic content

DOMESTIC CONTENT ASA
FINSL PERCENTAGE OF TOTAL

COMPONENT MANUFACTURER ASS MATERIAL COST
CHASSIS/FORD us. 39.57%
FIBERGLASS/OGP us. BAZ
TERIOR PANELSYCRANE COMPOSITE us. oan
WHEELCHAIR RAMPIBRAUN US. 4Bee,
PASSENGER DOORS/AEM us. OF t%
INTERIOR TRIMAVESTERLIND us. BADE
DROP FRAME, STEELRICHMOND us. 245%
INTERLOCKANTERMOTIVE {LGS} US. 0.42%
AIR COMPRESSORIOASIS us. 2.05%.
COMPRESSORBATIERY BOXICRYSTAL us. O.50%.
AIR BOX HARNESS/ACALIFPMAN us. 0.28%
EQUALIZER RAMPIRICHMOND us. Lage
NON SKID TAPEAVGOSTER us. 0.25%.
TCS0 AIC COMPONENTSIACC US. 7.18%
REAR BUMPER us. 0.73%
MIRRORSYROSCO US. 5.40%
ACRYLIC BARRIERISABIC us. B30
SEATSIFREEDMANIUSSC us. 2.87%
WINDOWS/HEHR Us. 0.78%
us. 0.00%
85.50%

Total assemibiy of ouses. from body structure through road tests oncurs at at Champion Bus, inc.
in inlay City, MIL Cutaway chassis are delivered to Champion Sus from the chassis manufacturer
and consequently al fmai assembhy, inckuding the installation and aescomnection of the engime,
Transmission, axes and cooling and braking systems sre perfommed at the chassis manufacturer's

locaton prior te arival in imlay Cty. The following activities take place in imiay City, Mic

Checkin, inspection and preperation of chassis
Fabncaton of vehicle steel body structure.

Qhampion Bus, kn.
Page 1

Af lFF20u7

Installation of vehicle body ontc chassis frame

Mounting of front and rear caps

Installation and interconnection of heat and air conditioning equipment
installation of floor decking and floor covering

Installation of electrical system and lighting

Instailation of passenger seats, stanchions and grab rails

installation of doors and windows

Installation of customer selected options such as destination signs, lifts, etc.
Water testing of completed vehicle

Road testing of completed vehicle

Final inspection of vehicle and preparation for shipment

The cost of final assembly will be 12% of the total cost.

Champion Bus, Inc.
Page 2 4/17/2017

BUY AMERICA CERTIFICATE OF COMPLIANCE WITH FTA
REQUIREMENTS FOR BUSES, OTHER ROLLING STOCK,
OR ASSOCIATED EQUIPMENT

(To be submitted with a bid or offer exceeding the small purchase threshold for Federal
assistance programs, currently set at $150,000.)

Certificate of Compliance

The bidder hereby certifies that it will comply with the requirements of 49 U.S.C.
Section 5323(j)(2)(C), Section 165(b)(3) of the Surface Transportation Assistance
Act of 1982, as amended, and the regulations of 49 CFR 661.11:

Date:

Signature:

Company Name:

Title:

Certificate of Non-Compliance

The bidder hereby certifies that it cannot comply with the requirements of 49 U.S.C. Section
5323(j\(2)(C) and Section 165(b)(3) of the Surface Transportation Assistance Act of 1982,
as amended, but may qualify for an exception to the requirements consistent with 49
U.S.C. Sections 5323(j)(2)(B) or (j)(2)(D), Sections 165(b)(2) or (b)(4) of the Surface
Transportation Assistance Act, as amended, and regulations in 49 CFR 661.7.

Date:

Signature:

Company Name:

Title:

Federal Motor Vehicle Safety Standards

The Proposer and (if selected) Contractor shall submit (1) manufacturers FMVSS self-certification sticker
information that the vehicle complies with relevant FMVSS or (2) manufacturer's certified statement that the
contracted buses will not be subject to FMVSS regulations.

Company name:
Name of signer:
Title:

Authorized signature Date

Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion
- Lower Tier Covered Transaction

(1) The prospective lower tier participant certifies, by submission of this bid or proposal, that neither it
nor its "principals” [as defined at 49 CFR § 29.105(p)] is presently debarred, suspended, proposed
for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by
any Federal department or agency.

(2) When the prospective lower tier participant is unable to certify to the statements in this certification,
such prospective participant shall attach an explanation to this proposal.

The bidder respondent and all subcontractors hereby certifies that he/she has not been debarred or
suspended from participation in Federal contracts. Please note - separate certification may be photo
copied and submitted by each subcontractor. (Pursuant to 49 CFR, Part 29)

CERTIFIED (Contractor) CERTIFIED (Sub-Contractor(s))
| | |
Company Company
| | | |
Signed By Signed By
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Name & Title Name & Title

| | | |

Date Date

DISCLOSURE OF LOBBYING ACTIVITIES

The undersigned [Coniractor] certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee of
an agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any Federal contract, the making of
any Federal grant, the making of any Federal loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any
person for making lobbying contacts to an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned
shall complete and submit Standard Form--LLL, "Disclosure Form to Report Lobbying,” in
accordance with its instructions [as amended by "Government wide Guidance for New
Resirictions on Lobbying,” 61 Fed. Reg. 1413 (1/19/96). Note: Language in paragraph (2)
herein has been modified in accordance with Séction 10 of the Lobbying Disclosure Act of
1995 (P.L. 104-65, to be codified at 2 U.S.C. 1601, et seq.)]

(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
under grants, loans, and cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying
Disclosure Act of 1995). Any person who fails to file the required certification shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

[Note: Pursuant to 31 U.S.C. § 1352(c)(1)-(2)(A), any person who makes a prohibited expenditure
or fails to file or amend a required certification or disclosure form shall be subject to a civil penalty
of not less than $10,000 and not more than $100,000 for each such expenditure or failure.]

The Contractor certifies or affirms the truthfulness and accuracy of each statement of its
certification and disclosure, if any. in addition, the Contractor understands and agrees that the
provisions of 31 U.S.C. A 3801, et seg., apply to this certification and disclosure, if any.

Executed this day of , 20.

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Name of Bidder

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Address

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City/State/Zip

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Name of Contractor's Authorized Official Signature of Contractor's Authorized Official

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Title of Contractor's Authorized Official

DELINQUENT PERSONAL PROPERTY STATEMENT

, hereby affirms under oath, pursuant to New Hampshire State
Code, that at the time the bid was submitted by_(company) was / was not (please circle one) charged with
delinquent personal property taxes on the General Tax List of Personal Property for Hillsborough County, New
Hampshire.

If such charge for delinquent personal property tax exists on the General Tax List of Personal Property for
Hillsborough County, New Hampshire, the amount of such due and unpaid delinquent taxes, including due
and unpaid penalties and interest shall be set forth below. A copy of this statement shall be transmitted to
the Hillsborough County Treasurer within thirty (30) days of the date it is submitted. If a contract is entered
into, a copy of this statement shall also be incorporated into the contract between NTS and the bidder and no
payment shall be made with respect to any contract unless such statement has been so incorporated as a
part thereof.

Delinquent Personal Property Tax *
Penalties *
interest *

Company

Signed By

Name & Title

Date

State of

County of

SWORN TO BEFORE ME THIS DAY OF ,20_

NOTARY PUBLIC
SEAL

MY COMMISSION EXPIRES

* Mark “N/A’ if not applicable

NON-COLLUSION AFFIDAVIT

This affidavit is to be filled out and executed by the bidder; if a corporation makes the bid, then by its properly
executed agent. The name of the individual swearing to the affidavit should always appear on the line marked
"Name of Affidavit.” The affidavit's capacity, when a partner or officer of a corporation, should be inserted on
- lines marked "Capacity." The affidavit should sign individual name at end not partnership or corporation name,
- and swear to said affidavit before a notary public, who must attach his/her seal.

State of. ;

County of ;

l, being first duly swom, do hereby state that
(Name of Affidavit)

lam of
(Capacity) (Name of Firm, Partnership, Corporation)

whose business is

and who resides at

and that

(Give names of all persons, firms, or corporation interested in the bid)

is/are the only person(s) with me/us in the profits of the herein contained contract; that the contract is made
without any connection or interest in the profits thereof with any persons making any bid or proposal for said
work; that the said contract is on my/our part, in all respects fair and without collusion or fraud, and also that no
members of the Board of Trustees, head of any department or bureau, or employee therein, or any employee
of the Authority, is directly or indirectly interested therein.

SIGNATURE OF AFFIDAVIT

SWORN TO BEFORE ME THIS DAY OF ,20__.

NOTARY PUBLIC

SEAL

MY COMMISSION EXPIRES