SECTION VIII- BIDDING FORMS

I. CHECKLIST OF DOCUMENTS……………………..………………....... 75 - 76

II. SLSU BID FORM NO. 1 (TECHNICAL PROPOSALS)…………………... 77

III. SLSU BID FORM NO. 2 (FINANCIAL PROPOSALS)…………………… 78 - 79

IV. SAMPLE FORMS…………………………………………………………80 - 95

1
 CHECKLIST OF DOCUMENTS

ENVELOPE NO. 1 - FIRST COMPONENT -ELIGIBILITY

AND TECHNICAL COMPONENT
I. ELIGIBILITY DOCUMENTS under ITB Clause 12.1 (a)

CLASS “A” DOCUMENTS

1. Legal Eligibility Documents:
(i). SEC/DTI Registration [ ]
(ii). Valid & Current Mayor’s Permit/ Municipal Licenses– 2017 [ ]
(iii) Valid Tax Clearance [ ]
2. Technical Eligibility Documents:
(iv)(a). The statement of all ongoing government and private [ ]
contracts shall include all such contracts within the year 2012 to
present, prior to the deadline for the submission and receipt of
bids, including contracts awarded but not yet started, if any and
(See attached Sample Form Nos. SF-GOOD-13a)

(iv)(b).Statement identifying the bidder’s single largest completed

[ ]
contract to be bid contracts within the year 2012 to present,
except under conditions provided for in Sec. 23.5.1.3 of the IRR (as
amended, GPPB Res. No. 16-2014). (See attached Sample Form
Nos. SF-GOOD-13b):

These statements shall include, for each contract, the

following:
(iv.1) Name and Location of the Contracts;
(iv.2) Date of Contracts;
(iv.3) Kind of goods sold;
(iv.4) Amount of contract and value of Outstanding Contracts;
(iv.5) Date of delivery of goods; and
(iv.6) End-user’s acceptance or official receipt(s) issued for the
contract, if completed.

3. Financial Eligibility Documents:

(v) The Prospective bidder’s audited Financial Statement for the year 2012, [ ]
stamped “received” by the BIR or its duly accredited and
authorized institutions showing, among others, the prospective
bidder’s total and current assets and liabilities
(vi) The prospective bidder’s computation for its Net Financial [ ]
Contracting Capacity (NFCC) which must be at least equal to the ABC to
be bid (See attached Sample Form Nos. SF-GOOD-14)

2
 CLASS “B” DOCUMENTS
(vii) Valid joint venture agreement, in case of a joint venture. [ ]

II. TECHNICAL DOCUMENTS under ITB Clause No.

12.1 (b):
(b.i) BID SECURITY (Please see table at [ ]
Section III-BDS 18.1)
(b.ii) TECHNICAL PROPOSAL
SLSU BID FORM NO. 1 [ ]
[ ]
(b.iii) OMNIBUS SWORN STATEMENT:
The Omnibus Sworn Statement by the
prospective bidder or its duly authorized [ ]
representative as to the following:
(1) Name, address and designation of authorized
representative
(2) The signatory is the duly authorized
representative of the prospective bidder, and granted
full power and authority to do, execute and perform
any and all acts necessary and/or to represent the
prospective bidder in the bidding, with the duly
notarized Secretary’s Certificate attesting to such fact,
if the prospective bidder is a corporation, partnership,
cooperative, or joint venture;(See attached Sample
Form Nos.- SF-GOOD-35/ SF-GOOD -36)
(a) Authority of Signatory - Special Power of
Attorney [ ]
(b) Authority of Signatory - Secretary’s
Certificate [ ]
(3) It is not “blacklisted” or barred from bidding
by the GOP or any of its agencies, offices,
corporations, or LGUs, including foreign
government/foreign or international financing
institution whose blacklisting rules have been
recognized by the GPPB;
(4) Each of the documents submitted in
satisfaction of the bidding requirements is an
authentic copy of the original, complete, and all
statements and information provided therein are true
and correct;
(5) It is authorizing the Head of the Procuring
Entity or his duly authorized representative/s to verify
all the documents submitted;
(6) Statement of compliance with the disclosure
provision under Section 47 of RA
9184 (Disclosure of Relations) in relation to
other provisions of R.A. 3019.
(7) It complies with existing labor laws and
standards.
(8) It complies with the responsibilities of a
prospective or eligible bidder provided
in the PBDs, such as:
a. Carefully examined all of the bidding
documents;
b. Acknowledged all conditions, local or

3
 otherwise, affecting the
implementation of the Contract;
c. Made an estimate of the facilities
available and needed for the contract
to be bid, if any, and;
d. Inquired or secured Supplemental/Bid
Bulletin(s) issued for the project.
(9) It did not give or pay, directly or indirectly,
any commission, amount, fee, or any form
of consideration, pecuniary or otherwise,
to any person or official, personnel or
representative of the government in
relation to any procurement project or
activity.

ENVELOPE NO. 2 - SECOND COMPONENT -

FINANCIAL COMPONENT

SLSU BID FORM NO. 2- Financial Proposal with undertaking [ ]

SLSU BID FORM NO. 1– TECHNICAL PROPOSAL

VALERIO B. CABALO, Ph.D.

Chair, Bids and Awards Committee
Southern Leyte State University
Sogod, Southern Leyte

SIr:

Herewith is our TECHNICAL PROPOSAL for your office requirement:

(INSTRUCTION TO BIDDER: Check the “Comply” box if bidder complies with the SLSU
Specifications. A Technical Proposal containing unchecked “Comply” boxes would be automatically
rated as “FAILED.”)

ITEM QTY SLSU SPECIFICATIONS BIDDER’S

SPECIFICATIONS

4
1 1 Generator Set with Automatic Transfer Connection (ATS) Comply

Specifications:
100 KVA 3 Phase
230-480 Volts
60 Hertz
Deisel-fed Engine
ATS Connection – 230 Volts x 400 Ampers – 3 Phase

Inclusions:
Training, Installation, Commissioning & Testing
Deliver to SLSU
Warranty

Very truly yours,

__________________________
Signature over printed name
__________________________
Position
_________________________
Company
_________________________
Telephone Nos.
_______________________
Date
SLSU BID FORM NO. 2
(Financial Proposals with Undertaking)
Date : ____________
Invitation to Bid No.: PB-2017-G-06

PROSE IVY G. YEPES, Ed. D.

President
Southern Leyte State University
Sogod, Southern Leyte

Attention: VALERIO B. CABALO, Ph.D.

The Chairman
Bids and Awards Committee

Dear Madam:

Having examined the Bidding Documents including Supplemental Bid Bulletin No._______the receipt
of which is hereby duly acknowledged, we, the undersigned, offer to bid for the “Supply, Delivery and
Installation of Various ICT Equipment and Accessories” of Southern Leyte State University Sogod Campus
in conformity with the said Bidding Documents for the sum of

5
 ____________________________________________________[total Bid amount in words and figures], with
detailed breakdown of prices as follows:

TOTAL PRICE
ITEM # QTY ITEM DESCRIPTION UNIT PRICE (Should be 12%
VAT Inclusive)

1 1 GENERATOR SET with ATS Connection ₱ ₱

TOTAL ₱

We undertake, if our Bid is accepted, to deliver the goods in accordance with the delivery schedule.

If our Bid is accepted, we undertake to provide a performance security in the form, amounts, and
within the times specified in the Bidding Documents.

We agree to abide by this Bid for the Bid Validity Period specified in BDS provision for ITB Clause 18.2
and it shall remain binding upon us and may be accepted at any time before the expiration of that period.

Until a formal Contract is prepared and executed, this Bid, together with your written acceptance
thereof and your Notice of Award, shall be binding upon us.

We understand that you are not bound to accept the lowest or any Bid you may receive.

We certify/confirm that we comply with the eligibility requirements as per ITB Clause Error:
Reference source not found of the Bidding Documents.

Dated this ________________ day of ________________ 20______.

[signature over printed name] [in the capacity of]

Duly authorized to sign Bid for and on behalf of:

_______________________________________________________________________
[company name, address, and tel. nos.]

6
 SOUTHERN LEYTE STATE UNIVERSITY – SOGOD CAMPUS
Sogod, Southern Leyte
Bids and Awards Committee

SAMPLE FORMS Page

For Goods Offered From Abroad 81

For Goods Offered Within the Philippines 82

Contract Agreement Form 83

84 - 85

7
Omnibus Sworn Statement

86 -87
Authority of Signatory – Special Power of Attorney
(SF-GOOD-35)

Authority of Signatory – Secretary’s Certificate 88 - 89

(SF-GOOD-36)

Statement of All Ongoing Government and Private Contracts Including

90
Contracts Awarded But Not Yet Started either similar in nature or not
(SF-GOOD-13a)

Statement identifying the bidder’s single largest completed contract to be

91
bid, except under conditions provided for in Sec. 23.5.1.3 of the IRR (as
amended, GPPB Res. No. 16-2014). (SF-GOOD-13b)

NFCC/Financial Documents for Eligibility Check 92

(SF-GOOD-14)
93
Bank Guarantee Form
94 - 95
Bid-Securing Declaration

8
 For Goods Offered From Abroad

Name of Bidder . Invitation to Bid1 Number __. Page

of .

1 2 3 4 5 6 7 8 9
Item Description Country Quantity Unit price CIF port of Total CIF or Unit Price Unit price Total Price
of origin entry (specify port) or CIP price per Delivered Duty Delivered Duty delivered
CIP named place item Unpaid (DDU) Paid (DDP) DDP
(specify border point (col. 4 x 5) (col 4 x 8)
or place of
destination)

[signature] [in the capacity of]

Duly authorized to sign Bid for and on behalf of ____________________________

1
?
If ADB, JICA and WB funded projects, use IFB.

9
 For Goods Offered From Within the Philippines

Name of Bidder . Invitation to Bid2 Number . Page

of .

1 2 3 4 5 6 7 8 9 10
Item Description Country Quantity Unit price Transportatio Sales and Cost of Total Price, Total Price
of origin EXW per item n and other taxes Incidental per unit delivered Final
Insurance payable if Services, if (col 5+6+7+8) Destination
and all other Contract is applicable, per (col 9) x (col 4)
costs awarded, item
incidental to per item
delivery, per
item

[signature] [in the capacity of]

Duly authorized to sign Bid for and on behalf of ____________________________

2
?
If ADB, JICA and WB funded projects, use IFB.

10
 Contract Agreement Form

THIS AGREEMENT made the _____ day of __________ 20_____ between [name of
PROCURING ENTITY] of the Philippines (hereinafter called “the Entity”) of the one part and [name of
Supplier] of [city and country of Supplier] (hereinafter called “the Supplier”) of the other part:

WHEREAS the Entity invited Bids for certain goods and ancillary services, viz., [brief
description of goods and services] and has accepted a Bid by the Supplier for the supply of those
goods and services in the sum of [contract price in words and figures] (hereinafter called “the Contract
Price”).

NOW THIS AGREEMENT WITNESSETH AS FOLLOWS:

1. In this Agreement words and expressions shall have the same meanings as are respectively
assigned to them in the Conditions of Contract referred to.

2. The following documents shall be deemed to form and be read and construed as part of this
Agreement, viz.:

(a) the Supplier’s Bid, including the Technical and Financial Proposals, and all other
documents/statements submitted (e.g. bidder’s response to clarifications on the bid),
including corrections to the bid resulting from the Procuring Entity’s bid evaluation;
(b) the Schedule of Requirements;
(c) the Technical Specifications;
(d) the General Conditions of Contract;
(e) the Special Conditions of Contract;
(f) the Performance Security; and
(g) the Entity’s Notice of Award.

3. In consideration of the payments to be made by the Entity to the Supplier as hereinafter

mentioned, the Supplier hereby covenants with the Entity to provide the goods and services and to
remedy defects therein in conformity in all respects with the provisions of the Contract

4. The Entity hereby covenants to pay the Supplier in consideration of the provision of the goods
and services and the remedying of defects therein, the Contract Price or such other sum as may
become payable under the provisions of the contract at the time and in the manner prescribed by the
contract.

IN WITNESS whereof the parties hereto have caused this Agreement to be executed in
accordance with the laws of the Republic of the Philippines on the day and year first above written.

Signed, sealed, delivered by the (for the Entity)

Signed, sealed, delivered by the (for the Supplier).

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 Omnibus Sworn Statement

REPUBLIC OF THE PHILIPPINES )

CITY/MUNICIPALITY OF ______ ) S.S.

AFFIDAVIT

I, [Name of Affiant], of legal age, [Civil Status], [Nationality], and residing at [Address of
Affiant], after having been duly sworn in accordance with law, do hereby depose and state that:

1. Select one, delete the other:

If a sole proprietorship: I am the sole proprietor or authorized representative of [Name of

Bidder] with office address at [address of Bidder];

If a partnership, corporation, cooperative, or joint venture: I am the duly authorized and

designated representative of [Name of Bidder] with office address at [address of Bidder];

2. Select one, delete the other:

If a sole proprietorship: As the owner and sole proprietor, or authorized representative of

[Name of Bidder], I have full power and authority to do, execute and perform any and all
acts necessary to participate, submit the bid, and to sign and execute the ensuing
contract for [Name of the Project] of the [Name of the Procuring Entity], as shown in the
attached duly notarized Special Power of Attorney;

If a partnership, corporation, cooperative, or joint venture: I am granted full power and

authority to do, execute and perform any and all acts necessary to participate, submit the
bid, and to sign and execute the ensuing contract for [Name of the Project] of the [Name
of the Procuring Entity], as shown in the attached [state title of attached document
showing proof of authorization (e.g., duly notarized Secretary’s Certificate,
Board/Partnership Resolution, or Special Power of Attorney, whichever is applicable;)];

3. [Name of Bidder] is not “blacklisted” or barred from bidding by the Government of

the Philippines or any of its agencies, offices, corporations, or Local Government Units,
foreign government/foreign or international financing institution whose blacklisting rules
have been recognized by the Government Procurement Policy Board;

4. Each of the documents submitted in satisfaction of the bidding requirements is an

authentic copy of the original, complete, and all statements and information provided
therein are true and correct;

5. [Name of Bidder] is authorizing the Head of the Procuring Entity or its duly
authorized representative(s) to verify all the documents submitted;

6. Select one, delete the rest:

If a sole proprietorship: The owner or sole proprietor is not related to the Head of the
Procuring Entity, members of the Bids and Awards Committee (BAC), the Technical
Working Group, and the BAC Secretariat, the head of the Project Management Office or
the end-user unit, and the project consultants by consanguinity or affinity up to the third
civil degree;

If a partnership or cooperative: None of the officers and members of [Name of Bidder] is

related to the Head of the Procuring Entity, members of the Bids and Awards Committee
(BAC), the Technical Working Group, and the BAC Secretariat, the head of the Project
 Management Office or the end-user unit, and the project consultants by consanguinity or
affinity up to the third civil degree;

If a corporation or joint venture: None of the officers, directors, and controlling

stockholders of [Name of Bidder] is related to the Head of the Procuring Entity, members
of the Bids and Awards Committee (BAC), the Technical Working Group, and the BAC
Secretariat, the head of the Project Management Office or the end-user unit, and the
project consultants by consanguinity or affinity up to the third civil degree;

7. [Name of Bidder] complies with existing labor laws and standards; and

8. [Name of Bidder] is aware of and has undertaken the following responsibilities as

a Bidder:

a) Carefully examine all of the Bidding Documents;

b) Acknowledge all conditions, local or otherwise, affecting the implementation of

the Contract;

c) Made an estimate of the facilities available and needed for the contract to be bid,
if any; and

d) Inquire or secure Supplemental/Bid Bulletin(s) issued for the [Name of the

Project].

9. [Name of Bidder] did not give or pay directly or indirectly, any commission,
amount, fee, or any form of consideration, pecuniary or otherwise, to any person or
official, personnel or representative of the government in relation to any procurement
project or activity.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ___, 20__ at
____________, Philippines.

_____________________________________
Bidder’s Representative/Authorized Signatory

SUBSCRIBED AND SWORN to before me this ___ day of [month] [year] at [place of
execution], Philippines. Affiant/s is/are personally known to me and was/were identified by me
through competent evidence of identity as defined in the 2004 Rules on Notarial Practice (A.M.
No. 02-8-13-SC). Affiant/s exhibited to me his/her [insert type of government identification card
used], with his/her photograph and signature appearing thereon, with no. ________ and his/her
Community Tax Certificate No. _______ issued on ____ at ______.

Witness my hand and seal this ___ day of [month] [year].

NAME OF NOTARY PUBLIC

Serial No. of Commission _______________
Notary Public for _______ until __________
Roll of Attorneys No. __________________
PTR No. ______ [date issued], [place issued]
Doc. No. _____ IBP No. ______ [date issued], [place issued]
Page No. _____
Book No. _____
Series of _____

13
Southern Leyte State University
Standard Form No.: SF-GOOD-35
Authority of Signatory

SPECIAL POWER OF ATTORNEY

I, , President
of , a
corporation incorporated under the laws of
, with its registered office at
, by virtue of Board Resolution No. dated
, has made, constituted and appointed true and
lawful attorney, for it and its name, place and stead, to do, execute and perform
any and all acts necessary and/or represent
in the bidding of
as fully and effectively as corporation might do
if personally present with full power of substitution and revocation and hereby
confirming all that said representative shall lawfully do or cause to be done by
virtue hereof.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

, 20__, at .

Affiant
Signed in the Presence of:

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) SS.

BEFORE ME, a Notary Public for and in Quezon City, Philippines, this
______ day of 201__, personally appeared:

NAME CTC NO. ISSUED AT/ON

known to me and known to be the same person who executed the foregoing
instrument consisting of ( ) pages, including the page whereon the
acknowledgments is written and acknowledged before me that the same is his
free and voluntary act and deed and that of the Corporation he represents.
 WITNESS MY HAND AND NOTARIAL SEAL, at the place and on the date
first above written.

Notary Public
Until 31 December 20__
PTR No.
_______________
Issued at: _____________
TIN
No.________________
Doc. No. ______
Page No. ______
Book No. ______
Series of ______

15
Southern Leyte State University
Standard Form No.: SF-GOOD-36
Authority of Signatory

SECRETARY’S CERTIFICATE

I, , a duly elected
and qualified Corporate Secretary of
, a corporation duly organized and existing under and by virtue of the law
of the __________________________________ DO HEREBY CERTIFY, that:

I am familiar with the facts herein certified and duly authorized to certify
the same;

At the regular meeting of the Board of Directors of the said Corporation

duly convened and held on ________________________ at which meeting a
quorum was present and acting throughout, the following resolutions were
approved, and the same have not been annulled, revoked and amended in any
way whatever and are in full force and effect on the date hereof:

RESOLVED, that ___________________________ be, as it hereby is,

authorized to participate in the bidding of
____________________________________ by the Office of the Ombudsman;
and that if awarded the project shall enter into contract with the Office of the
Ombudsman; and in connection therewith hereby appoint
_______________________________ acting as duly authorized and designated
representatives of ___________________________, are granted full power and
authority to do, execute and perform any and all acts necessary and/or to
represent _________________________________________ in the bidding as
fully effectively as the ________________________________________might do
if personally present with full power of substitution and revocation and hereby
satisfying and confirming all that my said representative shall lawfully do or cause
to be done by virtue hereof;

RESOLVED FURTHER THAT, the _____________________ hereby

authorizes its President to:

(1) execute a waiver of jurisdiction whereby the

______________________ hereby submits itself to the jurisdiction of
the Philippine government and hereby waives its right to question the
jurisdiction of the Philippine courts;

(2) execute a waiver that the

______________________________________ shall not seek and
obtain writ of injunctions or prohibition or restraining order against the
Office of the Ombudsman or any other agency in connection with this
project to prevent and restrain the bidding procedures related thereto,
the negotiating of and award of a contract to a successful bidder, and
the carrying out of the awarded contract.
 WITNESS the signature of the undersigned as such officer of the said
______________________________________ this
________________________.

_____________________________
(Corporate Secretary)

ACKNOWLEDGMENT

SUBSCRIBED AND SWORN to before me this ____day of

______________, 20__ affiant exhibited to me his/her
_____________________________ issued on
at _____________________________________, Philippines.

Notary Public

Doc. No. ______

Page No. ______
Book No. ______
Series of ______

17
Southern Leyte State University
Standard Form No.: SF-GOOD-13a
Statement of all ongoing government and private contracts within the period from CY-2012 to present,
including those awarded but not yet started which may be similar or not similar to the project being bided
Business Name : ______________________________________________________________
Business Address : ______________________________________________________________

Name of Client a a. Date Awarded Title of the Project % of Value of

. b. Date Started in the Contract Accomplishment Contract Amount Outstanding
O c. Date of Planned Actual Contracts
w Completion
n
e
r
’
s
N
a
m
e
b
.
A
d
d
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e
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.
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h
o

18
 n
e

N
Government:

Private:

Important notes:

This statement shall be supported with:

1 Notice of Award and/or Contract
2 Notice to Proceed issued by the owner

Submitted by : _____________________________________________________
(Print Name and Signature)
Designation : _____________________________________________________
Date : _____________________________________________________

19
Southern Leyte State University
Standard Form No.: SF-GOOD-13b

Statement of Bidder’s Single Largest Completed Contract within the period from CY- 2012 to present, which is similar in nature
Business Name : ______________________________________________________________
Business Address : ______________________________________________________________

Name of Client a. Owner’s Name Bidder’s Role a.

b. Address Title of the Project a. Date A
c. Telephone Nos. in the Contract Awarded m
b. Contract o
Effectivity u
c. Date nt
Completed/ at
Delivery A
w
ar
d
e
d
b.
A
m
o
u
nt
at
C
o
m
pl
et
io
n
c.
D
u

20
 ra
ti
o
n

Description %

Government

Private

Note : This statement shall be supported with:

1 Contract
2 Official Receipt(s) issued for the contract
3 End-user’s Certificate of Acceptance

Submitted by : _____________________________________________________
(Print Name and Signature)
Designation : _____________________________________________________
Date : _____________________________________________________

21
Southern Leyte State University
Standard Form No.: SF-GOOD-14

FINANCIAL DOCUMENTS FOR ELIGIBILITY CHECK

A. Summary of the Applicant Supplier’s/Distributor’s/Manufacturer’s assets and

liabilities on the basis of the attached income tax return and audited financial
statement, stamped “RECEIVED” by the Bureau of Internal Revenue or BIR
authorized collecting agent, for the immediately preceding year and a copy of
Schedule of Fixed Assets particularly the list of construction equipment.

Year 20____
1. Total Assets
2. Current Assets
3. Total Liabilities
4. Current Liabilities
5. Net Worth (1-3)
6. Net Working Capital (2-4)

B. The Net Financial Contracting Capacity (NFCC) based on the above data is
computed as follows:

NFCC = K (current asset – current liabilities) minus value of all outstanding

works under ongoing contracts including awarded contracts yet to be started

NFCC = P __________________________________________

K = 10 for a contract duration of one year of less, 15 for more than one year
up to two years and 20 for more than two years.

Submitted by:
______________________________________________
Name of Supplier / Distributor / Manufacturer
_____________________________________________
Signature of Authorized Representative
Date: ________________________________

22
 Bank Guarantee Form for Advance Payment

To: [name and address of PROCURING ENTITY]

[name of Contract]

Gentlemen and/or Ladies:

In accordance with the payment provision included in the Special Conditions of

Contract, which amends Clause Error: Reference source not found of the General
Conditions of Contract to provide for advance payment, [name and address of Supplier]
(hereinafter called the “Supplier”) shall deposit with the PROCURING ENTITY a bank
guarantee to guarantee its proper and faithful performance under the said Clause of the
Contract in an amount of [amount of guarantee in figures and words].

We, the [bank or financial institution], as instructed by the Supplier, agree

unconditionally and irrevocably to guarantee as primary obligator and not as surety
merely, the payment to the PROCURING ENTITY on its first demand without
whatsoever right of objection on our part and without its first claim to the Supplier, in the
amount not exceeding [amount of guarantee in figures and words].

We further agree that no change or addition to or other modification of the terms of the
Contract to be performed thereunder or of any of the Contract documents which may be
made between the PROCURING ENTITY and the Supplier, shall in any way release us
from any liability under this guarantee, and we hereby waive notice of any such change,
addition, or modification.

This guarantee shall remain valid and in full effect from the date of the advance
payment received by the Supplier under the Contract until [date].

Yours truly,

Signature and seal of the Guarantors

[name of bank or financial institution]

[address]

[date]

23
 BID SECURING DECLARATION FORM

REPUBLIC OF THE PHILIPPINES)

CITY OF _______________________) S.S.

x------------------------------------------------------x

BID SECURING DECLARATION

Invitation to Bid: [Insert Reference number]

To: [Insert name and address of the Procuring Entity]

I/We3, the undersigned, declare that:

1. I/We understand that, according to your conditions, bids must be

supported by a Bid Security, which may be in the form of a Bid-Securing
Declaration.

2. I/We accept that: (a) I/we will be automatically disqualified from bidding for
any contract with any procuring entity for a period of two (2) years upon
receipt of your Blacklisting order; and, (b) I/we will pay the applicable fine
provided under Section 6 of the Guidelines on the Use of Bid Securing
Declaration, within fifteen (15) days from receipt of the written demand by
the procuring entity for the commission of acts resulting to the
enforcement of the bid securing declaration under Sections 23.1(b), 34.2,
40.1 and 69.1, except 69.1(f), of the IRR of RA 9184; without prejudice to
other legal action the government may undertake.

3. I/We understand that this Bid Securing Declaration shall cease to be valid
on the following circumstances:

(a) Upon expiration of the bid validity period, or any extension thereof
pursuant to your request;

3
?
Select one and delete the other. Adopt the same instruction for similar terms throughout the
document.

24
 (b) I am/we are declared ineligible or post-disqualified upon receipt of
your notice to such effect, and (i) I/we failed to timely file a request
for reconsideration or (ii) I/we filed a waiver to avail of said right;

(c) I am/we are declared the bidder with the Lowest Calculated
Responsive Bid, and I/we have furnished the performance security
and signed the Contract.

IN WITNESS WHEREOF, I/We have hereunto set my/our hand/s this ____ day
of [month] [year] at [place of execution].

[Insert NAME OF BIDDER’S AUTHORIZED

REPRESENTATIVE]
[Insert Signatory’s Legal Capacity]
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of [month] [year] at

[place of execution], Philippines. Affiant/s is/are personally known to me and was/were
identified by me through competent evidence of identity as defined in the 2004 Rules on
Notarial Practice (A.M. No. 02-8-13-SC). Affiant/s exhibited to me his/her [insert type of
government identification card used], with his/her photograph and signature appearing
thereon, with no. ________ and his/her Community Tax Certificate No. _______ issued
on ____ at ______.

Witness my hand and seal this ___ day of [month] [year].

NAME OF NOTARY PUBLIC

Serial No. of Commission _______________

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 Notary Public for _______ until __________
Roll of Attorneys No. __________________
PTR No. ______ [date issued], [place issued]
IBP No. ______ [date issued], [place issued]

Doc. No. _____

Page No. _____
Book No. _____
Series of _____

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