03-15-19 Response to Request for Proposal 19-02JEB T. BRANHAM
Attorney at Law
March 15, 2019
City of Atlantic Beach
Attn: Procurement Manager
800 Seminole Road
Atlantic Beach, FL 32233
Re: Request for Proposal No. 19-02 — Code Enforcement Special Magistrate
To Whom it May Concern:
Enclosed please find Jeb T. Branham, P.A.'s response to the Request for Proposal No. 19-02, Code
Enforcement Special Magistrate for the City of Atlantic Beach, Florida. In compliance with the
request for proposal please, find the following:
Tab 2 Experience of the Attorney/Law Firm
Tab 3 Fee Proposal
Tab 4 References
Tab 4 Required Forms
Tab 5 Certificates of Insurance
Page 2
Page 6
Page 7
Page 8
Page 29
The firm's current professional liability insurance is included. Additional professional liability,
general liability, and workers compensation insurance will be obtained if the applicant is selected.
The firm has maintained offices at the following locations for the specified dates: 166 AIA North
Ponte Vedra Beach, Florida from 2002-05; 1400 Marsh Landing Parkway, Suite 103, Jacksonville
Beach, Florida from 2006-07; 333 1st Street North, Suite 305, Jacksonville Beach, Florida from
2008-11; 3500 3rd Street North, Jacksonville Beach, Florida from 2012-17; and 419 3rd Street
North, Jacksonville Beach, Florida from 2018 -present.
I am happy to speak with you should there be any questions concerning the information contained
within this proposal.
Sincerely,
Jeb T. Branham
JTB/jag
Enclosures
419 3rd Street North, Jacksonville Beach, Florida 32250
jeb@jebbranham.com (904) 339-0500 telephone (904) 339-0501 facsimile I www.jebbranham.com
City of Atlantic Beach
Response to Request for Proposal 19-02
Code Enforcement Special Magistrate
REPRESENTATION PROPOSAL BY
JEB T. BRANHAM, P.A.
JEB T. BRANHAM
419 3RD STREET NORTH
JACKSONVILLE BEACH, FLORIDA 32250
904) 339-0500
SUBMITTED MARCH 15, 2019
JEB T. BRANHAM I
City of Atlantic Beach
Response to Request for Proposal
Code Enforcement Special Magistrate
FIRM QUALIFI CATIONS
THE BENEFIT OF EXPERIENCE DEVELOPED AT TWO OF THE NATION'S BEST AND LARGEST LAW
FIRMS COMBINED WITH I O YEARS OF REPRESENTING MUNICIPAL GOVERNMENTS
My goal is to bring every client the benefit of experience developed at two of the nation's best and largest law
firms - McGuireWoods and King & Spalding - with the personal attention you can only get from a small
practice. We deliver the legal sophistication gained from working in a big firm environment for some of the
world's largest corporations like the Coca-Cola Company, General Motors, Eli Lilly & Company, Novartis
Pharmaceuticals, and 3M combined with individual, personalized attention.
QUALITY OF LEGAL SERVICES:
Practicing at the best firms and working for the most demanding clients in the world puts an attention to
quality in our work that most lawyers never have the opportunity or need to develop.
SERVICE AS TOWN ATTORNEY FOR TWO MUNICIPALITIES a OTHER GOVERNMENTAL
EXPERIENCE:
Jeb Branham has the honor and benefit of working as the Town Attorney for Callahan for 17 years and as the
Town Attorney for Baldwin for 15 years. The Ocean Highway and Port Authority, Nassau County recently
retained Mr. Branham as its counsel. Mr. Branham previously served as Atlantic Beach's special magistrate for
dangerous dog proceedings. There are few attorneys in the area with this experience handling the legal
matters unique to municipalities and government, combined with sophisticated, broad-based litigation
expertise.
My service as a town attorney includes the responsibility for prosecuting code enforcement violations,
handling all land use and zoning matters and the conduct of quasi-judicial proceedings. I have conducted
dozens of quasi-judicial proceedings, including numerous rezonings, annexations, and comprehensive plan
amendments. During my tenure, the Town of Callahan had a zoning matter proceed to Fla. Stat. s. 70.51
special magistrate proceedings and a subsequent appeal to the Circuit Court. The Circuit Court upheld the
Town's decision. On occasion, I represent private clients in land use and code enforcement matters, both
before city councils, in the state trial courts, and on appeal.
As the attorney for two Towns, I understand the importance of maintaining a thorough knowledge of and
ensuring full compliance with state public records, public meetings, and ethics laws. Drafting legislation and
regularly conducting hearings in which a municipality renders judgments affecting citizens' rights has given me
the experience necessary to effectively balance the sometimes competing interests of the government,
individuals, property owners, neighbors, and the citizenry as a whole.
JEB T. BRANHAM
City of Atlantic Beach
Response to Request for Proposal
Code Enforcement Special Magistrate
RESUME — JEB T. BRANHAM
419 3rd Street North — Jacksonville Beach, Florida 32250
904) 339-0500; jeb@jebbranham.com
wwwjebbranham.com
LICENSES AND COURT ADNIISSIONS
Florida Bar, September 2000. Also admitted to U.S.D.C., Middle District of Florida and the Eleventh Circuit Court of
Appeals.
Georgia Bar, November 1995. Also admitted to Georgia Supreme Court and Court of Appeals and U.S.D.C.,
Northern District of Georgia. Authorized by the State of Georgia to appear as sole or lead counsel at trials and
depositions.
LEGAL. EXPERIENCE
Jeb T. Branham, Esq. Jacksonville Beach, Florida (1/2002 — present). Sole practitioner or partner in small firm
from 2002 to 201 9, practicing in commercial and municipal law, emphasizing litigation, both trial and appellate.
Representative matters include Attorney for Ocean Highway and Port Authority, Nassau County, Town Attorney for
Baldwin and Callahan, Florida, settling administrative law matters with the State of Florida $500,000 under State's demand,
litigating the fleet -wide failure of marine engines for Costa Rican fishing lodge and subsequent nation-wide class action,
general counsel representation of national auto painting franchisor, litigating easement rights between regional restaurant
and land developer, and trademark registration for state and national surfing organizations.
McGuireWoods, Jacksonville, Florida (I/2000 - 12/2001). Commercial litigation department representing both
institutional and closely -held businesses in disputes from banking procedures to business torts. Representative matters
include litigation arising from the sale of multi-million dollar companies, distributorship termination, the fleet -wide failure
of marine engines, and — at trial and 1 I* Circuit appellate level — the termination of physicians from an insurance network.
Responsible for all aspects of litigation including coordinating and drafting discovery, taking and defending depositions, and
court appearances.
King & Spalding, Atlanta, Georgia (5/1998 - 12/1999). Tort litigation team defending automobile and medical device
manufacturers and commercial litigation team defending Coca-Cola in PepsiCo v. Coco -Cola antitrust litigation. Defended
high exposure and nationwide litigation matters (both pending and potential), with extensive experience addressing
document production logistics and privilege issues. Start -to -finish case handling responsibility for General Motors
automotive products liability cases.
JEB T. BRANHAM
Attorney at Law
3
City of Atlantic Beach
Response to Request for Proposal
Code Enforcement Special Magistrate
RESUME, CONTINUED
Hawkins & Parnell, Atlanta, Ga (9/1995 - 4/1998). Products liability defense for prescription pharmaceuticals,
medical devices, clothing and textiles, and industrial products. Broad range of litigation experience representing
insurers and insureds in commercial disputes and personal injury defense. Start -to -finish case handling and billing
responsibility with extensive client contact. Developed and implemented document retention policy for international
medical device manufacturer. Published opinion: Presto v. Sandoz Phormaceukcals Corp., 226 Ga. App. 547, 487 S.E.2d
70 (1997).
PROFESSIONAL ASSOCIATIONS
Elected to the Board of Governors of the State Bar of Georgia in 2013
Member of Florida Bar (member of City, County, and Local Govemment Law Section and Business Law
Section)
Member of the State Bar of Georgia
Member of the Jacksonville Bar Association
EDUCATI ON
University of Tennessee College of Law
Knoxville, Temessee
Juris Doctor, cum laude, May, 1995
Emory University
Atlanta, Georgia
B.A, English 1992
Honors and Achievements. Top 15% of law school class, dean's list all semesters; University of Tennessee Law
Review; Am. Jur. awards in Con Law 11 and Criminal Procedure. Merit scholarship from Southeastern Bankruptcy Law
Institute.
BACKGROUND
Born 1970, Knoxville, Tennessee. Married to Michelle for 12 years with one five-year old son. Civic activities include
former Board Member for Frum the Ground Up and Surfrider Foundation, First Coast Chapter. Ruling elder and
Sunday school teacher for Palms Presbyterian Church and served on the search committee fora new pastor. Member
of the legal committee of the Ocean Cay Homeowner's Association.
JEB T. BRANHAM
Attorney at Law
4 I
City of Atlantic Beach
Response to Request for Proposal
Code Enforcement Special Magistrate
EXPERIENCE -RELATED SPECIFIC INQUIRIES:
Mr. Branham previously served on the Board of Governors for the State Bar of Georgia. Although he has
practiced in local government law for 17 years, Mr. Branham is not board-certified nor does he hold
specific ratings from rating agencies. Mr. Branham and his firm were counterclaim defendants when he and
co -counsel sued a former client for fees owed. The case was resolved by settlement. Neither Mr. Branham
nor his firm have otherwise been sued, had judgments rendered against them, or had any bar complaints
lodged in the last five years. They do not employ lobbyists.
GOVERNMENTAL LITIGATION EXPERIENCE:
Began representing the Town of Callahan in 2003 to resolve numerous claims from prior administration's
misconduct.
Resolved proceedings instituted against the Town of Callahan by the Florida Department of
Transportation for utility relocation charges at a six -figure savings over FDOT's demands.
Resolved administrative proceedings instituted against the Town of Callahan for misconduct by a grant
administrator at a six -figure savings over the Department of Community Affair's demands.
Resolved inverse condemnation and trespass litigation filed against the Town of Callahan resulting from
retention pond constructed illegally on private property for market value of property.
On behalf of the Town of Hilliard, successfully resolved litigation between the Town and building
contractor over conversion of church into new Town Hall.
Served as lead negotiator for the Town of Baldwin on union contract with Teamsters.
Obtained a dismissal with prejudice of a lawsuit filed against the Town of Baldwin by a former employee
when prior litigation attorneys representing the Town were unsuccessful.
Obtained a temporary injunction for the Town of Baldwin to stop the operation of an unauthorized
borrow
Obtained a temporary injunction for the Town of Callahan to stop unpermitted construction.
Successfully defended the Town of Callahan's denial of a site plan in certiorari proceedings.
Obtained defense verdict for private corporation in code enforcement action in which the City of
Jacksonville sought over $400,000 in fines.
Appealed denial of variance for private landowner via writ of certiorari and obtained agreed-upon
resolution with the City of Neptune Beach.
Obtained multiple court orders authorizing the demolition of nuisance structures in code enforcement
proceedings.
JEB T. BRANHAM
Attorney at Law
5
City of Atlantic Beach
Response to Request for Proposal
Code Enforcement Special Magistrate
The Honorable Martin Fontes
Mayor, Town of Callahan
542300 U.S. Highway 1
Callahan, Florida 3201 I
Telephone: (904) 879-3801
Facsimile: (904) 879-6151
Email: m ayor@townofcallahan-fl.gov
Dates of Representation:
2002 to present
REFERENCES
The Honorable Sean Lynch
Mayor, Town of Baldwin
I 0 U.S. Highway 90 West
Baldwin, Florida 32234
Telephone: (904) 266-5031
Facsimile: (904) 266-4220
Email: baldwinmayor@comcast.net
Dates of Representation:
2004 to present
JEB T. BRAN HAM
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
CITY OF ATLANTIC BEACH
Request for Proposals
Special Magistrate Services
RFP #19-02
DOCUMENT REQUIREMENTS CHECKLIST
ALL REQUIRED DOCUMENTS, AS LISTED BELOW, MUST BE INCLUDED WITHIN YOURPROPOSALPACKAGE. ONE (1) ORIGINAL AND SIX (6) COPIES, PLUS AN ELECTRONIC.
FILE (CD OR FLASH DRIVE)
DE IN THE SAME
RDERD
DOCUMENTS
AS MDBELOW.
SHOULD BE SENT TO
THE CITY AND SHOULD
Proposals, and ALL required documents, submitted as complete packages (one original and six copies
plus one digital copy) to include the following under Tab 5, Required forms:
Signed copy of the Document Requirements Checklist
Signature Sheet acknowledging addendutns
E -Verify Statement
I/ Drug Free Workplace, if appropriate
Public Entity Crimes Statement
Non -Collusion Affidavit
Completed Fonn W-9 Request for Taxpayer Identification Number and Certification (form may
be obtained from the IRS website https://www.irs.gov/pub/irs-pdf/fw9.pdf
7. New Vendor Information Form
Proposer Acknowledgements and Agreements
7 Conflict of Interest Statement
Disputes Disclosure Form
Public Records Form
The above requirements have been noted and are understood by bidder. I understand that failure to
submit an item listed above may result in rejection of this bid.
SIGNATURE: ` PRINT: J e- Cr^r
COMPANY:
ADDRESS: 1 3
PHONE: 1 r 33i OS -00 FAX: 33 `1 a SO
EMAIL:DATE: 7/13A3:ret:73v;.-trra7-3-‘
01098179-1
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
Special Magistrate Services
RFP #19-02
SIGNATURE SHEET
Proposer: Ne. r‘,.
Firm: J e c T. G 2„ 1-r G n-•, d''. A-.
Address: .sA'cc t /v • ) 3c ck Sari/,11 l -Gc_l-•, Z 30Z U
Telephone Number: C'j Ott 22ct 0 DD p
ADDENDUM ACKNOWLEDGEMENT
The proposer shall acknowledge obtaining all addenda issued to this formal solicitation from the
City's web site by completing the blocks below. Failure to acknowledge all addenda may be
cause for rejection of the bid response.
Addendum No. Date Issued: .Z I (5 1 q
Addendum. No. Date Issued:
Addendum No. Date Issued:
Addendum No. Date Issued:
AUTHORIZED SIGNATURE: '
Y
TITLE:
h[Print/type name as Signed above): jar) 3
DATE:
01098179-1
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
Bid/Proposal Number:
Project Description:
E -VERIFY STATEMENT
Cope n-c()rcemQnt
SpQCth.i n a t ate
COMPANY/FIRM/CONTRACTOR acknowledges and agrees to the following:
The awarded COMPANY/FIRM/CONTRACTOR shall utilize the U.S. Department of
Homeland Security's E -Verify system, in accordance with the terms governing use of the
system, to confirm the employment eligibility of:
1. All persons employed by the SPECIAL MAGISTRATE/FIRM during the term of the
Contract to perforin employment duties within Florida; and
2. All persons assigned by the SPECIAL MAGISTRATE/FIRM to perform work pursuant to
the contract with the Department.
Company/Firm:
Authorized Signature:
Title:
Date:
01098179-1
Pyanham, P. Pf.
kkorn.
3I 3I Iq
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
DRUG-FREE WORKPLACE CERTIFICATION
Section 287.087, Florida Statues, effective January 1, 1991, specifies that preference must be given tovendorssubmittingacertificationwiththeirbid/proposal certifying they have a drug-free workplace. This
requirement effects all public entities of the State and is as follows:
IDENTICAL TIE BIDS - Preference shall be given to business with drug-free workplace programs.
Whenever two or more bids which are equal with respect to price, quality and service are received by the
State or by any political subdivision for the procurement of commodities or contractual services, a bidreceivedfromabusinessthatcertifiesthatithasimplementedadrug-free workplace program. In order to
have a drug-free workplace program, a business shall:
1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the workplace and specifying the actions
that will be taken against employees for violations of such prohibition.
2) Inform employees about the dangers of drug abuse in the workplace, the business's policy of
maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employeeassistanceprograms, and the penalties that may be imposed upon employees for drug abuse
violations.
3) Give each employee engaged in providing the commodities or contractual services that are under bid
a copy of the statement specified in subsection (1).
4) In the statement specified in subsection (1), notify the employees that, as a condition of working on
the commodities or contractual services that are under bid, the employee will abide by the terms of
the statement and will notify the employer of any conviction of, or plea of guilty or nolo contenders
to, any violation of Chapter 893 or of any controlled substance law of the United States or any state,
for a violation occurrence in the workplace no later than five (5) days after such conviction.
5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or
rehabilitation program if such is available in the employee's community, by any employee who is so
convicted.
6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of
this section.
AS THE PERSON AUTHORIZED TO SIGN THE STATEMENT, I CERTIFY THAT THIS FIRM
COMPLIES FULLY WITH THE ABOVE REQUIREMENTS.
VEND Q'S SIGNATURE
Q -Oa-
Bid/RFP Number
01098179-1
DATE
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
PUBLIC ENTITY CRIMES
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(A), FLORIDA
STATUTES, ON PUBLIC ENTITY CRIMES.
THIS FORM MUST BE SIGNED ANDS ORN TO IN THE PRESENCEOF A
NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
1. Thi sworn stat&
n,.n
t is su mitted to the City of Atlantic Beach
by e87inQfrj P f}
print ind vidpal's Cai>ram t f , P./t•
print name of entity submittin,g swoa,
em
whose business addre ss is 4 (3 r( N 41
a 0 114,
and (if applicable) its Federal Employer Identification Number (FEIN) is O -53
2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes,
means a violation of any state or federal law by a person with respect to and directly related to the
transaction of business with any public entity or with an agency or political subdivision of any other state
or of the United States, including, but not limited to, any bid or contract for goods or services to be
provided to any public entity or an agency or political subdivision of any other state or of the United
States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material
misrepresentation.
3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida
Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication
of guilt, in any federal or state trial court of record relating to charges brought by indictment or
information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or
nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:
1. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is active in the management of the entity
and who has been convicted of a public entity crime. The term "affiliate" includes those officers,
directors, executives, partners, shareholders, employees, members, and agents who are active in the
interest in another person, or a pooling of equipment or income among persons when not for fair
market value under an arm's length agreement, shall be a prima facie case that one person controls
another person. A person who knowingly enters into a joint venture with a person who has been
convicted of a public entity crime in Florida during the preceding 36 monthsshall be considered an
affiliate.
5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any
natural person or entity organized under the laws of any state or of the United States with the legal power
to enter into a binding contract and which, bids or applies to bid on contracts for the provision of goods or
services let by a public entity, or which otherwise transacts or applies to transact business with a public
entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees,
members, and agents who are active in management of an entity.
01098179-1
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
6. Based on infonnation and belief, the statement which I have marked below is true in relation to the
entity submitting this sworn statement. (Indicate which statement applies.)
Neither the entity submitting this sworn statement, nor any of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity,
nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent of
July 1, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity, or
an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity, or
an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of
Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer
determined that it was not in the public interest to place the entity submitting this sworn statement on the
convicted vendor list. (Attach a copy of the final order)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING
OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS
FOR THAT PUBLIC ENTITY ONLY AND, THAT ' THIS FORM IS VALID THROUGH
DECEMBER 31 OF THE CALENDAR YEAR IN WHICI1 IT IS FILED. I ALSO UNDERSTAND
THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017,
FLORIDA STATUTES, FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION
CONTAINED IN THIS FORM.
STATE OF `" R- D A
COUNTY OF T WI -Al --
PERSONALLY PERSONALLY APPEARED BEFORE ME, the undersigned authority,
y j Eg Q (04 -41 -1A -on who, after first being duly sworn by me, affixed
name of individual signing)
iirattule
aate)
I
his/her signature in the space provided above on this 3day of
01098179-1
019.
NOTARY P
My commission pires:
CARLA
Commission* GO 196739
aa= Expires April 8, 2022
s Tots
f; Bonded Thru Troy Fain Insurance 80038
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
Non -Collusion Affidavit
This sworn statement is submitted with Bid, Proposal or Contract for J Q • ECC,In hamam
entity)•(
2'1UnlThisswornstatemetissubmittedby
whose business
address is 41 Q 3 fO S -I-. K, j fl4t((Q. E.,/,(s) and (if applicable) federal Employer
Identification Number (FEIN) is )i - `7 6 ((91 ( (If a Sole Pro rietor and you have no
FEIN, include the last four (4) digits of your Social Security Number: 061 ' ).
JeB Banhc -fl
My name is and my relationship to the entity named above is
1.
2.
The above named is fully informed respecting the preparation and contents of the
proposal and of all pertinent circumstances respecting such proposal;
Such Proposal is genuine and is not a collusive or sham proposal;
attached
3. Neither the said Proposer nor any of its officers, partners, owners, agents, representatives,
employees, or parties in interest, including this affiant, has in any way colluded, connived, or
agreed, directly or indirectly, with any other Bidder, firm or person to submit a collusive or
sham Proposal in connection with such Contract, or has inany manner, directly or indirectly,
sought by agreement or collusion or communication or conference with any other Bidder,
firm, or person to fix the price or prices in the attached proposal or any other Bidder, or to fix
any overhead, profit or cost element of the proposal price or the proposal price of any other
Bidder, or to secure through any collusion, connivance, or unlawful agreement any advantage
against the City of Atlantic Beach, Florida or any person interested in the proposed Contract;
and
4. The price or prices quoted in the attached proposal are fair and proper and are not tainted by
any collusion, conspiracy, connivance, or unlawful agreement on the part of the Bidder or
any of its agents, representatives, owners, employees, or parties in interest, including this
affiant.
A3/( 5
Date
STATE OF FLORIDA
COUNTY OF D u.VAz-
PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first being
sw231 by me, affixed his/her signature at the space provided above on this j S44'day of
I rc -. , 2019, and is personally known to me, or has provided as
identification.
Notary Signature
01098179-1
My Commission expires:
CARtAJ.DIXON
Commission # GG 1967.39
Expires Apri18,2022
o n?.» Bonded TM' Troy Fain tnsulaace 800.985-7019
Form W-9
Rev. October 2018)
Department of the Treasury
Internal Revenue Service
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Jeb T. Branham, P.A.
2 Business name/disregarded entity name, if different from above
Request for Taxpayer
Identification Number and Certification
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
Individual/sole proprietor or
single -member LLC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not checkLLCiftheLLCisclassifiedasasingle -member LLC that is disregarded from the owner unless the owner of the LLC isanotherLLCthatisnotdisregardedfromtheownerforU.S. federal tax purposes. Otherwise, a single -member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions)
C Corporation S Corporation Partnership Trust/estate
5 Address (number, street, and apt. or suite no.) See instructions.
419 Third Street North •
6 City, state, and ZIP code
Jacksonville Beach, Florida 32250
7 List account number(s) here (optional)
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
Applies 10 accounts maintained outside the U.S.)
Requesters name and address (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for aresidentalien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
or
Employer identification number
2 0 3 3 1 6 7 1 5
Part 1I Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal RevenueService (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding becauseyouhavefailedtoreportallinterestanddividendsonyourtaxreturn. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part Il, later.
Sign
Here
Signature of
U.S. person /0-
General Instructio s
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its Instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who Is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
EIN), to report on an Information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
Form 1099 -INT (interest earned or paid)
Date i3A 5
Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
Form 1099-S (proceeds from real estate transactions)
Form 1099-K (merchant card and third party network transactions)
Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
Form 1099-C (canceled debt)
Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only If you are a U.S. person (Including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form W-9 (Rev. 10-2018)
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD ATLANTIC BEACH, FLORIDA 32233-5445
TELEPHONE (904) 247-5880 FAX: (904) 247-5819
WWW.COAB.US
NEW VENDOR INFORMATION REQUEST FORM
Please complete and return with all other bid documents
ki b 7, bran barn 11 P. -A-
Vendor Name (as it should appear on Purchase Orders and Check Payments)
Ala 3d S*(e6- No'%vh) Jarksonviug TQC, 1L 3 3a50
Remit to Address
Physical Address (if different from remittance)
Company Phone: ci 04 ` asq - M00 Company Fax: q 04 -(sq _05 01
Company Website:
Point of Contact Information:
Name:
Email Address:
Phone:
Fax:
Q_bIcy an hcUm . Com
r brcu,harn
e,b jebbon ham . corn
Q0LI,-.33G-0500
CIo -MG-0 5o 1
Should Purchase Orders be faxed or emailed? Provide correct information for either choice.
01098179-1
equldeb@i mham .cern
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
PROPOSER ACKNOWLEDGEMENTS AND AGREEMENTS
The undersigned, as an employee or agent of the Proposer, having the authority to sign a binding
agreement on behalf of the corporation, company, or firm presenting this submittal, confirms
understanding and/or agreement and/or takes exception with any statement in the following
sections of this RFP document.
1. GENERAL TERMS AND CONDITIONS
Understands and agrees to all terms.
2. SCOPE OF SERVICES, MINIMUM REQUIREMENTS AND QUALIFICATIONS
Understands and agrees to all terms.
PROPOSAL FORMAT
Understands and agrees to all terms.
Name: Title:111,0
3\ G 1 / V
Bid/RFP Title: \ `1. —b Bid/RFP No.: t `1 -o a'
Signature: Date:
01098179-1
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
CONFLICT OF INTEREST STATEMENT
Q
This sworn statement is submitted with Bid, Proposal or Contract forj2,2)—T., 6 t N afn
This sworn tateinent is submitted by (e city) f)(Ir1l. whose business address is
3ca . JadahV 111.e }} a icable) Federal- Employer Identification
Number (FEIN) is *J ,3316-1 1.5 (If a 1 o tor and you have no FEIN, include the last
four (4) digits of your Social Security Number: ).
My name is ane i t'etail s ii to the entity named above is
1. The above naweed entity is submitting a B'd/Prgposal fo the .City of Atlantic Beach Bid/RFP No.
titled l:U( (pnro rnpnt <y' Q • f O 0-cafe
2. The Affiant has made diligent inquiry and provides the information contained in the Affidavit based
upon his/her own knowledge.
3. The Affiant states that only one submittal for the above proposal is being submitted and that the above
named entity has no financial interest in other entities submitting proposals for the same project.
4. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement,
participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in
connection with the entity's submittal for the above proposal. This statement restricts the discussion of
pricing data until the completion of negotiations if necessary and execution of the Contract for this
project.
5. Neither the entity not its affiliates, nor anyone associated with thein, is presently suspended or
otherwise ineligible from participation in contract letting by any local, State, or Federal Agency.
6. Neither the entity nor its affiliates, nor anyone associated with thein have any potential conflict of
interest due to any other clients, contracts, or property interests for this project.
7. I certify that no member of the entity's ownership or management is presently applying for an
employee position or actively seeking an elected position with the City of Atlantic Beach.
8. I certify that no member of the entity's ownership or management, or staff has a vested interest in any
aspect of the City of Atlantic Beach.
9. In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above
named entity, will immediately notify the City of Atlantic Bea
STATE OF FLO DA
COUNTY OF Gt,VAi__.
3A3/
ature Date
PERSONALLY APPEARED BEFORE ME, the undersigned autho ty, who, after first being sworn b
me, affixed his/her signature at the space provided above on this' Viliay of rAti,TC/`\ , 20 / 1
and is personally known to me, or has provided as identification.
Notary Signature: Oki
01098179-1
My Commission expires:
CARLA J. DIXON
R; ..
Commission # GO 198739
Expires , ,. resApril 8,2022
rEo i;;4P° Bonded Poo Troy Fah Insurance 960.335-T016
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
DISPUTES DISCLOSURE FORM
Answer the following questions by placing as "X" after "YES" or "NO". If you answer
YES", please explain in the space provided, or via attachment.
Has your firm or any of its officers, received a reprimand of any nature or been suspended by the
The Florida Bar or any other regulatory agency or professional association within the last five (5)
years?
YES NO
Has your firm, or any member of your firm, been declared in default, terminated or removed
from a contract or job related to the services your firm provides in the regular course of business
within the last five (5) years?
YES NO
Has your firm had filed against it or filed any request for equitable adjustment, contract claims,
bid protest, or litigation in the past five (5) years that is related to the services your firm provides
in the regular course of business?
YES NO
If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or
protest, and state a brief description of the case, the outcome or status of the suit and the
monetary amounts or extended contract time involved.
I hereby certify that all statements made are true and agree and understand that any misstatement
or misrepresentation or falsification of facts shall be cause for forfeiture of rights for further
consideration of this proposal for the City of Atlantic Beach.
J PsraAharn , 31131,j-oq
Firm Date
JPS EaF-,hain
Au prized Signature Printed or Typed Name and Title
CODQ. En POCUM0147 c
Bid/RFP Title ( l a -e Bid/RFP Number
01098179-1
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
PUBLIC RECORDS PROVISIONS
FOR ALL CONTRACTS AND AMENDMENTS Effective as of
July 1, 2016 per Chapter 2016-20, Laws of Florida
This is to confirm that we have been informed of, and will abide by, the Public Records Provisions
regarding s. 119.0701 F
Signed:
Print:j0,12D__BCriMain
Company: L )Q. e O haul), PA. Phone: 4-3&61 — o'V 0
Email: VQ Liat38 i nhQM • UJM Date: ,g1131 1 q
Public Records Provisions, Page 2
01098179.1 .
RFP 19-02
City of Atlantic Beach
Code Enforcement Special Magistrate
PUBLIC RECORDS PROVISIONS
FOR ALL CONTRACTS AND AMENDMENTS Effective as of
July 1, 2016 per Chapter 2016-20, Laws of Florida
Section 119.0701. Public Records
a) IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION
OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY
TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT,
CONTACT DONNA BARTLE, THE CITY CLERK AND THE CUSTODIAN OF
PUBLIC RECORDS AT (904) 247-5809, dbartle(i)coab.us., 800 SEMINOLE
ROAD, ATLANTIC BEACH, FLORIDA 32233.
b) The contractor shall comply with Chapter 119, Florida Statutes, in regards to public records laws,
specifically to:
1. Keep and maintain public records required by the public agency to perform the service.
2. Upon request from the public agency's custodian of public records, provide the public agency
with a copy of the requested records or allow the records to be inspected or copied within a
reasonable time at a cost that does not exceed the cost provided in this chapter or as otherwise
provided by law.
3. Ensure that public records that are exempt or confidential and exempt from public records
disclosure requirements are not disclosed except as authorized by law for the duration of the
contract term and following completion of the contract if the contractor does not transfer the
records to the public agency.
4. Upon completion of the contract, transfer, at no cost, to the public agency all public
records in possession of the contractor or keep and maintain public records required by the
public agency to perform the service. If the contractor transfers all public records to the public
agency upon completion of the contract, the contractor shall destroy any duplicate public
records that are exempt or confidential and exempt for public records disclosure requirements.
If the contractor keeps and maintains public records upon completion of the contract, the
contractor shall meet all applicable requirements for retaining public records. All records
stored electronically must be provided to the public agency, upon request from the public
agency's custodian of public records, in a format that is compatible with the information
technology systems of the public agency.
c) Failure to provide the public records to the public agency within a reasonable time may subject
the contractor to penalties under s. 119.10 and s. 119.0701(4), Florida Statutes.
Public Records Provisions, Page 1
01098179-1
ACORE CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
03/13/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
Agency Marketing Services, Inc.
9800 4th Street N, Suite 400
CONTACT Bill HanawayNAME: y
A/CNN Ext): 727-384-1036 (A/c, No 727-343-4123
E-MAIL
ADDRESS: bhanaway@agencymarketing.com
St. Petersburg FL 33702
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA: Berkley Insurance Company 32603
INSURED
Jeb T. Branham, P.A.
419 3rd Street North
Jacksonville Beach FL 32250
INSURER B :
INSURER C :
EACH OCCURRENCE
INSURER D :
DAMAGE TO RENTED
PREMISES (Ea occurrence)
INSURER E :
INSURER F :
CLAIMS -MADE
GUVCKAUCJ a.n 1 rrrve+n L. ,...”n..• -n.. - -- -
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE INSO sWVD POLICY NUMBER
POLICY(EFF
O/
YEFF
POLICY EXPPOLICY EXP
LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence) CLAIMS -MADE OCCUR
MED EXP (Any one person)
PERSONAL &ADV INJURY
GENERAL AGGREGATE
GEN'LAGGREGATE
POLICY
OTHER:
LIMIT APPLIES
PRO - JECT
PER:
LOC PRODUCTS - COMP/OP AGG
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
SCHEDULED
AUTOS
NON -OWNED
AUTOS
COMBINED SINGLE LIMIT
Ea accident)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
Per accident)
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
AGGREGATE
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITYYIN
ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.
OFFICER/MEMBER EXCLUDED?
Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N N / A
PER
STATUTE
OTH-
ER
EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
A
Lawyers Professional Liability PLP -1354927-P5 11/05/2018 11/05/2019
250,000 Each Claim
500,000 Aggregate
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
Deductible: $2,500 each claim
Retroactive Date: 11/05/2012
CERTIFICATE HOLDER CANCELLATION
Jeb T. Branham, P.A.
419 3rd Street North
Jacksonville Beach FL 32250
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORDACORD25 (2014/01)
V '111
JEB T. BRANHAM, P.A.
419 3RD STREET NORTH
JACKSONVILLE BEACH, FLORIDA 32250
PHONE: 904.339.0500
FACSIMILE: 904.339.05 01
JEB@JEBBRANHAM. COM
WWW JEBBRANHAM. COM
JEB T. BRAN HAM
Attorney at Law