11-100-SOL-00007_Attachments.PDF

Attachment 1 l7- r 00-sol.-00007

ATTACT{MENT il 2

SMALL BUSINESS SUBCONTRAC'TING PLAN

OFFI(3E OF SMALI- AND DISADVANTFTGED BUSINESS UTILIZATION

SMALL BUSINESS SUBCONTTTACTING PLAN

The fol6wing outline meets the mtnimum requirements ctf section 8(d) of the Small ,Eusrness

Act, as amencled, anc! impler,nented by the Federal l\cquisition Regulations (FAR,) Subpari 19.7.

The tJ.S. Dep,a rtment of Health and Human Sieruices; (HHS), Office of Small and Ltisad'v'antaged

Busines s tJtiti;zation (OlSDBt-)) recommend Oirferors use the following format to submit proposed tndividual Suliccontracting Plans, inctuding modifications, /f is not intended tct replace any existing Corpctrate/Commerc,ial Plan that is tnore e>xtensivt>. A subcontracting Plan is required if the estimated cosf of the contract may exceed $70'0,000 ($1,500,000 for construction) Small busrnesses are exclucled Ques tions should be forw,arded to the Contracting Officer or

Operating Division (CPDIV) {}mall Busrness {ipeclali'sf.

HHS Operating Division (OPDIV):

SOLICITATIC)N OR CONTRACT NUMBER:

DATE OF PLAN:

CONTRACTOR:

ADDRESS:

STATE/ZIP CODE

DUNN & BRADSTREET NUMBER:

ITEM/SERVICE (Desc ription):

NEW 'INITIAL CONTRACT

pERtoD oF CONTRACT PETRFORMANCE (n/lM/DD/YYY\', - MM/DD/YYYY):

Base (if options apply) $ .Perform ance Period/QuantitY

Option 1 :

Option 2:

Option 3:

Option 4:

$ Perform a nce Period/QuantitY

PerJo rrn ance Period/Q uantitY

Perforrn ance Period/QuantitY

Perfo rrn ance Period/Q u antitY

Total Contract Cost

C (if applicable)

NEW PERIOD OF CONTRACT PERFORMANCE (MM/DD/YYYY

MM/DD/YYYY):

Orig inal/Base

Modification

Task Order

Perfrcrmance Period/QuantitY

-Perfrcrmance Period/QuantitY

-Pr:rfrcfffi ance Period/Quantity

---Modified l-otal Contract Cost

Failure to include the essenflalinformation ot'FAR'subpart 19.7 may be cause for eithe>r a delay in acceptance or the rejection of a bid or ofter when a subcontracting plan is required'

"SUBCOIVIR,A CT," as used in this claLtse, ffieon;s eny agreement (other than one invalving an employer-emtrtloyee relation:;hip) entered into b1r 61 Fed,eral Government prime contractor or subcontractor requesting supp/ies or services required for performance of the cctntract or subcontract.

lf assistancel is needed trc locate small business sources, contact the Small Business

Specialist (SBS) supporting the OPDIV SBS contact information is located on ther OSDBU website (h'!!pr://www.lrf s.oov/aboutismallbus;iness/osdbus;telff . html) or you may contact the

OSDBU headquarters at (202) 690-7300

HHS current subcontracting goal is 33.0% for Simall Business (hereafter referred to as SB), S.0O% for Small Disadvantaged Business, including B(a) Program Participants, Alaska Native

Corporations (ANC) and lndiln Tribes (hereafter referred to as SDB), 5.00% for Women-Owned

Small Busine,ss and Ejconomically Disadvantaged Women-Owned Small Business (hereafter referred to as WOSB) 3.00% HubZone bursiness (hereafter referred to as HUBZonr=),3'00%

Veteran Owned Small Business (hereafter referred to as; VOSB) and 3.00% Service Disabled

Veteran-Owned Small Business (hereafter referred to as; SDVOSB) concerns for Fiscal Year

(Fy) 2016. F:orthis procurement, HHS expects all proposed subcontracting plans to contain at a minimum thre aforenrentiorred percentages These percentages shall be expressed as percentages of the total estimated subcontracting dollars.

1. Type of Plan (check one)

Individual plan (all elemenlls developecl specifically for this contract and applicable for the full term of this contract).

Master plan (goals developed for this contract) all other elements standardized anO approved b), a lead agency Federal Official; must be renewed every three years and contractor must provide copy of lead agency etpproval.

Commercial products/service plan (goals are negotiated with the initial agency on a company-wide basis rather than for inrlividual contracts) this plan appliels to the entire production of commercial service or iterns or a portion thereof. The contractor sells commercial proclucts iand services cus;tomarily uSe,C for non-government purpo$es' The plan is; effective during the Offeror's fis<;al year (attach a copy) . The Summary Subcontracting Report (SSR) must include a breakout of subcontracting prorated for HH'S and other Federal agencies.

2. Goals

Below indicate the dollsr ancl percentage gorals for {3mall Business (SB), Small Disadrrantaged

(SDB) including Alaska l.lative Corporations and Indian Tribes, Women-owned and

Economically Diiadvantaged Women-Owned (WOSB), Hit;torically Underutilized Business Zone

(HUBZone),'Veteran Owned Small Business (VOSB), Service-Disabled Veteran-Owned iSOVOSS) Srnall Businesses and "Other than Srnall Elusiness" (Other) as sulccontractors.

lndicate the base year and each option yeiar, as specifred in FAR 19704 or projer:t annual subcontracting basl anrd goals under commercial plans. lf any contract has more four options, please attach- additional sheets which illustrate dollar amounts and percentages. PLEASE 'NOTEt

Z"ro.lotlars is not an acceptable qoal for the SB, SDB. W9SB, HUBZone.'VOSB or

SDVOSB cateq*iur $j4gq this does not demonjstrate a qood faith effort throughout the period of perforrnance of ttre contract. Formula for below: 2.b. + 2.h. = 2.a.

a. Total estimaterJ dollar value of ALL planned subcontracting, i.e., with ALL t'ypes of concerns under this contract is (Base Period - if oPtions aPPIY)

FY __1't Option

FY

-|nd

Option FY --3'd

OPtion FY _4''' Option

b. Total ,estimated dollar value and percent of planned subcontracting with SMALL

BUSINESSES (iinclucling SDB, WOSU, HLlBZone, VOSB and SDVOSB) . ri,9/o of "a")

FY __1" Option FY _zno Option FY __3'o Option FY 4'n Option

Total r:stimated dollar value and percent of planned subcontracting with SMALL andDf SADVANTAGED BUSINESSES: ti,o/o of "a") $

96 (Base Period - if oPtions aPPIY)

FY

-_znd

Option FY --3'o

OPtion c.

FY __1'' Option FY 4'n Option

d. Total estimated <lollar value and percent of planned subcontracting with WOMEN-OWNED SMALL BUSINESSES: (7o of "et") $

% (Base Period - if oplions aPPIY)

FY _-3'o Option Y 4'n OptionFY _.1't Option FY _znd Option dollar and percent of planned and and

HUBZone SIVIALL

- if options apprly)

F

e. Total estimated

BUSI NESSES

i. Provicle a descniPtion contract, afld indicate the> subcontracting with

(o/o of "a") $ % (Base Period

FY _-1't Option FY -!nd

Option Y __3'o Option FY _4'n Option

F f Total erstimated dollar and percent of SMALL BUSINESSES (% of "a") $ Period - if options apPrlY) planned subcontracting with VETERAN-OWNED % ('Base

FY __1't Option FY

-2no Option FY

--3'o Option Y _4'n Oprtion

Total erstimated dollar and percent of ;clanned subcontracting with SERVICE-DIISABLED

VETERAN-OWNED SMALL BUSINESSES: (7o o1i "a") $ iand

FY __1't Option ozb (Base Period - if oplions apply)

FY

-!nd

Option FY --3'o

OPtion FY _4'n Option and of ALL the products and/or s,ervices to be size and type of business strpplying them subcontrar;ted under this (check all that iaPPlY)

F g

h. Total estimatecl dolliar and percent of prlanned subcontracting with "OTHE,R THAN

SMALL BUSINESSES" (As defined by the SrnallBus/ness Administration as "any,entity that is not c/assified a,s a small business. Thi:; includes large bustnesses, s,fafe and local governm€rnfs, non-profit organtzations, Stublic:: utilities, educational institution's and foreign-owned firrns.) (oh of "a") $ and oli (Base Period

- if options; apply)

FY __1" option FY -2no

Option FY __3'o Option Y 4'n OptionF

Products and/or Services Other Small

Business SDB WOSB Hubz VOSB SDVOSB

j. Provide a description of the method ursed t,r develop the subcontracting goals for SB, SDB, \/VOSB, HUBZone and SDVOSEI concerns. l\ddress efforts made to ensure that maximum practicable subcontracting opporlunities have been made available fc,n those concerns and explain the method used to identify protential sources for solicitaticln purpo$es. Explain thr: method and stiate tl're quantitative basis (in dollars) used to establish the percentage goals. Also, explain how the areas to be subcontnacted to SB, WOSE], HUBZone, VOSB and SDVO{]B concerns'were determined, how the capabilities of thes;e concerns were considered contract opportunities and how such data comports with the cost proposal. ldentify any soufco lists or other resources used in the determination procesrs. (Attach additircnal rsheets, if necessary.)

k. lndirect costs have subcontracting lEoals lf indirect costs have been included, ,DXplain the proportionate share of such costs to be allocated as HUB,Zone, VOSB arrd SDVOSB conr3erns.

have not ._ been included in the dollar and pelrcentage above (check one).

I method used subcontracts to to determ ine the

SB, SDE}, WOSB,

3. Program Administrator:

NAMEl:

TITLE::

ADDFIESS:

TELEF'HONE:

E.MAIt-:

Duties: Does the individual named above have general overall responsibility for the company's subcontracting program, i.e., developing, preparing, and executing subcontracting plans and monitoring perrformance relative to the requirements of those subcontracting plans and perform the following duties? (lf NO is checked, please vrho in thre company performs those duties, or indicate why the duties are not performed in your company on a separate sheet of paper and submit with th,e proposeld subcontracting plan.)

a. Developing anrJ promoting company-wide polir:y initiatives that denronstnate the company's support for awarding cclntracts and subcontracts to SB, SDB, WOSB, HUBZone, VOSB and SDVOSB corrcerns; and for assuring that these concerns are included on the source lists for solicitationsi for proclucts and services they are capable of providing; _ye$ _ no

b. Develc,ping and maintaining bidder source lists of SB, SDB, WOSB, HUBZone, VOSB and SDVOSB concerns from all possible srturces; __yes no

c. Ensurirrg periodic rotation of potential subcontractors on bidder's lists; _ yes _. no

d. Assurirrg that SEl, SD[3, WOSB, HUBZ]one, VOSB and SDVOSB businesses are included on the bidders' list for every subcontract s;olicitaticrn for products and serv'ices that they are capable of providing. _ yes _ flo

e. Ensurirrg that R.equests for Proposals (RFF's) are designed to permit the maximum practicable participation of SB, SDB, WOSI3, HUBZlone, VOSB and SDVOSB concerns.

_ yes no f . Reviewing subcontracl solicitations to remove staterments, clauses, etc., wftich might tend to restrict or prol'ribit small, 8(a), ISDB, WOSB, HUBZone, VOSB and SDVOSB small business participation yes no

g. Accessing various sources for the iderrtification of SB, SDB, WOSB, HUBZ,cne, VOSB and SDVOSB concerns to include the System forA,ward Management (ht!pr://sarn.gov ), local small business and minority associati,cns, local chambers of commerce and Federal agencies' Small Business Offices;_ yes ._ no

h. Establishing and maintaining contract and subcontt'act award records; _ yes -- no

Partici;pating irr Business Opportunity'Workshops, l/linority Business Enterprise Seminars, Trade Fairs, Procurement (lonferences, etc;

yes no

Ensuring that SB, SDB, WOSB, HUBllone, VOSB iand SDVOSB concerns are made aware of subcorrtracting opportunities and assisting concerns in preparing responsive bids to, the company; yes no

k. Condur:ting or arranging for the conduct of training 1[or purchasing personnel regarding the internt and inrpact of Section B(d) of the Small Brusiness Act, as amende,C; _- yes no

m. Preparing and submitting timely, required subcontract reports;

and making any

_yes -_ no

_yes _no

n. Condu,cting or arranging training for purchasing personnel regarding the intent and impact of 8(d) of the S;mall Business A,ct on purchasing procedures; _ yes no

o. Coordinating ttre company's activities during the conduct of compliance revlews by Federal agencies, ancl yes no

p. Other duties:

4. Equitable Opportunity

Describe efforts the t3{feror will undertake to ens;ure that SB, SDB, WOSB, HUBZone, VOSB and SDVOSB concerns will lrave an equitable opportunity to compete for subcontracts. These efforts include, but are not lintited to, the follo'wing activities:

a. Outreach efforts to obtain sources:

1. Contact minority and small business trade associations; 2) contact business development organizations; and local chambers of commerce; 3) attend SB, SDB, WO{}B, HUBZone, V'OSB and SDVOSB procurement conferences and trade fairs: 4) review sources from the Siystem for Award Management (h'gg,//www.sam.qov); 5) revievv sources from the Small Business Administration (SBA), Dynamic Small Business Search database (DSBS) http://dsbs.sba.qov/); 6) Consid,er using other sources such as thre National Institutes of Health (NlH) e-Porlals in Commerce, (e-PlC), (hr[!p:i/epic;.od.nih.qov/). Thre Nlll e-PlC is not a mandatory source; however, it may be used at the Offeror's <liscretion; and 7) Utilize newspaper and magazine ads to encourage ne\/v sources.

b. Internerl efforts to guiCe and encourage purchasing personnel.

1. Conduct workshops, seminars and training programs;

2. Establish, maintain, and utilizer SB, SDB, WOSB, HUBZone, VOSB and SDVOSB source lists, guides, and other data for soliciting subcontractors; and

L Monitoring the company's subcontracting program performance adjustrnents nec;essary to achieve the subc;ontract plan goals;

3. Monitor erctiviti'es to evaluate c<lmpliance with the subcontracting plan.

Additional efforts;:

5. Flow Down Clause

The contractor agrees to irrclude the provisions; under FAR 52.219-8, "lUtilization ,cf Small Business Concerns," in all acquisitions exceeding the sim;clified acquisition threshold that offers further subcontracting opportunities. All subr:ontr;actors, except small business concerns, tlrat receive subcontracts in excess of $700,000 ($1,500,0C10 for construction) must adopt and comply with a plan similar to the plan required by FAR 52.21 9-9, "Sn'lall Businerss

Subcontracting Plan." Note. In accordance with FA,R 52.212-5(e) and 52.244-6(c) the contractor is not required to include flow-drcwn clause FAR 52.219.-9 if it is subcontracting commercial itelms.

6. Reporting and Cooperation

The contractorgives assurance of 1)cooperation in any studies orsurveys that may be required; 2) submission of periodic reports which illustrate compliance with tl're subcontracting plan; 3) submrssion of its Individual SubcontriactinS; Report (lSR) and Summary Subcontract Report (SSR); and 4) srubcontractors submission of lSRs ernd SSRs. lSRs and SSRs shall be submitted viil the Electronic Subcontracting Reporting System (eSRS) website

Reporting Period Report Due Due Date

Oct '1 - Mar 31 ISR 4t30

Aprl-Sept30 ISR 10/30

Ctctl-Sept30 SSRI 10/30

Contract Completion Year End SDE} Report

30 days after completion https ://esrs.svm pl icitv.corn/i n dex? tab=siry i n &cck= 1

Please refer l.o FAR Part 19.7 for instruction concerning the submission of a Commercial Plan:

SSR is due orn 10/30 each year for the previous fiscal year ending 9/30.

a. Submit ISR (bi-annually) for the awarding Contracting Officer's review and acoeptance via thel eSRS website.

b Currently. S{iR (arrnually) must be subrnitted for the HHS eSRS Agency Coordinator review and acceptance via the eSRS website. (Nofe. Log onto the OSDBU website to view the HHS A,genc;y Cr:ordinator contact information (http://www. lr hs. g ov/q ra nts/small-businr:ss-proq rams/index. htm l\

Note: The Rlequesf for Proposal (RFP) will indicate whether a subcontracting plan is required. Due to the nature and complexity of many HHS contracts, particularly the Centers for hledicare and Medicaid (CMS), the contractor may not be required to submit ifs subcontrercting reports through the eSRS. The Contracting Officer will confirm reporTing requirements pri<>r to the rssuanc e of an award. For more information, contact Agency Coordinator-eSRS on 202-690-7300.

7. Record keeping

FAR 19 704(a) (1 1) requires a list of the types of records your company will maintain to demonstrate the procedures adopted to c;omply with the requirements and goals in the subcontracting; plan. The following is a rec;itation of ther types of records the contractor truill maintain to delmonstrate the procedures adopted to comp,ly with the requirements and goals in the subcontrar:ting plan, These records will include, but nclt be limited to, the following.

c, SB, SDB, WOSB, HUBZone, VOSB and SDVOSB source lists, guides and other dal.a identifying such vendors;

d. Orrganizations contacted in an attempt to locate SB, SDB, WOSB, HUBZone VOSB anrj SDVOSB sources;

e. On a contract-by-r:ontract basis, records on all subcontract solicitations over

$1r10,000, which irndicate for each solicitation (1)whether SB, SDB, WOSB, HLlBZone, VOSB and/or SDVOSE] concerns were solicited, if not, why not and the reasons solicited (loncerns did not receive subc;ontract awards;

Rec;ords to support other outreach efforls, e.g., r:ontacts with minority and small business tracJe ass;ociations, attenclancel at small and minority business procurement conferences and trade fairs;

Rer;ords to support internal guidance and encoLlragement provided to buyers through (1) worksl'rops, seminars, training programs, incentive awards; and (2) monitoring perforn'lance to evaluate cornpliance with the program and requirements;

ancl

On a contract-by-c;ontract basis, rocord:s to suplrort subcontract award data including the name, acjdress;, and business type and size of each subcontractor. (This is not required on a contract-by-contract basis for connmercial plans.)

O1-rer records to support your compliance with the subcontracting plan: (Please des;cribe)

8. Timely Pa'yments to Sub,contractors

FAR 19.702 rr:quires your company to establish and use procedures to ensure the timely payment of arnounts due pursuant to the terms of your subcontracts with SB concerns, ]SDB, WOSB, HUBZlone, VOSB and SDVOSB concerns.

Your compan\1 has established and used such procedures:

yes no

9. Description of Good Faith Effort

Maximum practicable utilization of SB, SDB, \I/VOSB, HUB,Zone, VOSB and SDVOSB concerns as subcontrac;tors in Governrnent contracts is; a matter of national interest with both social and economic berrefits. When a contractor fails to make a good faith effort to comply with a subcontracting plan, these objectives are not achieved, and 15 U.S.C. 637(d) (4) (F) directs that liquidated damages shall be paid by the contractor. ln order to demonstrate your compliarrce with a good faith efforl to achieve the SB, SDB, WOSB, HUBZone, VOSB and bOVOSg small business subcontracting goalls, outline the steps your company plans to take.

These steps lvill be negotiateld with the contriacting official prior to approval of the plan.

f g h

SIGNATURE F'AGE

Signatures Required:

This subcontracting

Signature:

Typed/Print Name:

Title:

Date:

Signature:

Typed/Print Niame

Title:

plan was submitted by:

This plan wa$ reviewed bY:

Contracting Officer Date:

This plan was reviewed bY:

Signature:

Typed/Print Name:

Title HHS Small Business SPecialist Date.

This plan was reviewed bY:

Signature:

Typed/Print Name:

Title:

Date.

Signature:

Typed/Print Nlame:

Title:

This plan was approved bY:

Small Business Administration Procurement Center Representative

Contrircting Officer Date:

ATTACHMENT #3

CONTRACTOR,S POINTS OF CONTACT

complete the following and return with the BUslNEss PROPOSAL

Name, Title and Address* of Business Representative with whom daily contact is required

Name, lnstitutional Title and Arldress of Proposed Principal

These exact addresses are necessary to ensure that contact can be made with the proper individual(s) in the most exPeditious manner.

*Please use actual street addrelss, not P'O' Box'

Telephone:

Organization:

*street Address:

City, lState,ZiP Code:

Telephone:

Organization:

*Street Address:

City, Stat e, ZiP Code:

Please complete the following questionnaire and return via e-mail to the attention of:

Name(s): Dorothv McMillan, Contracting Officer Dorothv.McMlillan@hhs.gov bv June 30, 2017.

This survey pertains to:

De pa rtm e nt/Co m po ne nt :

Contract Number:

Date of Survey:

--_Name of Person Completing SurveY:

Signature of Person Comprleting Survey:

Your Company/'Agency:

Your Role in this Contract (circle' one):

CO Contract Specialist Project Crff icer Other

Contract Value (including optiorts)'. $

Performance Preriod:

(including optictn pe riods)

Type of Contract:

Approximate percentage of work being performerd lnformation on subcontractor(s) (where more thon

(vENDOR NAME)

(or com pletr:d ) by su bcontractor(s) of work was completed by the :subcontractor):

Subcontractor Program Managr:r Phone

Subcontractor Progra m [t/lanager Phone rrunffi Page 1Attachment 4 - 1,7'100-SOL-C|0007

I tl

J.

4.

Past Perform ance Questionnatire

General description of productsT'services required under the conrtract:

RATINGS

please answer each of the follovving questions with a rating that is based on objective measurable performance inclicators to the maximum extent pos;sible Commentary to support rating may be noted al:

the end of the questionnaire under'additional comments'.

Assign each area a rating of 0 (LJnsatisfactory), 1 (Poor), 2(Fai),3 (Good),4 (Excellent) or 5 (Outitanding). LJse the attached Rating Guidelines as guidance in making these evaluations. Circle the appropriate iating. lf you do not have enough personal knowledge or feedback from internal customers who direcly received products and services from the contractor lo make a determination orl any of the performance criteria belrcw, please circle "N/A" (not applicable /no opinion).

QUALITY OF SERVICE

Compliance rruith contract req u irements 123 4 5 N/A

Accuracy of reports 123 4 5 N/A

Effectiveness; of Personnel 123 4 5 N/A

Technical excellence 12345N/A

COST CONTRICL

'1, Record of forecasting and controlling target cos;ts

012 3 4 5 N/A

2, Current, accurate anrJ c;omplete billings 012 3 4 5 N/A

3 Relationship of negotiated costs to actuals 012 3 4 5 N/A

4 Cost efficiencies 012 3 4 5 N/A

TIMELINESS OF PERFORMANCE

1 Met rnterim rnilestones 012 3 4 5 N/A, 2 Reliability 012 3 4 5 N/4, 3, Responsive to technicill direction 012 3 4 5 N/4, 4 Completed on time including wrap-up and contract administrtltion

012 3 4 5 N/A rnffi

Attachment 4 - 1,7-100'SOL-00007 Page 2

Past Perform ance Question netire

5. Met delivery s;chedules 012 3 4 5 N/A

6. Liquidated damages assessecl: Yes No (circle one)

BUSINESS REI-ATIONS

1 Effective management, including subcontracts 012345N/A

2. Reasonable/r;ooperative behavior 012 3 4 5 N/A

3. Responsive to contra,ct requirraments 012 3 4 5 N/A

4. Notification of problems;

012345N/A

5. Flexibility 012 3 4 5 N/A

6. Pro-active vs reactive 012 3 4 5 N/A

7 Effective small/small di:sadvantaged business subcontracting program

012 3 4 5 N/A

CUSTOMER SATISFACTION

1 The contractor is comnritted to customer satisfetction

Yes No (circle one)

2. Would you recommencl selection of this firm again?

Yes No (circle one)

ADDITIONAL (3OMMEN-TS

Attachment 4 - 17'1C10''SOL-00007 Palge 3

Past Perform ance Questionnetire

Past Performance Ratinq Guidelines

Time'liness of Performance Contractor delays are jeoparrdizing performance of contract objectives

Contractor is unable to manage costs effectively

Contractor is hilving major difficulty in managtng costts effectively

Contractor is hiaving some problems; in managing costs effectively

0 - Unsatisfactorv

Contractor is having major difficulty meeting miles;tones and delivery scheCules

1 - Poor

Contractor is usuallY effective in meeting miles;tones and delivery schedules

Contractor is effective in managing costs and submits current, accurate and complete billintSs

4 - Excellent

Quality of Procluct or Selrvice Contractor is not in complrance and is jeopardizing achievement of contr;act objectiries

Major problerns have been encountered

Some problerns; have been encountered

M rnor i neff i ci e n cies/erro rs have been identified

Cost Control

Contractor is usually effective in managing costs

Contractor is having some problems meeting m iles;tones and delivery schedules

Contractor is effective in meeting milestones and delivery schedules

Response to inquiries, tech n ica l/service/ad m i n istr ative issues is effective

Contractor is in compliance witlr contract requirements and/or delivers quality orod ucts/services

5@rac|OrhaEdEmonstratedanoutstandingperformiance level in any of the above four catelgories that justifies adding a point to the score. lt is expected that this rarting will be used in performance clearly exceelds the prerformance levels described as "Excellent".

those rare circumstances when contractor re

Attachment 4 - 17 -1C)0-SOL-00007 Page 4

ATTACHMENT #5

PROPOSAL IN'TENT RESPONSE FORM

RFP NO:

RFP TitIC:

please review tlre Request for Proposal (RFP) Furnish the infortnation requested below and return this page to the Corrtracting Officer/Contract Specialist identified on liection A-solicitation/Contract Forrnr by June fi,,2U'7 your expression of interrt is not binding but will greratly assist us in planning for proposal evaluation

Choose one of the following Options:

Do intend to submit a proposal

_ Do Not intend to subnrit a proposal lf you are not responding, to this RFP, please provtde your reason(s):

Please provide the following contact information:

Name (First, Mtddle lnitial, Last):

Title:

Organizatton:

E-mail:

DISCLOSURE

Complete this fornt to disclose

OF LOBBYING ACTIVITIES

lobbying actir,'ities pursuant to 31 U.S'C' 1352

Apprc,ved by OMt)

0348-0046

2. Status of Federal Action:

I la. bid/offer/application L-- rb. initial award

c. Post-awarrl ype of Federal Action:

I a. contract --l b. grant

c. cooPerative agreement

d. loan

e. loan guarantee

f. loan insurance

5. ff Repo.ting Entity in No.4 is a subawardee, Enter Name and Address of'Prime:

ressionaf District, if known'.

+. ttame and Address of lleporting Entity:

flerime ! subawardee

Tier---, if known'.

ressionaf District , if known' 4c

7. Federal Program Name/Description:

OFDA Number, if aPPlicable'.

6. Federal DePartmenUAgency:

9. Award Amounrt, if known:

& Federal Action Number, if known:

a. l.tame atld Address; of Lobby'ing Registrant b. lndividuals Perrforming Services different from No. 10a) (/asf name, fir:;t name, Ml)'.

(including address if

(if individual, last name, first niame, Ml)"

Signature:

Print Name:

Telephone No.:

lrA lnformation requested through this I'orm is authorized by title 31 U'S C' section I l' rssz This disclosure of lobbying

'ctivities is a material representation of fact upon which reliance was placed by the tier above when this transactton was maoe oi entered into This disclosure is required pursuant to 31 U.S C 1352 This information will be available for pub,lic inspection. Arry person who fails to file the requireddisc|osuresha|lbesubjecttoacivi|pena|tyofnotlessthan$10,000and not more than $100,000 for each sur:h failure

Authorized for Local fleprod uction

Standard Form LLL (Rev. 7-97)Federal Use OnlY:

{iee reverse for public burden disclosule' Report Type:

[ '_-l

a. initial filing L-----r b. material change

For Material Ghange OnlY:

year quarter date of last rePort _

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INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be compteted by the reporting entity, whether subawardeeor prime Federal recipient, at the initiation or receipl of a covered Federal action, or a materialchange to a prevrous fiting, pursuani to title 31 u.s.c. section 1352. The filing of a fom is required for each payment or agreementto make paymentto any lobbying;ntity for influencing or attempting to influence an officer or employeeof any agency, a Member of Congress, an officer or employeeof bongr"r", or "n "rptoyeeof a Memberof Congress in connectionwith a covered Federalaction. Completeall items that applyfor both the initialfiling and materiill change report. Refertothe implementing guidance published by the Office ofManagementand Budget for additional infomation

,1.ldentifythetypeofcoveredFederalactionforwhichlobbyingactivityisand/orhasbeensecuredtoinfluencetheoutcomeofacoveredFederalactior' ldentify the status ofthe covered Federal action ldentify the appropriateclassification of this repor{. lf this is a followup report caused by a materialchange to the information previously rcported' enter the ye;rand quarter in which the change occurred. Enter the date of the last previouslysubmitted report by this reporting entityfor this covered FedeEl aqtron-

Enter the fult name, address, city, Stateand zip code ofthe reporting entity. tnclude CongressionalDistrict, if known Checl the appropriateclassification ot tne reporting entity that desig;ates if it is, or expects to be, a prime or subaward recipient. ldentify the tier of the subawardee' e g , the flrst subawardee oftfre prime isine tit tier. Subawards include but are not limited to subcontracts, subgrants and contract awards undel grants ll the organization filing the report in item 4 checks "Subawardee," then enter the full name, address' city' State and zip code of the prime Federal recipient. Include Congressional District, if known

6. Enterthe nameofthe Federatagency making the award or loan commitment. Include at least one organizationallevelbelow agency name' if known For example, Department ofTransportation, United States Coast Guard

7. Enter the Fedgralprogram name or oescription for the covered Federal action (item 1). lf known, enter the full Catalog of FederelDomestic Assistance

(CFDA) numberforgrants, cooperative agreements, loans' and loan commitments

8. Enter the most appropriate Federal identifying number availablefor the Federalaction identified in item 1 (e.9.' Request for Proposal (RFP) number;

InvitationforBid(|FB)numberigranrannouncementnumber;thecontract'grant,or|oanawardnumberitheapplication/proposaIcontroInumtEr assigned by the Federal agency) lnclude prefixes' e g., "RFP-DE-90-001 "

9. For a covered Federalactaon where there has been an award or loan commitment by the Federalagency, enter the Federalamount of the award/loan commitmentfor the prime entity identified in item 4 or 5

.10. (a) Enterthe fullname, address, city, state and zip code ofthe lobbying regiskant under the Lobbying Disclosure Act of 1995 engaged by the reponing entity identified in item 4 to influence the covered Federal action'

(b) Enter the fu names ofthe individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name' and

Middle lnitial (Ml).

4.

5.

1 1. The certifying official shall sign and diate the form, print his/her name, title, and telephone number.

According to the paperwork Reduction Act, as amended, no persons are requiredto respond to a collectionof information unless it displays a valid oMB contr(

Number. The valid oMB control number for this information collection is oMB No. 0348-0046 Public reporting burden for.this -colleclion -11llT:1":i]

:,:iil""::;, H;;;01r,""L. o"i i"ro""se, inctuding time for reviewing instructions, searching existing data sources, gathering and maintaining the di needed,andcompletingandreviewingthecollectionofinformation.sendcommentsregardingtheburdenestimateoranyotherasp:g::,i::,::]:"-"::jl information, including suggestions for reducing this burden, to the office of Managementand Budget' Paperwork Reduction Projecl (0348-0046)' Washington'