19-LITCGrantResponseFormAttachmentB.docx

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF REVENUE

ATTACHMENT B

RESPONSE FORM

FOR

LOW INCOME TAXPAYER CLINICS

ISSUED: October 10, 2018

RESPONSES DUE: November 9, 2018

BID NUMBER: BD-19-1028-DR115-JB001-32032

SUBMITTED BY:_________________________________

SECTION 1: ORGANIZATION INFORMATION

Legal Name:_____________________________________ Any other name(s) under which the Organization/Entity does, or has done business: _____________________________________________________

Principal Address:______________________________________ Website Address:______________________________________

FEIN:____________________________

SECTION 2: CONTACT PERSON

Include the following information for the individual who should be contacted for purposes of discussing any aspect of this completed Response Form submitted by the Respondent.

Name:________________________________________________ Title:_________________________________________________ Address:______________________________________________ Phone Number:____________________ Email:____________________________

SECTION 3: PROGRAM REGION

List the regions that are/will be covered by your Entity:

SECTION 4: CERTIFICATIONS

Provide the information requested below and attach the required documents.

A. Cover Letter Attach a cover letter that:

a. Certifies that the information contained in the Respondent’s response to this Grant Application is true and complete.

b. Certifies that the Respondent has the capability and willingness to perform all responsibilities set forth in the Grant Application and of the Grant Agreement (Attachment A).

c. If applicable, certifies that the Respondent is an entity registered with the Department of Revenue and/or the Massachusetts Secretary of State.

d. Certifies that the Response submitted on COMMBUYS is identical to the Response submitted to DOR in hard copy and on flash drives.

e. States that Respondent accepts the terms of this Grant Application and of the Grant Agreement (Attachment A), without substantive change.

f. States that the Response will remain in effect until a Grant Agreement resulting from this Grant Application is executed.

g. Certifies that that Respondent is in stable financial condition and has not been in bankruptcy and/or receivership within the last three calendar years.

h. Certifies that the Respondent has complied with all applicable laws of the Commonwealth relating to taxes, wage reporting and the withholding and remitting of child support, and is in good standing with respect to all returns due and taxable payable. Note that DOR may verify the compliance of every Respondent with the tax, wage reporting and child support laws of another jurisdiction upon receipt of the Respondent’s Response.

i. Discloses any civil litigation, criminal investigation, indictment, prosecution or other proceeding that has been brought against Respondent in the last three years.

j. A statement indicating whether or not the Respondent or any of its employees has a possible conflict of interest in connection with the performance of services required under Grant Agreement resulting from this Grant Application and if so, the nature of that conflict. (Any questions about the applicability or operation of chapter 268A should be addressed to the State Ethics Commission at (617) 371-9500. The State Ethics Commission’s website is www.mass.gov/ethics.)

k. Is signed by an authorized signatory of the Respondent.

5. REQUIRED FORMS

Submit the Commonwealth-required forms below. All of the forms may be downloaded from the “File Attachments” section of this solicitation on the COMMBUYS website.

6. RESPONSES

Your response must demonstrate your ability to assume all requirements in Section 2 of Attachment A (Grant Agreement). If you are unable to provide the information required in a specific submission requirement, identify which information is not being submitted, and why.

7. ORGANIZATIONAL CAPACITY

Provide a brief overview of your organization/entity to include:

a. Formation date, goals and mission;

b. Experience in providing services to low income taxpayers and/or taxpayers with limited English proficiency;

c. Experience in assisting taxpayers in all aspects of the earned income credit under M.G.L. c. 62, section 6(h);

d. Use of measurable outcomes to evaluate quality; and

e. Qualifications of clinic staff and training provided to students or volunteers

8. PROPOSED PROGRAM

Provide a summary of the services and activities you are proposing to implement in accordance with Section 2.1 (Program Plan) of the Grant Agreement (Attachment A).

Program Plan Attach a Program Plan that lists, among other things, the locations that will be served, the services that will be provided with the Grant Funding, any milestones and completion dates.

The Program Plan must also: (i) include the titles and functional descriptions of all Key Personnel performing services under the grant funding; and (ii) list the current and/or proposed clinic locations.

9. BUDGET PLAN

a. Budget Attach a completed Budget. The budget must reflect all activities in State Fiscal Year 2019 that the Grant Funds will be funding. All funds may only be expended for services provided by June 30, 2019.

b. Budget Narrative Attach a budget narrative to support your Budget Plan. Describe each line item and provide a breakdown of all costs, including salaries and fringe benefits.