20._CCHCS-MC-331A_-_Proposal_Sub_Checklist.pdf

Proposal Number: SD23-00097

Attachment 20

CCHCS-MC-331A – Proposal Submittal Checklist Page 1 of 2 Rev. 05/31/2019

PROPOSAL SUBMITTAL CHECKLIST

SERVICE TYPE: On-Site Dialysis Services

The checklist below is a summary of documents to be submitted based on requirements in the Request for Proposal. This checklist should be returned with your bid. Place a check-mark or “X” next to each document being submitted to the State. An original signature is required on the document(s) where specified.

The company name identified on all documents submitted to the State (e.g., licenses, permits, certifications, and insurance) must be identical to the company name written on the Payee Data Record (STD 204). Failure to submit these documents in the manner prescribed may delay award of Agreements. For possible reasons for rejection of bids, please refer to the rules governing competition in Request for Proposal, Section 2.9 Competitive Bidding and Proposal Responsiveness.

_____ Proposal Submittal Checklist (CCHCS-MC-331A)

_____ Bid Rate Sheet (Note: For Bidder’s convenience, the Bid Rate Sheet is an Excel spreadsheet. The spreadsheet(s) are password protected and cannot be altered, except where highlighted. The Bidder will enter figures or amounts into each of the highlighted cells and print the document.)

_____ Customer Reference Questionnaire (CCHCS-MC-415) (Note: The bidder must submit two Customer Reference Questionnaires (CCHCS-MC-415) and two Letters of Reference)

_____ Bidder Certification (CCHCS-MC-333)

_____ Equipment Specifications, if applicable

_____ Signed Payee Data Record (STD 204)

_____ Supplement Vendor Payee Data Record Form

_____ Subcontractor/Consultant List (CCHCS-MC-391)

_____ Non-Small Business Subcontractor Preference Request (CCHCS-MC-392)

_____ Small Business Subcontractor/Supplier Acknowledgement (CCHCS-MC-393)

_____ Disabled Veteran Business Enterprise (DVBE) Participation in Exempt Contracts (CCHCS-MC-1786)

_____ Contractor Contact Information (CCHCS-MC-332)

_____ Conflict of Interest Compliance Certificate (CCHCS-MC-412)

_____ Commercially Useful Function (CUF) Certification Form (CCHCS-MC-345), if applicable

Proposal Number: SD23-00097

Attachment 20

CCHCS-MC-331A – Proposal Submittal Checklist Page 2 of 2 Rev. 05/31/2019

_____ Contractor Certification Clauses (CCC 04/2017). Submit a copy of the first page with an original signature.

_____ Copy of valid California city or county business license (if applicable); or if a corporation located within the State of California, incorporation documents or letter from the California Secretary of State Certification of Good Standing; or if not a California business, an affidavit that business is in good standing with the state, province, or country in which business is headquartered.

_____ Fictitious Name Permit, if applicable

_____ Non-Collusion Declaration (CCHCS-MC-379):

☐ Organizational Chart ☐ Identification of parent corporations in which Bidder has an interest ☐ Identification of existing financial relationships with other Contractors

_____ Declaration of Capacity to Provide Services (CCHCS-MC-396)

_____ Darfur Contracting Act (CCHCS-MC-394)

_____ Iran Contracting Act (CCHCS-MC-323)

_____ California Civil Rights Laws Attachment (DGS OLS 04)

Based on business entity type, additional document(s) shall be submitted, when applicable.

Corporations ☐ Articles of Incorporation

(Board of Directors, President or Vice President, Secretary or Assistant Secretary)

Limited Liability Company (LLC) ☐ Articles of Organization

(LLC shall have one or more members, members shall have management duties, and if the company is to be managed by one or more managers and not by all members, the articles of organization shall contain a statement to that effect.)

Limited Partnership ☐ Certificate of Limited Partnership

(An entity having one or more general partners and one or more limited partners.)

General Partnership ☐ Statement of Partnership Authority

(The association of two or more persons to carry on as co-owners of a business for profit forms a partnership.)

Limited Liability Partnership ☐ Application to Register a Limited Liability Partnership

(The association of two or more persons to carry on as co-owners of a business for profit forms a partnership.)