ATT 5_FORMS - Amendment 2.docx

RFP 24361820R0002

ATTACHMENT 5

FORMS AND QUESTIONNAIRES REQUIRED

FOR EVALUATION

The following forms and questionnaires are required as part of the Offeror’s submission for consideration in the PASS/FAIL portion of the Evaluation. Failure to complete any of these forms or questionnaires may cause an Offeror to be removed from consideration.

Forms included:

· Bankruptcy and Ownership Disclosure Form

· Experience Questionnaire

· Place of Performance / Ownership & SAM Registration Form

· Exceptions & Assumptions Response Form

Please remember to SIGN each form that asks for a signature. Refer to Section 16 of the solicitation for what constitutes an acceptable signature.

Additionally, the Bankruptcy Disclosure and Place of Performance / Ownership & SAM Registration form will also be required for completion and submission for each subcontractor, to accompany any subcontracting plan.

BANKRUPTCY AND OWNERSHIP DISCLOSURE

Current Company Name:

DUNS # used for this solicitation:

Tax ID Number (TIN):

Doing Business As (dba):

I certify that in the past eleven (11) years, under the name/dba, DUNS or TIN noted above, (check one and fill in, if applicable):

No bankruptcies have been filed.

List the Name and DUNS for all previous company names, parent companies, subsidiaries, mergers, acquisitions, consolidations, novations, or other changes in name/DUNS or structure for the past eleven (11) years, as well as disclose any bankruptcies in that same time period.

Company Name (and dba if applicable)

(previous name, parent, subsidiary, merger, acquisition, consolidation, novation, etc) Any bankruptcies filed in past 11 years? (Yes or No)

(attach additional pages as necessary)

In addition to the above, the PRIME offeror must also disclose whether their company is for sale, either through their owners or through private equity firms. The Government reserves the right to use this information in evaluation of risk.

(Subcontractors shall simply state “Subcontractor to <Name of Prime>”)

Signature:

Date:

Name:

Title:

Phone:

EXPERIENCE QUESTIONNAIRE

Company Name:

DUNS #:

1) Identify any/all customers for whom your company provided FSA administration services starting or ending within the past ten (10) years. Include Customer Name and Address, type of customer (whether they are a private company, or federal/state/local government), the dates of service, Quantity (maximum number of participant accounts active at one time), and types of FSA’s included (HC/LEX/DC). Include at least 10 separate customers within the last ten (10) years for whom you are administering concurrent program(s) totaling at least 40% of the number of current FSAFEDS participants provided.

Customer Name, and Address

a) b) c) d) e) f) g) h) i) j) k) l)

(add lines as needed)

2) Provide contact & contract information for each Customer noted above which we may contact to verify your experience, if needed.

Customer Name (from above)

a) b) c) d) e) f) g) h) i) j) k) l)

(add lines as needed)

3) Using the chart below, indicate the total number of active FSA participants being managed by your company and the number of participants, as specified in the following chart, for calendar years ending 2015, 2016, 2017, 2018, and 2019 (to date).

a. Total Employers Serviced

(i) Total dollar amount of FSA elections

(ii) Number of employers

b. Total Accounts

(i) Number of Health Care FSA accounts (HC & LEX)

(ii) Number of Dependent Care (DC) FSA accounts

c. Total account Dollars

(i) Total dollar amount of Health Care FSA elections (HC & LEX)

(ii) Total dollar amount of DC FSA elections

4) Describe your company’s largest FSA administration contract in force. Provide a description of how the service was implemented, how it is being managed, describe administration, education and marketing, customer service, reporting, and claim processing. Be specific. Identify any outside resources that were called upon for any portions of the work.

PLACE OF PERFORMANCE / OWNERSHIP

& SAM REGISTRATION

Company Name:

DUNS #:

PRIME OFFEROR or SUBCONTRACTOR:

1) Is the above company a U.S. owned company?

2) What is this company’s State of Domicile?

3) Is this DUNS # currently registered in SAM with an active registration?

Name:

Title:

Phone:

PRIME OFFEROR ONLY:

4) List all locations in which contract performance might take place if selected for award, as well as type(s) of labor to be performed in each location:

5) Please describe your understanding with regard to the ownership and FDIC insurance of all financial institutions used to house the assets related to FSAFEDS participant accounts as stated in the solicitation.

6) If selected to proceed to Phase Two, do you agree to provide full details of each financial institution proposed for use, to include ownership and FDIC insurance?

Name:

Title:

Phone:

EXCEPTIONS & ASSUMPTIONS

RESPONSE FORM

Company Name:

DUNS #:

In submitting our proposal package for evaluation, I certify that on behalf of my company,

· I have asked any and all questions necessary to obtain a clear understanding of the requirements.

· My company takes no exceptions to the stated requirements in the PWS, and have made no assumptions about the requirements in our proposal.

· We (myself and my company) understand, that the Government may not answer any new questions, nor clarify any incorrect assumptions made by an Offeror once evaluations have begun.

Further, we understand that:

1) The Start-Up Period and Start-Up Costs are paid in arrears following successful completion of the ATO.

2) Following receipt of ATO, the Contractor will be paid in arrears for services rendered at the intervals stated in the PWS.

3) The call center must be fully operational with toll free lines and trained staff by the start of Base Period One.

4) The Contractor is responsible for all banking fees incurred in performance of the resultant contract.

5) The Contractor will be receiving claims from every country where the U.S. has eligible employees and must translate and / or financially convert eligible expenses and reimbursements accordingly.

Name:

Title:

Phone: