ATT 5_FORMS -02.25.22 clean.docx

RFP 24361821R0002 BENEFEDS

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 PHASE ONE 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 Disclosure Form

· Minimum Experience Statement

· Ownership & Place of Performance Compliance Forms

· SAM Registration Form

· Section 889 Compliance Form (FAR 52.204-24 & 52.204-26)

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

In PHASE TWO, the following forms or questionnaires are required for submission.

· Subcontractor Ownership & Place of Performance Compliance Form

· Subcontractor Section 889 Compliance Form

· Exceptions & Assumptions Response Language

BANKRUPTCY DISCLOSURE

Current Company Name:

DUNS #:

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)

Signature:

Date:

Name:

Title:

Phone:

MINIMUM EXPERIENCE STATEMENT

Company Name:

DUNS #:

For Phase One Evaluation, Offerors must describe a clear history of providing (a)enrollment, (b)premium administration, and (c)customer services / call center functions. Offerors must also be prepared to propose key personnel staff who are highly qualified and experienced, and who have a proven success record in the development and delivery of a program with similar size, scope and complexity to BENEFEDS within the last ten years. The prime offeror must have experience administering concurrent program(s) totaling at least 40% the number of current BENEFEDS participants and including more than ten (10) separate payroll systems.

Please use this form to give a brief (maximum two pages) synopsis of how your company as the prime offeror meets the experience requirements stated above. Be sure to address whether your intended key personnel meet or exceed the stated minimum. Do not send their resumes at this time, they will not be reviewed.

Offerors may delete the entire instruction section from this form (in italics) in order to have the full two pages allowed for this submission.

Name:

Title:

Phone:

OWNERSHIP & PLACE OF PERFORMANCE COMPLIANCE

PRIME CONTRACTOR

Company Name:

DUNS #:

PRIME OFFEROR:

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

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

3) In submitting my company’s Phase One documentation, I understand that ALL performance under the contract to be awarded must be performed within the 50 U.S. States and District of Columbia only, and all employees of the prime or any subcontractor must be physically located and performing within these geographic limitations. if successful in Phase One, my company will not propose any non-compliant performance as part of my Phase Two proposal submission..

4) Please describe your understanding with regard to the ownership and FDIC insurance of all financial institutions used to house BENEFEDS related funds, as stated in the solicitation.

5) 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:

OWNERSHIP & PLACE OF PERFORMANCE COMPLIANCE

SUBCONTRACTOR

Subcontractor Name:

DUNS #:

Name of PRIME Contractor to which you are a proposed SUBCONTRACTOR:

1) Is this Subcontractor a U.S. owned company?

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

3) The subcontractor named above understands that ALL performance under the contract to be awarded must be performed within the 50 U.S. States and District of Columbia only, and all employees of the prime or any subcontractor must be physically located and performing within these geographic limitations.

Subcontractor

Name:

Title:

Phone:

SAM.gov REGISTRATION FORM

List the names and DUNS of the Prime and all intended subcontractors for Government verification of SAM.gov registration status

Prime Offeror Company Name:

DUNS #:

All Intended Subcontractors:

Company Name:

DUNS #:

Company Name:

DUNS #:

Company Name:

DUNS #:

Company Name:

DUNS #:

Company Name:

DUNS #:

Company Name:

DUNS #:

Company Name:

DUNS #:

Company Name:

DUNS #:

Company Name:

DUNS #:

(Add lines or pages as needed)

Prime Offeror (Submitter)

Name:

Title:

Phone:

SECTION 889 COMPLIANCE

In Phase One, the PRIME must complete and submit this form. In Phase Two, the PRIME must collect completed copies of this form from ALL subcontractors and submit to the Government for review.

Company Name:

DUNS #:

Prime or Subcontractor?

If Subcontractor, what is the name of the PRIME?

52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS AND VIDEO SURVEILLANCE SERVICES OR EQUIPMENT (Nov 2021) The Offeror shall not complete the representation at paragraph (d)(1) of this provision if the Offeror has represented that it "does not provide covered telecommunications equipment or services as a part of its offered products or services to the Government in the performance of any contract , subcontract , or other contractual instrument" in paragraph (c)(1) in the provision at 52.204-26, Covered Telecommunications Equipment or Services —Representation, or in paragraph (v)(2)(i) of the provision at 52.212-3, Offeror Representations and Certifications-Commercial Products or Commercial Services. The Offeror shall not complete the representation in paragraph (d)(2) of this provision if the Offeror has represented that it "does not use covered telecommunications equipment or services , or any equipment , system, or service that uses covered telecommunications equipment or services " in paragraph (c)(2) of the provision at 52.204-26, or in paragraph (v)(2)(ii) of the provision at 52.212-3.

(a) Definitions . As used in this provision— Backhaul , covered telecommunications equipment or services , critical technology , interconnection arrangements , reasonable inquiry , roaming , and substantial or essential component have the meanings provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment .

(b) Prohibition.

(1) Section 889(a)(1)(A) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L. 115-232) prohibits the head of an executive agency on or after August 13, 2019, from procuring or obtaining, or extending or renewing a contract to procure or obtain, any equipment , system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. Nothing in the prohibition shall be construed to—

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul , roaming , or interconnection arrangements ; or

(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into any user data or packets that such equipment transmits or otherwise handles.

(2) Section 889(a)(1)(B) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L. 115-232) prohibits the head of an executive agency on or after August 13, 2020, from entering into a contract or extending or renewing a contract with an entity that uses any equipment , system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. This prohibition applies to the use of covered telecommunications equipment or services , regardless of whether that use is in performance of work under a Federal contract . Nothing in the prohibition shall be construed to—

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul , roaming , or interconnection arrangements ; or

(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into any user data or packets that such equipment transmits or otherwise handles.

(c) Procedures. The Offeror shall review the list of excluded parties in the System for Award Management (SAM) ( https://www.sam.gov) for entities excluded from receiving federal awards for "covered telecommunications equipment or services ".

(d) Representation. The Offeror represents that—

(1) It □ will, □ will not provide covered telecommunications equipment or services to the Government in the performance of any contract , subcontract or other contractual instrument resulting from this solicitation . The Offeror shall provide the additional disclosure information required at paragraph (e)(1) of this section if the Offeror responds "will" in paragraph (d)(1) of this section; and

(2) After conducting a reasonable inquiry , for purposes of this representation, the Offeror represents that— It □ does, □ does not use covered telecommunications equipment or services , or use any equipment , system, or service that uses covered telecommunications equipment or services . The Offeror shall provide the additional disclosure information required at paragraph (e)(2) of this section if the Offeror responds "does" in paragraph (d)(2) of this section.

(e) Disclosures.

(1) Disclosure for the representation in paragraph (d)(1) of this provision. If the Offeror has responded "will" in the representation in paragraph (d)(1) of this provision, the Offeror shall provide the following information as part of the offer :

(i) For covered equipment —

(A) The entity that produced the covered telecommunications equipment (include entity name, unique entity identifier , CAGE code, and whether the entity was the original equipment manufacturer (OEM) or a distributor, if known);

(B) A description of all covered telecommunications equipment offered (include brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and

(C) Explanation of the proposed use of covered telecommunications equipment and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.

(ii) For covered services—

(A) If the service is related to item maintenance: A description of all covered telecommunications services offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); or

(B) If not associated with maintenance, the Product Service Code (PSC) of the service being provided; and explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.

(2) Disclosure for the representation in paragraph (d)(2) of this provision. If the Offeror has responded "does" in the representation in paragraph (d)(2) of this provision, the Offeror shall provide the following information as part of the offer :

(i) For covered equipment —

(A) The entity that produced the covered telecommunications equipment (include entity name, unique entity identifier , CAGE code, and whether the entity was the OEM or a distributor, if known);

(B) A description of all covered telecommunications equipment offered (include brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and

(C) Explanation of the proposed use of covered telecommunications equipment and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.

(ii) For covered services—

(A) If the service is related to item maintenance: A description of all covered telecommunications services offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); or

(B) If not associated with maintenance, the PSC of the service being provided; and explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.

(End of provision)

Disclosures in response to 52.204-24 (e)(1) and (2):

Fill in if/as applicable:

52.204-26 COVERED TELECOMMUNICATIONS EQUIPMENT OR SERVICES-REPRESENTATION (OCT 2020)

(a) Definitions. As used in this provision, "covered telecommunications equipment or services" and "reasonable inquiry" have the meaning provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment.

(b) Procedures. The Offeror shall review the list of excluded parties in the System for Award Management (SAM) (https://www.sam.gov) for entities excluded from receiving federal awards for "covered telecommunications equipment or services".

(c) (1) Representation. The Offeror represents that it [ ]does, [ ]does not provide covered telecommunications equipment or services as a part of its offered products or services to the Government in the performance of any contract, subcontract, or other contractual instrument.

(2) After conducting a reasonable inquiry for purposes of this representation, the offeror represents that it [ ]does, [ ]does not use covered telecommunications equipment or services, or any equipment, system, or service that uses covered telecommunications equipment or services.

Name:

Title:

Phone:

EXCEPTIONS & ASSUMPTIONS DISCLAIMER

Company Name:

DUNS #:

Please include the following language in your Phase Two proposal (or complete this form and submit as part of your proposal package):

In submitting our PHASE TWO proposal 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 in order to prepare my proposal.

· My company takes no exceptions to the stated requirements in the PWS or other requirement documents 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 charges (other than Start Up Period Travel) are invoiced in arrears following successful completion of the ATO.

2) During the Base and subsequent periods of performance, the Contractor will receive payment for its services by the methods described and at the intervals as stated in the PWS.

3) The call center must be fully operational with toll free lines and trained staff by the start of the Base Period (January 1, 2023).

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

Name:

Title:

Phone: