2012ATTACH3-14.RFPsamhsaidiq.doc

RFP No. 283-12-1000

VOUCHER REVIEW SHEET

Contract No.: _______________________________

Reference No. ______________ Contractor: (CONTRACTOR FILL-IN)

DUNS #______________

Contractor Sent Date: (CONTRACTOR FILL-IN) X Cost Reimbursement

Receive in DCM/OPS: (DCM FILL-IN) IQC Word Order

Date Due in DCM:

Letter of Credit

Date Due in PSC/DFS:

Fixed Price

Contract Finance Payment

(N/A if Letter of Credit)

To: , Project Officer (CONTRACTOR FILL-IN) From: Lynn Tantardini ,Division of Contracts Management, OPS, SAMHSA l Choke Cherry Road, Room 7-1051, Rockville, MD 20852 Subject: Voucher No.: (CONTRACTOR FILL-IN) Period Covered: (CONTRACTOR FILL-IN)

Project Officer:

Please review the Voucher, answer the following and return to DCM by date shown above.

YES

NO

1. Are costs commensurate with efforts expended?

2. Are all elements of cost reasonable, in support of contract performance and consistent with amounts negotiated?

3. Have deliverables received during the period been timely and acceptable

4. Do you recommend payment be made as claimed?

5. Do you question any costs claimed? If yes, explain below.

(ATTACH ADDITIONAL SHEET OF PAPER IF NEEDED):

P.O. sign and date here:

Signature

Date

To: Program Support Center:

PAY THIS AMOUNT:

Division of Fiscal Services

AMOUNT CLAIMED:

Room 16-23

AMOUNT TO BE SUSPENDED FROM PAYMENT: $

In accordance with the Prompt Payment Provisions (Subsection (b)(4)), INTEREST IS, IS NOT payable under this Invoice or “Contract Financing Payment.”TO BE PAID NOT LATER THAN . * NOTE: THIS INVOICE/VOUCHER IS APPROVED FOR PROVISIONAL PAYMENT ONLY. All payments are subject to change pending final audit.

Reason for Suspension:

Approved for payment:

Contract Specialist

Date

PACKAGING AND DELIVERY OF THE PROPOSAL

Your proposal shall be organized as specified in Section L.2., "Instructions to Offerors" - General Instructions. Shipment and marking shall be as indicated below.

EXTERNAL PACKAGE MARKING

In addition to the address cited below, mark each package as follows:

"RFP NO. 283-12-1000”

TO BE OPENED BY AUTHORIZED GOVERNMENT PERSONNEL ONLY"

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY:

NUMBER OF COPIES

TECHNICAL PROPOSAL: ORIGINAL* AND 8 COPIES TO:

BUSINESS PROPOSAL: ORIGINAL* + CD Rom TO:

Lynn Tantardini Contract Specialist

Substance Abuse, Mental Health Services Administration, DHHS Division of Contracts Management, OPS

1 Choke Cherry Road, Room 7-1051 Rockville, Maryland 20852

BILLING INSTRUCTIONS

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

DIVISION OF CONTRACTS MANAGEMENT

Guide for Preparing Vouchers Under

Cost-Reimbursement Type Contracts

I.

INTRODUCTION

A.

GENERAL

This Guide presents procedures for the preparation of Contractor's reimbursement claims under (1) cost-reimbursement type contracts; (2) the cost-reimbursement portions of fixed-price contracts; (3) letter contracts which provide for reimbursement of costs; (4) time and material contracts; and (5) labor-hour contracts. The term "cost-reimbursement type contracts" as used in this Guide includes all of the foregoing contractual arrangements.

B.

DESK AUDIT

To expedite final payment on contracts subject to desk audit, the contractor may be required to provide the information set forth in III, C, of this guide.

C.

PRESCRIBED GOVERNMENT FORMS

Standard Form 1034 "Public Voucher for Purchases and Services Other Than Personal" (Figure 1), and Standard Form 1035, "Public Voucher for Purchases and Services Other Than Personal - Continuation Sheet" (Figure 2), should be utilized by Contractors to show the amount claimed for reimbursement under cost-reimbursement type contracts, and to provide the necessary supporting detail, respectively. The SF 1035 may also be used to furnish any additional information as may be required by the Contracting Officer in accordance with the terms of the contract. The voucher and continuation sheet may be on reproduced copies of the forms providing they conform to the official Government forms in format and are marked "original".

The Contractor may attach to the SF 1034, Public Vouchers for Purchases and Services Other Than Personal, Form HHS-646, Financial Report of Individual Project/Contract, or self-designed form may be used if it contains the information required by this Guide and is otherwise acceptable to the Contracting Officer.

D.

TIME OF SUBMISSION

Vouchers may be submitted at the beginning of each billing period for costs incurred during the preceding billing period. Costs incurred earlier than the preceding billing period, but not previously billed for, may be included, but the amount and month(s)in which such costs were incurred must be stated in the SF 1035 or equivalent form. Vouchers shall not be submitted more frequently than once each month unless such arrangements are made with the Contracting Officer.

E.

COST INCURRANCE PERIOD

Costs must be incurred within the contract performance period or the period covered by pre-contract cost provisions.

F.

CONTRACTOR'S FISCAL YEAR

Vouchers must be prepared in such a manner that costs claimed can be associated or identified with the Contractor's fiscal year. This will ensure proper application of indirect cost rates to the direct costs of a particular fiscal year.

II.

PREPARATION OF PUBLIC VOUCHERS

A.

GENERAL

This information which a Contractor is required to submit in its public vouchers (SF 1034 and 1035) is set forth in the explanatory notes which follow. These notes are keyed to the entries on the illustrative public vouchers, Figures 1 and 2.

B.

COMPLETION OF SF 1034

The following information is required to be submitted on SF 1034 or equivalent (Refer to Figure 1):

(a) U. S. Department, Bureau of Establishment and Location enter the complete address as shown in the contract.

(b) Date Voucher Prepared - insert the date on which the voucher was prepared.

(c) Contract Number and Date - insert the number and the date of the contract under which reimbursement is claimed.

(d) All blocks lettered (d) should normally be left blank.

(e) Voucher No. - insert the appropriate serial number of each voucher including the completion and final voucher. A separate series of consecutive numbers, beginning with number 1, shall be used by the Contractor for each contract.

(f) Payee's Name and Address - insert name and address of Contractor to which payment should be made. In the case of an assignment of claims, also insert the organization to which payments have been assigned.

(g) Payee's Account Number - this space may be used by the Contractor to record the account or job number assigned to the contract.

(h) Number and Date of Order - enter the number and date of the applicable order. (Applicable only when billings are consequent to work assignments of the cost occurrence period.)

(i) Date of Delivery/Services - show the month and year, beginning and ending dates of the cost incurrence period.

(j) Articles and Services - insert the following: "For detail see attached page(s)".

(k) Amount and Total - insert the amount claimed for the period indicated in (i) above.

(l) Identification - each voucher submitted must be prominently identified as one of the following:

(i) Interim Voucher - "Cost Reimbursable - Provisional Payment".

(ii) Completion Voucher - "Cost Reimbursable Completion Voucher".

(iii) Final Voucher - "Cost Reimbursable - Final Voucher".

(m) Type the following certification, signed by an authorized official, on the face of the SF 1034:

"I certify that all payments requested are for appropriate purposes and in accordance with the applicable); Total Contract Value; and Amount of Fee payable (if applicable).

Name of Official and Title

C. COMPLETION OF SF 1035

The following information is required to be submitted on SF 1035 or equivalent (refer to Figure 2):

(1) Insert the name of the Government Agency as shown under of the SF 1034.

(2) Insert the voucher number as shown on the SF 1034.

(3) Schedule No. - Leave blank.

(4) If more than one sheet is used, insert the sheet number in numerical sequence, showing Page of . Use as many sheets as necessary to show the required information.

(5) Insert payee's name and address as in the SF 1034.

(6) Insert the contract number as shown on the SF 1034.

(7) Insert the latest: total estimated cost; total fee (if applicable); total contract value; and amount of fee payable (if applicable).

(8) Insert:

"Summary of claimed current and cumulative cost" and "fee earned", if applicable.

(9) Unless otherwise required by the contract, insert the major elements of incurred cost which are defined as follows:

(1) Direct Costs

(a) Direct Labor: This consists of salaries and wages for direct performance of the contract.

(b) Fringe Benefits:

This represents fringe benefits applicable to direct labor and billed as direct cost. Fringe benefits included in indirect costs should not be identified here.

(c) Capitalized Nonexpendable Equipment: This represents personal property of a capital nature; i.e., property acquired at a cost of $1000 or more and that has a service life of more than two years.

Form HHS 565, Report of Accountable Property as outlined in the HHS publication "Contractor's Guide for control of Government Property" will accompany the contractor's public voucher (SF 1034/SF 1035) as required.

(d) Material, Supplies and Non-capitalized Equipment: These are consumable materials, supplies and equipment other than those described in (c) above.

(e) Premium Pay: This is remuneration in excess of the basic hourly rate.

(f) Consultant's Fee: These are fees paid to consultants. List names, time, and charges for the current billing period. If required by the terms and conditions of the contract, cite the applicable COA number.

(g) Travel: Domestic travel is travel within the United States, its territories, possessions, and Canada. It should be billed separately from foreign travel.

(h) Other: List all other direct costs in total unless significant in amount. If significant, list costs elements and dollar amount separately; i.e., subcontracts.

2.

Indirect Costs (as applicable)

(a) Fringe Benefit: Cite the formula (rate and base) in effect during the time the costs were incurred and for which reimbursement is claimed.

(b) Overhead: Cite the formula (rate and base) in effect during the time the costs were incurred and for which reimbursement is claimed.

(c) G&A: Cite the formula (rate and base) in effect during the time the costs were incurred and for which reimbursement is claimed.

(10) Insert the current costs claimed by major cost elements. Costs claimed for reimbursement can be only those amounts that are consistent with the term "costs" as defined in allowable cost and payment clause. Where it is found that amounts claimed do not meet this definition, such costs together with their associated costs and fee will be disallowed. All adjustments included herein must be explained in detail.

(11) Insert the cumulative costs claimed to date by major cost elements.

(12) Costs claimed for cost-typed subcontracts must be supported by information similar to the SF 1035 for each subcontractor. Costs for fixed-price subcontracts shall be on the basis of items delivered or services received, accepted and paid by the prime contractor.

(13) Insert the total costs for the current and cumulative periods.

(14) If the contract provides for an incentive or fixed-fee, insert the fee earned for the current and cumulative periods and the formula for such computation; e.g., if payment of the fee is based on a percentage of costs, the target incentive fee or fixed-fee earned shall be determined by applying the percentage ration of target incentive fee or fixed-fee to the total estimated cost of the contractor. However after payment of 85% of the fee, the Contracting Officer may withhold further payment of fee to establish a reserve to protect the interests of the Government. This reserve may not exceed 15% of the total fee, or $100,000, whichever is less.

(15) Each invoice should have a roll up page and detail information for each task.

For Example Contract Estimated Cost

$100,000

Fixed-Fee

6,000 Total CPFF

$106,000

Maximum Fee Payable

$ 5,100

(85% of 6,000)

Fixed-Fee

$ 6,000 - 6%

Estimated Cost

$100,000

Therefore, fixed-fee may be billed at 6% of actual costs incurred until the maximum fee of $5,100 has been paid. Any fee withheld is payable upon submission of appropriate closing documents after final audit of the contract has been completed and all audit exceptions have been resolved.

(15) Insert the total costs claimed and the fee due for the current ad cumulative periods.

(16) If applicable, resubmission of any previously claimed amounts which were suspended should be shown below the current amount claimed and footnoted to cite the number of the public voucher on which the deduction was made and the date and number of the related suspension notice.

Suspensions from which the contractor has successfully appealed shall be identified by referencing the Contracting Officer's letter of approval.

(17) Insert the current amount claimed. Transfer this amount to SF 1034.

III. GENERAL INSTRUCTIONS

A.

Costs Requiring Prior Authorization and Approval The contractor should be aware of the requirements for prior written approval from the Contracting Officer for certain costs (e.g., premium pay, foreign travel). Whenever the voucher includes such costs not authorized by the contract, reference must be made to the Contracting Officer's Authorization letter (COA).

B.

Withholding and Releases of Contract Reserves

Contractual provisions covering fees, patents, royalties, etc., usually provide for the accumulation of a withholding reserve until certain contract requirements are met to the satisfaction of the Contracting Officer. It is the contractor's responsibility to include appropriate adjustments in his reimbursement claims to cover the required accumulation and release of contract withholding reserves. The contractor should resolve any questions regarding the amount of these reserves with the Contracting Officer.

C.

Contractor's Completion Voucher DUE WITHIN 12 months of EXPIRATION After all costs have been assigned to the contract and all contract performance provisions have been completed, the Contractor shall promptly submit, but in any event within twelve (12) months from the date of such completion, its completion voucher to the office designated in the contract directly to the Contracting Officer to finalize the financial settlement of the contract). This voucher must be specifically identified as the completion voucher and should include the remaining cost, fees, and reserves claimed to be due by the Contractor. It will not include items and amounts which may be set out in any qualifications in the Contractor's release of claims. A separate completion voucher shall be submitted for each individual project or task order for which a separate series of public vouchers has been submitted.

Final payment on prescribed contracts may be made on the basis of a desk audit. To expedite final settlement on these contracts, the Contracting Officer may request the Contractor to submit detailed support for costs claimed under one or more interim vouchers.

D.

Contractor's Final Voucher and Closing Documents DUE WITHIN 18 months of EXPIRATION After completion of the final audit and all suspensions and/or audit exceptions have been resolved and there is mutual agreement between the Contractor and the Contracting Officer on the final allowable cost and fee, if any, the Contractor shall submit its final voucher and the appropriate closing documents to the office designated in the contract. This voucher shall be specifically identified as the final voucher, and must be supported by the following documents:

(1) Contractor's Release

(2) Assignee's Release, if applicable.

(3) Contractor's Assignment of Refunds, Rebates, Credits and Other Amounts

(4) Assignee's Assignment of Refunds, Rebates, Credits, and Other Amounts, if applicable

(5) Contractor's Affidavit or Waiver of Lien, when required by the contract

If final settlement of the contract is in the amount shown on the completion voucher, the Contractor need not submit a final voucher, but only the additional closing documents cited above.

The final voucher shall also include any final indirect rate variance adjustments from indirect rates being finalized. This final voucher is due within 6 months after receipt of the Completion Voucher mentioned above. If the indirect rates are not finalized at this time the contract will be closed out based on the provisional rates.

E.

Currency All Department contracts are expressed in the United States dollars. Where expenditures are made in a currency other than United States dollars, billings on the contract shall be expressed, and reimbursement by the United States Government shall be made, in that other currency at amounts coincident with the actual costs incurred. Currency fluctuation may not be on a basis of gain or loss to the Contractor. Notwithstanding the above, the total of all invoices paid under this contract may not exceed the United States dollars authorized.

F.

Government Liaison

Any questions concerning delays in payment of Contractor's vouchers should be addressed to the office designated to receive the voucher; matters relative to performance or the instructions set forth in this Guide, should be addressed to the Contracting Officer.

Exhibit A to Billing Instructions

In addition to the requirements of the billing Instructions for Cost-Reimbursement Type Contracts, the contractor agrees to included the following supplemental information on each invoice for the cost categories shown below broken down by tasks:

Direct Labor (1) Position Category

(2) Employee Identification Number or Name

(3) Hours Expended

(4) Hourly Rate

Travel (1) Detail purpose of travel (i.e., seminar, course, site visit, etc.)

(2) Dates and duration of travel

(3) Point of departure and destination

(4) Names of individuals

(5) Per diem rate

(6) Travel costs (air fare, care rental (including mileage), taxis, etc.)

Material or Equipment (Rental or Purchase (1) Description, quantity and amount of each item

(2) COA letter number, if applicable

Consultants (1) Name

(2) Rate

(3) Number of days and dates

(4) COA letter number, if applicable

Indirect Costs

(1) Rate

(2) Base

Other Direct Costs All other expenditures must be described and the respective amounts shown.

Billing Instructions to be included in any subcontracts shall call for the supplemental information cited above. The prime Contractor shall provide, with each invoice that contains subcontract costs, a copy of the supplemental information provided by the subcontractor.

Contractor's Fiscal Year

Invoices must be prepared in such a manner that costs claimed can be associated or identified with the Contractor's fiscal year.

SAMPLE INVOICE/FINANCING REQUEST

(a) Contracting Officer

Division of Contracts Management

Office of Program Services, SAMHSA

1 Choke Cherry Road, Room 7-1051 Rockville, Maryland 20857 (b) Invoice/Financing Request No.

(c) Date Voucher Prepared

(d) Contract No. and Date

(e) Payee's Name and Address

ABC CORPORATION

100 Main Street

Anywhere, U.S.A. Zip Code (f) Total Estimated Cost of Contract

Attention:

Name, Title and Phone Number of Official to Whom Payment is Sent (g) Total Fixed Fee

(h) This invoice/financing request represents reimbursable costs from August 1, 1992 through August 31, 1992.

(k) Direct Costs

(1) Direct Labor

(2) Fringe Benefits

(3) Accountable Personal Property

(Attach HHS-565)

Permanent

General Purpose

(4) Materials and Supplies

(5) Premium Pay

(6) Consultant Fee

Dr. Jones/1 day @ 100-COA #3

(7) Travel - Domestic (see detail)

Foreign

(8) Subcontract Cost

(9) Other

Total Direct Costs

(l) Cost of Money

(Factor) or (Appropriate Base)

(m) Indirect Costs - Overhead

% of Direct Labor or Other Base (Formula)

(n) Fixed-Fee Earned (Formula)

(o) Total Amount Claimed

(p) Adjustments

Outstanding Suspensions

(q) Grand Totals

(i) Amount Billed for

Current Period $ 3,400

3,000

2,000

2,000

$ 0 $ 11,600

2,400

4,000

$ 18,700

$ 18,700

(j) Cumulative Amount From Inception to Date of this Billing $ 6,800

1,200

8,000

2,000

4,000

$20,650

3,600

6,000

1,400 $31,650

$29,950

"I certify that all payments requested are for appropriate purposes and in accordance with the contract."

(Name of Official)

(Title)

DISCLOSURE OF LOBBYING ACTIVITY

1. Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

2. Status of Federal Action:

a. bid/offer/application

b. Initial award

c. post-award

3. Report Type:

a. initial filing

b. material change

For Material Change Only:

year ______ quarter _______ date of last report________

4. Name and Address of Reporting Entity:

G Prime G Subawardee

Tier_____, if known:

Congressional District, if known:

5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime

Congressional District, if known:

CFDA Number, if applicable: __________________

10. a. Name and Address of Lobbying Entity

(if individual, last name, first name, MI):

(attach Continuation Sheet(s)

b. Individual Performing Services (including address if different from No. 10a)

(last name, first name, MI)

SF-LLL-A, if necessary)

11. Amount of Payment (check all that apply):

$__________ G actual G planned

13. Type of Payment (check all that apply):

G a. retainer

G b. one-time fee

G c. commission

G d. contingent fee

G e. deferred

G f. other; specify: _____________________________

12. Form of Payment (check all that apply):

G a. cash

G b. in-kind; specify: nature_____________ value______________

14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for payment indicated in Item 11:

(attach Continuation Sheet(s) SF-LLL-A, if necessary)

16.

Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each failure.

Signature:______________________________________

Print Name:_____________________________________

Title:__________________________________________

Telephone No.:_________________Date:____________

Standard Form‑-LLL

DISCLOSURE OF LOBBYING ACTIVITIES

CONTINUATION SHEET

Approved by OMB

0348-0046

Reporting Entity:_________________________________ Page _____ of _____

Authorized for Local Reproduction

Standard Form‑-LLL-A

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

This disclosure form shall be completed by the reporting entity, whether subawardee of prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing of attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1.

Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2.

Identify the status of the covered Federal action.

3.

Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action.

4.

Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5.

If 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.

Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7.

Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8.

Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract, grant, or loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001."

9.

For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.

10.

(a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a); Enter Last Name, First Name, and Middle Initial (MI).

11.

Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material charge report, enter the cumulative amount of payment made or planned to be made.

12.

Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment.

13.

Check the appropriate box(es). Check all boxes that apply. If other, specify nature.

14.

Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted.

15.

Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.

16.

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

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the

Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D.C. 20503.

CONTACT POINTS – THIS MUST BE FILLED OUT and INCLUDED IN THE BUSINESS PROPOSAL Complete the following and return with the BUSINESS PROPOSAL.

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

Name

Telephone Number

Institutional Title

FAX Number

Institutional Office

Institution Name **Street Address City, State Zip Code

Name, Institutional Title and Address of Proposed Project Director Name

Telephone Number

Institutional Title

FAX Number

Institutional Division, etc.

**Street Address City, State Zip Code

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

* May not necessarily be same as legal address of offeror.

**Please use actual street address, not P.O. Box.

BREAKDOWN OF PROPOSED ESTIMATED COST (PLUS FEE) AND LABOR HOURStc \l3 "BREAKDOWN OF PROPOSED ESTIMATED COST (PLUS FEE) AND LABOR HOURS

INSTRUCTIONS FOR USE OF THE FORMAT

1.

Refer to Business Proposal Instructions, Section L of this solicitation. The Instructions contain the requirements for proper submission of cost/price data which must be adhered to.

2.

This format has been prepared as a universal guideline for all solicitations issued by the Center for Substance Abuse Prevention. It may require amending to meet the specific requirements of this solicitation. For example, this solicitation may require the submission of cost/price data for three years listed on this form. (See Section L.1., General Information for the estimated duration of this project.) If this solicitation is phased, identify each phase in addition to each year. Total each year, phase, and sub-element.

3.

This format must be used to submit the breakdown of all proposed estimated cost elements. List each cost element and sub-element for direct costs, indirect costs and fee, if applicable. In addition, provide detailed calculations for all items. For example:

a.

For all personnel, list the name, title, rate per hour and number of hours proposed. If a pool of personnel is proposed, list the composition of the pool and how the cost proposed was calculated. List the factor used for prorating Year One and the escalation rate applied between years.

Offeror's proposal should be stated in the same terms as will be used to account for and record direct labor under a contract (i.e. percentage of effort is used for most faculty and professional employees at educational institutions). If percentages of effort are used, the basis to which such percentages are applied must also be submitted by the offeror. The attached format should be revised to accommodate direct labor proposed as a percentage of effort.

b.

For all materials, supplies, and other direct costs, list all unit prices, etc., to detail how the calculations were made.

c.

For all indirect costs, list the rates applied and the base the rate is applied to.

d.

For all travel, list the specifics for each trip.

e.

For any subcontract proposed, submit a separate breakdown format.

f.

Justification for the need of some cost elements may be listed as an attachment, i.e., special equipment, above average consultant fees, etc.

4.

If the Government has provided "uniform pricing assumptions" for this solicitation, the offeror must comply with and identify each item.

RFP Number:

Organization:

Date:

BREAKDOWN OF PROPOSED ESTIMATED COST (PLUS FEE) AND LABOR HOURS

Cost Element

Direct Labor

Labor Category - Title & Name

Project Director

Writer

Conference Manager

Total Labor & Fringe

Total Labor Costs

Other Direct Costs

Reproduction

Telephone

Supplies

Subcontracts (separate line and name each) (subs proposal attached)

Consultants (have a breakdown of fee attached, breakdown by task by year)

Travel (have breakdown of travel attached, breakdown by task, by year)

Total ODC=s

Subtotal of Total Labor & ODC=s

Subtotal **

Total Estimated Costs

PROPOSAL INTENT RESPONSE SHEET – DOMAIN ____tc \l3 "PROPOSAL INTENT RESPONSE SHEET RFP No. 283-12-1000

TITLE:

"Substance Abuse and Mental Health Services Administration Indefinite Delivery Indefinite Quantity (SAMHSA IDIQ) PLEASE REVIEW THE ATTACHED REQUEST FOR PROPOSAL. FURNISH THE INFORMATION REQUESTED BELOW AND RETURN THIS PAGE BY THE EARLIEST PRACTICABLE DATE, BUT NOT LATER THAN DECEMBER 19, 2011 YOUR EXPRESSION OF INTENT IS NOT BINDING BUT WILL GREATLY ASSIST US IN PLANNING FOR PROPOSAL EVALUATION.

DO INTEND TO SUBMIT A PROPOSAL

DO NOT INTEND TO SUBMIT A PROPOSAL FOR THE FOLLOWING REASONS:

COMPANY/INSTITUTION NAME:

AUTHORIZED SIGNATURE:

TYPED NAME AND TITLE:

EMAIL ADDRESS:

COMPANY PHONE NUMBER:

COMPANY FAX NUMBER:

DATE:

COLLABORATORS/CONSULTANTS/SUBCONTRACTORS (PROVIDE NAME(S) AND ORGANIZATION)

Please provide the Domains you will be proposing and the subcontractors by Domain. You can use the chart below and place a checkmark in the Domain number that the subcontractor will be proposed in or you can use you own method to illustrate the team by Domain.

Prime

Sub names

RETURN TO THE FOLLOWING BY FAX: 240-276-1510

Substance Abuse and Mental Health Services Administration, DHHS Division of Contract Management

Attention: Lynn Tantardini, Contract Specialist 1 Choke Cherry Road, Room 7-1051 Rockville, MD 20852

PLEASE RETURN THIS PAGE BY: DECEMBER 19, 2011

NOTE:

This Notice is for the Technical Evaluation Review Group who will be reviewing the proposals submitted in response to this RFP. THE OFFEROR SHALL PLACE A COPY OF THIS NOTICE ON TOP OF EACH COPY OF THE TECHNICAL PROPOSAL.

GOVERNMENT NOTICE FOR HANDLING PROPOSALS

This proposal shall be used and disclosed for evaluation purposes only, and a copy of this Government notice shall be applied to any reproduction or abstract thereof. Any authorized restrictive notices which the submitter places on this proposal shall be strictly complied with. Disclosure of this proposal outside the Government for evaluation purposes shall be made only to the extent authorized by, and in accordance with, the procedures in HHSAR paragraph 352.215-1.

(f) If authorized in agency implementing regulations, agencies may release proposals outside the Government for evaluation, consistent with the following:

(1) Decisions to release proposals outside the Government for evaluation purposes shall be made by the agency head or designee;

(2) Written agreement must be obtained from the evaluator that the information (data) contained in the proposal will be used only for evaluation purposes and will not be further disclosed;

(3) Any authorized restrictive legends placed on the proposal by the prospective Contractor or subcontractor or by the Government shall be applied to any reproduction or abstracted information made by the evaluator;

(4) Upon completing the evaluation, all copies of the proposal, as well as any abstracts thereof, shall be returned to the Government office which initially furnished them for evaluation; and

(5) All determinations to release the proposal outside the Government take into consideration requirements for avoiding organizational conflicts of interest and the competitive relationship, if any, between the prospective Contractor or subcontractor and the prospective outside evaluator.

(g) The submitter of any proposal shall be provided notice adequate to afford an opportunity to take appropriate action before release of any information (data) contained therein pursuant to a request under the Freedom of Information Act (5 U.S.C. 552); and, time permitting, the submitter should be consulted to obtain assistance in determining the eligibility of the information (data) in question as an exemption under the Act. (See also Subpart 24.2, Freedom of Information Act.)

SYSTEM NOTICE

09-30-0049

09-30-0049

SYSTEM NAME:

Consultant Records Maintained By SAMHSA Contractors, HHS/SAMHSA/OA.

Minor alterations have been made to this system of records notice. The following categories should be revised in their entirety:

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSES OF SUCH USES:

1. The Department of Health and Human Services (HHS) may disclose information from this system of records to the Department of Justice, or to a court or other tribunal, when (a) HHS, or any component thereof; or (b) any HHS employee in his or her individual capacity where the Department of Justice (or HHS, where it is authorized to do so) has agreed to represent the employee; or (d) the United States or any agency thereof where HHS determines that the litigation is likely to affect HHS or any of its components, is a party to litigation or has an interest in such litigation, and HHS determines that the use of such records by the Department of Justice, the court or other tribunal is relevant and necessary to the litigation and would help in the effective representation of the governmental party, provided, however, that in each case, HHS determines that such disclosure is compatible with the purpose for which the records were collected.

2. Disclosure may be made to a congressional office from the record of an individual in response to a verified inquiry from the congressional office made at the written request of that individual.

3. SAMHSA proposes to contract with private firms for the purposes of handling logistics for conferences, reviews, development of training materials, and of obtaining the services of consultants. Relevant records will be disclosed to such a contractor or may be developed by the contractor for use in the project. The contractor shall be required to maintain Privacy Act safeguards with respect to such records.

4. Information in this system of records is used routinely to prepare W-2 and 1099 Forms to submit to the Internal Revenue Service and applicable State and local governments those items to be included as income to an individual.

SAFEGUARDS:

Measures to prevent unauthorized disclosures are implemented as appropriate for each location. Each site implements personnel, physical and procedural safeguards such as the following:

1. Authorized Users: Only SAMHSA personnel working on these projects and personnel employed by SAMHSA contractors to work on these projects are authorized users as designated by the system managers.

2. Physical safeguards: Records are stored in locked rooms, locked file cabinets, and/or secured computer facilities.

3. Procedural safeguards: Contractors who maintain records in this system are instructed to make no further disclosure of the records except as authorized by the system manager and permitted by the Privacy Act. Privacy Act requirements are specifically included in contracts and in agreements with grantees or collaborators participating in research activities supported by this system. HHS project directors, contract officers, and project officers oversee compliance with these requirements.

4. Implementation guidelines: DHHS Chapter 45-13 and supplementary Chapter PHS.hf: 45-13 of the General Administration Manual, and Part 6, "Automated Information Systems Security" in the HHS Information Resources Management Manual.

Readers who notice any errors or omissions in the SAMHSA systems of records notices are invited to bring them to my attention at the following address: Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Room 12-105, Rockville, Maryland 20857.

Dated: October 13, 1994

Elaine Parry, Executive Officer, Substance Abuse and Mental Health Services Administration.

[FR Doc. 94-27615 Filed 12-27-94; 8:45 am]

System Notice No. 09-30-0049 as printed in the Federal Register, Vol. 58, No. 248, Wednesday, December 29 1993, Beginning on 69002.

09-30-0049 System Name:

Consultant Records Maintained by SAMHSA Contractors, HHS/SAMHSA/OA

SECURITY CLASSIFICATION:

None

SYSTEM LOCATION:

Records are located at various contractor sites. A list of specific contractor sites is a available from the appropriate system manager.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

Consultants who participate in Substance Abuse and Mental Health Services Administration (SAMHSA) conferences, meeting, evaluation projects, or technical assistance at site locations arranged by contractors.

CATEGORIES OF RECORDS IN THE SYSTEM:

Names, addresses, Social security numbers, qualifications, curricula vitae, travel records, and payment records for consultants.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

SAMHSA; Public Health Service Act, sections 301 (42 U.S.C 241), 332 (U.S.C. 249(c)), and 501-05 (42 U.S.C. 290aa et seq.). CSAT: Center for substance Abuse Treatment, section 507-12 (42 U.S.C. 290bb et eg.). CSAP: Center for Substance Abuse Prevention Section 515-8 (42 U.S.C. 290aa-5 et seq). CMHS: Center for Mental Health Services, sections 506 (42 U.S.C 290aa-5) and 520-35 (42 U.S.C. 290bb-31 et seq.). Protection and Advocacy for Individuals with Mental Illness Act of 1986 as amended (42 U.S.C. 10801 et seq.); Refugee Education Assistance Act of 1980 section 501(c) (8 U.S.C. 1522 note), Pub L. 96-442; Executive Order 12341; and Disaster Relief Act of 1974, section 413, Pub L. 93-288, as amended by section 416 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub L. 100-107.

PURPOSE(s):

This umbrella system of records covers a varying number of separate sets of records used in different projects. These records are established by contractors to organize programs, obtain and pay consultants, and to provide necessary reports programs for SAMHSA. SAMHSA personnel may use records when a technical assistance consultant is needed for a specialized area of research, review, advice, etc.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSES OF SUCH USES:

1. The Department of Health and Human Services (HHS) may disclose information from this system of records to the Department of Justice, or to a court or other tribunal, when (a) HHS, or any component thereof; or (b) any HHS employee in his or her individual capacity where the Department of Justice (or HHS where it is authorized to do so) has agreed to represent the employee; or (d) the United States or any agency thereof where HHS determines that the litigation is likely to affect HHS or any of its components is a party to litigation or has an interest in such litigation, and HHS determines that the use of such records by the Department of Justice, the court or other litigation and would help in the effective representation of the governmental party, provided, however, that in each case, HHS determines that such disclosure is compatible with the purpose for which the records were collected.

2. Disclosure may be made to a congressional office from the record of an individual in response to a verified inquiry from the congressional office made at the written request of that individual.

3. SAMHSA proposes to contract with private firms for the purposes of handling logistics for conferences reviews, development of training materials and of obtaining the services of consultants. Relevant records will be disclosed to such a contractor or may be developed by the contractor for use in the project. The contractor shall be required to maintain Privacy Act safeguards with respect to such records.

4. Information in this system of records is used routinely to prepare W-2 and 1099 Forms to submit to the Internal Revenue Service and applicable State and local governments those items to be included as income to and individual.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THE SYSTEM:

STORAGE:

Records may be stored in file folders, on index cards, computer tapes and disks, microfiche, microfilm.

RETRIEVABILITY:

Information will be retrieved by name.

SAFEGUARDS:

Measures to prevent unauthorized disclosures are implemented as appropriate for each location. Each site implements personnel, physical, and procedural safeguards such as the following:

1. Authorized users: Only SAMHSA personnel working on these projects and personnel employed by SAMHSA contractors to work on this project are authorized users as designated by the system managers.

2. Physical safeguards: Records are stored in locked rooms, locked file cabinets; and/or secured computer facilities.

3. Procedural safeguards: Contractors who maintain records in this system are instructed to make no further disclosure of the records except as authorized by the system manager and permitted by the Privacy Act. Privacy Act requirements are specifically included in contracts and in agreements with grantees or collaborators participating in research activities supported by this system. HHS project directors, contract officers, and project officers oversee compliance with these requirements.

4. Implementation guidelines: DHHS Chapter 45-13 and supplementary Chapter PHS.hf: 45-13 of the General Administration Manual, and Part 6, "ADP System Security" in the HHS Information Resource Management Manual.

RETENTION AND DISPOSAL:

Records will be destroyed 3 years after they are no longer used or if payment in involved, 3 years after closeout of the contract.

SYSTEM MANAGER(s) AND ADDRESS:

The policy coordinating official for this system of records is also the System Manager. SAMHSA Contracts Officer, Substance Abuse and Mental Health Services Administration, Office of the Administrator, Office of Management, Planning, and Communications, 1 Choke Cherry Road, Rockville, Maryland 20857.

NOTIFICATION PROCEDURE:

To determine if a record exists, write to the appropriate System Manager at the address above. Provide notarized signature as proof of identity. The request should include as much of the following information as possible: (a) Full name: (b) title of project individual participated in; (c) SAMHSA project officer, and (d) approximate date(s) of participation.

RECORD ACCESS PROCEDURES:

Same as notification procedures. Requesters should also reasonably specify the record contents being sought. Individuals may also request an accounting of disclosures of their records, if any.

CONTESTING RECORD PROCEDURES:

Contact the official at the address specified under Notification Procedures above and reasonably identify the record, specify the information being contested, and state the corrective action sought, with supporting information to show how the record is inaccurate, incomplete, untimely, or irrelevant.

RECORD SOURCE CATEGORIES:

Information gathered from individual consultants and form assignment or travel documents.

SYSTEMS EXEMPTED FORM CERTAIN PROVISIONS OF THE ACT:

None.

Readers who notice any errors or omissions in the SAMHSA systems of records notices are invited to bring them to my attention at the following address:

Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, Maryland 20857

-Dated: December 17, 1993

Elaine Parry, Acting Executive Officer, Substance Abuse and Mental Health Services Administration

(FR DOC 93-31242 Filed 12-28-93; 8:45 am)

CLIENT LETTER

(Suggested Format)

Subject: RFP No. 283-12-1000 Dear {Insert Client}:

We are currently responding to the Department of Health & Human Services, Public Health Services, Substance Abuse and Mental Health Services Administration, for the procurement of a contract entitled, "Substance Abuse and Mental Health Services Administration Indefinite Delivery Indefinite Quanitity (SAMHSA IDIQ) The Government is placing increased emphasis in its procurement=s on past performance as a source selection factor. It requires that clients of entities responding to solicitations be identified and their participation in the evaluation process be requested.

Based on your knowledge concerning our work can you please complete the attached Contractor Performance Information by January 12, 2012 and forwarded it to the following address:

Contracting Officer

RFP 283-12-1000

1 Choke Cherry Road, 7-1051 Rockville, MD 20852 Your cooperation is appreciated. Any questions may be directed to: .

Sincerely, {Insert Offeror}

DHHS, SAMHSA: Final ___ Interim___ Report

CONTRACTOR PERFORMANCE INFORMATION

Contract Number:

2.

Type of Contract:

3.

Contract Value (Current plus any unexercised options):

Period of Performance (including any option periods):

5. Description of Requirement:

6.

Ratings. Summarize contractor performance and circle or type in the number below that corresponds to the performance rating for each category. Please see the attachment, which explains the rating scale.

ADVANCE \d2Comments:

Comments:

Comments:

Comments:

Comments:

7. Total score:

Evaluated by:

Agency/Organization Date ____________

Name and Title _________________________________________________ Telephone number ____________

Signature _____________________________________________ E-mail address _______________________

Contractor Performance Evaluation

Instructions for Completing Contractor Performance Information Form

Based on the rating area elements presented below and the rating guidelines on the back of this sheet, please evaluate contractor performance in each of the rating areas. On the AContractor Performance Information@ form, circle (or type in the AComments:@ area) the rating from 0 to 4 that most closely matches your evaluation of the contractor=s performance. Please add written comments for each rating. If you wish, you may attach additional comments or information. We would also appreciate your answers to the specific questions, if any, on the back of the form. Please return the form to the address indicated on the back of the form. Thank you for your time and your cooperation.

SAMHSA will use the information from this form to evaluate offerors competing for contract awards.