3-HSS-26-019 - Agency with Choice - Attachment 2 - Non-Collusion Statement.docx
DOCX document 128 KB Posted
- Attached to
- Agency with Choice
- Solicitation number
- HSS-26-019
- Issued by
- Delaware
About this file
This document is a Non-Collusion Statement for Contract No. HSS-26-019 issued by the Delaware Health and Social Services Division of Developmental Disabilities (DDDS). The contract opportunity is for an Agency with Choice (AWC) Financial Management Services provider, with a proposal deadline of October 31, 2025, at 1:00 PM EST. The selected provider will serve as a Common Law Employer responsible for providing Financial Management Services to participants or their representatives who choose self-directed supports for personal care and respite services for individuals with intellectual and developmental disabilities living at home with their families.
The non-collusion statement requires vendors to certify they have not engaged in any anti-competitive bidding practices. The document includes sections for vendor classification, including options to identify as a Minority Business Enterprise (MBE), Woman Business Enterprise (WBE), Disadvantaged Business Enterprise (DBE), Veteran Owned Business Enterprise (VOBE), or Service-Disabled Veteran Owned Business Enterprise (SDVOBE). Vendors must also disclose any federal, state, or local government suspensions or debarments within the past five years. The form requires a signature from an authorized representative who can legally enter into a formal contract with the Delaware Division of Developmental Disabilities.
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Text version
Delaware Health and Social Services
Division of Developmental Disabilities d
Attachment 2
| CONTRACT NO.: | HSS-26-019 |
| CONTRACT TITLE: | Agency With Choice |
DEADLINE TO RESPOND: October 31, 2025, at 1:00 PM EST
NON-COLLUSION STATEMENT
This is to certify that the undersigned Vendor has neither directly nor indirectly, entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free competitive bidding in connection with this proposal, and further certifies that it is not a sub-contractor to another Vendor who also submitted a proposal as a primary Vendor in response to this solicitation submitted this date to the State of Delaware, Division of Developmental Disabilities (DDDS).
It is agreed by the undersigned Vendor that the signed delivery of this bid represents, subject to any express exceptions set forth at Attachment 3, the Vendor’s acceptance of the terms and conditions of this solicitation including all specifications and special provisions.
NOTE: Signature of the authorized representative MUST be of an individual who legally may enter his/her organization into a formal contract with the State of Delaware, Division of Developmental Disabilities (DDDS).
Corporation
Partnership
Individual
COMPANYNAME (Check one)
NAME OF AUTHORIZED REPRESENTATIVE
(Please type or print)
SIGNATURE TITLE
COMPANY ADDRESS
PHONE NUMBER FAX NUMBER
| EMAIL ADDRESS | ______________________________ | ||
| STATE OF DELAWARE | |||
| FEDERAL E.I. NUMBER | LICENSE NUMBER_____________________________ |
COMPANY CLASSIFICATIONS:
CERT. NO.: __________________
| Certification type(s) |
| Circle all that apply |
| Minority Business Enterprise (MBE) | |
| Yes | No |
| Woman Business Enterprise (WBE) | |
| Yes | No |
| Disadvantaged Business Enterprise (DBE) | |
| Yes | No |
| Veteran Owned Business Enterprise (VOBE) | |
| Yes | No |
| Service-Disabled Veteran Owned Business Enterprise (SDVOBE) | |
| Yes | No |
[The above table is for informational and statistical use only.]
PURCHASE ORDERS SHOULD BE SENT TO:
(COMPANY NAME)
ADDRESS
CONTACT
PHONE NUMBER FAX NUMBER
EMAIL ADDRESS
AFFIRMATION: Within the past five years, has your firm, any affiliate, any predecessor company or entity, owner, Director, officer, partner or proprietor been the subject of a Federal, State, Local government suspension or debarment?
YES NO if yes, please explain image1.png image2.png
File details come from the government source that posted it. Updated .