4-HSS-26-048- Attachment 2 - Non-Collusion Stmt.docx
DOCX document 129 KB Posted
- Attached to
- PROMISE Personal Care Services
- Solicitation number
- HSS-26-048
- Issued by
- Delaware
About this file
This is a Non-Collusion Statement form issued by the Delaware Department of Health and Social Services, Division of Substance Abuse and Mental Health (DSAMH), for the PROMISE Personal Care Services contract (HSS-26-048). The statement certifies that bidding vendors have not engaged in collusion, price-fixing, or other anti-competitive conduct in connection with their proposal submission. The proposal deadline is January 12, 2026, at 1:00 PM EST. The form requires completion by an authorized representative of the bidding organization who is legally empowered to enter into a binding contract with the State of Delaware on behalf of their company.
The Non-Collusion Statement form requests standard vendor information including company name, authorized representative name and signature, title, address, contact information, and federal Employer Identification Number and license number. The form includes checkboxes for vendors to self-identify their business classifications, including Minority Business Enterprise (MBE), Woman Business Enterprise (WBE), Disadvantaged Business Enterprise (DBE), Veteran Owned Business Enterprise (VOBE), and Service Disabled Veteran Owned Business Enterprise (SDVOBE) status with corresponding certification numbers. The form also includes an affirmation section requiring vendors to disclose whether their firm or any affiliated entities, predecessors, owners, directors, officers, partners, or proprietors have been subject to federal, state, or local government suspension or debarment within the past five years, with a requirement to explain any affirmative responses.
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Delaware Health and Social Services
Division of Substance Abuse and Mental Health d
Delaware Health and Social Services
Division of Substance Abuse and Mental Health d
Attachment 2
| CONTRACT NO.: | HSS-26-048 |
| CONTRACT TITLE: | PROMISE Personal Care Services |
DEADLINE TO RESPOND: Due 01/12/2026, 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 Substance Abuse and Mental Health
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 Substance Abuse and Mental Health.
Corporation
Partnership
Individual
COMPANY NAME __________________________________________________________________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 .