5749 - Attachment C - Info and Certification Sheet.pdf

Procurement S-10000-00007742 – CBO Collective Lead Organization for Child, Youth, and Family Support Att C

DAS Procurement Services, Version 1.0 – August 16, 2021 Page 1 of 3

ATTACHMENT C — OFFEROR INFORMATION AND

CERTIFICATION SHEET

Legal Name of Offeror:

Address: City, State, Zip:

State of Incorporation: Entity Type:

Contact Name: Telephone: Email:

Oregon Business Registry Number (if required):

Any individual signing below hereby certifies they are an authorized representative of Offeror and that:

1. Offeror understands and accepts the requirements of this PROCUREMENT. By submitting a Offer, Offeror agrees to be bound by the Contract terms and conditions in Attachment A and as modified by any Amendment, except for those terms and conditions that Agency has reserved for negotiation, as identified in the PROCUREMENT.

2. Offeror acknowledges receipt of any and all Amendments to this PROCUREMENT.

3. Offer is a Firm Offer for 180 days following the Opening.

4. If awarded a Contract, Offeror agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Contract.

5. I have knowledge regarding Offeror’s payment of taxes and by signing below. I hereby certify that, to the best of my knowledge, Offeror is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

6. Offeror does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Offeror does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owned or an emerging small business. If applicable, Offeror has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into a contract with an anticipated contract price of $150,000 or more with a Offeror that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.

7. Offeror complies with ORS 652.220 and does not unlawfully discriminate against any of Offeror’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class. “Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.

https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx

Procurement S-10000-00007742 – CBO Collective Lead Organization for Child, Youth, and Family Support Att C

DAS Procurement Services, Version 1.0 – August 16, 2021 Page 2 of 3

Contractor’s continuing compliance constitutes a material element of this Contract and a failure to comply constitutes a breach that entitles Agency to terminate this Contract for cause.

Contractor may not prohibit any of Contractor’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Contractor may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

8. Offeror is not engaged in the provision of broadband Internet access service, or if at any time Offeror is engaged in or may engage in the provision of broadband Internet access service Offeror is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Contract.

9. Offeror and Offeror’s employees, agents, and subcontractors are not included on:

A. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at:

https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or

B. the government wide exclusions lists in the System for Award Management found at:

https://www.sam.gov/portal/

10. Offeror certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Offeror, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the PROCUREMENT. If any changes occur with respect to Offeror’s status regarding conflict of interest, Offeror shall promptly notify the State in writing.

11. Offeror certifies that all contents of the Offer (including any other forms or documentation, if required under this PROCUREMENT) and this Offer Certification Sheet are truthful and accurate and have been prepared independently from all other Offerors, and without collusion, fraud, or other dishonesty.

12. Offeror understands that any statement or representation it makes, in response to this PROCUREMENT, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Contract being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.sam.gov/portal/

Procurement S-10000-00007742 – CBO Collective Lead Organization for Child, Youth, and Family Support Att C

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13. Offeror acknowledges these certifications are in addition to any certifications required in the Contract and Statement of Work in Attachment A at the time of Contract execution.

14. 15. 16.

Authorized Signature Date

17. 18. 19.

(Printed Name and Title)

20. 21.