6-Attachment 4 - Bidders Form Attestations (fillable forms).pdf

Attachment 4: Bidders Form and Attestations

Council on Aging of Southwestern Ohio Bidder’s Information Form for RFP 001-26

APPLICANT NAME: ____________________________________________________________

Type or Print Legibly - Each box is limited on characters.

Attachments should be clearly marked with the Question or Item # to which the Attachment pertains and affixed to the end of the BIDDER'S INFORMATION form in order by question/item #.

1. Legal Name of Business

(If different from W-9 form, attach written explanation)

2. Doing Business As (dba) Name (if different from Legal Name)

3. Federal Tax Identification Number (Social

Security Number OR Employer Identification Number)

4. NPI #

5. Main Business Address (Physical location) Street Address

City, State, Zip Code

County

7. Mailing Address

(if different from Main Business Address)

Attention

Address

County City, State, Zip Code

8. Executive In Charge’s Name & Title

9. Executive in Charge’s E-mail Address

10. Business Phone Number (including area code)

11. Business Fax Number (including area code)

12. Organization’s Website Address (if applicable)

13. Indicate the appropriate ownership structure of the business

Private Private/Non-profit Publicly Traded

Charitable/Religious Public/Government Other (Specify)

14. Have any of the owners, officers, directors, or any other person who has control over the business been convicted of a felony under local, state, or federal law?

No

Yes - If yes, identify the offender and offense below.

Name Title

Offense(s)

Year of Conviction

To list multiple persons/convictions, attach a separate page.

15. Have any of the owners, officers, directors, or any other person who has control over the business ever applied for, or held a license for a business, trade or profession?

Yes - If yes, identify the person by title, license, and issuing authority.

No

16. Have any of the owners, officers, directors, or any other person who has control over the business ever been denied such a license, had that license revoked or suspended, or been disciplined with respect to that license?

Yes - If yes, explain.

No

17. Have any of the owners, officers, directors, or any other person who has control over the business been disciplined for, or have any actions ever been taken against them by any public licensing authority or professional organization for any breach of ethics or unprofessional conduct or failure to make required disclosures?

Yes - If yes, explain.

No

18. Are all the business’ federal, state, and local income and employment taxes current?

(Federal employment taxes include Medicare and Social Security taxes)

Yes

No - If no, explain

19. Within the past three years, if the business was responsible for remitting withholding taxes or sales taxes, has it paid such taxes in a timely manner?

Yes

No - If no, explain

20. Within the past three years has the business, as the result of any audits or monitoring reviews of state funded programs, been required to submit a corrective action plan?

No

Yes - If yes, submit a copy of the monitoring report and the corrective action plan. Applicants do NOT have to submit copies of reports issued by COA or corrective action plans already submitted to COA.

21. Has the business ever failed to pay any government–insured debt or any debt owed to a government entity?

Yes - If yes, please identify

No

Council on Aging of Southwestern Ohio

Bidder’s Information Form for RFP 001-26

APPLICANT NAME: ____________________________________________________________

22. Name of individual authorized to sign a Provider Agreement, if issued

Authorized Signatory’s contact information for Provider Agreement, if issued

Name (type/print)

Title (type/print)

Street or P.O. Box

City, State, Zip Code

Phone Number (including area code)

E-mail Address

STATEMENT OF UNDERSTANDING

The undersigned acknowledges and understands that Council on Aging of Southwestern Ohio (“COA”) complies with Ohio’s public record laws and regulations; therefore any information submitted pursuant to this process may become a public record. The undersigned hereby waives any right to privacy of any information provided herein. The undersigned acknowledges and understands any information that is proprietary or a trade secret to the business must be marked and designated as such prior to submitting it in this process. The undersigned further acknowledges that the burden of proof that the document(s) is proprietary/trade secret rests with the applicant.

The undersigned affirms that the information contained in this Application is true to the best of the undersigned’s knowledge and belief, and acknowledges and agrees that COA shall have the right to verify the same to its satisfaction.

The undersigned also affirms that the undersigned has read and understands the Request for Proposal, ESP Rules, Conditions of Participation, and all applicable Service Specifications. The undersigned further understands that implementation of and adherence to the Rules and Service Specifications in the delivery of authorized services, and adherence to all reporting requirements will be binding in accordance with the Provider Agreement in order to receive reimbursement for services delivered.

The undersigned acknowledges and agrees that COA, in its sole and absolute discretion, reserves the right to reject any or all Proposals and any part or parts of any Proposal, and also the right to waive any informalities or irregularities in any Proposal, and also the right to modify inconsistencies in any Proposal. Any Proposal which, in COA’s sole and absolute discretion, does not meet the requirements, is incorrect, incomplete, irregular, conditional, obscure, illegible or which contains additions not requested or irregularities of any kind may be rejected.

The undersigned acknowledges and agrees that COA, in its sole and absolute discretion, reserves the right to award a Service Provider Agreement to any applicant, notwithstanding applicant’s scores, in order to assure services are available and the needs of the program are being met.

The undersigned hereby acknowledges she/he has read and understands all requirements and specifications of the Request for Proposal, including Appendices and Attachments; and accepts the procedures, evaluation criteria, mandatory contract terms and conditions, and all other administrative requirements set forth in this Request for Proposal.

Signature ( Electronic Signature or Sign in Blue Ink) Date

Print/Type Name Print/Type Title

BIDDER’S CERTIFICATION OF PAYMENT OF PERSONAL PROPERTY TAX

STATE OF COUNTY

Before me, a Notary Public, in and for said County and State, personally appeared who, being duly sworn that he/she is the owner or an officer vested with the authority to commit said company to contractual obligations and having been awarded a public contract let by competitive bid, and that by this statement, states that at this time neither he/she nor the corporation is charged with any delinquent personal property taxes on the general tax list of personal property of any county, or that attached hereto is a list of all delinquent personal property taxes charged against him/her of the corporation.

Name of Company ______________________________________________________________

By __________________________________________________________________________

Signature

Sworn before me and signed in my presence the ______day of _________, 20 .

Notary Public Signature

This certification is in compliance with Section 5719.042 of the Ohio Revised Code which requires a certification of delinquent personal property tax by any successful bidder prior to the execution of the contract of a political subdivision; and in the event there are any due and unpaid delinquent taxes, a copy of this statement shall be transmitted to the County Treasurer within 30 days.

DEBARMENT, SUSPENSION, INELIGIBILITY AND EXCLUSION CERTIFICATION

I certify that the entity identified below has not been debarred, suspended, or otherwise found ineligible to receive funds by any organization of the executive branch of the federal government.

I further certify that should any notice of debarment, suspension, ineligibility, or exclusion be received by the organization, Council on Aging of Southwestern Ohio will be notified immediately.

Entity:

Type name of person authorized to sign Title

Signature Date signed

NON-COLLUSION AFFIDAVIT

STATE OF

COUNTY OF SS.

being first duly sworn, deposes and says that he/she is __________________________________ of

(sole owner, partner, president, etc.)

the party making the foregoing proposal or bid; that such bid is genuine and not collusive or sham; that said bidder has not colluded, conspired, connived, or agreed, directly or indirectly, with any bidder or person to put in a sham bid, or that such other person shall refrain from bidding and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference, with any person, to fix the bid price affiant or any other bidder, or to fix any overhead, profit or cost element of said bid price, or of that of any other bidder, or to secure any advantage against Council on Aging of Southwestern

Ohio or any person or persons interested in the proposed contract; and that all statements contained in said proposal or bid are true; and further that such bidder has not, directly or indirectly submitted this bid, or contents thereof, or divulged information relative thereto any association or to any member or agent thereof.

AFFIANT

Sworn to and subscribed before me this day of 20___.

NOTARY PUBLIC

My commission expires: