Exhibit_E.3__Subcontractor_Proposal_Information_Checklist.doc

Provider Enrollment and Oversight

75FCMC18R0014

Exhibit E.3

PEO IDIQ SUBCONTRACTOR Proposal Information Checklist

Each subcontractor to a prime contractor shall complete the following checklist for the PEO IDIQ and Site Verification Services task order proposal as applicable. This submission will allow CMS to more readily identify various aspects of the proposal. Please check the appropriate items and provide an explanation, if necessary.

1) Prime Offeror’s Name: _________________________________ (Who you are subcontracting with under this submission)

2) Subcontractor company name, address, point of contact and telephone number

In accordance with the North American Industry Code 541990, indicate the company’s business size:

_____ Large Business

_____ Small Business – if so, please indicate any applicable socioeconomic status (i.e. WoSB, HubZone)

3) If a newly formed company, provide name and address of parent companies forming the new entity:

a. __________________ b.__________________

4) Dun & Bradstreet, Data Universal Numbering System (DUNS) No. ____________

5) Productive Hours for Exempt and Non-Exempt Employees ________

6) Description of Services Being Provided for the Prime for each Performance Requirement:

Ex. Fingerprinting

Please complete the below only if the anticipated subcontract arrangement for any performance requirement is a Cost-Type or non-commercial T&M arrangement. The subcontractor shall have an acceptable or adequate accounting system. Evidence of this shall be provided with the subcontract proposal submission.

Has your accounting system been deemed adequate or acceptable for use on Government cost reimbursement or non-commercial T&M contracts? Yes _____ No _____

If yes, give name and address of agency that deemed the system adequate or acceptable:

7) List of proposed subcontractors (if applicable):

(i.e. Large, SDVOSB, 8a)**

**If the NAICS above does not fit with the subcontract requirement, provide the appropriate NAICS and why it was chosen.

8) PEO IDIQ - Site Verification Services Task Orders

a) Proposing on SVS Eastern Region Task Order as Subcontractor?

___yes (complete 9 below) ___ no (do not fill out 9 below)

b) Proposing on SVS Western Region Task Order?

___yes (complete 10 below) ___ no (do not fill out 10 below)

9) Description of services being provided under the SVS Eastern Region:

Number of FTEs and Hours Proposed as the Subcontractor on the Eastern Region:

TOTAL PROPOSED FTEs:

SVS Eastern Region

OY1

Direct

Subs

Total

TOTAL PROPOSED HOURS:

SVS Eastern Region

OY1

Direct

Subs

Total

10) Description of services being provided for the SVS Western Region:

Number of FTEs and Hours Proposed as the Subcontractor:

TOTAL PROPOSED FTEs:

SVS Western

OY1

Direct

Indirect

Subs

Total

TOTAL PROPOSED HOURS:

SVS Western

OY1

Direct

Indirect

Subs

Total