8-HSS-26-047 - BEHAVIORAL HEALTH NUTRITION SERVICES - Attachment 6 - Subcontractor Information Form.docx

DOCX document 126 KB Posted

Attached to
BEHAVIORAL HEALTH NUTRITION SERVICES
Solicitation number
HSS-26-047
Issued by
Delaware

About this file

This is a Subcontractor Information Form attachment for the Delaware Health and Social Services Division of Substance Abuse and Mental Health's Behavioral Health Nutrition Services procurement (Contract No. HSS-26-047). The form serves as a template for proposing vendors to identify and document any subcontractors they intend to utilize in delivering behavioral health nutrition services to individuals with serious mental illness and substance use disorders. The form requires vendors to provide subcontractor company information, including mailing address and relevant certifications, and requests a detailed description of the work the subcontractor will perform as part of the overall service delivery.

The form includes sections for certifying subcontractor business classifications, including Women Business Enterprise (WBE), Minority Business Enterprise (MBE), Disadvantaged Business Enterprise (DBE), Veteran Owned Business Enterprise (VOBE), and Service Disabled Veteran Owned Business Enterprise (SDVOBE) designations. Both the proposing vendor and the subcontractor must provide signed acknowledgments and authorizations on the form, with separate forms required for each subcontractor. This document is a standard procurement requirement designed to ensure transparency regarding supply chain composition and to facilitate tracking of utilization of certified business enterprises in state contracting.

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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 6

SUBCONTRACTOR INFORMATION FORM

PART I – STATEMENT BY PROPOSING VENDOR

1. CONTRACT NO.

HSS-26-047

2. Proposing Vendor Name:

3. Mailing Address

4. SUBCONTRACTOR

a. NAME

4c. Company OSD Classification:

Certification Number: _____________________

b. Mailing Address:

4d. Women Business Enterprise |_| Yes |_| No 4e. Minority Business Enterprise |_| Yes |_| No 4f. Disadvantaged Business Enterprise |_| Yes |_| No 4g. Veteran Owned Business Enterprise |_| Yes |_| No 4h. Service Disabled Veteran Owned Business Enterprise |_| Yes |_| No

5. DESCRIPTION OF WORK BY SUBCONTRACTOR

6a. NAME OF PERSON SIGNING

7. BY (Signature)
8. DATE SIGNED

6b. TITLE OF PERSON SIGNING

PART II – ACKNOWLEDGEMENT BY SUBCONTRACTOR

9a. NAME OF PERSON SIGNING

10. BY (Signature)
11. DATE SIGNED

9b. TITLE OF PERSON SIGNING

* Use a separate form for each subcontractor image1.png image2.png

File details come from the government source that posted it. Updated .