AGE-Required Bidder Certifications Form~1.docx
DOCX document 40 KB Posted
- Attached to
- SFY27 FY26 PS Guardianship Program, GSA 4
- Solicitation number
- BD-27-1040-1040C-1040L-130979
- Issued by
- Massachusetts
About this file
This is an AGE-Required Bidder Certifications Form for the Massachusetts Executive Office of Health and Human Services' SFY27 FY26 PS Guardianship Program under GSA 4. The form must be completed and submitted as a required element of a bidder's business response, with proposals due August 12, 2026. The RFR seeks qualified service providers to deliver guardianship services to eligible individuals within a specified service area. The certification requires signatures from both the Chief Executive Officer and Chief Financial Officer (or equivalents), each attesting under pains and penalties of perjury to the accuracy and completeness of submitted information. Bidders must certify their qualifications and contract readiness, ability to begin performance by the anticipated contract start date, acceptance of all contract provisions without modification, absence of conflicts of interest, compliance with privacy and security obligations under Massachusetts General Laws, and availability of identified key personnel.
The certification form requires bidders to attest to sound financial condition, absence of outstanding liabilities to the Internal Revenue Service or government agencies, and no current or past litigation or findings of non-compliance under federal or state law. For parent companies (if applicable), similar financial certifications are required along with an unconditional guarantee of all financial and other obligations. Bidders must acknowledge their full responsibility for all Material Subcontractor performance and certify that subcontracts contain terms consistent with the contract. Material Subcontractors must submit separate certifications confirming their readiness to perform, absence of conflicts of interest, non-debarred status, completion of MassHealth Federally Required Disclosure Forms, and ability to provide additional information as required. Bidders are obligated to notify the agency of any changes to submitted statements. The RFR documentation does not disclose specific contract value, contract term, renewal options, pricing structure, incumbent provider information, or detailed evaluation criteria.
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Other files
| File | Type | Posted |
|---|---|---|
| Business Reference Form~4.docx | DOCX document | |
| PS Guardianship GSA 4 - WTO Notice.docx | DOCX document | |
| 2026 Guardianship Scope of Services~1.docx | DOCX document | |
| RFR FY26 PS Guardianship Program RFR GSA4 .docx | DOCX document |
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AGE-REQUIRED BIDDER CERTIFICATIONS
Completion of these Certifications is a required element of the Bidder’s Business Response as described in Section 5.0 of the RFR. Failure to submit this form may result in a Bidder’s response being rejected as non-responsive.
Name of Bidder: (hereinafter, “Bidder”) Chief Executive Officer (Or Equivalent): Enter name of CEO here By my signature below, I certify that the information below, and any attached statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I sign under the pains and penalties of perjury, and may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Chief Financial Officer (Or Equivalent): Enter name of CFO here By my signature below, I certify that the information below in response to Certification with Regard to Bidder Financial Condition and Certification with Regard to Bidder’s Parent Company Financial Condition and any attached statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I sign under the pains and penalties of perjury, and may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
A check in the box of each item, below, indicates an affirmative response to the certification. If one or more of the boxes are not checked, please provide an explanation on a clearly labeled separate sheet.
1. Bidder’s Qualifications and Contract Readiness |_| The undersigned certifies that the Bidder will be ready to begin performance of all services and responsibilities described in this RFR by the anticipated Contract Start Date and that the Bidder is able to completely perform all services and responsibilities at the proposed costs and fees stated in the Bidder’s cost response and by the dates specified herein.
2. Acceptance of Independent Assessment Entity Model Contract (Attachment A, Model Contract) |_| The undersigned accepts all of the provisions of Scope of Service, including the Commonwealth Terms and Conditions and the Commonwealth of Massachusetts Standard Contract Form, in their entirety and without modification.
3. Bidder’s Interests
| |_| | The undersigned certifies that the Bidder’s interest will not conflict in any manner or degree with the performance of services required under the Contract. |
| |_| | The undersigned certifies that the Bidder has submitted all of the information required under Section 5 of this RFR. The undersigned certifies that such information is complete, truthful, and accurately reflects the Bidder’s business. The undersigned certifies that they will provide any additional information required by AGE pursuant to Section 5 of this RFR. |
| |_| | The undersigned certifies that the Bidder does not now, and shall not for the duration of the Contract term, knowingly having a director, officer, partner, or person with a beneficial ownership of more than 5 percent of the Bidder’s equity, or affiliate of any of the above, who is debarred, suspended, or excluded, or from having an employment, consulting, or other agreement with an individual or entity for the provision of items and services that are significant and material to the Bidder’s obligations under the Contract. |
4. Privacy and Security (Including HIPAA) Certification |_| The undersigned certifies that the Bidder will adhere to all applicable obligations regarding the protection of personal information, as defined in M.G.L. c. 93H, and personal data, as defined in M.G.L. c. 66A, owned or controlled by AGE that the Bidder may access in connection with its performance under the Contract.
5. Certification of Key Personnel |_| The undersigned certifies that the Key Personnel identified in the Bidder’s Response to this RFR are employees, consultants, or under obligation to the Bidder such that they will be available to work on this Contract, and that they shall not be reassigned without the prior written approval of AGE.
6. Subcontractors |_| The undersigned certifies that the Bidder acknowledges its understanding that the Bidder will not be relieved of any legal obligations under any Contract resulting from this RFR as a result of any contracts with Material Subcontractors or subcontractors, that the Bidder shall be fully responsible for the Material Subcontractor’s or subcontractor’s performance, and that all Material Subcontractor agreements, subcontracts, and other agreements or arrangements for reimbursement will be in writing and will contain terms consistent with all terms and conditions of the Contract.
7. Financial Condition (If one or more of the boxes in this section are not checked, please attach an explanation on a clearly labeled separate sheet.)
| |_| | The undersigned certifies that the Bidder is in sound financial condition and is able to meet requirements set forth in the appropriate Scope of Services. |
| |_| | The undersigned certifies that the Bidder has no outstanding liabilities to the Internal Revenue Service or other government agencies. |
| |_| | The undersigned certifies that the Bidder is not the subject of any current litigation or findings of non-compliance under federal or state law. |
| |_| | The undersigned certifies that the Bidder has not been the subject of any past litigation or findings of non-compliance under federal or state law. |
8. Certification with Regard to Bidder’s Parent Company Financial Condition (If Applicable)
| |_| | The undersigned certifies that Name of Parent Company is in sound financial condition. |
| |_| | The undersigned certifies that Name of Parent Company has no outstanding liabilities to the Internal Revenue Service or other government agencies. |
| |_| | The undersigned certifies that Name of Parent Company is not the subject of any current litigation or findings of non-compliance under federal or state law. |
| |_| | The undersigned certifies that Name of Parent Company has not been the subject of any past litigation or findings of non-compliance under federal or state law. |
| |_| | The undersigned certifies that Name of Parent Company will provide an unconditional guarantee, in a form acceptable to AGE, of all financial and other obligations under the Contract. |
9. Changes to Statements |_| The undersigned acknowledges the Bidder’s obligation to notify AGE of any changes in the statements made herein.
10. Signatures Signature and date stamps, or the signature of anyone other than the provider/fiscal agent, or in the case of a legal entity, person legally authorized to sign on behalf of the entity, are not acceptable.
Signed under the pains and penalties of perjury this day of , 2026 Signature of the Chief Executive Officer (or equivalent)
Printed Name of Signatory
Date
Signed under the pains and penalties of perjury this day of , 2026 Signature of the Chief Financial Officer (or equivalent)
Printed Name of Signatory
Date
Certification with Regard to Material Subcontractor To be completed by the Bidder and each and every Material Subcontractor. A separate certification shall be submitted by each Material Subcontractor.
| |_| | We the undersigned certify that Material Subcontractor Name will be ready to begin performance of responsibilities described in this RFR, explicitly subcontracted by the Bidder to us by the contract start date, and that Material Subcontractor Name is able to perform all services and responsibilities that include: Insert description of services and responsibilities. |
| |_| | We the undersigned certify that Material Subcontractor Name’s interest does not now, and at no time will, conflict in any manner or degree with the performance of services required under the Contract. |
| |_| | We the undersigned further certify that Material Subcontractor Name does not now, and shall not for the duration of their subcontracted term, knowingly having a director, officer, partner, or person with a beneficial ownership of more than 5 percent of Material Subcontractor Name’s equity, or affiliate of any of the above, who is debarred, suspended, or excluded, or from having an employment, consulting, or other agreement with an individual or entity for the provision of items and services that are significant and material to their subcontracted obligations under the Contract. |
| |_| | The undersigned certifies that such information, as Material Subcontractor Name submitted to the Bidder is complete, truthful, and accurately reflects Material Subcontractor Name’s business regarding the services and responsibilities subcontracted by the Bidder to us. |
| |_| | The undersigned certify that Material Subcontractor Name has completed and submitted a MassHealth Federally Required Disclosure Form. |
| |_| | The undersigned certify that the Bidder and Material Subcontractor Name will provide any additional information required by AGE pursuant to this RFR. |
Bidder Signature
Printed Name of Signatory
Title
Date
Material Subcontractor Signature
Printed Name of Signatory
Title
Date
AGE-Required Bidders’ Certifications
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