Appendix A-Cover Sheet rev 2.4.26.docx

Santa Clara County –Behavioral Health Services Department RFP-BHS-FYXX-XXXX: RFP Title

APPENDIX A

County of Santa Clara – Behavioral Health Services Department RFP-BHS-FY26-0513: Independent Living Home Habitability Improvements Project

COVER SHEET

Agency or Name:

Mailing Address:

City, State, and Zip Code:

Telephone Number: Fax Number:

Name & Title of Contact Person:

Telephone Number: Fax Number:

Email Address:

SECTION I

Requested Forgivable Loan Amount (Subject to County review and approval)

Amount: $

Initials:

SECTION II

Please read before continuing: If ANY item in Section II is marked NO, the Applicant is NOT eligible for this funding opportunity.

Applicant Eligibility

Property Eligibility

ACTION REQUIRED: Proof of ownership or legal authority AND photos of requested repairs are required.

Applicant Certification

Please read before continuing: If ANY item in Section II is marked NO, do NOT submit an application. The Applicant is NOT eligible for this funding opportunity.

SECTION III

Applicant understands, agrees, and warrants:

1. That applicant has carefully read and fully understands the information that was provided by the County to serve as the basis for submission of this proposal;

2. That applicant has the capability to successfully undertake and complete the responsibilities and obligations of the proposal being submitted;

3. That all information contained in the proposal is true and correct to the best of applicant’s knowledge;

4. That applicant signed a non-collusion affidavit herewith attached with the proposal;

5. That applicant did not receive unauthorized information from any County staff or consultant during the proposal period except as provided for in the RFP packet, addenda thereto, or the pre-proposal conference;

6. That by submission of this proposal, the applicant acknowledges that the County has the right to make any inquiry it deems appropriate to substantiate or supplement information supplied by the applicant, and applicant hereby grants the County permission to make said inquiries, and to provide any and all requested documentation in a timely manner; and

7. That applicant offers and agrees to furnish the goods and services specified in the proposal.

A proposal will not be accepted unless it is signed in ink in the designated signature space below.

I hereby certify that I am an authorized representative of the above agency and to the best of my knowledge and belief that:

The data in this response is true and accurate; the Applicant has investigated all aspects of the RFP; the Applicant is aware of the applicable facts pertaining to the RFP process, procedures, and requirements; the Applicant has read and understands the RFP; the Applicant has the capability to successfully undertake and complete the responsibilities and obligations of their response being submitted; the agency will be able to meet all of the minimum proposal requirements as specified in this RFP; and the Applicant will comply with the necessary certifications and assurances if a contract is awarded.

This shall constitute a warranty, the falsity of which entitles the County to pursue any remedy authorized by law, including the right to declare any contract made as a result thereof to be void.

By signing below, the submission of a proposal shall be deemed a representation and certification by the applicant that has investigated all aspects of the RFP; that it is aware of the applicable facts pertaining to the RFP process, its procedures and requirements; and that it has read and understands the RFP. No request for modification of the proposal shall be considered after its submission on the grounds that the applicant was not fully informed as to any fact or condition.

If applicant is an INDIVIDUAL, sign here:

Date Applicant’s Signature

Applicant's Typed Name and Title

If applicant is a CORPORATION, the duly authorized officer(s) shall sign here:

The undersigned certify that they are respectively:

and

Title

Title of the CORPORATION named below; that they are designated to sign this proposal cost form by resolution or by the Secretary of State's certificate of authorization, for and on behalf of the below named CORPORATION, and that they are authorized to execute same for and on behalf of said CORPORATION.

Corporation Name (type or print)

By:

Date:

Title:

By:

Date:

Title: