Appendix D.docx

APPENDIX D

County of Santa Clara – Behavioral Health Services Department RFSQ-BHS-FY23-0108: Substance Use Residential Withdrawal Management Services

OFFEROR’S QUESTIONNAIRE

All information requested in the Questionnaire shall be furnished by the Offeror and shall be submitted with the response to this Request for Statement of Qualifications (RFSQ). Statements shall be complete, accurate, and in the form requested. Any omissions, inaccuracies, or misstatements may be cause for the rejection of a response in whole or part.

1. Name of Offeror exactly as it is to appear on a service agreement, and address at which Offeror would receive notice under the agreement:

2. Offeror, if selected, is:

☐ An Individual;

☐ A Corporation; or ☐ Other: Click or tap here to enter text. If "Other", attach explanation.

3. If a corporation, answer the following:

A. When incorporated?

B. In what state?

C. Authorized to do business in California?

If so, what date?

Years:

Stock

Vice President:

Years:

Stock

Secretary:

Years:

Stock

Treasurer:

Years:

Stock

Other:

Years:

Stock

Stock %:

Member:

Stock %:

Member:

Stock %:

Member:

Stock %:

F. Name, address and shares of stock held by other principal stockholders: (A Principal Stockholder is defined as a stockholder who holds 10% or more of standing stock of the corporation).

4. Has Offeror ever had a bond or surety denied, canceled, or forfeited?

YES ☐ NO ☐ If yes, state name of bonding company, date, amount of bond and reason for such cancellation or forfeiture in an attached statement.

5. Has Offeror ever declared bankruptcy or been declared bankrupt?

YES ☐ NO ☐ If yes, state date, court jurisdiction, docket number, amount of liabilities and amount of assets.

6. Has your organization ever received a “Notice of Intent to Consider Corrective Action” or “Notice of Corrective Action” letter due to non-compliance of contract provisions for services provided on behalf of the County?

YES ☐ NO ☐

7. Have any County Agreements held by Offeror for services similar to those listed in this RFSQ ever been canceled or terminated?

YES ☐ NO ☐

· If yes, please confirm the reason(cancelation, failure, or refusal to complete a contract, other) and

· indicate which organization/individual/entity initiated the process.

8. Has Offeror ever been sued for issues pertaining to fee payment, performance, or any other issues relating to the services listed in the RFSQ?

YES ☐ NO ☐ If yes, give details.

9. Is Offeror currently engaged or has been engaged in any litigation which will or could affect its ability to pay fees or perform the services required by a service agreement resulting from this RFSQ?

YES ☐ NO ☐ If yes, give details.

10. List any lawsuits filed against Offeror, Offeror’s subsidiaries, parent, other corporate affiliates, or subcontractors in the past five (5) years and the outcomes of those lawsuits. Identify the parties involved and circumstances. Also, describe any civil or criminal litigation or investigations pending against the Offeror.

11. List at least two persons, firms and/or governmental bodies with which Offeror has had agreements with that have since concluded, and thus are no longer active customers of Offeror. Provide a contact person’s name and phone number for each former customer.

12. State the number of persons employed by Offeror who are engaged in providing the services listed in this RFSQ. Indicate what percentages of these employees are employed locally and what percentage of those employees would directly service an account resulting from this RFSQ. Of the employees indicated, what percentage is management and what percentage are operational?

13. Please list and describe any audits and investigations in which the Offeror was or is the subject.

The undersigned hereby declares under penalty of perjury that all statements, answers and representations made in this questionnaire are true and accurate, including all supplementary statements hereto attached. In the case of a corporate Offeror, the signature of one duly authorized representative is sufficient.

Signature

(Please print or type name)

Title

Signature

(Please print or type name)

Title