Appendix E rev 07142025.docx

APPENDIX E

County of Santa Clara – Behavioral Health Services Department

Declaration Submittal Form Solicitation No:

RFSQ-BHS-FY24-0084

Solicitation Title:

Program Evaluator Services

Legal Company Name (include d/b/a if applicable):

Federal Tax Identification Number:

Type of Business (Check One):

☐ Individual Proprietorship ☐ Corporation ☐ Partnership ☐ Other: _______________________ Company Address (If declaring Local Preference, address must be in Santa Clara County):

Company Contact Person:

Company Internet Web Address:

Email Address:

Phone Number:

NON-COLLUSION DECLARATION

The party making the foregoing proposal declares that the proposal is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the bid is genuine and not collusive or sham; that the proposer has not directly or indirectly induced or solicited any other proposer to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any proposer or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the proposer has not in any manner directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the proposer or any other proposer, or to fix any overhead, profit, or cost element of the bid price, or of that of any other proposer, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true; and, further, that the proposer has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid.

DECLARATION OF COMPLIANCE WITH EQUAL OPPORTUNITY/NONDISCRIMINATION AND WAGE THEFT PREVENTION The County of Santa Clara does not tolerate acts of discrimination or wage theft as defined below. Accordingly, Santa Clara County Board of Supervisors’ Policy Manual, Section 5.5.5.4, includes the following:

Equal Opportunity/Nondiscrimination No party contracting with the County will discriminate against any subcontractor, employee, or applicant for employment, because of age, race, color, national origin, ancestry, religion, sex, gender, sexual orientation, mental disability, physical disability, medical condition, political beliefs, organizational affiliations, or marital status with respect to recruitment, selection for training including apprenticeship, hiring, employment, assignment, promotion, layoff, rates of pay or other forms of compensation. It is further the policy of the County that no party contracting with the County may discriminate in the provision of services under the contract because of age, race, color, national origin, ancestry, religion, sex, gender, sexual orientation, mental disability, physical disability, medical condition, political beliefs, organizational affiliations, or marital status.

It is the policy of the County that parties contracting with the County must comply with all applicable federal, state, and local pay equity laws, including, but not limited to, the Federal Equal Pay Act, Title VII of the Civil Rights Act of 1964, the California Fair Pay Act, and the California Fair Employment and Housing Act. A potential contractor that has submitted a formal bid to provide goods and/or services to the County may be disqualified if the potential contractor has been found, by a court, arbitrator, arbitral panel, or a final administrative action of an investigatory government agency, to have violated applicable pay equity laws in the five years prior to the submission of a bid to provide goods and/or services. A current contractor found by a court, arbitrator, arbitral panel, or final administrative action of an investigatory government agency to have violated applicable pay equity laws, in the five years prior to or during the term of the contract with the County, may be in material breach of its contract with the County if the violation is not fully disclosed and/or satisfied per County guidelines and contract requirements. Such breach may serve as a basis for contract termination and/or any other remedies available under law, including a stipulated remediation plan. Pay equity violations disclosed by a contractor or potential contractor will be assessed on a case-by-case basis in light of the totality of the circumstances, including whether the violation is serious, repeated, willful, and/or pervasive, the size of the contractor, and any mitigating factors.

Wage Theft Prevention It is the policy of the County that all parties contracting with the County must comply with all applicable federal, state, and local wage and hour laws, including, but not limited to, the Federal Fair Labor Standards Act, the California Labor Code, and any Minimum Wage Ordinance enacted by the County or any city within the County of Santa Clara. A potential contractor that has submitted a formal or informal bid to provide goods and/or services to the County may be disqualified if the potential contractor has been found, by a court or by final administrative action of an investigatory government agency, to have violated applicable wage and hour laws in the five years prior to the submission of a bid to provide goods and/or services. A current contractor found by a court or by final administrative action of an investigatory government agency to have violated applicable wage and hour laws, in the five years prior to or during the term of the contract with the County, may be in material breach of its contract with the County if the violation is not fully disclosed and/or satisfied per County guidelines and contract requirements. Such breach may serve as a basis for contract termination and/or any other remedies available under law, including a stipulated remediation plan.

Please complete the certification below.

Check mark here if Proposer has no violations to disclose pursuant to Board Policy Manual § 5.5.5.4.

Check mark here if Proposer has been found by a court or final administrative action of an investigatory government agency to have violated federal, state, or local wage and hour laws within the last five (5) years.

Check mark here if Proposer has included in the proposal response the following for each violation: (1) a copy of the court order and judgment and/or final administrative decision; and (2) documents demonstrating either that the order/judgment has been satisfied, or, if the order/judgment has not been fully satisfied, a written and signed description of proposer’s efforts to date to satisfy the order/judgment.

DECLARATION OF COMPLIANCE WITH THE LEVINE ACT

Proposer certifies that it will comply, and will ensure that its agents (as that term is defined under California Government Code section 84308(h)) and its subcontractors identified in this proposal and/or later identified in an agreement with the County (“Subcontractors”) comply, with Government Code section 84308 (“Levine Act”), which (1) requires a party to a proceeding involving certain contracts to disclose on the record of the proceeding any contribution, as defined by Government Code section 84308(a)(6), of more than $500 that the party or their agent has made to any member of the County Board of Supervisors or any Other Elected County Officer, within the prior 12 months, and (2) prohibits a party to a covered proceeding from making a contribution, as defined by Government Code section 84308(a)(6), of more than $500 to any Elected County Officer during the proceeding and for 12 months following the final decision in the proceeding. Proposer agrees to submit any disclosures required to be made under the Levine Act at https://www.sccgov.org/levineact. If the contract awarded under this solicitation is of the type subject to the Levine Act and is to be considered or voted upon by the County’s Board of Supervisors, the Proposer shall complete the Levine Act Contractor Form: Identification of Subcontractors and Agents, and if applicable, shall ensure that any Subcontractor completes the Levine Act Subcontractor Form: Identification of Agents, and the Proposer must ensure that all forms are submitted to the County prior to execution of the contract.

The undersigned declares that he or she is an official/agent of responding firm or individual and is empowered to represent, bind, and execute contracts on behalf of the firm or individual. The undersigned declares under penalty of perjury, under the laws of the State of California, that all statements in this Submittal Form and response are true and correct, with full knowledge that all statements are subject to investigation and that any incomplete, unclear, false or dishonest response may be grounds for denial or revocation of the accompanying bid or proposal and may result in being barred from doing business with the County of Santa Clara as well as additional legal consequences.

Proposer’s Authorized Representative Signature:

Print Name:

Title:

Date:

Revised June 26, 2025