Appendix F-Proposer's FEIN and License Information Form.docx
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- Solicitation number
- RFP-BHS-FY26-0513
- Issued by
- Santa Clara County, California
About this file
This is a Proposer's FEIN and License Information Form for the County of Santa Clara Behavioral Health Services Department's RFP-BHS-FY26-0513: Independent Living Home Habitability Improvements Project. The form requires all offerors to submit complete and accurate information regarding their legal business name, Federal Employer Identification Number (FEIN), California Secretary of State business registration, and relevant professional licenses. Proposers must disclose licenses held with the Medical Board of California and Board of Behavioral Sciences, as well as facility provider licenses through the California Department of Social Services for care facilities, the California Department of Health Care Services for substance use treatment facilities, and the California Department of Public Health for healthcare facilities. All respondents must provide signatures under penalty of perjury certifying the accuracy and truthfulness of all submitted information.
The County anticipates awarding forgivable loans to qualified operators of unlicensed independent living homes serving individuals with serious mental illness through this one-time funding opportunity. The project aims to improve habitability and safety in shared independent living homes through improvements such as ADA-compliant bathroom updates, kitchen and bathroom remodels, appliance replacements, fire system upgrades, painting, flooring, and furniture replacement to meet HUD housing quality standards. The anticipated contract term runs from execution through June 30, 2027, allowing time for completion of County-approved improvements, required inspections, and compliance verification for loan forgiveness. Multiple awards are anticipated, and operators must demonstrate legal operation, willingness to grant the County first right of refusal for future vacancies, and assurance that improvements will prevent closure or increase bed capacity.
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APPENDIX F
County of Santa Clara – Behavioral Health Services Department RFP-BHS-FY26-0513: Independent Living Home Habitability Improvements Project
PROPOSER’S FEIN AND LICENSE INFORMATION FORM
All information requested in the Form shall be furnished by the Offeror and shall be submitted in response to this electronic solicitation. Information 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. Legal name and Federal Employer Identification Number (FEIN) of Offeror exactly as it appears on the W9 (include DBA, if applicable): ___________________________________________________________
2. What is your business name under the California Secretary of State: ___________________________________________________________
3. Do you have a license with the Medical Board of California?
☐ Yes License Type: _________________________ License Number: _______________________ ☐ No, I am an individual without a license with the Medical Board of California ☐ Not applicable (contracting with an organization)
4. Do you have a license with the Board of Behavioral Sciences?
☐ Yes License Number: ________________________ ☐ No, I am an individual without a license with the Board of Behavioral Sciences ☐ Not applicable (contracting with an organization)
5. Are you a Care Facility Provider (licensed through the California Department of Social Services)?
☐ Yes Facility Number (must contain 9 digits): ________________________ Licensed Bed Count: ________________________________________ ☐ No
6. Are you a Substance Use Treatment Facility Provider (licensed or certified by California Department of Health Care Services)?
☐ Yes License/Certification Type: ________________________________ License Status: _________________________________________ Licensed Bed Count: _____________________________________ ☐ No
7. Are you a Healthcare Facility Provider (licensed through the California Department of Public Health)?
☐ Yes License Number: ___________________________ License Facility ID: __________________________ License Status: ____________________________ Licensed Bed Count: ________________________ ☐ No
The undersigned hereby declares under penalty of perjury that all statements, answers and representations made in this form are true and accurate.
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Last Reviewed and Approved by Counsel on 12/04/2024
File details come from the government source that posted it. Updated .