Att A Application.docx

RFGA: S-10000-00005295 – Survivor Investment Partnership Application and Certification Att A

ATTACHMENT A

RFGA: S-10000-005295 – Survivor Investment Partnership Application and Certification Legal Name of Applicant:

Address:

City, State, Zip:

State of Incorporation (if applicable):

Entity Type:

Contact Name:

Telephone:

Email:

Oregon Business Registry Number (if required):

Certification Office for Business Inclusion and Diversity (COBID) Certification(s) held through COBID (Check all that apply): ☐DBE, ☐MBE, ☐WBE, ☐SDVBE or ☐ESB Does Applicant plan to subcontract with a subcontractor that holds Certification through COBID? ☐ Yes ☐ No For more information on COBID: https://www.oregon.gov/biz/programs/cobid/pages/default.aspx What counties, District or geographical area will be served?

What population(s) will be served?

Attachment F contains Agency’s Districts Map for your reference Section 1 – Application

1. Please provide a summary that demonstrates how you will improve or expand services to DVSA Survivors.

2. Please provide a summary that demonstrates your ability to target DVSA services to Survivors from historically underserved populations.

3. Please provide a summary that demonstrates your ability to provide Culturally Responsive services to DVSA Survivors.

4. Please provide a summary that demonstrates your proposed use of direct Survivor Investment Dollars and how such use will improve or expand services to DVSA Survivors specifically.

5. Please provide a summary that addresses how your services will help DVSA Survivors attain self-sufficiency and prevent Survivors from returning to an abusive situation.

6. Please provide a summary that demonstrates your plan to spend the requested funding by the end of June 30, 2024.

7. Please provide a summary that demonstrates your ability to collect and disseminate aggregate data needed for reconciliation of SIP funds.

8. If Applicant is already receiving funds, please describe how these funds will be kept separate from the other funds. (This question will not be scored, for informational purposes only).

Section 2 – Certification Any individual signing below hereby certifies they are an authorized representative of Proposer and that:

1. Applicant certifies the Applicant is a new Recipient of funding for DVSA services from the Oregon Department of Human Services or expanding to provide services for a culturally specific population that Applicant is not already serving.

2. Applicant understands and accepts the requirements of RFGA S-10000-00005295. By submitting this Application, Applicant agrees to be bound by the Grant Agreement terms and conditions in Attachment B and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation as identified in RFGA S-10000-00005295.

3. Applicant acknowledges receipt of any and all Addenda to RFGA S-10000-00005295.

4. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620, and ORS chapters 316, 317 and 318.

5. Applicant and Applicant’s employees, agents, and subcontractors are not included on:

a. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf, or

b. the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/.

6. Applicant certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Applicant, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFGA. If any changes occur with respect to Applicant’s status regarding conflict of interest, Applicant shall promptly notify the State in writing.

7. Applicant certifies that, all contents of the Application (including any other forms or documentation, if required under RFGA S-10000-00005295) are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.

8. Applicant understands that any statement or representation it makes, in response to RFGA S-10000-00005295, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a “claim” {as defined by the Oregon False Claims Act, ORS 180.750(1)} made under Grant Agreement being a “false claim” {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

9. Applicant acknowledges these certifications are in addition to any certifications required in the Grant Agreement and Program Description in Attachment B at the time of Grant Agreement execution.

10. Applicant has read and is familiar with the provisions of Oregon’s Public Records Law, Oregon Revised Statutes (“ORS”) 192.311 through 192.478, and the Uniform Trade Secrets Act as adopted by the State of Oregon, which is set forth in ORS 646.461 through 646.475. Applicant understands that the Application is a public record held by a public body and is subject to disclosure under the Oregon Public Records Law unless specifically exempt from disclosure under that law. Applicant acknowledges this Application is not exempt from disclosure.

Authorized Signature

Date

5473/sml Page 9 of 34