Att A Application~1.docx

RFGA: S-10000-00009881 – Survivor Investment Partnership Application and Certification Att A

ATTACHMENT A

RFGA: S-10000-00009881 – 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?

Are you currently receiving funding from Oregon Department of Human Services (ODHS) or Oregon Department of Justice (DOJ)? If so, please list what funding you are receiving from ODHS or DOJ.

Attachment D 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 Survivors of domestic violence and sexual assault (DVSA) if your agency currently provides DVSA services, OR how you will implement DVSA services if your agency does not currently provide these services.

2. Please identify the specific population you plan to offer services with this Survivor Investment Partnership (SIP) grant. Please provide a summary that demonstrates how you will work with this specific population.

3. Please provide a summary that demonstrates your ability to provide Culturally Responsive services, including outreach, to Survivors of DVSA. Please list the DVSA services you currently provide, or plan to provide with SIP funds.

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

5. Please provide a detailed plan that demonstrates how you will spend the requested funding by the end of June 30, 2025 for each of the Cost categories. Reference the budget table below. (This budget table is also found in Section 2.4.2 of the RFGA)

*Maximum amount allowed per category.

**Amount of cost category may be increased, provided that the total costs of all categories shall not exceed $283,424.00 annually or $566,848.00 for the biennium.

6. Please provide a summary that demonstrates your ability to collect and disseminate aggregate data needed for reconciliation of SIP funds. Examples of data collection are age range, gender identity, race, type of services provided.

7. If Applicant is already receiving funding from other sources including Oregon Department of Human Services (ODHS), or DOJ, or both, please describe how the SIP funds will be kept separate from the other funding streams. (This question is for informational purposes and will not be scored.).

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 DVSA services for a culturally specific population that Applicant is not already serving.

2. Applicant understands and accepts the requirements of RFGA S-10000-00009881. 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-10000-00009881.

3. Applicant acknowledges receipt of any and all Addenda to RFGA S-10000-00009881.

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-10000-00009881) 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-10000-00009881, 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

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