Att C - Cover Sheet - Baker Malheur County.pdf
PDF 145 KB Posted
- Attached to
- RFA for HFO Baker and Malheur Counties
- Solicitation number
- S-58800-00017054
- Issued by
- Oregon
About this file
This is a Cover Sheet attachment for Request for Application (RFA) S-58800-00017054 issued by the State of Oregon's Department of Administrative Services (DAS) Procurement Services for the Healthy Families Oregon Service Provider program in Baker and Malheur Counties. The document serves as the official application cover page that prospective service providers must complete and submit as part of their proposal response. The attachment requires applicants to provide standard organizational information including legal name, address, state of incorporation, entity type, contact person details, and Oregon Business Registry Number. No specific information regarding project scope, deliverables, response deadlines, site visits, bidder conferences, or award dates is contained within this cover sheet.
The document is primarily a certification and attestation form requiring authorized representatives to confirm their organization's understanding of RFA requirements, receipt of all addenda, tax compliance status, and absence from federal exclusion lists maintained by the Office of Foreign Assets Control and the System for Award Management. Applicants must also certify the absence of conflicts of interest, the accuracy and truthfulness of application contents, and acknowledge potential liability under the Oregon False Claims Act for false or fraudulent statements. No pricing information, set-aside provisions, incumbent details, or funding sources are specified in this cover sheet, as these elements would be addressed in other RFA attachments and documents.
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Text version
RFA S-58800-00017054 – Healthy Families Oregon Service Provider, Baker and Malheur Counties Att C
DAS Procurement Services, Version 4.0 – December 21, 2018 Page 1 of 2
ATTACHMENT C — COVER SHEET
Legal Name of Applicant:
Address: City, State, Zip:
State of Incorporation: Entity Type:
Contact Name: Telephone: Email:
Oregon Business Registry Number:
Any individual signing below hereby certifies they are an authorized representative of Applicant and that:
1. Applicant understands and accepts the requirements of this RFA, including all addenda and attachments.
2. Applicant acknowledges receipt of any and all addenda to this RFA.
3. If awarded a Grant, Applicant agrees to perform the activities and meet the requirements set forth in the final negotiated Grant.
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, subgrantees, and contractors 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://sam.gov/
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 RFA. If any changes occur with respect to Applicant’s status regarding conflicts 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 this RFA) and this Cover Sheet 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 this RFA, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information, could give rise to liability or penalties under the Oregon False Claims Act, ORS
180.750 to 180.785.
https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://sam.gov/
RFA S-58800-00017054 – Healthy Families Oregon Service Provider, Baker and Malheur Counties Att C
DAS Procurement Services, Version 4.0 – December 21, 2018 Page 2 of 2
9. Applicant acknowledges these certifications are in addition to any certifications required in the Grant in Attachment A at the time of Grant execution.
Authorized Signature Date
(Printed Name and Title)
File details come from the government source that posted it. Updated .