Att J - Attestation Form.docx

ATTESTATION FORM

ATTACHMENT J

Respondent Name:

Respondent’s Internal Response Manager’s Name:

This person will be the dedicated contact to receive State correspondence specific to this solicitation.

Respondent’s Internal Response Manager’s Email Address:

1.0 Mandatory Submissions and Requirements: Disagreement with these items may result in the response being disqualified.

Section 3.2 Attachment A: Minority and Women Business Enterprise form, IDOA provided certification letter and Subcontractor’s signed letter on company letterhead.

☐ Have completed, signed, and submitted or ☐ Opting not to submit

Section 3.2 Attachment A1: Indiana Veteran Owned Small Business form IDOA provided certification letter and Subcontractor’s signed letter on company letterhead.

☐ Have completed, signed, and submitted

☐ Opting not to submit

2.0 Confirm mutual understanding and submission.

1.15 and 2.1 Confidential Information:

The complete list of Confidential and Redacted files is specified in section 4.0 of this attachment.

☐ Have read, and submitted

☐ Have read, and does not apply to response

or ☐ Confirm Respondent’s Legal Representation has read, and submitted alternative language per Attachment E.

2.6.3. Subcontractors

(Additional subcontractors/those not submitted in Attachment A/Attachment A1)

☐ Have read, agree, listed subcontractors in 5.0 of this attachment and submitted documents

☐ Have read, and does not apply to response

3.0 Claim clarification

*Validated by Respondent within Buy IN Designation List at https://www.in.gov/idoa/procurement/supplier-resource-center/programs-and-preferences/buy-indiana/

☐ NO, not claiming

4.0 Confidential / Redacted File: confirm submission if applicable More rows may be inserted if necessary

Responses must include the following required information:

· List all documents or sections of documents, for which statutory exemption to APRA;

· Specify which statutory exception of APRA applies for each document or section of the document;

· Provide a description explaining how the statutory exception to the APRA applies for each document or section of the document; and

· Provide a separate redacted or confidential, whichever is applicable, version of the document. File name should use the following format:

· (insert rfp #) _ (insert Att letter) _CONFIDENTIAL

· (insert rfp #) _ (insert Att letter) _REDACTED

· More rows may be inserted if necessary

Page #

5.0 Subcontractors per RFP 2.6.3 (additional subcontractors/those not submitted in Attachment A/Attachment A1)

☐ Executed contract

☐ Letter of Agreement

☐ Executed contract

☐ Executed contract

☐ Executed contract

☐ Executed contract

☐ Executed contract

☐ Executed contract

6.0 Respondent additional attachments (OPTIONAL) Comment by IDOA Procurement: This can be removed in its entirety if IDOA considers it appropriate to do so.

2 v.07112024