Att J - Attestation Form.docx

RFP XX-XXXXX 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.

or ☐ Opting not to submit

2.0 Confirm Mutual Understanding and Submission

RFP Sections 1.14 and 2.1 Confidential Information:

The complete list of Confidential and Redacted files is specified in Section 5.0 of this attachment.

☐ Have read, and submitted or ☐ Have read, and does not apply to response

Attachment E Section 5.0:

Contract Terms/Clauses ☐ Confirm Respondent’s Legal Representation has read and accepts Sample Contract language.

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

Attachment E Section 13.0: Subcontractors (Additional subcontractors/those not submitted in Attachment A) ☐ Have read, agree, listed subcontractors in Attachment E and submitted documents or ☐ Have read, and does not apply to response

3.0 Claim Clarification

It is the Respondent’s responsibility to confirm its Buy Indiana certification is active as of the submission date the sourcing event. Check status within the Buy IN Designation List at https://www.in.gov/idoa/procurement/supplier-resource-center/programs-and-preferences/buy-indiana/.

Buy IN must be affirmatively claimed. The State will only validate the Respondent’s claim to determine eligibility of potential points.

The State will not look up status on behalf of each Respondent without the Respondent’s claim on this document.

If Respondents are not certified but wish to be, follow the Department of Administration Procurement Division instructions within RFP Section 1.16, Procurement Division Registration. Along with registering, the Respondent can begin the Buy IN certification process.

When applying to Buy IN status, be sure to allow sufficient time to complete this process, at least twenty (20) business days. The Respondent’s Buy Indiana status must be finalized when the solicitation response is submitted to the State.

Defining an Indiana Business:

“Indiana business” refers to any of the following:

1. A business whose principal place of business is located in Indiana.

2. A business that pays a majority of its payroll (in dollar volume) to residents of Indiana.

3. A business that employs Indiana residents as a majority of its employees.

4. A business that makes significant capital investments in Indiana.

5. A business that has a substantial positive economic impact on Indiana.

Substantial Capital Investment:

Any company that can demonstrate a minimum capital investment in Indiana of $5 million or more in plant and/or equipment or annual lease payments in Indiana of $2.5 million or more shall qualify as an Indiana business under IC 5-22-15-20.5 (b)(4).

Substantial Indiana Economic Impact:

Any company that is in the top 500 companies (adjusted) for one of the following categories: number of employees (DWD), unemployment taxes (DWD), payroll withholding taxes (DOR), or Corporate Income Taxes (DOR); it shall qualify as an Indiana business under IC 5-22-15-20.5 (b)(5).

*Validated by Respondent within Buy IN Designation List

☐ NO, not claiming

4.0 Qualified State Agency Preference Scoring

"Qualified Agency" refers to a nonprofit agency for persons with severe disabilities that meets the provisions of IC 5-22-13. When applicable, pursuant to Indiana Code 5-22-13, the qualified agency submitting or participating in a response to this solicitation will be awarded preference points for Indiana Veteran Business Enterprise equal to the Respondent awarded the highest combined points awarded for such preferences in the scoring of this solicitation. A list of active/certified “Qualified Agencies” can be found at: https://web.abilityin.org/state_use/Certified-Ability-Indiana-Organizations.

Please note participation below:

☐ NO, not claiming

5.0 Confidential / Redacted File: Confirm Submission If Applicable

Per RFP Section 1.14, 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

6.0 Authorizing Document

Respondent personnel signing the Executive Summary of the proposal must be legally authorized by the organization to commit the organization contractually. This section shall contain proof of such authority. A copy of corporate bylaws or a corporate resolution adopted by the board of directors indicating this authority will fulfill this requirement. Please enter your response below and indicate if any attachments are included.

Please indicate the principal contact for the proposal along with an address, telephone number, and e-mail address, if that contact is different than the individual authorized for signature. Additionally, the Company’s Bidder ID #, FEIN, Type of Business (i.e., Corporation, Sole Proprietor, LLC, etc.), and North American Industry Classification System (NAICS) Code should all be included in the Executive Summary with the contact information.

7.0 Secretary of State

Per RFP Section 1.17: if awarded the contract, the Respondent will be required to register, and be in good standing, with the Secretary of State. The registration requirement is applicable to all limited liability partnerships, limited partnerships, corporations, S-corporations, nonprofit corporations, and limited liability companies.

Information concerning registration with the Secretary of State may be obtained by contacting:

Secretary of State of Indiana Corporation Division 402 West Washington Street, E018 Indianapolis, IN 46204

(317) 232-6576 www.in.gov/sos

Please indicate your status with respect to the Office of the Indiana Secretary of State.

8.0 Respondent Additional Attachments (optional)

More rows may be inserted if necessary.