Att J - Attestation Form revised.docx
DOCX document 45 KB Posted
- Attached to
- Hearing Aid Devices and ServicesBid Documents
- Solicitation number
- 26-86494
- Issued by
- Marion County, Indiana
About this file
This Attestation Form (Attachment J) is a mandatory submission document for respondents to the Indiana Department of Administration's RFP 26-86494 for Hearing Aids, Devices, and Services for the Family and Social Services Administration's Deaf and Hard of Hearing Services division. The form requires respondents to confirm completion and submission of all mandatory components, including pricing (Section 1.10), executive summary (Section 3.2), and technical and business proposals (Attachments E and F). Respondents must designate an internal response manager to serve as the dedicated state contact and must attest to reading and meeting all requirements related to confidential information, subcontractor documentation, contract terms and clauses, and the ability to supply required products and services. The form includes checkboxes for optional submissions such as the Minority and Women Business Enterprise form (Attachment A) and Indiana Veteran Owned Small Business form (Attachment A1), as well as a section for respondents claiming Buy Indiana Initiative status. Additionally, the attestation form requires respondents to identify any documents or sections seeking confidential or redacted status under Indiana's Access to Public Records Act (APRA), providing the statutory exception reference, rationale, and separate redacted or confidential versions of applicable documents.
The form includes sections for respondents to list any additional subcontractors beyond those submitted with Attachments A or A1, with documentation requirements including either executed contracts or letters of agreement for each subcontractor. Respondents must provide the subcontractor name, function to be performed, and confirmation of document submission. Optional additional attachments may be submitted by respondents and should reference the corresponding RFP attachment. This attestation form serves as the respondent's formal confirmation of compliance with all mandatory submission requirements and mutual understanding of the solicitation terms and conditions.
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Text version
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.
| Attachment J: Attestation Form |
| ☐ Have completed in its entirety and submitted |
| Section 1.10 Pricing |
| ☐ Have read and meet this requirement |
| Section 3.2 Executive Summary |
| ☐ Have completed, signed, and submitted |
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
| Section 3.2 Attachment C: Indiana Economic Impact |
| ☐ Have read, completed, and submitted |
| Section 3.2 Attachment D: Cost Proposal (Excel Workbook) |
| ☐ Have completed and submitted |
| Section 3.2 Attachment E: Business Proposal |
| ☐ Have completed and submitted |
| Section 3.2 Attachment F: Technical Proposal |
| ☐ Have completed and submitted |
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
| 2.2.1 Ability and Desire to Supply the Required Products or Services |
| ☐ Have read, and agree |
| 2.3.6 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.
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
| 2.6.2 Buy Indiana Initiative/Indiana Company |
| ☐ YES claiming (points only awarded if certification is finalized per Buy Indiana registry* at time of Sourcing Event Submission Date) |
*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
| Filename |
| Document Section |
| Document |
Page #
| Statutory exception reference |
| Rationale for application of the statute |
| Submitted |
5.0 Subcontractors per RFP 2.6.3 (additional subcontractors/those not submitted in Attachment A/Attachment A1)
| Subcontractor Name |
| Function to be performed |
| Document Submitted |
☐ Executed contract
☐ Letter of Agreement
☐ Executed contract
☐ Executed contract
☐ Executed contract
☐ Executed contract
☐ Executed contract
☐ Executed contract
6.0 Respondent additional attachments (OPTIONAL)
| Filename |
| RFP Attachment Reference |
2 v.07112024
File details come from the government source that posted it. Updated .