Attach A_Req.Vendor Info_6-20-23.docx

Attachment A

Attachment A complete Required Vendor Information

Attachment A—Section I.

REQUIRED VENDOR INFORMATION and CERTIFICATIONS Purpose: ODJFS requires the following information on vendors who submit proposals or bids in response to any ODJFS Requests for Proposals (RFPs) or Requests for Letterhead Bids (RLBs), in order to facilitate the development of the contract (or finalization of a purchase) with the selected vendor. ODJFS reserves the right to reject your proposal if you fail to provide this information fully, accurately, and by the deadline set by ODJFS. Further, some of this information (as identified below) must be provided in order for ODJFS to accept and consider your proposal\bid. Failure to provide such required information will result in your proposal’s immediate disqualification.

Instructions: Provide the following information regarding the vendor submitting the proposal or bid. Vendors may either print this attachment, complete and sign it, or may provide the required information and certifications (each fully re-stated from this attachment) on their letterhead as the opening pages of their proposals. It is mandatory that the information provided is certified with an original signature (in blue ink, please) from a person with authority to represent the vendor. Vendors are to provide the completed and signed information and certifications as the cover pages of their original proposal submitted to ODJFS.

IMPORTANT: If the RFP\RLB specified a maximum page limit for vendor proposals\bids, the attachment of any required certifications, other documents, or additional pages needed to fully provide the information requested here will NOT be counted against that page limit.

Vendors must provide all information

3. Vendor Name: (legal name of the vendor – person or organization – to whom contract\purchase payments would be made)

3a. Vendor’s Ohio Administrative Knowledge System (OAKS) ID#: [Vendors may apply for an OAKS vendor ID# at: http://ohiosharedservices.ohio.gov/Vendors.aspx. The necessary forms to be completed and remitted to Ohio Shared Services are the Vendor Information Form (OBM-5657) and the IRS Form W-9. Completion and/or submission of these forms to Ohio Shared Services does not assume a vendor/applicant award of any ODJFS contract/grant.]

6. Print or type information on the vendor representative/contact person authorized to answer questions on the proposal\bid:

Vendor Representative NAME and TITLE:

Address: E-Mail Address:

Phone #: ______________________________ Fax #: ______________________________

7. Print or type the name of the vendor representative authorized to address contractual issues, including the authority to execute a contract on behalf of the vendor, and to whom legal notices regarding contract termination or breach, should be sent (if not the same individual as in #7, provide the following information on each such representative and specify their function):

Vendor Representative NAME and TITLE:

Address: E-Mail Address:

Phone #: ______________________________ Fax #: ______________________________

8. Is this vendor an Ohio certified MBE? Yes No If yes, attach a copy of current certification to proposal\bid. (IF ODJFS has specified the RFP\RLB\purchase document as an opportunity open exclusively to Ohio Certified MBEs, then failure to attach a copy of current certification WILL RESULT IN DISQUALIFICATION.)

9. Mandatory Vendor Certifications:

ODJFS may not enter into contracts with/make purchases from any vendors who have been found to be ineligible for state contracts under specific federal or Ohio statutes or regulations. Vendors responding to any ODJFS RFP\RLB or other purchase opportunity MUST certify that they are NOT INELIGIBLE by signing each of the three statements below. Failure to provide proper affirming signature on any of these statements will result in the disqualification of your proposal\bid.

I______________________________ (signature of representative shown in Item # 7, above) hereby certify and affirm that _____________________________ (name of the vendor shown in Item # 3, above), has not been debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in transactions by the United States Department of Labor, the United States Department of Health and Human Services, or any other federal department or agency as set forth in 29 CFR Part 98, or 45 CFR Part 76, or other applicable statutes.

AND

I______________________________ (signature of representative shown in Item #7, above) hereby certify and affirm that _____________________________ (name of the vendor shown in Item # 3, above), is not on the list established by the Ohio Secretary of State, pursuant to ORC Section 121.23, which identifies persons and businesses with more than one unfair labor practice contempt of court finding against them.

AND

I______________________________ (signature of representative shown in Item #7, above) hereby certify and affirm that _____________________________ (name of the vendor shown in Item # 3, above), either is not subject to a finding for recovery under ORC Section 9.24, or has taken appropriate remedial steps required under that statute, or otherwise qualifies under that section to enter into contracts with the State of Ohio.

10. Equal Employment Opportunity Information on the Vendor and any Subcontractor(s) A. Provide vendor employee data both nationwide (including Ohio staff), and Ohio office employees separately:

Nationwide: Ohio Offices:

Total Number of Employees: _________ __________

% of those who are Women: _________ __________

% of those who are Minorities: _________ __________

B. If you are the selected vendor, will you subcontract any part of the work?

NO -or- YES, but for less than 50% of the work -or- YES, for 50% or more of the work

If yes, provide the following information on each subcontractor (additional pages may be added as needed):

Subcontractor Name: _____________________________________________________________ Address: _____________________________________________________________ Work To Be _____________________________________________________________ Performed: _____________________________________________________________ (a brief description) _____________________________________________________________

Subcontractor’s Estimated Percentage of Total Project (in % of work, not % of dollars): __________

If 50% or more of the work will be subcontracted, then ALSO provide the following information on ALL proposed subcontractors:

Nationwide: Ohio Offices:

Total Number of Employees: _________ __________

% of those who are Women: _________ __________

% of those who are Minorities: _________ __________

C. Identify all state contracts which the vendor has had approved by the Controlling Board since the beginning of the last fiscal year (i.e., since July 01, 2013) through this fiscal year to date. Also include contracts approved for ODJFS or institutions of higher education:

Total number of contracts: ______

For each state contract, list the state agency and provide the following information:

State Agency/Educational Institution: __________________________________________________ Contract Dollar Amount: __________

State Agency/Educational Institution: __________________________________________________ Contract Dollar Amount: __________

State Agency/Educational Institution: __________________________________________________ Contract Dollar Amount: __________

Attach additional pages if needed

11. Vendor and Grantee Ethics Certification

As a vendor or grantee doing business with* or receiving grants from the State of Ohio, I certify on behalf of ________________________________________________________(name of vendor or grantee):

(1) I have reviewed and understand Ohio ethics and conflict of interests laws, as found in Chapter 102. and Sections 2921.42 and 2921.43 of the Ohio Revised Code.

(2) I acknowledge that failure to comply with this certification, is, by itself, grounds for termination of this contract or grant with the State of Ohio.

Signature of authorized agent Date

*”Doing business with” includes all contracts for goods and services, excluding purchases made using the State of Ohio’s Payment Card Program that cost less than $1,000.

12. I have read the ODJFS Model Contract attached to the RFP/RLB, and if awarded a contract, I will not ____(or) I will_____ request changes to the standard language. If changes are requested, I will redline the requested changes and return the Model Contract with my proposal/bid for consideration by ODJFS. ODJFS will review those requested changes if you are the selected vendor. All requested changes to Model Contract language are subject to ODJFS approval. ODJFS may reject your proposal/bid if the requested changes are not acceptable. (NOTE: Item 13 is not applicable and not required when the subject ODJFS procurement opportunity is offered only to State Term Schedule Vendors.)

13. I _________________________________________, (vendor representative in Item # 7) hereby affirm that this proposal accurately represents the capabilities and qualifications of _____________________________________________ (vendor’s name), and I hereby affirm that the cost(s) bid to ODJFS for the performance of services and/or provision of goods covered in this proposal in response to the ODJFS RFP/RLB/other purchase opportunity is a firm fixed price, inclusive of all incidental as well as primary costs. (Failure to provide the proper affirming signature on this item may result in the disqualification of your proposal\bid.)

14. Location of Business Declaration: Vendors responding to any ODJFS RFP/RLB/RFGA (etc.) must certify that no public funds shall be spent on services provided/performed offshore by completing, signing, and returning the “Location of Business Form,” which is the final section of this attachment. FAILURE TO PROPERLY COMPLETE, SIGN AND RETURN THIS FORM, INCLUDING THE “LOCATION OF BUSINESS FORM,” WILL RESULT IN DISQUALIFICATION OF THE VENDOR FROM CONSIDERATION FOR AWARD OF AN ODJFS CONTRACT.

15. I ____________________________, (vendor representative in Item # 7) hereby attest that I understand that any and all information included in this proposal is not confidential and/or trade secret information (as defined in Sections 3.3, 5.2, D., 8.5, and 8.25 of the RFP or where found in an RLB document) and that the proposal submission may be posted in its entirety on the Internet for public viewing. Following submission to ODJFS, all proposals submitted may become part of the public record. ODJFS reserves the right to disqualify any vendor whose proposal is found to contain such prohibited personal information. The vendor affirms that they shall be solely responsible for any and all information disclosed in the proposal submission and any or all information released by ODJFS in a public records request(s).