Attach C1 Admin Response.docx

ATTACHMENT C1 - BIDDER RESPONSE TEMPLATE

ADMINISTRATIVE REQUIREMENTS RESPONSE (Pass/Fail)

RFA NO. 25-DCYF-CW-098

Caregiver Supports Area 11

Instructions: Bidders must complete this template and attach the PDF to their emailed RFA Response. Please thoroughly read all instructions in the RFA before completing. All mandatory information must be provided for the Bidder to be responsive. Bidder may provide additional documentation as an additional Attachment; the documentation should be specified in this form. Also, please write your Business Name on the bottom of each page of this Response Template.

ADMINISTRATIVE REQUIREMENTS (Mandatory Pass/Fail)

Bidder Information:

Business Name:

Address:

Telephone:

Email of Legal Entity or Individual:

|_|No

Federal Tax Identifier Number:

WA State Uniform Business Identifier (UBI) Number:

|_|No

Key Personnel

Identify the key personnel you will utilize in performing this Contract, and their experience and qualifications.

Please provide an org chart and resumes in your proposal

Contract History:

Has the Bidder’s performance on any contract unsatisfactory and resulted in a contract termination in the past five (5) years?

|_|Yes |_|No

If yes, provide a list of those contracts terminated, and include the following:

· Other party’s Name

· Address

· Telephone Number

· Description of the Incident

· Bidder’s Position on the matter

State of Washington Employee(s):

If yes, provide the following information for each individual:

· Name

· Employing Agency

· Job Title while with the Agency

· Separation Date

Insurance Requirements:

Proprietary or Confidential Information:

If applicable, identify the Sections of the Response which the Bidder considers “Proprietary” or “Confidential” information:

(Optional) OMWBE Certification:

Is Bidder or Bidder’s subcontractor OMWBE Certified?

|_|Yes

If yes, Bidder’s OMWBE Certification #:

If Subcontractor(s) is OMWBE Certified, Subcontractor(s) names:

If yes, subcontractor(s) OMWBE Certification #:

(Optional) Veteran Owned Business:

Is Bidder or Bidder’s subcontractor certified Veteran Owned Business?

|_|Yes

If yes, Bidder’s DVA Certification #:

If Subcontractor(s) is Certified Veteran Owned Business, Subcontractor(s) names:

If yes, subcontractor(s) DVA Certification #:

(Optional) Small Business:

|_|No If yes, please be sure to sign and return Attachment B.1 Small Business Self-Certifications as part of your proposal.

If Subcontractor(s) is a self-certified Washington Small Business, Subcontractor(s) names:

If yes, please be sure return a sign Attachment B.1 Small Business Self-Certifications for each subcontractor as part of your proposal.

Checklist of Mandatory Response Attachments:

|_|Completed and signed Bidders Certification and Assurances Form (Attachment B)

|_|Completed and Signed Administrative Requirements (Attachment C1; this document)

|_|Completed Application (Attachment C2)

|_|Letters of Support and Collaboration

|_|Coordination with Neighboring Organizations

|_|Key Personnel and Org Chart

Page 3 of 3 RFA # 25-DCYF-CW-098 Administrative Requirements