Attachment 1 Proposer Certification and Information Sheet.pdf

RFGP OregonBuys #S-47100-00008281

OED #23-151 Page 32 of 98 Version 2.0 - July 6, 2015

ATTACHMENT 1

PROPOSER CERTIFICATION AND INFORMATION SHEET

Proposer Organization Name: ________________________________________________________

Primary Contact Person: Title:

Address: City, State, Zip

Telephone: E-mail Address:

Name and title of the person(s) authorized to represent the Proposer in any negotiations and sign any Grant Agreement that may result:

Name: Title:

Telephone: E-mail Address:

Demographic Area Served _______________________________ Populations Served: ____________________

By signing this sheet and submitting a Proposal, the undersigned (a) certifies that they are a duly authorized representative of the Proposer, has been authorized by the Proposer to make all representations, attestations, and certifications contained in this Proposal, and to submit this Proposal on behalf of the Proposer.

1. Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFGP) and this Proposer Certification Sheet, are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.

2. Proposer and its employees and agents are not included on:

a. the list titled “Specially Designated Nationals and Blocked Persons” maintained by the Office of Foreign Assets Control of the United States Department of the Treasury and currently found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf

b. the government wide exclusions list in the System for Award Management found at:

https://sam.gov/search/?page=1&pageSize=25&sort=-modifiedDate&sfm%5Bstatus%5D%5Bis_active%5D=true&sfm%5BsimpleSearch% 5D%5BkeywordRadio%5D=ALL

3. Proposer is not in violation of:

a. any tax laws of this state, including but not limited to those included in: ORS

320.005 to 320.150 and 403.200 to 403.250 and ORS chapters 118, 314, 316, 317, 318, 321 and 323 and local taxes administered by the Department of Revenue;

b. any tax provisions imposed by a political subdivision of this state that apply to Contractor, to Contractor’s property, operations, receipts, or income, or to Contractor’s performance of or compensation for any work performed by Contractor; or

c. any rules, regulations, charter provisions, or ordinances that implement or enforce any of the foregoing tax laws or provisions.

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4. Proposer complies with ORS 652.220 and does not unlawfully discriminate against any of Proposer’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class.

“Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.

Proposer may not prohibit any of Proposer’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Proposer may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

5. Proposer may not request funding for expenditures already funded by any other agency or department of the State of Oregon or the federal government.

6. Proposer does not discriminate in its employment practices regarding race, creed, age, religious affiliation, gender, disability, sexual orientation, or national origin. When awarding subcontracts, Proposer does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owns or an emerging small business.

7. Information and costs included in this Proposal shall remain valid for 90 days after the Proposal due date or until a Grant Agreement is executed, whichever comes first.

8. The statements contained in this Proposal are true and complete to the best of the Proposer’s knowledge and Proposer accepts as a condition of the Grant, the obligation to comply with the applicable state and federal requirements, policies, standards, and regulations. The undersigned recognizes that this is a public document and open to public inspection.

9. Proposer understands that any statement or representation it makes, in response to this RFGP, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" (as defined by the Oregon False Claims Act, ORS 180.750(1)), made under Contract being a "false claim" (ORS 180.750(2)) subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

10. The Proposer acknowledges receipt of all addenda issued under this RFGP.

11. If the Proposer is awarded a Grant as a result of this RFGP, the Proposer will be required to complete, and will be bound by, a Grant Agreement, substantially in the form attached to this RFGP and found in the OregonBuys system. At the time of signing the Grant Agreement with OED, the Proposer will be required to provide its Federal Employer Identification Number (FEIN) or Social Security Number (SSN) as applicable.

12. Proposers must demonstrate a presence in one or more specific counties and describe the population(s) on which the Proposer will focus its outreach and system navigation efforts.

OED #23-151 Page 34 of 98 Version 2.0 - July 6, 2015

County: Population Served:

Signature: Date:

(Authorized to Bind Proposer)

*** THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE PROPOSAL ***