Attachment #3 - Subcontractor Disclosure Form.docx

Solicitation No. 185-2517-2025

Title: HSEM Disaster Case Management

Attachment #3: Subcontractor Disclosure Form

(Submit this completed form with your proposal submission. Fully complete a form for each proposed subcontractor. If a section does not apply, label it “not applicable.” If the Respondent does not intend to use subcontractor(s), this form does not need to be returned.)

Primary Respondent (“Primary Respondent”):

Subcontractor Contact Information (individual who can address issues re: this RFP)

Name:

Address:

Tel:

Fax:

E-mail:

Subcontractor Detail

Subcontractor Legal Name (“Subcontractor”):

“Doing Business As” names, assumed names, or other operating names:

Form of Business Entity (i.e., corp., partnership, LLC, etc.)

State of Incorporation/organization:

Primary Address:

Tel:

Fax:

Local Address (if any):

Addresses of Major Offices and other facilities that may contribute to performance under this RFP/Contract:

Number of Employees:

Number of Years in Business:

Primary Focus of Business:

Federal Tax ID:

Subcontractor’s Accounting Firm:

If Subcontractor is currently registered to do business in Iowa, provide the Date of Registration:

Percentage of Total Work to be performed by this Subcontractor pursuant to this RFP/Contract.

General Scope of Work to be performed by this Subcontractor

Detail the Subcontractor’s qualifications for performing this scope of work

By signing below, Subcontractor agrees to the following:

1. Subcontractor has reviewed the RFP, and Subcontractor agrees to perform the work indicated in this submitted Proposal if the Primary Respondent is selected as the winning Respondent in this procurement;

2. Subcontractor recognizes and agrees that if the Primary Respondent enters into a contract with the Agency as a result of this RFP, all restrictions, obligations, and responsibilities of the contractor under the contract shall also apply to the subcontractor;

3. Subcontractor agrees that it will register to do business in Iowa before performing any services pursuant to this contract, if required to do so by Iowa law; and,

4. Subcontractor certifies that it will comply with Davis-Bacon requirements if applicable to the resulting contract.

The person signing this Subcontractor Disclosure Form certifies that he/she is the person in the Subcontractor’s organization responsible for or authorized to make decisions.

I hereby certify that the contents of the Subcontractor Disclosure Form are true and accurate and that the Subcontractor has not made any knowingly false statements in the Form.

Signature for Subcontractor:

Printed Name/Title:

Date:

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