Attachment 4 Applicant Certification Form.pdf
PDF 181 KB Posted
- Solicitation number
- S-44300-00018213
- Issued by
- Multnomah County, Oregon
About this file
This is an Applicant Certification Form for a Request for Grant Application (RFGA 6287) related to Hospital-Based Violence Intervention (HVIP) Expansion Funding administered by the State of Oregon Department of Administrative Services (DAS) Procurement Services. The form requires applicants to certify their understanding and acceptance of the grant agreement requirements outlined in the RFGA documentation. Applicants must acknowledge receipt of all addenda, confirm that their application constitutes a firm offer valid for 90 days following the closing date, and commit to performing all activities and meeting reporting requirements specified in the final project description of the grant agreement. The grant opportunity supports planning for and development of HVIPs outside of Multnomah County through seed grants to establish partnerships between community-based organizations and health systems providing emergency room and urgent care services, with the goal of creating a learning community committed to exploring partnerships and planning for future HVIP implementation.
The certification form requires applicants to represent that they are current with all tax obligations under Oregon state and local law and do not unlawfully discriminate in employment practices or subcontract award decisions. Applicants with an anticipated contract price of $150,000 or more must certify implementation of written policies preventing sexual harassment, sexual assault, and discrimination against protected class members. Additional certifications address compliance with wage and hour laws, broadband internet service regulations, exclusion from federal sanctions lists, and the absence of conflicts of interest with the State of Oregon. Applicants must certify that all application contents are truthful, accurate, and prepared independently without collusion or fraud, acknowledging that false statements or material omissions may constitute false claims subject to the Oregon False Claims Act and associated penalties. The form requires signature by an authorized representative attesting to the applicant's eligibility and commitment to the grant agreement terms and conditions.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment 3 Sample Grant Agreement~3.pdf | ||
| Attachment 2 HVIP Budget Template.xlsx | XLSX spreadsheet | |
| 6287-0 Attachment 1 Application~1.docx | DOCX document | |
| 6287 Opportunity Notice Hospital Based Violence Intervention.pdf |
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Text version
OB S-44300-00018213/RFGA 6287 – HVIP Expansion Funding
DAS Procurement Services, Version 4.0 – December 21, 2018 Page 1 of 3
ATTACHMENT 4 —
APPLICANT CERTIFICATION FORM
Legal Name of Applicant:
Address: City, State, Zip:
State of Incorporation: Entity Type:
Contact Name: Telephone: Email:
Oregon Business Registry Number (if required):
Any individual signing below hereby certifies they are an authorized representative of Applicant and that:
1. Applicant understands and accepts the requirements of this RFGA. By submitting a Proposal, Applicant agrees to be bound by the Grant Agreement terms and conditions in Attachment A and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFGA.
2. Applicant acknowledges receipt of any and all Addenda to this RFGA.
3. Application is a Firm Offer for 90 days following the Closing.
4. If awarded a Grant Agreement, Applicant agrees to perform the activities and meet the reporting requirements set forth in the final project description of the Grant Agreement.
5. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.
6. Applicant does not unlawfully discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Applicant 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. If applicable, Applicant has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into a contract with an anticipated contract price of $150,000 or more with a Applicant that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.
https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx
DAS Procurement Services, Version 4.0 – December 21, 2018 Page 2 of 3
7. Applicant complies with ORS 652.220 and does not unlawfully discriminate against any of Applicant’s employees in the payment of wages or other compensation for activities 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.
Applicant’s continuing compliance constitutes a material element of this Grant Agreement and a failure to comply constitutes a breach that entitles Agency to terminate this Grant Agreement for cause.
Applicant may not prohibit any of Applicant’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Contractor 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.
8. Applicant is not engaged in the provision of broadband Internet access service, or if at any time Applicant is engaged in or may engage in the provision of broadband Internet access service Applicant is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Contract.
9. Applicant and Applicant’s employees, agents, and subcontractors are not included on:
A. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at:
https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or
B. the government wide exclusions lists in the System for Award Management found at:
https://www.sam.gov/
10. Applicant certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Applicant, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFGA. If any changes occur with respect to Applicant’s status regarding conflict of interest, Applicant shall promptly notify the State in writing.
11. Applicant certifies that all contents of the Application (including any other forms or documentation, if required under this RFGA) and this Applicant Certification Sheet are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.
12. Applicant understands that any statement or representation it makes, in response to this RFGA, 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 Grant Agreement 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.
https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.sam.gov%2F&data=05%7C02%7CKimberley.WISDOM%40das.oregon.gov%7C66cb231ae7934e01711708dd930da837%7Caa3f6932fa7c47b4a0cea598cad161cf%7C0%7C0%7C638828409047344090%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=IdZyl8xEvEqeWNuMxSBw%2BbWIbdZZNl0P73s2LPo7CVo%3D&reserved=0
DAS Procurement Services, Version 4.0 – December 21, 2018 Page 3 of 3
Applicant acknowledges these certifications are in addition to any certifications required in the Grant Agreement and Project Description in Attachment A at the time of Grant Agreement execution.
Authorized Signature Date
(Printed Name and Title)
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