Attachment_4_-_General_Certifications_Form.docx
DOCX document 29 KB Posted
- Attached to
- RFP 25-03 Employee Assistance Program
- Solicitation number
- 0000036100
- Issued by
- California
About this file
This document is a General Certifications Form for RFP 25-03 for an Employee Assistance Program issued by a California Court, requiring bidders to complete mandatory certifications related to their business qualifications and legal compliance. The form requires bidders to certify their lack of conflicts of interest, confirm they are not suspended or debarred from state contracting, verify tax compliance, and attest to conflict minerals regulations.
The certification form requires bidders to verify their legal and ethical standing through several key declarations, including confirming they are not on state tax delinquency lists, have no disqualifying conflicts of interest with judicial branch entities, and are not scrutinized companies under California Public Contract Code. By signing the document, the bidder's authorized representative legally attests to the accuracy of these certifications and agrees to the terms, which are a mandatory component of the bid submission process for the Employee Assistance Program contract.
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| Attachment_3_-_Acceptance_of_Short_Form_Agreement_Terms.docx | DOCX document | |
| Attachment_7B_-_DVBE_Declaration.docx | DOCX document | |
| Exhibit_A_-_USI_Marketing_Letter_RFP_25-03_EAP.pdf | ||
| Exhibit_C1_-_ACI_EAP_Benefits_Summary.pdf | ||
| Exhibit_C2_-_ACI_Utilization_Q-4_2024.pdf | ||
| Exhibit_C3_-_ACI_Utilization_Q-1_2025.pdf | ||
| Attachment_7A_-_Bidder_Declaration.docx | DOCX document | |
| Exhibit_B_-_Payment_Provisions-Benefits.docx | DOCX document | |
| Exhibit_C4_-_ACI_Service_Agreement.pdf | ||
| RFP_25-03_Employee_Assistance_Program.docx | DOCX document | |
| Attachment_1_-_Administrative_Rules.docx | DOCX document | |
| Exhibit_D_-_EAP_RFP_25-03_Benefits_Matrix.xlsx | XLSX spreadsheet | |
| Attachment_2_-_Services_-_Short_Form_Agreement_Terms.docx | DOCX document | |
| Attachment_5_-_Good_Standing_Form.docx | DOCX document | |
| Attachment_6_-_Darfur_Contracting_Act_Certification.docx | DOCX document | |
| Exhibit_E_-_2025_Benefit_Fair_Locations.xlsx | XLSX spreadsheet |
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Text version
RFP 25-03 Employee Assistance Program
ATTACHMENT 4
GENERAL CERTIFICATIONS FORM
Read the following clauses carefully. If agreed, sign this attachment and return with your bid or proposal. Please note that the Court will reject any bid or proposal that does not include this properly completed and signed attachment.
Conflict of Interest. Bidder has no interest that would constitute a conflict of interest under California Public Contract Code (PCC) sections 10365.5, 10410 or 10411; Government Code sections 1090 et seq. or 87100 et seq.; or California Rules of Court, rule 10.103 or 10.104, which restrict employees and former employees from contracting with judicial branch entities.
Suspension or Debarment. Bidder certifies that neither Bidder nor any of Bidder’s intended subcontractors is on the California Department of General Services’ list of firms and persons that have been suspended or debarred from contracting with the state because of a violation of PCC 10115.10, regarding disabled veteran business enterprises.
Tax Delinquency. Bidder certifies that it is not on either (i) the California Franchise Tax Board’s list of 500 largest state income tax delinquencies, or (ii) the California Board of Equalization’s list of 500 largest delinquent sales and use tax accounts.
Conflict Minerals. Bidder certifies that either (i) it is not a scrutinized company as defined in PCC 10490(b), or (ii) the goods or services the Bidder would provide to the Court are not related to products or services that are the reason the Bidder must comply with Section 13(p) of the Securities Exchange Act of 1934. (Note: PCC 10490(b) defines a “scrutinized company” as “a person that has been found to be in violation of Section 13(p) of the Securities Exchange Act of 1934 by final judgment or settlement entered in a civil or administrative action brought by the Securities and Exchange Commission and the person has not remedied or cured the violation in a manner accepted by the commission on or before final judgment or settlement.”)
By signing below, signer indicates acceptance of the clauses above on behalf of Bidder and certifies they are duly authorized to legally bind the Bidder:
Legal Name of Company (Printed):
| Signature: |
| Date Executed: |
Printed Name and Title of Person Signing:
Rev. 2020-07 Page 1 of 1
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