Attachment 4 RFP 865 Cover Form Amended 25-5-2025.docx

ATTACHMENT 4 – COVER FORM

RFP # 856865 System Integration Builder Attachment 4, Cover Form must be completed, signed, and submitted with your Proposal. Failure to complete and submit this form may result in your Proposal being deemed non-responsive.

Instructions: The Technical Proposal must include a signed copy of this cover form. Copy and paste this form onto your company letterhead, or include the following information: Offeror’s company name, mailing address, phone number, fax number, e-mail address, and name of Offeror’s authorized signer. The cover form must include the RFP Number and Title and must be signed by an individual authorized to commit the Offeror to the contents of the Proposal.

1. General Information and Confirmations

☐ Limited Liability Corporation (LLC) ☐ Limited Liability Partnership ☐Sole Proprietorship ☐ Other (specify)

Offeror’s Tax Identification Number

EIN:

Offeror’s DUNS Number

DUNS:

Is Offeror a legal entity with the legal right to contract?

☐ Yes ☐ No

Other than modifications/exceptions identified on Attachment 3, in compliance with Section 2.4 of this RFP, does Offeror accept, and is Offeror willing to comply with, the requirements of this RFP and attachments, including but not limited to those identified in Attachment L – SI Builder Contract Template?

☐ Yes ☐ No

Is Offeror in compliance with applicable equal employment regulations?

☐ Yes ☐ No

Does Offeror affirm that it has not employed any company or person other than a bone fide employee working solely for the Offeror or a company regularly employed as its marketing agent, to solicit or secure the Contract, and that it has not paid or agreed to pay any company or person, other than a bone fide employee working solely for the Offeror or a company regularly employed by the Offeror as its marketing agent, any fee, commission, percentage, brokerage fee, gifts, or any other consideration contingent upon or resulting from the award of the Contract.?

☐ Yes ☐ No

Does Offeror understand and agree that for breach or violation of the above term, the State has the right to annul the Contract without liability or, in its discretion, to deduct from the offered price the amount of any such fee, commission, percentage, brokerage fee, gifts, or contingencies.

☐ Yes ☐ No

Firm(s) and/or staff responsible for writing the Proposal

Names:

Does Offeror affirm that it is not currently suspended, debarred, or otherwise excluded from federal or state procurement and non-procurement programs?

Note: vendor information is available at https://sam.gov.

☐ Yes ☐ No

Does the Offeror affirm that the Proposal will be firm and binding for ninety (90) calendar days from the Proposal opening date?

☐ Yes ☐ No

2. Identification of Key Personnel Offeror must identify the individual who will fill each of the following roles. If the Offeror is selected to participate in demonstrations/interviews, the named individuals are the only individuals who may interview (no substitutions will be permitted).

Project Manager

Solution Architect

Implementation/Integration Manager

Security Compliance Manager

SI Quality Assurance/Testing Manager

Maintenance and Operations Manager

3. Attestation and Signature This Submittal must be dated and signed by an officer or agent (“Representative”) duly authorized to execute contracts for the Offeror. I certify that I have read and understand this RFP and I am authorized to sign this Proposal on behalf of the Offeror.

Signed By:

Printed Name:

Date: ________________________________________