attachment-5-rfa-2027-dltss-03-mfptc-appendix-d.pdf

New Hampshire Department of Health and Human Services Appendix D – Transmittal Letter and Vendor Information

TRANSMITTAL LETTER

Solicitation ID Number

Vendor Name

Vendor Address

Vendor Telephone State of NH Vendor Code Number (required)

Counties your organization is applying to serve

Belknap ☐ Carroll ☐ Cheshire ☐ Coos☐ Grafton ☐ Hillsborough ☐ Merrimack ☐ Rockingham ☐ Strafford ☐ Sullivan ☐

Date of Submission

To whom it may concern:

We hereby submit this response to the Solicitation referenced above, in complete accordance with all conditions and specifications set forth in the Solicitation.

We attest to the fact that:

1. The Vendor has read and fully understands this Solicitation and agrees to be bound by its terms, conditions, and requirements.

2. The Vendor has read and fully understands Appendix A - Scope of Services and Appendix B - Form P-37 General Provisions and Standard Exhibits.

3. The Vendor’s Solicitation Response is effective for a period of 180 days from the Vendor Solicitation Response Due Date or until the Effective Date of any resulting Contract, whichever is later.

4. The prices, terms and conditions, and services in the Vendor’s Solicitation Response have been established without collusion with other vendors.

5. This document is signed by a person who is authorized to legally obligate the responding Vendor.

Further, in accordance with RSA 21-I:11-c, the undersigned Vendor certifies that neither the Vendor nor any of its subsidiaries, affiliates or principal officers is currently debarred from performing work on any project of the federal government or the government of any state.

Authorized Signature

Authorized Signature (printed)

Title

Telephone

Email

1. Vendor Contact Information

Primary Point of Contact Individual who will serve as the Vendor’s primary contact for all other matters relating to the Solicitation.

Name

Title

Email

Telephone

Fiscal Contact Individual who will serve as the Vendor’s primary contact for fiscal matters.

Name

Title

2. Vendor References Provide the information requested below for three (3) individuals or organizations who have knowledge of your organization’s capability to deliver services applicable to this Solicitation. The Department may contact references at its discretion. A current Department employee will not be considered a valid reference.

Vendor Reference 1 Individual/Organization Name

Description of Work Complete

Dates of Performance Vendor Reference 2

Vendor Reference 3

3. Affiliations – Conflict of Interest

Does your organization have any affiliations that might result in a conflict of interest in relation to this Solicitation?

Choose an item.

a. If YES, explain the relationship(s) and how the affiliation(s) would not represent a conflict of interest.

4. Executive Summary

a. Provide a general company overview:

i. Describe the company’s management, organizational structure, and history; ownership and subsidiaries; company background and primary lines of business; headquarters and satellite locations; mission statement;

and number of employees.

ii. Summarize the organization’s current project commitments, as well as major government and private sector clients.

iii. Summarize the organization’s programs and activities, as well as the number of people served.

iv. Describe any strengths considered to be assets to the organization and notable company accomplishments.

b. Provide an overview of the services the Vendor intends to provide.

i. Describe the organization’s understanding of the services requested in this solicitation and any problems anticipated in accomplishing the work.

ii. Summarize the overall design of the project in response to achieving the deliverables as defined in this solicitation.

iii. Describe the organization’s familiarity with the project elements, its solutions to the problems presented and knowledge of the requested services.

iv. Summarize how the organization is capable of effectively completing the services outlined in the solicitation.