Attachment 8 - State_and_Local_Authorization_Licensure_Self_Attestation-1.docx

ATTACHMENT 8

STATE AND LOCAL AUTHORIZATION/LICENSURE SELF-ATTESTATION

INSTRUCTIONS TO OFFERORS – READ BEFORE COMPLETING ATTACHMENT 8

Red instructional/reference text may be deleted before submission. Required template headings, field labels, certification/attestation language, signature fields, and response fields shall not be deleted, renamed, or altered.

Before Submission: The Offeror may delete only instructional or reference text shown in red. Deletion of red instructional/reference text will not affect the completeness of the submission.

The following shall remain in each completed Attachment 8:

Attachment title;

Government-provided section headings and field labels;

All required response fields;

Government-provided certification and attestation language;

Authorized representative name, title, signature, and date fields; and The Offeror's completed responses.

The Offeror may expand response fields as necessary but shall not delete, rename, combine, or otherwise modify Government-provided headings, field labels, required response fields, certification/attestation language, or signature fields.

Complete and sign a separate Attachment 8 for each proposed facility/site and jurisdiction, as required by L.8.

The Offeror shall identify all applicable state and local authorization, licensure, approvals, or documented support associated with the proposed facility/site and shall identify any pending approvals, restrictions, conditions, or known state or local objections that may affect performance, as required by this attachment.

Page Limit. There is no page limit for Attachment 8.

Formatting. Narrative responses shall use a minimum 12-point font. Tables, charts, figures, text boxes, headers, and footers may use a minimum 10-point font. Government-provided template text, headings, labels, certification/attestation language, and signature fields shall retain their existing formatting. All text shall be legible and comply with Section L.5.

1. Offeror and Proposed Facility/Site

Prime Offeror Name

Prime Offeror UEI

Facility / Site Name

Facility Operator / Performing Entity

Facility Street Address

City / County / State / ZIP Code

2. State and Local Authorization / Licensure Status

License/authorization type and number: ____________________ Status: ☐ Issued ☐ Pending ☐ Not Applicable Expiration date (if applicable): ____________________

Approval/permit: ____________________ Status: ☐ Issued ☐ Pending ☐ Not Applicable

Accreditation: ____________________ Status: ☐ Current ☐ Pending ☐ Not Applicable

Status: ☐ Approved ☐ Pending ☐ Not Applicable

3. Pending Approvals, Restrictions, Conditions, or Objections

4. Supporting Documentation Identify and attach supporting state/local authorization and licensure documentation, as applicable. List the documents submitted with this self-attestation:

5. Self-Attestation and Certification By signing below, the authorized representative attests that, as of the proposal submission date, the Offeror has the necessary state and local authorization, licensure, approvals, or documented support to operate the proposed licensed Secure Care and/or HSF level(s) of care in the jurisdiction identified above, subject to any pending approvals, restrictions, conditions, or known state or local objections disclosed in this Attachment 8. The undersigned certifies that the information provided is accurate and complete to the best of their knowledge.