RFA S-10000-00016003 – Adult Protective Services Contract Attorneys Attachment A

ATTACHMENT A — APPLICATION PACKET

PART 1 — APPLICATION

Legal Name of Applicant: ____________________________________________________

Primary Contact Person: _____________________________________________________

Applicant is:

☐ an Individual ☐a Publicly Held Company ☐ a Privately Held Company

Address: _______________________________________________________________________

City, State, Zip: ________________________________________________________________

Telephone: ________________________ Facsimile Number: ______________________

Email Address: ________________________________________________________________

Languages available: _________________________________________________________

Oregon State Bar Number: __________________________________________________

Please respond to the following:

Are you an active member of the Oregon State Bar in good standing with no disciplinary history in the past five years? ☐ Yes ☐ No

Do you live and practice Law within the State of Oregon? ☐ Yes ☐ No

Do you have experience in protective proceedings (guardianships/conservatorships)? ☐ Yes ☐ No

Please check County or Counties that Applicant would like listed on the Contract Attorney Registry for Adult Protective Services, provided to Petitioners to assist them in selecting a Contract Attorney:

(check all that apply)

☐ All Counties

☐ Baker County ☐ Benton County ☐ Clackamas County ☐ Clatsop County ☐ Columbia County ☐ Coos County ☐ Crook County ☐ Curry County ☐ Deschutes County ☐ Douglas County ☐ Gilliam County ☐ Grant County ☐ Harney County ☐ Hood River County ☐ Jackson County ☐ Jefferson County ☐ Josephine County ☐ Klamath County ☐ Lake County ☐ Lane County ☐ Lincoln County ☐ Linn County ☐ Malheur County ☐ Marion County ☐ Morrow County ☐ Multnomah County ☐ Polk County ☐ Sherman County ☐ Tillamook County ☐ Umatilla County ☐ Union County ☐ Wallowa County ☐ Wasco County

☐ Washington County ☐ Wheeler County ☐ Yamhill County

ATTACHMENT A — APPLICATION PACKET

PART 2 — INFORMATION AND CERTIFICATION SHEET

1. Applicant understands and accepts the requirements of RFA S-10000-00016003. By submitting an Application, Applicant agrees to be bound by the Contract terms and conditions in Attachment B, Sample Contract and as modified by any Addenda.

2. Applicant acknowledges receipt of any and all Addenda to this RFA.

3. Application is a Firm Offer for 180 days following the Closing.

4. If awarded a Contract, Applicant agrees to perform and meet the performance standards set forth in the scope of work of the Contract.

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 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 an 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.

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 work 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 the awarded Contract and a failure to comply constitutes a breach that entitles Agency to terminate the awarded Contract 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.

https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx

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 awarded 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/portal/

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 RFA. 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 RFA S-10000-00016003) and this Application 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 RFA S- 10000-00016003, 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 Contract 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.

13. Applicant acknowledges these certifications are in addition to any certifications required in the Contract and Statement of Work in Attachment B at the time of Contract execution.

Authorized Signature Date

(Printed Name and Title) https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.sam.gov/portal/