EXHIBIT A-9

PAST PERFORMANCE - CLIENT REFERENCE FORM

Respondent Name:

The respondent shall provide two (2) separate and verifiable, Non-Agency client references, on the following pages. The clients listed must be for work similar in nature to that specified in this solicitation. The same client may not be listed for more than one (1) reference, and confidential clients shall not be included. In the event the respondent has had a name change since the time work was performed for a listed reference, the name under which the respondent operated at that time must be provided in the space provided for Respondent Name.

The Agency’s Procurement Officer or designated Purchasing staff will make up to three (3) attempts to contact each of the client references provided by the respondent to complete the Evaluation Questionnaire for Past Performance (see below). The Procurement Officer will record the scores given by each client reference. If the Procurement Officer is unable to contact a client reference to complete the Evaluation Questionnaire for Past Performance, the respondent shall receive an evaluation score of zero (0) for that Client Reference.

Clients that are listed as subcontractors in the response will not be accepted as Past Performance references under this solicitation and will receive an evaluation score of zero (0) for that Client Reference. Entities having an affiliation with the respondent (i.e. currently parent, subsidiary having common ownership, having common directors, officers or agents or sharing profits or liabilities) may not be accepted as Past Performance references under this solicitation.

Responses which do not contain client references will receive a score of zero (0) for the past performance evaluation component.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

NON-AGENCY

CLIENT REFERENCE #1

Respondent Name:

Client’s Name:

Address:

Contract Performance Period:

Location of Services:

Brief description of the services performed by the respondent for this client:

NON-AGENCY

CLIENT REFERENCE #2

Respondent Name:

Client’s Name:

Address:

Contract Performance Period:

Location of Services:

Brief description of the services performed by the respondent for this client:

Evaluation Questionnaire for Past Performance

Questions that are not scored by the Client Reference according to the rating scale provided, will receive a score of zero (0) for the question.

Respondent Name:

Non-Agency Client’s Name:

1. Briefly describe the services the respondent performed for your organization:

2. Define the relationship between the respondent and the client reference as one of the following:

(circle one)

Prime Vendor; or Subcontractor.

Score

3. How would you rate the Contract implementation with this respondent?

(Excellent = 5; Good = 4; Acceptable = 3; Fair = 2; Poor = 1)

4. How would you rate the respondent’s customer service to clients?

(Excellent = 5; Good = 4; Acceptable = 3; Fair = 2; Poor = 1)

5. Did the respondent consistently meet all of its performance/milestones deadlines?

(Yes = 5; No = 0)

6. Did respondent staff maintain open lines of communication with your organization?

7. Did the respondent’s project/contract manager effectively manage the Contract?

8. Was the respondent’s staff responsive to technical direction from your organization?

9. Did the respondent go beyond the call of duty to resolve urgent issues/concerns expediently?

10. Was the respondent’s staff knowledgeable of the Contract requirements and scope of work?

11. Was the respondent proactive in developing/recommending improvements for increasing the efficiency of processes?

12. Would you contract with this respondent again?

Total Score:

Client Reference Verified by:

Name (printed)

Title

Signature

Date

AHCA RFP 015-25/26, Attachment A, Exhibit A-9, Page 5 of 5