Attachment A - Information and Certification.pdf
PDF 116 KB Posted
- Solicitation number
- S-10000-00002702
- Issued by
- Marion County, Oregon
About this file
This document is an Attachment A - Respondent Information and Certification Sheet for Request for Information (RFI) #S-10000-00002702 - Electronic Visit Verification (EVV) Non-Web Based Solution, issued by the Oregon Department of Human Services (ODHS). The RFI is seeking information for a time tracking solution that complies with the CURES Act to capture and verify data on services delivered by Personal Support Workers (PSWs) when they do not have internet access or when the individuals they assist live in areas with limited cell service. The RFI is for planning and informational purposes only, and ODHS may issue a separate procurement in the future or directly negotiate for the required services.
The document requires respondents to provide their legal name, address, state of incorporation, entity type, contact information, and Oregon business registry number (if required). Respondents must certify that they have not attempted to induce any other organization to submit or not submit a response, that the contents of the information and certification sheet are truthful and accurate, and that the response will be used for planning and informational purposes only.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment C - Disclosure Affidavit.pdf | ||
| RFI S-10000-00002702.pdf | ||
| Attachment B - Response Requirements.pdf | ||
| FI1107-22 - RFI.pdf |
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Text version
Request for Information #S-10000-00002702 – EVV Non-Web Based Solution Attachment A
Attachment A ZJ Page 1 of 1
ATTACHMENT A — RESPONDENT INFORMATION AND
CERTIFICATION SHEET
Legal Name of Respondent (as filed with the IRS):
Address: City, State, Zip:
State of Incorporation: Entity Type:
Contact Name: Telephone: Email:
Oregon Business Registry Number (if required):
Any individual signing below hereby certifies they are an authorized representative of Respondent and that:
1. No attempt has been made or will be made by the Respondent to induce any other person or organization to submit or not submit a Response.
2. All contents of this Respondent Information and Certification Sheet are truthful and accurate and have been prepared independently from all other Responses, and without collusion, fraud, or other dishonesty.
3. Respondent acknowledges that the Response for any of the services described in this RFI will be used for planning and informational purposes only. ODHS may issue a separate procurement in the future or directly negotiate for the services required by ODHS.
4. 5. 6.
Authorized Signature Date
7. 8. 9.
(Printed Name and Title)
10. 11.
File details come from the government source that posted it. Updated .