Attachment C_Applicant Information and Certification Sheet.docx
DOCX document 40 KB Posted
- Attached to
- RFA - Early Literacy Success Community Grants
- Solicitation number
- S-58100-00013327
- Issued by
- Oregon
About this file
This document is an Applicant Information and Certification Sheet for the Early Literacy Success Community Grants Request for Application (RFA) issued by a state agency, likely in Oregon. The document is a standardized form for potential grantees to complete, providing organizational details and certifying compliance with various state and federal requirements. While specific project details are not outlined in this attachment, the form indicates that applicants are seeking to participate in a grant program focused on early literacy initiatives.
The certification sheet requires applicants to provide comprehensive organizational information including legal name, contact details, tax identification, business registry numbers, and insurance coverage. Applicants must certify compliance with multiple legal and ethical standards, including non-discrimination policies, tax law adherence, absence of conflicts of interest, and verification that they are not on any government exclusion lists. The document emphasizes transparency and accountability, with applicants attesting to the truthfulness of their application and understanding potential legal consequences for false statements. Insurance requirements include Workers' Compensation, Commercial General Liability, Physical Abuse and Molestation coverage, Automobile Liability, and Directors and Officers Liability, with specific minimum coverage amounts specified.
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Text version
RFA S-58100-000***** – Early Literacy Success Community Grants
Att C
ATTACHMENT C – APPLICANT INFORMATION & CERTIFICATION SHEET
Early Literacy Success Community Grants Request for Application (RFA)
Applicant’s Legal Name (must match name registered with the IRS):
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| Address: Click or tap here to enter text. |
| Mailing Address (if different): Click or tap here to enter text. |
| Contact Name: Click or tap here to enter text. |
| Email: Click or tap here to enter text. |
| Phone: Click or tap here to enter text. |
| Fax: Click or tap here to enter text. |
State of Incorporation:
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Tax ID #:
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| Federal Unique Entity Identifier or UEI #: Click or tap here to enter text. |
| Oregon Business Registry #, if required (Registry # must be “active” prior to grant execution.) |
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Insurance (indicate whether Applicant currently has the required insurance or will obtain required insurance): See Exhibit B to Attachment A – Sample Grant Agreement for requirements
| INSURANCE TYPE |
| CURRENTLY MEETS REQUIREMENT |
| WILL OBTAIN PRIOR TO GRANT SIGNING |
| · Workers’ Compensation |
| ☐ |
| ☐ |
| · Commercial General Liability - Not less than $1,000,000 per occurrence - Not less than $2,000,000 aggregate |
| ☐ |
| ☐ |
| · Physical Abuse and Molestation - Not less than $1,000,000 per occurrence - Not less than $3,000,000 aggregate |
| ☐ |
| ☐ |
| · Automobile Liability – $1,000,000 |
| ☐ |
| ☐ |
| · Directors, Officers, and Organization Liability - Not less than $1,000,000 per occurrence |
| ☐ |
| ☐ |
Any individual signing below hereby certifies they are an authorized representative of Applicant and that:
1. Applicant understands and accepts the requirements of this RFA. By submitting an Application, Applicant agrees to be bound by the Grant terms and conditions in Attachment A and as modified by any addenda, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFA.
2. Applicant acknowledges receipt of any and all addenda to this RFA.
3. If awarded a Grant, Applicant agrees to perform the project activities and meet the standards set forth in the final negotiated scope of the Grant.
4. 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.
5. Applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, or national origin. When awarding contracts, 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.
6. 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.
7. Applicant and Applicant’s employees, agents, and contractors 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/
8. 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.
9. Applicant certifies that all contents of the Application (including any other forms or documentation, if required under this RFA) and this Application Cover Sheet are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.
10. Applicant understands that any statement or representation it makes, in response to this RFA, 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 a Grant 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.
11. Applicant acknowledges these certifications are in addition to any certifications required in the Grant at the time of Grant execution.
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Signature
Date
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Printed Name
Title
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