Attachment_C_-_Campaign_Contribution_Disclosure_Form_-_2024.docx
DOCX document 34 KB Posted
- Attached to
- Medical Transportation Services
- Solicitation number
- RFA-042-1644156-DMA
- Issued by
- Orange County, San Francisco City, California
About this file
The document is a Campaign Contribution Disclosure Form for the County of Orange, requiring applicants to disclose any campaign contributions made to Board of Supervisors members or County Agency Officers within the past 12 months. The form is part of a broader Medical Transportation Services Request for Applications (RFA) issued by the Orange County Health Care Agency (HCA), seeking qualified organizations to provide non-emergency medical transportation services for various county-mandated populations, including arrested, incarcerated, detained, and other individuals requiring medical transport. The RFA will accept applications on an ongoing basis until December 31, 2024, with services commencing throughout 2024, and applications must remain valid for 365 calendar days from submission.
The contract offers a cooperative agreement potentially available to all Orange County departments and other governmental entities, with a maximum contract obligation of approximately $900,000. Reimbursement is structured on a fee-for-service basis, with a $400 base rate for Basic Life Support emergency transport, plus additional charges for mileage and out-of-county transports. Funding sources are diverse, including state, federal, county, and fees/licenses/other funds, contingent upon sufficient fund availability. Providers must maintain extensive insurance coverage, meet confidentiality standards, and comply with comprehensive documentation and reporting requirements. The County reserves the right to reject applications, conduct compensation plan analyses, and negotiate with qualifying applicants. Providers must use a third-party logistics application (VectorCare) and maintain staffing with certified Emergency Medical Technicians.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment_II_Forms_A-D.xlsx | XLSX spreadsheet | |
| RFA_042-1644156-DMA.pdf | ||
| Attachment_I_-_Contract_Template.pdf | ||
| Attachment_I_-_Contract_Template.pdf | ||
| RFA_042-1644156-DMA.pdf | ||
| Attachment_C_-_Campaign_Contribution_Disclosure_Form_-_2024.docx | DOCX document | |
| Attachment_II_Forms_A-D.xlsx | XLSX spreadsheet |
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Text version
COUNTY OF ORANGE
CAMPAIGN CONTRIBUTION DISCLOSURE FORM
Application or Solicitation Number:
Application or Solicitation Title:
Was a campaign contribution, regardless of the dollar amount, made to any member of the Orange County Board of Supervisors or to any County Agency Officer within the last 12 months by the applicant, or, if applicable, any of the applicant’s proposed subcontractors or the applicant’s agent or lobbyist?
Yes ____ No_____
If no, please sign and date below.
If yes, please provide the following information:
Applicant’s Name:
Contributor or Contributor Firm’s Name:
Contributor or Contributor Firm’s Address:
Is the Contributor:
| o | The Applicant | Yes___ | No ___ | |
| o | Subcontractor | Yes___ | No ___ | |
| o | The Applicant’s agent/ or lobbyist | Yes___ | No ___ |
Note: Under California law as implemented by the Fair Political Practices Commission, campaign contributions made by the Applicant and the Applicant’s agent/lobbyist who is representing the Applicant in this application or solicitation must be aggregated together to determine the total campaign contribution made by the Applicant.
Identify the Board of Supervisors Member(s) and County Agency Officer(s) to whom you, your subcontractors, and/or agent/lobbyist made campaign contributions within the last 12 months, the name of the contributor, the dates of contribution(s) and dollar amount of the contribution. Each date must include the exact month, day, and year of the contribution.
Name of Board of Supervisors Member or County Agency Officer:
Name of Contributor:
Date(s) of Contribution(s):
Amount(s):
(Please add an additional sheet(s) to identify additional Board Members or County Agency Officer to whom you, your subconsultants, and/or agent/lobbyist made campaign contributions)
By signing below, I certify that the statements made herein are true and correct. I also agree to disclose to the County any future contributions made to Board Members or County Agency Officers by the applicant, or, if applicable, any of the applicant’s proposed subcontractors or the applicant’s agent or lobbyist after the date of signing this disclosure form, and within 12 months following the approval, renewal, or extension of the requested license, permit, or entitlement to use.
Date Signature of Applicant
| _______________________________________ | ________________________________ | |
| Print Firm Name, if applicable | Print Name of Applicant |
ORANGE COUNTY BOARD OF SUPERVISORS
AND COUNTY AGENCY OFFICERS
Board of Supervisors
Andrew Do, First District
Vicente Sarmiento, Second District
Donald P. Wagner, Third District
Doug Chaffee, Fourth District
Katrina Foley, Fifth District
County Agency Officers
Claude Parrish, Assessor
Andrew Hamilton, Auditor-Controller
Hugh Nguyen, Clerk-Recorder
Todd Spitzer, District Attorney-Public Administrator
Don Barnes, Sheriff-Coroner
Shari L. Freidenrich, Treasurer-Tax Collector
1/1/24
File details come from the government source that posted it. Updated .