Attachment D - RFA Bidder Response.doc

Solicitation # 1745-662

Attachment D, Applicant Response Form

ALTERNATIVE PAYMENT OPTIONS – DIVISION OF CHILD SUPORT

Instructions: Please thoroughly read all instructions in this Request for Applications (RFA) before completing.

Applicants must complete this template (typed, using Arial font size no less than 12 point) and attach to their RFA Response. All mandatory information must be provided in order to be responsive. Applicant may provide additional documentation as an additional attachment with specific references included in this form. Also, please write your Business Name on the bottom of each page of this Response Template.

D.1.a. ADMINISTRATIVE REQUIREMENTS RESPONSE (not scored)

Applicant Information: Information must be listed here and Applicant must fill out a Contractor Intake Form, a Vendor Registration & a W-9.

Yes

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No

WA State Uniform Business Identifier (UBI) Number, if available:

Letter of Submittal

Yes

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No

Applicant confirmed currently licensed to do business in Washington State or is committed to becoming licensed within 30 days of being determined an Apparent Successful Applicant.

Applicant provided a Washington State Master Business License.

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Yes

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No

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Yes

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No

Applicant confirmed currently licensed to do business in all locations where payments will be accepted.

Applicant provided a Master Business License for each state, territory, or country in which they will provide receipting services related to this RFA.

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Yes

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No

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Yes

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No

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Yes

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No

Applicant must certify registration in System for Award Management (SAM), the official U.S. Government system that consolidates the capabilities of CCR/FedReg.ORCA, and EPLS prior to entering into an agreement and understands that DSHS must verify.

In addition to Contractor Intake Form requirements, Applicant must provide the Commercial And Government Entity (CAGE) Code.

Applicant must certify that neither they nor their business are included on the “Excluded Parties List” with the System for Award Management (SAM).

Applicant must provide North American Industry Classification System (NAICS) code.

Applicant certifies by signature below that they are registered in SAM and understands DSHS will verify

Signature

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CAGE Code_____________________________________________________________

Applicant certifies by signature below that they are not on Excluded Parties List Signature

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NAICS Code _____________________________________________________

D.1.b. Applicant Minimum Qualification Requirements:

All locations listed or attached

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Yes

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No

Applicant agrees, “This Request for Applications (RFA) and any resulting Contract shall not be governed by the United Nations Convention on the Sale of Goods, 1980, but shall be governed by the Washington State Uniform Commercial Code and other Washington State laws.”

Signature

If selected as an Apparent Successful Applicant, Applicant agrees and certifies they must comply with the rules set forth by the Credit Card Associations (VISA, MasterCard, Discover and American Express) and federal rules under Regulation E and Regulation Z as applicable to provided services.

In addition, Applicant certifies they must comply with data security requirements of the Payment Card Industry Data Security Standard (PCI-DSS).

Applicant certifies by signature below that they will comply with the rules set forth by the Credit Card Associations (VISA, MasterCard, Discover and American Express) and federal rules under Regulation E and Regulation Z as applicable to provided services. Applicant also certifies they will comply with data security requirements of the Payment Card Industry Data Security Standard (PCI-DSS).

Signature

Signature

Signature

Service outage recovery plan labeled and included

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Yes

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No (If no, please explain)

Signature

Signature

Signature

D.1.c. Experience and Qualifications: Applicants must answer each question. If Applicants provide attachments as part of their answers, Applicants must label each attachment with the corresponding question number, and include them as part of their Experience and Qualifications Proposal.

40 points possible for Questions 1-4.

Applicant must provide an Experience and Qualifications Proposal (Section 4 of Application Binder).

Applicant must provide an Experience and Qualifications Proposal that demonstrates their knowledge, skills, abilities, and experience in providing the service.

If Applicant designates Key Personnel who will provide services, the Successful Applicant is bound to utilize those Key Personnel in providing services. An awarded contract may include provisions specific to Key Personnel and additional requirements.

Experience and Qualifications attachments labeled and included

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Yes

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No

Question #1

What experience has your company had in delivery of services as described in this RFA?

5 points possible

Question #2

What has contributed the most to the success of your business in delivery of the services described in this RFA?

Question #3

How will your company ensure the electronic transfer of funds and payment details for delivery into the DCS/DSHS bank account in U. S. Dollars within two (2) business days of vendor’s receipt of payment?

20 points possible

Question #4

How does your company resolve problems and ensure customer service?

10 points possible

Please provide the name and contact information of the ongoing dedicated vendor representative for DCS staff and for customers using this service. (These can be different individuals.)

D.1.d. RFA Documents and Amendments:

Applicant must list all RFA Documents and Amendments downloaded by the Applicant from WEBS in order by date.

D.1.e. Project Scope: Applicants must answer each question. If Applicants provide attachments as part of their answers, Applicants must label each attachment with the corresponding question number, and include them as part of their Service Proposal.

40 points possible for Questions 1-3 of Service Proposal and 5 points possible for Fee Schedule Proposal.

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Yes

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No

Question #1

Name locations, types of payments accepted (i.e. cash, credit/debit card, etc.), and payment channels (i.e. kiosks, telephone, Internet, walk-in, etc.) to which this application relates (see Section A.3. Description of Services for locations.)

Question #2

Describe how you will provide the services in Section A.3. Description of Services to meet the DSHS service delivery specifications.

Provide a detailed plan for the smooth implementation of alternative payment option services to include a testing schedule, overall project schedule, expected involvement required by DSHS/DCS staff, and any other components deemed necessary.

Vendors are encouraged to be creative and innovative in responding to this RFA. Please discuss alternate approaches to the requested services where feasible, or additional services offered which may not be specifically requested. If your company has other payment options in which DSHS/DCS may be interested, please describe them here.

15 points possible

Question #3

What contingencies does your agency have in place for emergencies (inclement weather, system failure, security breach – data or theft, etc.) that would ensure minimum service delivery can be met to include transfer of funds and payment detail remittance? Describe the vendor’s disaster recovery plan that will allow for the continuation of business at the minimum levels. The plan must be available to DSHS/DCS for inspection upon request.

20 points possible

Fee Schedule Proposal (Section 5 of Application Binder) Applicants must provide a Fee Schedule that identifies their rates, expenses, or other costs to provide each type of payment accepted (i.e. cash, credit/debit card, etc.), and each type of payment channel (i.e. kiosks, telephone, Internet, walk-in, etc.) to which this application applies. All fees must remain fixed for the Successful Applicant Vendors awarded a contract during the awarded contract’s period of performance. Vendors must collect and pay any taxes, if applicable.

Fees charged should reflect charges to payers only. This proposal shall not include fees to DSHS/DCS for any part of this service.

In the case of chargeback or returned funds, the vendor will be responsible to recover funds from the customer.

5 points possible Fee schedule attachments labeled and included

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Yes

Signature

Please describe this process:

Signature

Please describe how you will accomplish this process:

Reports: Applicant certifies the ability to provide daily reports in an agreed upon format, regarding payments received. Data to be collected and reported to DSHS/DCS may include: payer name, address, DSHS/DCS payer account number, SSN, phone number, email address (if available), number of payments received, amount of each payment, total amount received, and payment source.

Please provide a sample report.

Applicant certifies by signature below that they have the ability to provide daily reports in an agreed upon format, regarding payments received. Data to be collected and reported to DSHS/DCS may include: payer name, address, DSHS/DCS payer account number, SSN, phone number, email address (if available), number of payments received, amount of each payment, total amount received, and payment source.

Signature Sample report labeled and included

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Yes

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No

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Yes

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No

If known, please state the name and contact information for the person(s) assigned:

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Yes

D.1.f. Provide three (3) non-Applicant owned or non-DSHS customer references: References must be from customers where the Applicant provided similar services. Applicant must fill out the Reference Check form, giving DSHS the ability to obtain information.

References are scored Pass/Fail.

References–Applicant must provide three (3) non-Applicant owned or non-DSHS customer references for their company. Applicant customer reference information is to be provided by using the form in Attachment F – Applicant Reference Form. Noncompliance with the reference requirement can be grounds for disqualification of the Applicant. The completed reference forms will not be shown to the Applicant at any time and will become the property of DSHS/DCS.

DSHS/DCS may, at its option, contact other Applicant customers for references, by telephone or other means, and evaluate the Applicant based upon these references.

References are scored Pass/Fail.

Three (3) Reference Check forms filled out and signed by Applicant included

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Yes

Reference #1: FORMCHECKBOX

Contact Name:

Telephone:

Email:

Services Provided:

Reference #2: FORMCHECKBOX

Contact Name:

Telephone:

Email:

Services Provided:

Reference #3: FORMCHECKBOX

Contact Name:

Telephone:

Email:

Services Provided:

D.1.g. Contract History:

List contract(s) where Applicant performed similar services, where the combined number of years is five (5) or more years. Identify the Firm(s) or Agency(s) involved, services provided, & dates.

Was the Applicant’s performance on any contract in the past five (5) years unsatisfactory and resulted in a contract termination?

If so, provide a list of those contracts terminated, and include the following:

· Other party’s Name and Address

· Telephone Number

· Description of the Incident

· Applicant’s Position on the matter

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Yes

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No

D.1.h. Insurance Requirements:

Applicant must provide copies of required insurance coverage as outlined in the RFA Sample Contract, Attachment A.

Certificate of Insurance included

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Yes

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No

D.1.i. State of Washington Employee(s):

Is or was the Applicant’s officer(s) and/or employee(s) an employee of any agency of the State of Washington during the last 24 months preceding the Response Due Date for this RFA?

If yes, provide the following information for each individual:

· Name

· Employing Agency

· Job Title while with the Agency

· Separation Date

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Yes

D.1.j. Proprietary or Confidential Infontial Informatiovices_______ t is for DES' separate document from this Response. FQQ.n dying OEM and product li:

If applicable, Applicant shall identify the Sections of the Response which the Applicant considers “Proprietary” or “Confidential” information:

D.1.k. Statements to the RFA Coordinator:

Any other statements the Applicant would like to convey, including any requested or proposed variations between the Response and the RFA:

DSHS/DCS will not sign any Merchant Agreements, Vendor Contracts or Vendor Agreements. (See RFA Section A 1. d)

D.1.l. OMWBE Certification: (Optional)

Yes

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No If Yes, please provide your OMWBE Certification Number _______________

D.1.m. Checklist of Mandatory Response Attachments:

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Completed and signed Applicants Certification and Assurances Form (Attachment C)

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Completed Administrative Requirements Response (Applicant Response Template, Attachment D; this document)

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Completed Written Response (Applicants Response Template, Attachment D; the Written Response must be a separate document from other attachments)

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Completed Contractor Intake Form (Attachment E)

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Completed Statewide Payee Vendor Registration with W-9 (Attachment H) – W-9 MUST BE RETURNED WITH THIS SUBMISSION

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