Attachment E - Disclosure Exemption Affidavit.pdf

RFP S-10000-00001153 – Fee-for-Service Representative Payee Services Attachment E

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ATTACHMENT E — DISCLOSURE EXEMPTION AFFIDAVIT

Submission of this Attachment E, with the signature of the Affiant, and notarization of the signature, is only required if there is information listed on page 3.

Proposer will submit a fully redacted version of its Proposal if page 3 of this

Attachment E is completed.

[Insert Name], (Affiant), being first duly sworn under oath, and representing [insert Proposer

Name] (hereafter “Proposer”), hereby deposes and swears or affirms under penalty of perjury that:

1. I am an employee of the Proposer, I have knowledge of the Request for Proposals referenced herein, and I have full authority from the Proposer to submit this affidavit and accept the responsibilities stated herein.

2. I am aware that the Proposer has submitted a Proposal, dated on or about [insert date] (the

“Proposal”), to the State of Oregon (State) in response to Request for Proposals S-10000-

00001153, for Fee-for-Service Representative Payee Services, and I am familiar with the contents of the RFP and Proposal.

3. I have read and am familiar with the provisions of Oregon’s Public Records Law, Oregon

Revised Statutes (“ORS”) 192.311 through 192.478, and the Uniform Trade Secrets Act as adopted by the State of Oregon, which is set forth in ORS 646.461 through ORS 646.475. I understand that the Proposal is a public record held by a public body and is subject to disclosure under the Oregon Public Records Law unless specifically exempt from disclosure under that law.

4. I have reviewed the information contained in the Proposal. The Proposer believes the information listed in Exhibit A is exempt from public disclosure (collectively, the “Exempt

Information”), which is incorporated herein by this reference. It is my opinion that the Exempt

Information is exempt from disclosure under Oregon’s Public Records Law under the specifically designated sections as set forth in Exhibit A or constitutes “Trade Secrets” under either the Oregon Public Records Law or the Uniform Trade Secrets Act as adopted in Oregon because that information is either:

A. A formula, plan, pattern, process, tool, mechanism, compound, procedure, production data, or compilation of information that:

i. is not patented,

ii. is known only to certain individuals within the Proposer’s organization and that is used in a business the Proposer conducts,

iii. has actual or potential commercial value, and

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iv. gives its user an opportunity to obtain a business advantage over competitors who do not know or use it.

or

B. Information, including a drawing, cost data, customer list, formula, pattern, compilation, program, device, method, technique or process that:

i. Derives independent economic value, actual or potential, from not being generally known to the public or to other persons who can obtain economic value from its disclosure or use; and

ii. Is the subject of efforts by the Proposer that are reasonable under the circumstances to maintain its secrecy.

5. I understand that disclosure of the information referenced in Exhibit A may depend on official or judicial determinations made in accordance with the Public Records Law.

Affiant’s Signature

State of ___________)

) ss:

County of ________)

Signed and sworn to before me on ___________ (date) by ______________________ (Affiant’s name).

Notary Public for the State of _________________

My Commission Expires: _________

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EXHIBIT A TO ATTACHMENT E

Proposer identifies the following information as exempt from public disclosure under the following designated exemption(s):