Attachment E-Responsibility Inquiry.pdf

Solicitation #10000-00011335 (RFA5936) Nursing Facility Client Care Surveyors Att. E

DAS Procurement Services, Version 1.0 – December 9, 2016 Page 1 of 3

ATTACHMENT E - RESPONSIBILITY INQUIRY

Agency will determine responsibility of an Applicant prior to award and execution of a Contract. In addition to this form, Agency may notify Applicant of other documentation required, which may include but is not limited to recent profit-and-loss history, current balance statements and cash flow information, assets-to-liabilities ratio, including number and amount of secured versus unsecured creditor claims, availability of short and long-term financing, bonding capacity, insurability, credit information, materials and equipment, facility capabilities, personnel information, record of performance under previous contracts, etc. Failure to promptly provide requested information or clearly demonstrate responsibility may result in an Agency finding of non-responsibility and rejection.

1. Does Applicant have available the appropriate financial, material, equipment, facility and personnel resources and expertise, or ability to obtain the resources and expertise, necessary to demonstrate the capability of Applicant to meet all contractual responsibilities? YES / NO .

2. Within the last five years, how many contracts of a similar nature has Applicant completed that, to the extent that the costs associated with and time available to perform the contract remained within Applicant′s control, Applicant stayed within the time and budget allotted, and there were no contract claims by any party? Number: ____

How many contracts did not meet those standards? Number: ____ If any, please explain.

Response:

3. Within the last three years has Applicant (incl. a partner or shareholder owning 10% or more of Applicant’s firm) or a major subcontractor (receiving 10% or more of a total contract amount) been criminally or civilly charged, indicted or convicted in connection with:

• obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract,

• violation of federal or state antitrust statutes relating to the submission of bids or Applications, or

• embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property? YES / NO .

If "YES," indicate the jurisdiction, date of indictment, charge or judgment, and names and summary of charges in the response field below.

Response:

4. Within the last three years, has Applicant had:

• any contracts terminated for default by any government agency, or

• any lawsuits filed against it by creditors or involving contract disputes? YES / NO .

If "YES," please explain. (With regard to judgments, include jurisdiction and date of final judgment or dismissal.)

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Response:

5. Does Applicant have any outstanding or pending judgments against it? YES / NO .

Is Applicant experiencing financial distress or having difficulty securing financing? YES / NO .

Does Applicant have sufficient cash flow to fund day-to-day operations throughout the proposed contract period? YES / NO

If "YES” on the first question or second question, or “NO” on the third question, please provide additional details.

Response:

6. Within the last three years, has Applicant filed a bankruptcy action, filed for reorganization, made a general assignment of assets for the benefit of creditors, or had an action for insolvency instituted against it? YES / NO .

If "YES," indicate the filing dates, jurisdictions, type of action, ultimate resolution, and dates of judgment or dismissal, if applicable.

Response:

7. Does Applicant have all required licenses, insurance and/or registrations, if any, and is Applicant legally authorized to do business in the State of Oregon? YES /NO .

If "NO," please explain.

Response:

8. Pay Equity Certificate. This certificate is required if Applicant employs 50 or more full-time workers and the prospective contract price is estimated to exceed $500,000. [This requirement does not apply to architectural, engineering, photogrammetric mapping, transportation planning or land surveying and related services contracts.] Does a current authorized representative of Applicant possess an unexpired Pay Equity Certificate issued by the Department of Administrative Services? YES / NO

/ N/A . [If the certificate was provided with the Bid or Application submitted for a solicitation related to the prospective contract, then it is not necessary to resubmit it. Just indicate “see Bid” or “see Application” in the response field. Otherwise, if applicable, submit a copy of the certificate with this form.]

Response:

AUTHORIZED SIGNATURE

By signature below, the undersigned Authorized Representative on behalf of Applicant certifies to the best of his or her knowledge and belief that the responses provided on this form are complete, accurate, and not misleading.

DAS Procurement Services, Version 1.0 – December 9, 2016 Page 3 of 3

Applicant Name: RFA: #5936-Solicitation#10000- 00011335

Project Name: Nursing Facility Client Care Surveyors

Authorized Signature Date

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