Attachment F Responsibility Inquiry.pdf

Bid Solicitation # S-10000-00006578 ODHS # 5651 Responsibility Inquiry Page 1 of 3

ATTACHMENT F - RESPONSIBILITY INQUIRY

ODHS will determine responsibility of an Applicant prior to award and execution of a Contract. In addition to this form, ODHS 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 ODHS 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.

Bid Solicitation # S-10000-00006578 ODHS # 5651 Responsibility Inquiry Page 2 of 3

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.)

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.

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.

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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.

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. 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.]

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.

Applicant Name:

RFP: # S-0000-00006578

Project Name: Consultant for Organizational Change

Authorized Signature Date

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