4050 Esplanade Way 4050 Esplanade Way, Suite 360 Tallahassee, FL 32399-0950

Ron DeSantis, Governor Tom Berger, Interim Secretary

REVISED ATTACHMENT I

FORMS

General Instructions to Respondents

A. Deadline.

The Respondent must complete, sign, and submit the forms in this Attachment I, Forms, by the deadline to submit Proposals and all required documents in the Business Network specified in section 1.1, Timeline of Events, of the RFP.

B. Completion.

All forms requiring signature may be completed by the Respondent using either electronic or wet-ink signature.

REMAINDER OF PAGE LEFT INTENTIONALLY BLANK

FORM 1 – CONTACT INFORMATION

For solicitation purposes, the Respondent’s contact person will be:

Should the Respondent be awarded the Contract, the Account Manager’s contact information will be:

Name

Title

Company Name

Address

Telephone

Fax

E-mail

FEID #

Name of Respondent’s Organization

Signature of Authorized Representative and Date

Print Name

FORM 2 – NOTICE OF CONFLICT OF INTEREST

Company Name

For the purpose of participating in the solicitation process and complying with the provisions of Chapter 112, Florida Statutes, the company states the following conflict(s) of interest exists as noted below (if none, write N/A in the applicable section(s) below):

The persons listed below are corporate officers, directors or agents and are currently employees of the State of Florida or one of its agencies:

The persons listed below are current State of Florida employees who own an interest of five percent (5%) or more in the company named above:

Name of Respondent’s Organization

Signature of Authorized Representative and Date

Print Name

FORM 3 – NON-COLLUSION STATEMENT

am authorized to make this statement on behalf of my firm and its owner, directors and officers. I am the person responsible in my firm for the price(s) and amount(s) of this Reply, and the preparation of the Reply. I state that:

1. The price(s) and amount(s) of this Reply have been arrived at independently and without consultation, communication or agreement with any other Provider, potential provider, Reply, or potential Reply.

2. Neither the price(s) nor the amount(s) of this Reply, and neither the approximate price(s) nor approximate amount(s) of this Reply, have been disclosed to any other firm, vendor, Respondent, or potential Respondent, and they will not be disclosed before Reply opening.

3. No attempt has been made or will be made to induce any firm or persons to refrain from submitting a Reply for this contract, or to submit a price(s) higher that the prices in this Reply, or to submit any intentionally high or noncompetitive price(s) or other form of complementary Reply.

4. The Reply of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit a complementary or other noncompetitive Reply.

are not currently under investigation, by any governmental agency and have not in the last ten years been convicted or found liable for any act prohibited by state or federal law in any jurisdiction, involving conspiracy or collusion with respect to Reply, on any public contract, except as follows:

I state that I and the named firm understand and acknowledge that the above representations are material and important, and will be relied on by the State of Florida for which this Reply is submitted. I understand and my firm understands that any misstatement in this statement is, and will be treated as, fraudulent concealment from the State of Florida of the true facts relating to the submission of Replies for this contract.

Dated this day of

Name of Firm:

Signed by:

Print Name

FORM 4 – STATEMENT OF NO PRIOR DISQUALIFYING INVOLVEMENT

I, as an authorized representative of the Respondent, certify that nothing in section 287.057(17)(c), Florida Statutes (below), prohibits the Respondent’s entry into any Contract resulting from this solicitation.

287.057 Procurement of commodities or contractual services. — (17)(c) A person who receives a contract that has not been procured pursuant to subsections (1)-(3) [of s. 287.057, F.S.] to perform a feasibility study of the potential implementation of a subsequent contract, who participates in the drafting of a solicitation or who develops a program for future implementation, is not eligible to contract with the agency for any other contracts dealing with that specific subject matter, and any firm in which such person has any interest is not eligible to receive such contract. However, this prohibition does not prevent a Respondent who responds to a request for information from being eligible to contract with an agency.

Name of Respondent’s Organization

Signature of Authorized Representative and Date

Print Name

FORM 5 – ADDENDUM ACKNOWLEDGEMENT FORM

This acknowledgment form serves to confirm that the Respondent has reviewed and accepted all Addendum(s) to the solicitation posted on the Vendor Information Portal.

Please list all Addendum(s) below.

FORM 6 – SUBCONTRACTING

Complete the information below on all subcontractors that will provide services to the Respondent to meet the requirements of the resultant contract, should the Respondent be awarded. Submission of this form does not indicate the Department’s approval, but provides the Department with information on proposed subcontractors for review.

Please complete a separate sheet for each subcontractor.

There will be subcontractors for this solicitation YES ____ NO ____ (place a checkbox where applicable). If not, Respondents are not required to complete the remainder of this form.

Service:

Company Name:

Contact:

Address:

Telephone:

Fax:

Current Office of Supplier Development certification of woman-, veteran-, or minority-owned small business enterprise

Yes ________ No ___________

W-9 verification:

Yes ________ No ___________

In a job description format, describe below the responsibilities and duties of the subcontractor based on the technical specifications or statement of work outlined in this solicitation.

REVISED Attachment I – Forms RFP No.: 26-83111500-RFP Page 1 of 1 Contact Center Services

REVISED Attachment I – Forms RFP No.: 26-83111500-RFP Page 1 of 5 Contact Center Services image1.png