Attachment_II_Forms_A-D.xlsx

XLSX spreadsheet 41 KB Posted May 20, 2026

Attached to: Fiscal Intermediary Services
Solicitation number: 042-1804224-RPT
Issued by: Orange County, San Francisco City, California

About this file

Written by GovTribe AI · Aug 24, 2026

This file contains application forms and submission requirements for a Fiscal Intermediary Services contract opportunity issued by the County of Orange Health Care Agency in California. The contract seeks qualified organizations to serve as a fiscal intermediary to coordinate with the HCA in distributing rental subsidies and housing intervention payments to approved providers on behalf of eligible individuals referred by the HCA. The document establishes mandatory submission requirements including a completed application checklist, agency description form, bidder certifications, and board of directors information. All applications must remain valid for a minimum of 365 calendar days from the application due date, and applicants must certify their ability to provide required insurance coverage and their understanding of county contract terms and conditions.

The submission requirements mandate that applicants provide comprehensive organizational documentation, including articles of incorporation or business licensing, bylaws, corporate organizational charts, financial statements, audit reports, and evidence of federal and tax status. Applicants must disclose any conflicts of interest, current client relationships, and potential financial interests that could impact service delivery. The application must identify the contract signature authority and solicitation contact person, detail the organization's current annual operating budget broken down by funding sources, and provide a complete board of directors roster including member names, addresses, contact information, tenure dates, occupations, and affiliations. Applicants must also certify compliance with all RFA requirements or submit detailed exceptions with supporting justifications for any proposed deviations.

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File	Type	Posted
Fiscal_Intermediary_Services.pdf	PDF	Aug 21, 2026
Fiscal_Intermediary_Model_Contract_Fnl.docx	DOCX document	Aug 18, 2026

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Cover Page Attachment II

Forms A-D

RFP No.: ___________

[Solicitation Title]

Released Month Day, 202X

Form A - Checklist Use this checklist to identify whether or not all items requested have been included. This form is to be completed and included in the uploaded BidSync file. Failure to provide the requested information and/or documentation may result in disqualification of your Application.

Organization Name:

	Upload File				Item(s) Enclosed/
Completed			Page and Section Number
	A.	Cover Page/Executive Summary
	B.	Agency Description (Form B - Attachment II)
	C.	Bidder Certifications (Form C - Attachment II)
	D.	Board of Directors (Form D - Attachment II)
	E.	Campaign Contribution Form
	F.	Reference Letters
	G.	Documentation
		1.	If incorporated:
			a.	Articles of Incorporation
			b.	By-Laws
			c.	Resolution empowering Corporate Officer
		2.	If not incorporated: Documentation empowering

Authorized Representative

	3.	Fictitious Business Name statement and Proof
	4.	Partnership Papers/joint Venture Agreements
	5.	Evidence of Federal/State tax status
	6.	IRS W-9 Form
	7.	Business License/Certifications/CUP (as applicable)
	8.	Table of Contents from P&P manual
	9.	Corporate Organizational Chart
	10.	Unique Entity Identifier (UEI)
	11.	Good Neighbor Policy [REMOVE IF IT DOES NOT APPLY]
H.	Recent Financial Statement
I.	Audits/Reviews/Inspection Reports
J.	Active Litigation, Resolution, and Performance Issues
K.	Past/Current/Threatened Litigation, Liens, and Claims
L.	Services Questionnaire

FORM A - APPLICATION PREPARATION CHECKLIST

Form B - Agency Description

1.	Organization Legal Name:
		(As Specified in The Articles of Incorporation or State License)
	Business Address:

2.	Contract Signature Authority - Identify below the person empowered to sign a contract:
	Corporate Officer or Authorized Representative Name and Title:
	Corporate Officer or Authorized Representative

Email address:

	Corporate Officer or Authorized Representative
Telephone:		Fax:

3. Date Organization Established:

4. Type of Business (Check One)

Nonprofit Corporation Other (Specify):

5. Current Annual Operating Budget:

	Operating Budget Generated From:
	Non-Orange County
Government Contracts:		$			ERROR:#DIV/0!
	Orange County
Government Contracts:		$			ERROR:#DIV/0!
	Non-Governmental Contracts:		$			ERROR:#DIV/0!
	Donations:		$			ERROR:#DIV/0!
	Participant Fees:		$			ERROR:#DIV/0!
	Other (Specify): _______________		$			ERROR:#DIV/0!
	Other (Specify): _______________		$			ERROR:#DIV/0!
	TOTAL:		$	0.00		ERROR:#DIV/0!

6.	Solicitation Contact Person - Identify below the person who will represent the organization during the solicitation evaluation process:
	Solicitation Contact Name and Title:
	Solicitation Contact Email Address:
	Solicitation Contact Telephone:

Solicitation Submittal Authority:

The undersigned hereby acknowledges: "I have read and understand the contents of, and have authority to submit the attached proposal/application on behalf of the above-named organization. It is correct to the best of my knowledge and represents the organization's proposal/application for the provision of the requested services."

Corporate Office or Authorized Representative Date Telephone

FORM B - AGENCY DESCRIPTION

Form C - Applicant's Cert.

Organization Name:

Validity of Application

The County requires that all applications be valid for at least 365 calendar days from the application due date. Submissions not valid for at least 365 calendar days from the application due date will be considered non-responsive. The applicant shall state the length of time for which the submitted application shall remain valid below:

Validity of RFA (in days) (Signature Required)

Certification of Understanding

The County assumes no responsibillity for any understanding or representation made by any of its officers, employees or agents during or prior to the execution of any Contract resulting from this solicitation unless:

1.	Such understanding or representations are expressly stated in the Contract, and;
2.	The Contract expressly provides that the County therefore assumes the responsibility.

Representations made but not expressly stated and for which liability is not expressly assumed by the County in the Contract shall be deemed only for the information of the applicant.

By signing below, applicant certifies that such understanding has been considered in this response.

(Signature Required)

Certificate of Insurance

The applicant shall certify its willingness and ability to provide the required insurance coverage and certificates as set forth in Section I.O of the Request for Applications (RFA) by signing below.

(Signature Required)

Conflict of Interest

Attach the following on a separate piece of paper and include with Form C:

Provide a description of your organization’s conflict of interest systems and procedures that are in place and apply to the services to be provided to the County.

Disclose any financial, business or other relationship with the County, any other entity that the County Board of Supervisors governs or with the city and county in which the service locations are located, which may have an impact, effect or influence on the outcome of the services you propose to provide. Provide a list of current clients, employees, principals or shareholders (including family members) who may have a financial interest in the outcome of the services you propose to provide (If applicable).

Disclose any financial, business or other relationship within the last three (3) years with any organization or member of any organization who may have a financial interest in the outcome of the work. If you believe that no conflict of interest exists or would exist, sign below.

(Signature Required)

Minimum Submission Requirements Statement

Applicant shall certify that it meets all minimum submission requirements set forth above in this Section II by signing below.

(Signature Required)

Statement of Compliance

A statement of compliance with all parts of this RFA or a listing of exceptions and suggested changes must be submitted in response to this RFP:

1. This response is in strict compliance with said RFA, including the terms and conditions set forth in the Contract and its Attachment(s), and no exceptions thereto are proposed.

(Signature Required)

2. This response is in strict compliance with said RFA, including the terms and conditions set forth in the Contract and its Attachment(s), except for those proposed exceptions listed in a separate attachment hereto.

(Signature Required)

Attachment for each proposed exception must include

1) The RFA page number and section of the provision applicant is taking exception to;

2) The complete provision applicant is taking exception to;

3) The applicant's suggested rewording;

4) Reason(s) for submitting the proposed exception; and,

5) Any impact the proposed exception may have on cost, scheduling, or other areas.

FORM C Applicant Certifications

Form D - Board of Directors

Organization Name:
Provide the following information about your Board of Directors
Number of Members:	Term Length:	Meeting Dates:
Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

FORM C - BOARD OF DIRECTORS

File details come from the government source that posted it. Updated Aug 24, 2026.