Attachment-U.-Contract-Affidavit.pdf

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Attached to
COMMUNITY-BASED BEHAVIORAL HEALTH EVALUATIONS FOR MULTIPLE REGIONS
Solicitation number
BPM053561
Issued by
Maryland

About this file

This is a Contract Affidavit form required by the Maryland Department of Juvenile Services for the Community-Based Behavioral Health Evaluations procurement across three geographic regions (Eastern, Capital South, and Western). The affidavit establishes the legal authority of the business representative executing the document and certifies compliance with Maryland state requirements including registration or qualification with the State Department of Assessments and Taxation, financial disclosure obligations under State Finance and Procurement Article 13-221 (requiring filing when contracts exceed $200,000 annually), and political contribution disclosure requirements under Election Law Article Title 14 (mandating disclosure of contributions to candidates for elective office when contracts reach $200,000 or more). The contract term runs five years from June 1, 2026 through May 31, 2031 with no renewal options, and the affidavit must be executed and submitted prior to contract award. A pre-bid conference is scheduled for March 18, 2026 at 11:00 a.m. virtually, with written questions due March 25, 2026 at 2:00 p.m., and bids due April 1, 2026 at 2:00 p.m. via eMMA.

The affidavit further requires the contractor to certify compliance with Maryland's Drug and Alcohol Free Workplace regulations (COMAR 21.11.08), which mandate maintaining a drug and alcohol-free workplace, publishing employee notification statements, prohibiting employees from working under the influence, establishing awareness programs, and implementing sanctions for violations including termination or rehabilitation requirements. The affiant must declare under penalties of perjury that all information provided is true and correct. No federal funding is involved in this procurement. Contractors must maintain Commercial General Liability insurance ($1 million per occurrence/$3 million aggregate), Professional Liability insurance ($1 million per claim/$3 million aggregate), Cyber Security/Data Breach coverage ($5 million per occurrence), and Workers' Compensation insurance. A 5% Minority Business Enterprise subcontracting participation goal applies, with MBE-certified prime contractors permitted to self-perform 2.5% and fulfill the remaining 2.5% through certified subcontractors.

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Other files

File Type Posted
eMMA COVER Letter- 26-MULTI-CS-BH-001.pdf PDF
Appendix 1 Abbreiviations and Definitions.pdf PDF
Attendee List, Meeting Agenda & Q & A's- Community Behavioral Health Evals @ Multi Regions- 26-MULTI-CS-BH-001.pdf PDF
Attachment-U.-Contract-Affidavit.pdf PDF
Attachment-A.-Bid-Proposal-Affidavit.pdf PDF
Attachment-2.-Pre-Bid_-Pre-Proposal-Conference-Response-Form-26-MULTI-CS-BH-001.pdf PDF
Amendment #1- Community Based Behavioral Health Evals @ Multi Regions- 26-MULTI-CS-BH-001.pdf PDF
BID FORM- BH Evals Regions Capital, Eastern, Western 5 Year Contract- .xlsx XLSX spreadsheet
Appendix 7 Psychosexual Eval Report Template.pdf PDF
Professional Services Supplemental- BPM053561- Behavioral Health Evals- 26-MULTI-CS-BH-001.pdf PDF
Appendix 6 Psychiatric Eval & Certificate of Need Templates.pdf PDF
FINAL IFB- 26-MULTI-CS-BH-001- Community Behavioral Health Evals 2.17.26 TW.SJ.OAG.RC.JG (amended).pdf PDF
Attachment-F.-Bidder-Offeror-Information-Sheet.pdf PDF
Appendix 8 DJS Policy List - Community Evaluation Contract.pdf PDF
Appendix 4 Psychological Report Template.pdf PDF
Appendix 2 Community Office Locations.pdf PDF
5.1 Appendice Table.pdf PDF
5.1 Appendice Table.pdf PDF
FINAL IFB- 26-MULTI-CS-BH-001- Community Behavioral Health Evals 2.17.26 TW.SJ.OAG.RC.JG.pdf PDF
Professional Services Supplemental- BPM053561- Behavioral Health Evals- 26-MULTI-CS-BH-001.pdf PDF
Attendee List, Meeting Agenda & Q & A's- Community Behavioral Health Evals @ Multi Regions- 26-MULTI-CS-BH-001.pdf PDF
Appendix-4.-MBE-Participation-Goal.pdf PDF
Appendix 4 Psychological Report Template.pdf PDF
Appendix 2 Community Office Locations.pdf PDF
Attachment-I.-Conflict-of-Interest-Affidavit.pdf PDF
eMMA COVER Letter- 26-MULTI-CS-BH-001.pdf PDF
Amendment #1- Community Based Behavioral Health Evals @ Multi Regions- 26-MULTI-CS-BH-001.pdf PDF
Appendix 3 Bidder's Staff Qualification Checklist - Community Evaluations.pdf PDF
Appendix 1 Abbreiviations and Definitions.pdf PDF
Appendix 5 Updated TOJ Template January 2025.pdf PDF
Attachment-F.-Bidder-Offeror-Information-Sheet.pdf PDF
Appendix 8 DJS Policy List - Community Evaluation Contract.pdf PDF
Appendix 7 Psychosexual Eval Report Template.pdf PDF
Appendix 5 Updated TOJ Template January 2025.pdf PDF
Attachment-F.-Bidder-Offeror-Information-Sheet.pdf PDF
Attachment-A.-Bid-Proposal-Affidavit.pdf PDF
BID FORM- BH Evals Regions Capital, Eastern, Western 5 Year Contract- .xlsx XLSX spreadsheet
5.1 Appendice Table.pdf PDF
Professional Services Supplemental- BPM053561- Behavioral Health Evals- 26-MULTI-CS-BH-001.pdf PDF
eMMA COVER Letter- 26-MULTI-CS-BH-001.pdf PDF
Appendix-4.-MBE-Participation-Goal.pdf PDF
Appendix 4 Psychological Report Template.pdf PDF
Appendix 2 Community Office Locations.pdf PDF
Appendix 7 Psychosexual Eval Report Template.pdf PDF
Attachment-2.-Pre-Bid_-Pre-Proposal-Conference-Response-Form-26-MULTI-CS-BH-001.pdf PDF
FINAL IFB- 26-MULTI-CS-BH-001- Community Behavioral Health Evals 2.17.26 TW.SJ.OAG.RC.JG.pdf PDF
Appendix 6 Psychiatric Eval & Certificate of Need Templates.pdf PDF
Appendix 1 Abbreiviations and Definitions.pdf PDF
Attachment-U.-Contract-Affidavit.pdf PDF
Appendix 8 DJS Policy List - Community Evaluation Contract.pdf PDF
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Attachment U. Contract Affidavit effective date: July 2024

Attachment U. Contract Affidavit

A. AUTHORITY

I hereby affirm that I, ________________________________ (name of affiant) am the __________________________________ (title) and duly authorized representative of __________________________________ (name of business entity) and that I possess the legal authority to make this affidavit on behalf of the business for which I am acting.

B. CERTIFICATION OF REGISTRATION OR QUALIFICATION WITH THE STATE

DEPARTMENT OF ASSESSMENTS AND TAXATION

I FURTHER AFFIRM THAT:

The business named above is a (check applicable box):

(1) Corporation - domestic or foreign;

(2) Limited Liability Company - domestic or foreign;

(3) Partnership - domestic or foreign;

(4) Statutory Trust - domestic or foreign;

(5) Sole Proprietorship.

and is registered or qualified as required under Maryland Law. I further affirm that the above business is in good standing both in Maryland and (IF APPLICABLE) in the jurisdiction where it is presently organized, and has filed all of its annual reports, together with filing fees, with the Maryland State Department of Assessments and Taxation. The name and address of its resident agent (IF APPLICABLE) filed with the State Department of Assessments and Taxation is:

Name and Department ID Number: __________________

Address: _______________________________ and that if it does business under a trade name, it has filed a certificate with the State Department of Assessments and Taxation that correctly identifies that true name and address of the principal or owner as:

Name and Department ID Number: _____________________________

Address: _______________________________

C. FINANCIAL DISCLOSURE AFFIRMATION

I FURTHER AFFIRM THAT:

I am aware of, and the above business will comply with, the provisions of State Finance and Procurement Article, §13-221, Annotated Code of Maryland, which require that every business that enters into contracts, leases, or other agreements with the State of Maryland or its agencies during a calendar year under which the business is to receive in the aggregate $200,000 or more shall, within 30 days of the time when the aggregate value of the contracts, leases, or other agreements reaches $200,000, file with the Secretary of State of Maryland certain specified information to include disclosure of beneficial ownership of the business.

D. POLITICAL CONTRIBUTION DISCLOSURE AFFIRMATION

I FURTHER AFFIRM THAT:

I am aware of, and the above business will comply with, Election Law Article, Title 14, Annotated Code of Maryland, which requires that every person that enters into a procurement contract with the

Attachment U. Contract Affidavit effective date: July 2024

State, a county, or a municipal corporation, or other political subdivision of the State, during a calendar year in which the person receives a contract with a governmental entity in the amount of $200,000 or more, shall file with the State Board of Elections statements disclosing: (a) any contributions made during the reporting period to a candidate for elective office in any primary or general election; and (b) the name of each candidate to whom one or more contributions in a cumulative amount of $500 or more were made during the reporting period. The statement shall be filed with the State Board of Elections: (a) before execution of a contract by the State, a county, a municipal corporation, or other political subdivision of the State, and shall cover the 24 months prior to when a contract was awarded; and (b) if the contribution is made after the execution of a contract, then twice a year, throughout the contract term, on or before: (i) May 31, to cover the six (6) month period ending April 30; and (ii) November 30, to cover the six (6) month period ending October 31.

E. DRUG AND ALCOHOL FREE WORKPLACE

(Applicable to all contracts unless the contract is for a law enforcement agency and the agency head or the agency head’s designee has determined that application of COMAR 21.11.08 and this certification would be inappropriate in connection with the law enforcement agency's undercover operations.)

I CERTIFY THAT:

(1) Terms defined in COMAR 21.11.08 shall have the same meanings when used in this certification.

(2) By submission of its Proposal, the business, if other than an individual, certifies and agrees that, with respect to its employees to be employed under a contract resulting from this solicitation, the business shall:

(a) Maintain a workplace free of drug and alcohol abuse during the term of the contract;

(b) Publish a statement notifying its employees that the unlawful manufacture, distribution, dispensing, possession, or use of drugs, and the abuse of drugs or alcohol is prohibited in the business' workplace and specifying the actions that will be taken against employees for violation of these prohibitions;

(c) Prohibit its employees from working under the influence of drugs or alcohol;

(d) Not hire or assign to work on the contract anyone who the business knows, or in the exercise of due diligence should know, currently abuses drugs or alcohol and is not actively engaged in a bona fide drug or alcohol abuse assistance or rehabilitation program;

(e) Promptly inform the appropriate law enforcement agency of every drug-related crime that occurs in its workplace if the business has observed the violation or otherwise has reliable information that a violation has occurred;

(f) Establish drug and alcohol abuse awareness programs to inform its employees about:

(i) The dangers of drug and alcohol abuse in the workplace;

(ii) The business's policy of maintaining a drug and alcohol free workplace;

(iii) Any available drug and alcohol counseling, rehabilitation, and employee assistance programs; and

(iv) The penalties that may be imposed upon employees who abuse drugs and alcohol in the workplace;

(g) Provide all employees engaged in the performance of the contract with a copy of the statement required by §E(2)(b), above;

(h) Notify its employees in the statement required by §E(2)(b), above, that as a condition of continued employment on the contract, the employee shall:

Attachment U. Contract Affidavit effective date: July 2024

(i) Abide by the terms of the statement; and

(ii) Notify the employer of any criminal drug or alcohol abuse conviction for an offense occurring in the workplace not later than 5 days after a conviction;

(i) Notify the procurement officer within 10 days after receiving notice under §E(2)(h)(ii), above, or otherwise receiving actual notice of a conviction;

(j) Within 30 days after receiving notice under §E(2)(h)(ii), above, or otherwise receiving actual notice of a conviction, impose either of the following sanctions or remedial measures on any employee who is convicted of a drug or alcohol abuse offense occurring in the workplace:

(i) Take appropriate personnel action against an employee, up to and including termination; or

(ii) Require an employee to satisfactorily participate in a bona fide drug or alcohol abuse assistance or rehabilitation program; and

(k) Make a good faith effort to maintain a drug and alcohol free workplace through implementation of §E(2)(a)—(j), above.

(3) If the business is an individual, the individual shall certify and agree as set forth in §E(4), below, that the individual shall not engage in the unlawful manufacture, distribution, dispensing, possession, or use of drugs or the abuse of drugs or alcohol in the performance of the contract.

(4) I acknowledge and agree that:

(a) The award of the contract is conditional upon compliance with COMAR 21.11.08 and this certification;

(b) The violation of the provisions of COMAR 21.11.08 or this certification shall be cause to suspend payments under, or terminate the contract for default under COMAR 21.07.01.11 or 21.07.03.15, as applicable; and

(c) The violation of the provisions of COMAR 21.11.08 or this certification in connection with the contract may, in the exercise of the discretion of the Board of Public Works, result in suspension and debarment of the business under COMAR 21.08.03.

F. CERTAIN AFFIRMATIONS VALID

I FURTHER AFFIRM THAT:

To the best of my knowledge, information, and belief, each of the affirmations, certifications, or acknowledgements contained in that certain Bid/Proposal Affidavit dated _____________________, and executed by me for the purpose of obtaining the contract to which this Exhibit is attached remains true and correct in all respects as if made as of the date of this Contract Affidavit and as if fully set forth herein.

I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT

THE CONTENTS OF THIS AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE, INFORMATION, AND BELIEF.

Date: _______________________

By: ________________________ (print name of Authorized Representative and Affiant)

_________________________________ (signature of Authorized Representative and Affiant)

Attachment U. Contract Affidavit

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