AttachmentA_Business Information.pdf

Attachment A: Business Information RFP Number K5871 Page 1 of 4

REQUEST FOR PROPOSALS (RFP)

RFP NO K5871

ATTACHMENT A: BUSINESS INFORMATION

Proposer’s Organization Information

Legal Business Name:

Address:

Phone:

Email:

Current 501 (c)(3) Tax Exempt Status? ☐ Yes ☐ No

Date 501(c)(3) Established:

Employer Identification Number (EIN):

Unified Business Identifier (UBI):

Number of Current Employees:

Current Organizational Chart Provided: ☐ Yes ☐ No (Submittal is Required)

Key Personnel and Primary Roles for this Grant

Name: Primary Role:

Attachment A: Business Information RFP Number K5871 Page 2 of 4

Additional Organizations If applicable, list any other essential organizations that are necessary to the Proposer’s administration of this Grant – excludes distribution partners.

Legal Business Name:

Address:

Phone:

Email:

Legal Business Name:

Address:

Phone:

Email:

Identify State Employees (Current or Formerly Employed by Washington State) Employed by the Proposer or on the Proposer’s governing board as of the date of this submission.

WSDA FA will follow up with the Proposer’s to determine if a conflict of interest exists. If there is a conflict, the Proposer may be disqualified.

Status: Employee Name: Current Position in the Proposer’s Organization:

☐ Current ☐ Former

State Agency:

Attachment A: Business Information RFP Number K5871 Page 3 of 4

Status: Employee Name: Current Position in the Proposer’s Organization:

☐ Current ☐ Former

State Agency:

Status: Employee Name: Current Position in the Proposer’s Organization:

☐ Current ☐ Former

State Agency:

Retired State Employees (2008 Early Retirement Factor - WAC 415-02-340)

Any staff who will work on this grant on the organization’s behalf and have retired from the state of Washington, under provisions of the 2008 Early Retirement Factors must be disclosed.

Status: Employee Name: Current Position in the Proposer’s Organization:

☐ Retired under ERF

State Agency:

Status: Employee Name: Current Position in the Proposer’s Organization:

☐ Retired under ERF

State Agency:

Termination for Default If the Proposer has had a Contract terminated for default in the last five (5) years, describe such incident.

Termination for default is defined as notice to stop performance due to the Proposer’s non-performance or poor performance and the issue of performance was either (a) not litigated due to inaction on the part of the Proposer; or (b) litigated and such litigation determined that the Proposer was in default.

Terminations for Default?

☐ Yes ☐ No If yes, complete the Short Description below and WSDA FA will follow up with additional requirements.

Short Description of Incident:

Attachment A: Business Information RFP Number K5871 Page 4 of 4

ATTACHMENT A: BUSINESS INFORMATION