Contracting Qualification Form~23.docx

Contracting with the Commonwealth of Massachusetts To Provide Human and Social Services Potential New Provider Self-Assessment Screening for Preliminary Eligibility to Contract With the Executive Office of Health and Human Services (EOHHS)

In order to become eligible to contract with the EOHHS agencies, your organization must answer yes to the three following questions.

3. Does your organization have a financial history as demonstrated by one or more of the following documents: audited financial statements; letter/line of credit in the name of the organization; IRS Form 990 – Return of Organization Exempt from Income Tax; or Form PC – Massachusetts Office of the Attorney General - Division of Public Charities? _______Yes _______No

If you answered yes to all three questions, then proceed to the Contracting Qualification Form (link opens to the Contracting Qualification Form and to the Instructions to Complete the Form)

If you answered no to any of the questions, you are not eligible to apply for EOHHS contracts/funding at this time. Organizations that have not incorporated can access information about organizing a non-profit corporation at the following websites:

· The Secretary of the Commonwealth Corporation Division

· The Secretary of the Commonwealth Citizen Information Service

For more information on the Commonwealth’s Procurement Access and Solicitation System, please refer to the following Website, www.commbuys.com

Potential New Provider Self Screening 083007

Contracting Qualification Form Responding to (RFR) #: ____________________ Issued by EOHHS Agency: ___________________

I. Information for Primary Organization:

Primary Organization Name: _____________________________________FEIN #: ______________________

___ Check here, if the primary organization is a “non-contracting parent” entity and attach the Supplement (Page 2) for the child/affiliate organization information.

Organization Type (check one): __ Non Profit __ For Profit __ Governmental Entity (Go to Sec II, #3 below)

Contact Person: First Name Last Name Title Telephone # E-mail Address

II. Submission Materials - Covering the primary organization and all affiliated entities as required by instructions (link opens to instructions, PDF or RTF):

1. Financial/Audit Information: Required for all commonly controlled, affiliated or related entities. See the instructions for details. Fiscal Year End: ____________

Submission Type (Choose those that apply):

____ Audit Report ____ Uniform Financial Report (UFR) ____ Form PC - MA Office of the Attorney General, ____ Corrective Action Plan (CAP) Division of Public Charities

2. Additional Submission Requirements (All items must be provided, except as noted in item 3 below):

____ a) Federal Employer ID # (FEIN) Documentation / W-9 ____ d) Board/Principals Information ____ b) Terms & Conditions for Human and Social Services ____ e) Organizational Chart Contracting ____ c) Articles of Organization/Corporate Bylaws

3. Exemption: If the submission is for a Governmental Entity, please check here ____. Only items 2a and 2b must be provided.

III. Related Party Disclosure Certification The signatory below represents that all required related party disclosures have been made in a complete and accurate manner and that all pricing and procurement requirements pertaining to related party relationships have been fulfilled in compliance with 808 CMR 1.00 and the supplemental guidance material promulgated by the Operational Services Division of the Commonwealth. If applicable, please attach a separate document describing any current related party transactions.

IV. Federal Disclosure, Tax and Other Compliance Certification Under the penalties of perjury, the signatory below certifies that neither the organization nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation by any Federal or state department or agency that the organization complies with the laws and regulations relating to State and Federal Taxes and with all other requirements of the Terms and Conditions for Human and Social Services contracting and that all qualification submission information and attachments are true and complete to the best of my knowledge and signatory’s knowledge and belief. The certification line below must be signed and dated by the authorized signatory for each organization covered by this submission. The signatory for the Primary Organization should sign below on this page. The signatory for each additional organization should sign on the supplemental page(s) covering information for child/affiliate organizations.

Authorized Signature: ________________________________________________ Date: ______________________

FOR PPA INTERNAL USE:

Qualification Status: ___________________ Early Termination Date if Conditional or Provisional: _____________

Audit Opinion: _____________________________ Findings: ___________________________________________

Comments: ___________________________________________________________________________________

PPA Approval: ______________________________________________ Date: ___________________________

Supplement to Contracting Qualification Form (Complete this section for each affiliated organization. This page may be copied as required.)

Primary Organization Name: _________________________________________ FEIN #: __________________

Child/Affiliate Organization Name: ____________________________________ FEIN #: __________________

Organization Type (check one): ___ Non Profit ___ For Profit ___ Governmental Entity

Contact Person: First Name Last Name Title Telephone # E-mail Address

Related Party Disclosure Certification The signatory below represents that all required related party disclosures have been made in a complete and accurate manner and that all pricing and procurement requirements pertaining to related party relationships have been fulfilled in compliance with 808 CMR 1.00 and the supplemental guidance material promulgated by the Operational Services Division of the Commonwealth. If applicable, please attach a separate document describing any current related party transactions.

Federal Disclosure, Tax and Other Compliance Certification Under the penalties of perjury, the signatory below certifies that neither the organization nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation by any Federal or state department or agency that the organization complies with the laws and regulations relating to State and Federal Taxes and with all other requirements of the Terms and Conditions for Human and Social Services contracting and that all qualification submission information and attachments are true and complete to the best of my knowledge and signatory’s knowledge and belief. The certification line below must be signed and dated by the authorized signatory for each organization covered by this submission. The signatory for each additional organization should sign on the supplemental page(s) covering information for their child/affiliate organizations.

Authorized Signature _____________________________________________ Date ____________

Child/Affiliate Organization Name: ________________________________FEIN #: ______________

Contact Person: First Name Last Name Title Telephone # E-mail Address

Related Party Disclosure Certification The signatory below represents that all required related party disclosures have been made in a complete and accurate manner and that all pricing and procurement requirements pertaining to related party relationships have been fulfilled in compliance with 808 CMR 1.00 and the supplemental guidance material promulgated by the Operational Services Division of the Commonwealth. If applicable, please attach a separate document describing any current related party transactions.

Federal Disclosure, Tax and Other Compliance Certification Under the penalties of perjury, the signatory below certifies that neither the organization nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation by any Federal or state department or agency that the organization complies with the laws and regulations relating to State and Federal Taxes and with all other requirements of the Terms and Conditions for Human and Social Services contracting and that all qualification submission information and attachments are true and complete to the best of my knowledge and signatory’s knowledge and belief. The certification line below must be signed and dated by the authorized signatory for each organization covered by this submission. The signatory for each additional organization should sign on the supplemental page(s) covering information for their child/affiliate organizations.

Authorized Signature ________________________________________________ Date ____________ image1.wmf