CTR079168_Pre_Contract_Documents.pdf

Page 1 of 2PUR-1031A FORFF (5-24) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Division of Financial Operations

Office of Procurement

PROCUREMENT ASSISTANCE (PA) REQUEST

1. PROCUREMENT UNIT NAME: 2. PA NUMBER/SUB-NUMBER: 3. REQUEST DATE:

4. DIVISION/ADMINISTRATION/PROGRAM: 5. DIVISION CONTACT PERSON: 6. TELEPHONE NUMBER:

7. TYPE OF REQUEST/AGREEMENT (check all that apply):

Scope of Work Review

Solicitation

CI /SS /NPTQ Review

Amendment

Extension Yrs/Mos

Corrective Action

Assignment

Contract (Competitive Award)

Direct Contract

Intergovernmental Agreement (IGA)

Interagency Service Agreement (ISA)

Memorandum of Understanding (MOU)

Task Order

IT Agreement/EULA

Set-Aside

COOP

Grant Agreement

If Exempt by Statute A.R.S. No.:

Other

8. DETAILED DESCRIPTION OF REQUEST OR NEED:

9. OTHER DOCUMENTS AND INFORMATION:

Certificate of Insurance (COI) Compliant and Included If CI /SS /NPTQ, No.:

Business Associate Agreement/Data Sharing Agreement Central Registry Check/Fingerprinting Sign and Date when Checked

10. FUNDING SOURCE & AMOUNT (check the appropriate boxes):

Federal State Grant Other Estimated aggregate spend $499K or less

Estimated aggregate spend $500K or more

11. DESCRIPTION OF SERVICES OR CONTRACT TITLE: 12. CONTRACT NUMBER:

13. CONTRACTOR NAME/DBA: 14. FEIN NUMBER:

15. CONTRACTOR CONTACT PERSON’S NAME AND TITLE:

16. E-MAIL ADDRESS/TELEPHONE NO.:

17. CONTRACT ORIGINAL START DATE: 18. MAXIMUM END DATE:

19. CONTRACT CURRENT END DATE: 20. AMENDED END DATE:

21. SINGLE AUDIT STATUS:

Contractor/Vendor

Subrecipient N/A

22. LEGAL AD AUTHORIZATION:

FUNCTION CODE: OBJECT CODE: DEPARTMENT OBJECT CODE:

BA SIGNATURE FOR APPROVAL (Legal Ads):

23. AUTHORIZATIONS (Signatures, NO Initials) & DATES:

24. AUTHORIZED DIVISION REQUESTOR: 25. FINANCIAL SERVICES ADMINISTRATION:

26. ATTORNEY GENERAL (IGA, 3rd Party, etc.): 27. PROCUREMENT OFFICER:

28. PROCUREMENT OFFICER COMMENTS:

Team Stacie DCAD-26-093 10/16/2025

ADES/DCAD/HML Teri Ponticello (520) 705-7318

Submitting Direct Contract for Native American Connections - Homeless Youth and Family Services (Emergency Shelter/RRH)

CI2008

TP 11/18/25

Homeless Youth and Family Services TBD

Native American Connections 86-0293585

Joel Buenviaje, Contract Administrator

J.Buenviaje@nativeconnections.org 602.254.3247

06/30/2026

Arizona S.B.1735

Stacie Dearinure <sdearinure@azdes.gov>

Significant Procurement Notification Form 1 message

Google Forms <forms-receipts-noreply@google.com> Mon, Sep 22, 2025 at 3:31 PM To: frubio@azdes.gov

Thanks for filling out Significant Procurement Notification Form Here's what was received.

Edit response

Significant Procurement Notification Form The following information is required to be provided to the State Procurement Administrator by all state governmental units (SGU; agencies, boards, and commissions) as per Standard Procedure 003 - Significant Procurement Role (SP 003 link).

Notes about this Google Form to provide notification of a SPR:

• You will receive a copy of your response via email

• You may edit your response after it is submitted in two ways. To ensure there's no duplication of efforts, please do one of the following:

1) Once you submit the form, you may click on "Edit you response" in the same browser; or

2) If some time has passed and it's necessary to make edits, please check your email for the original submission as it will have an "Edit response" link. If you don’t remember when you originally submitted your SPR notification, you may check the date and time on the spreadsheet via https://spo.az.gov/contracts/significant-procurement-roles and match it to the email.

• If your entry needs to be deleted, email SPOCompliance@azdoa.gov to provide an explanation for the deletion. If accepted, SPO Compliance will delete the entry.

Please contact the State Procurement Office (SPO) at SPOCompliance@azdoa.gov for any questions.

Email *

10/17/25, 9:40 PM State of Arizona Mail - Significant Procurement Notification Form https://mail.google.com/mail/u/0/?ik=5bda0cdb29&view=pt&search=all&permthid=thread-f:1844005057106763975&simpl=msg-f:1844005057106763975 1/3 https://docs.google.com/forms/d/e/1FAIpQLSdxSzWnNvO30KUubljXrDSub3gfqJ1GX15weZF0kbYkDUx3Qw/viewform?usp=mail_form_link https://docs.google.com/forms/d/e/1FAIpQLSdxSzWnNvO30KUubljXrDSub3gfqJ1GX15weZF0kbYkDUx3Qw/viewform?edit2=2_ABaOnufqlFmMlVjQ9kGRhVM083DzC11ZNU0M9FGZ-pnObw8o5V8KnSBi4XoZa80d4vE0-Ds https://spointra.az.gov/resources/standard-procedures https://spo.az.gov/contracts/significant-procurement-roles https://spo.az.gov/contracts/significant-procurement-roles mailto:SPOCompliance@azdoa.gov mailto:SPOCompliance@azdoa.gov frubio@azdes.gov

What is the name of the person leading the procurement? *

Frances Rubio

Which agency is the procurement for? If it is a mandatory statewide contract, select your agency. *

Economic Security, Department of

What is the title of the procurement? *

Homeless Youth and Families Eviction Prevention, Emergency Shelter and Rapid Rehousing

What is the procurement type? *

RFQ - Request for Quotation

IFB - Invitation for Bid

RFP - Request for Proposal

✓ CI - Competition Impracticable (SPO Form 101)

Emergency Procurement (SPO Form 102)

SS - Sole Source (SPO Form 103)

NPTQ - Not Practicable to Quote (Determination Template D301(4))

Other:

10/17/25, 9:40 PM State of Arizona Mail - Significant Procurement Notification Form https://mail.google.com/mail/u/0/?ik=5bda0cdb29&view=pt&search=all&permthid=thread-f:1844005057106763975&simpl=msg-f:1844005057106763975 2/3 mailto:frubio@azdes.gov

What is the date when the first procurement disclosure statement (PDS) was signed (i.e. SPO Form 120 or SPO Form 130)? *

MM

09 /

DD

04 /

YYYY

What is the actual date or estimated date that the purchased materials will be delivered or the purchase of services or construction will begin, per A.R.S. § 41- 753(D)? *

MM

10 /

DD

15 /

YYYY

What is your name (if different from above)?

Stacie Dearinure

What is your e-mail address (if different from above)?

sdearinure@azdes.gov

Create your own Google Form

NOTICE: This e-mail (and any attachments) may contain PRIVILEGED OR CONFIDENTIAL information and is intended only for the use of the specific individual(s) to whom it is addressed. It may contain information that is privileged and confidential under state and federal law. This information may be used or disclosed only in accordance with law, and you may be subject to penalties under law for improper use or further disclosure of the information in this e-mail and its attachments. If you have received this e-mail in error, please immediately notify the person named above by reply e-mail, and then delete the original e-mail. Thank you.

10/17/25, 9:40 PM State of Arizona Mail - Significant Procurement Notification Form https://mail.google.com/mail/u/0/?ik=5bda0cdb29&view=pt&search=all&permthid=thread-f:1844005057106763975&simpl=msg-f:1844005057106763975 3/3 mailto:sdearinure@azdes.gov https://docs.google.com/forms?usp=mail_form_link

CI2008

NATIVE AMERICAN CONNECTIONS, INC.

Unique Entity ID

UYAHK4KGL617

CAGE / NCAGE

4Y9C9

Purpose of Registration

All Awards

Registration Status

Active Registration

Expiration Date

Nov 4, 2026

Physical Address

3216 N 3RD ST

Phoenix, Arizona 85012-2682

United States

Mailing Address

3216 N 3RD ST

Phoenix, Arizona 85012-2682

United States

Business Information

Doing Business as

(blank)

Division Name

(blank)

Division Number

(blank)

Congressional District

Arizona 03

State / Country of Incorporation

Arizona / United States

URL

(blank)

Registration Dates

Activation Date

Nov 10, 2025

Submission Date

Nov 4, 2025

Initial Registration Date

Dec 26, 2007

Entity Dates

Entity Start Date

Nov 13, 1972

Fiscal Year End Close Date

Jun 30

Immediate Owner

CAGE

(blank)

Legal Business Name

(blank)

Highest Level Owner

CAGE

(blank)

Legal Business Name

(blank)

Executive Compensation

Registrants in the System for Award Management (SAM) respond to the Executive Compensation questions in accordance with Section 6202 of

P.L. 110-252, amending the Federal Funding Accountability and Transparency Act (P.L. 109-282). This information is not displayed in SAM. It is sent to USAspending.gov for display in association with an eligible award. Maintaining an active registration in SAM demonstrates the registrant responded to the questions.

Proceedings Questions

Registrants in the System for Award Management (SAM.gov) respond to proceedings questions in accordance with FAR 52.209-7, FAR 52.209-9, or 2. C.F.R. 200 Appendix XII. Their responses are displayed in the responsibility/qualification section of SAM.gov. Maintaining an active registration in SAM.gov demonstrates the registrant responded to the proceedings questions.

Exclusion Summary

Active Exclusions Records?

No

SAM Search Authorization

I authorize my entity's non-sensitive information to be displayed in SAM public search results:

Yes

Entity Types

Business Types

Entity Structure

Corporate Entity (Tax Exempt)

Entity Type

Business or Organization

Organization Factors

(blank)

Profit Structure

Non-Profit Organization

Last updated by Jennifer Jennings on Nov 04, 2025 at 01:32 PM NATIVE AMERICAN CONNECTIONS, INC.

Nov 24, 2025 03:29:10 PM GMT https://sam.gov/entity/UYAHK4KGL617/coreData?status=null Page 1 of 2

Socio-Economic Types

Check the registrant's Reps & Certs, if present, under FAR 52.212-3 or FAR 52.219-1 to determine if the entity is an SBA-certified HUBZone small business concern. Additional small business information may be found in the SBA's Dynamic Small Business Search if the entity completed the

SBA supplemental pages during registration.

Financial Information

Accepts Credit Card Payments

No

Debt Subject To Offset

No

EFT Indicator

CAGE Code

4Y9C9

Points of Contact

Electronic Business

Jennifer Jennings, Senior Director of Real

Estate Development

3216 N 3RD Street

Phoenix, Arizona 85012

United States

Government Business

Whitney Rios, Senior Director of Fund

Development and Philanthro

3216 N 3RD Street

Phoenix, Arizona 85012

United States

Past Performance

Theresa Perkins, CFOO

3216 N 3RD ST

Phoenix, Arizona 85012

United States

Service Classifications

NAICS Codes

Primary

Yes

NAICS Codes

621420

NAICS Title

Outpatient Mental Health And Substance Abuse Centers

623220 Residential Mental Health And Substance Abuse Facilities

Disaster Response

This entity does not appear in the disaster response registry.

Last updated by Jennifer Jennings on Nov 04, 2025 at 01:32 PM NATIVE AMERICAN CONNECTIONS, INC.

Nov 24, 2025 03:29:10 PM GMT https://sam.gov/entity/UYAHK4KGL617/coreData?status=null Page 2 of 2