Document A - Proposer Information and Certifications.pdf

RFGP S-44300-0001737/6312

OPIOID SETTLEMENT COMMUNITY GRANT

DOCUMENT A – PROPOSER INFORMATION AND

CERTIFICATIONS

Document A

Proposer Information and Certifications Opioid Settlement Community Grant

RFGP 6312, OregonBuys Bid # S-44300-0001747

Instructions

Complete this form to provide information about your organization and the points of contact for your Opioid Settlement Community Grant application. Before completing this section, please review RFGP Section 2: Proposer Eligibility Requirements.

Items marked with a * are required. You must provide all required information in this form for your application to pass the initial eligibility screening. Failure to meet any Opioid Settlement Community Grant application requirements may result in disqualification. Applications disqualified during initial eligibility screening will not be reviewed by Oregon Health Authority and will not be considered for Opioid Settlement Community Grant funding.

1.1 Eligibility Screening

All Proposers must complete this section first. Your responses will determine whether your organization and proposed project meet the minimum requirements for funding.

Any response marked "ineligible” will disqualify the application. If you have questions about eligibility, please review Section 2 of the RFGP.

https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/OSPTRboarddocuments/Opioid_Settlement_Community_Grant_Request_for_Grant_Proposals_Final.pdf

DOCUMENT A – PROPOSER INFORMATION AND

1. * Is your organization or Fiscal Sponsor physically located in Oregon and legally registered in Oregon (for example, with the Oregon Secretary of State)?

a. Yes

b. No (ineligible)

2. * Will your project primarily serve people in Oregon?

3. * Does your project align with at least one Funding Category and at least one Eligible Strategy in Section 4 of the RFGP?

4. * Can your project be completed by June 30, 2029?

The Grant Agreement covers a two-year period from July 1, 2027, through June 30, 2029.

Recipients may use awarded funds at any time during this period, and all funds must be spent or fully reserved for specific upcoming costs no later than June 30, 2029. Projects may finish before the end of the two-year term without penalty.

5. * Does your organization have experience that supports this project, such as staff expertise, organizational history, or experience serving the population you intend to support?

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6. * Do you have letters of commitment for each partner organization named in your application?

a. Yes

c. Not applicable

7. * Has your organization received direct funding from the Oregon Health Authority in the last 3 years?

b. No

If yes: Is your organization in good standing with OHA, including meeting reporting, fiscal, and performance requirements? OHA will verify this.

c. I’m not sure

If not in good standing or unsure: Please briefly describe the issue (for example, a performance improvement plan or contract termination).

Open field

8. * Is this the only proposal your organization is submitting as the lead Proposer?

Organizations may partner on multiple applications but may submit only one as the lead Proposer

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9. * Will this funding be used for a new project or to expand or enhance existing work?

Proposers may not use Opioid Settlement Community Grant funds to replace, duplicate, or supplant existing State, local, tribal, or private funding of infrastructure or services, such as staff salaries.

10. * Is your organization a State Agency or Tribal Government?

These entities are not eligible to apply. Organizations serving Tribal communities may apply, and any Proposer may partner with state agencies or Tribal Governments.

a. Yes (ineligible)

1.2 Organization Information

11. *Legal Organization Name (as registered with the Oregon Secretary of State):

12. Organization doing business as (DBA) (if different from above):

13. *Organization Address:

14. State of Incorporation (if applicable):

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15. *Oregon Business Registry Number:

16. Organization webpage (if applicable):

17. *Tax ID, Employer identification number (EIN) or Federal Employer Identification Number (FEIN); link to IRS webpage to search EIN:

18. Select the category that best describes your organization:

a. Local government or public agency

b. Behavioral health or healthcare provider

c. Community-based or non-profit organization

d. Academic or workforce partner

e. Other (please specify): _______________

1.3 Proposer Contact Information

Primary Contact Information

19. *Primary Contact name:

20. *Primary Contact email (This must be a person’s email address, not an organization’s general email address)

21. *Primary contact phone number:

Secondary Contact Information

22. Secondary contact name:

23. Secondary contact email:

24. Secondary contact phone number:

https://www.irs.gov/businesses/small-businesses-self-employed/employer-id-numbers

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Authorized Signatory

25. *Authorized signature name:

26. *Authorized signature email:

1.4 Fiscal Sponsorship

If your organization has a fiscal sponsor, please provide the following information. If you do not have a fiscal sponsor, leave this information blank and proceed to the next section.

27. *Do you have a fiscal sponsor? Yes/No

A. *Fiscal Sponsor Name:

B. *Fiscal Sponsor Organization Name:

C. *Fiscal Sponsor Address:

D. State of Incorporation (if applicable):

E. *Fiscal Sponsor Oregon Business Registry Number:

F. Fiscal Sponsor Organization webpage (if applicable):

G. *Fiscal Sponsor Tax ID, EIN or FEIN (link to IRS webpage to search EIN):

H. *Primary Fiscal Sponsor Contact name:

I. *Primary Fiscal Sponsor Contact email:

J. *Primary Fiscal Sponsor contact phone number:

https://www.irs.gov/businesses/small-businesses-self-employed/employer-id-numbers

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1.5 Proposer Responsibility requirements

Agency will decide whether a Proposer is responsible before awarding and signing a Grant Agreement. Besides this form, the Agency may ask the Proposer for additional documents. These may include recent profit-and-loss statements, current balance sheets, cash flow information, the ratio of assets to liabilities (including details about secured and unsecured creditors), information about available short- and long-term financing, bonding and insurance coverage, credit history, materials and equipment, facility capabilities, staff qualifications, and past performance on contracts.

If the Proposer does not promptly provide the requested information or cannot clearly show that they are responsible, the Agency may determine the Proposer is not responsible and reject the proposal.

28. *Does Proposer have, or have the ability to obtain, the financial resources, materials, equipment, facilities, personnel, and expertise, necessary to demonstrate their capability to meet all obligations under a Grant Agreement awarded through this RFGP?

YES / NO

29. *Within the last five years, how many similar contracts or grants has the Proposer completed where, for the portions of work under the Proposer′s control, the Proposer stayed within the planned schedule and budget, and no party filed any contract or related claims?

Number: ____

a. How many contracts did NOT meet those standards? Number: ____

If any, please explain: ___

30. *Within the last three years, has Proposer (including any partner or shareholder who owns 10% or more of the firm) or any major subcontractor

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receiving 10% or more of a total contract amount, been criminally or civilly charged, indicted or convicted for any of the following:

• Obtaining, attempting to obtain, or performing a public contract, subcontract, grant, or subgrant

• Violating federal or state antitrust laws relating to submitting bids or Proposals

• Embezzlement, theft, forgery, bribery, falsifying or destroying records, making false statements, tax evasion, or receiving stolen property?

YES / NO

If "YES," provide the jurisdiction, the date of indictment, charge, or judgment, and the names involved, along with a brief summary of the charges in the space below.

Response: __

31. *Within the last three years, has the Proposer had:

• any contracts terminated for default by a government agency, or

• any lawsuits filed against the Proposer by creditors or involving contract disputes?

YES / NO

If "YES," please provide an explanation. (For any judgments, include the jurisdiction and the date of the final judgment or dismissal.)

32. *Does Proposer have any outstanding or pending judgments against it?

YES / NO

If “YES,” Please provide additional details

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33. Is Proposer experiencing financial distress or having difficulty securing financing?

YES / NO

If “YES,” Please provide additional details

34. Does Proposer have sufficient cash flow to fund day-to-day operations throughout the proposed Grant Agreement period?

YES / NO

If "NO,” please provide additional details.

35. *Within the last three years, has Proposer filed for bankruptcy, filed for reorganization, made a general assignment of assets for the benefit of creditors, or had an insolvency action filed against it?

YES / NO

If "YES," provide the filing dates, jurisdictions, type of action, final outcome, and the dates of any judgment or dismissal, if applicable.

36. *Does Proposer have all required licenses, certifications, insurance and/or registrations, if any, and is Proposer legally authorized to do business in the State of Oregon? YES / NO

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If "NO," please explain.

37. *By attesting below the Authorized Representative on behalf of Proposer certifies to the best of his or her knowledge and belief that the responses provided on this form are complete, accurate, and not misleading:

□ Proposer attests to the information listed above