Document F - Proposer Acknowledgements and Compliances.pdf
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- Solicitation number
- S-44300-00017937
- Issued by
- Oregon
About this file
This is a Proposer Acknowledgements and Compliances form for the Oregon Health Authority's Request for Grant Proposals (RFGP) for Opioid Settlement Community Grants. Proposers applying for funding to address the opioid crisis in one of five categories—Primary Prevention, Overdose Prevention and Risk Reduction, Treatment, Recovery, or Innovative Research—must complete and submit this certification form as part of their proposal package. By signing this document, proposers agree to accept all RFGP requirements, comply with the Sample Grant Agreement terms and conditions outlined in Appendix 3, acknowledge receipt of any amendments or addenda, and commit to performing the negotiated scope of work and meeting established performance standards.
The form requires proposers to certify compliance with multiple state and federal requirements, including tax law compliance under Oregon Revised Statutes, non-discrimination in employment and subcontracting practices, wage equity standards, and sexual harassment prevention policies for grants anticipated to exceed $150,000. Proposers must also verify that neither they nor their employees, agents, or subcontractors appear on the U.S. Treasury's Specially Designated Nationals list or the System for Award Management exclusions database. Additionally, proposers must disclose any actual or potential conflicts of interest with the state and certify that all proposal contents are truthful, accurate, and prepared independently without collusion or fraud. The certification carries significant legal weight, as false statements or material omissions may constitute false claims under the Oregon False Claims Act and subject proposers to associated liabilities and penalties.
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DOCUMENT F
PROPOSER ACKNOWLEGEMENTS & COMPLIANCES
Legal Business Name:
City, State, Address: Zip:
Entity Type (e.g., Corp, State of Incorporation: LLC):
Contact Name: Telephone: Email:
Any individual signing below hereby certifies they are an authorized representative of Proposer and that:
1. Proposer understands and accepts the requirements of this Request for Grant Proposals (RFGP). By submitting a Proposal, Proposer agrees to be bound by the Grant Agreement terms and conditions in Appendix 3 (Sample Grant Agreement) and as modified by any Amendment, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFGP.
2. Proposer acknowledges receipt of any and all Amendments or Addenda to this RFGP.
3. If awarded a Grant Agreement, Proposer agrees to perform the scope of work and meet the performance standards set forth in the final negotiated statement of work of the Grant Agreement.
4. I have knowledge regarding Proposer’s payment of taxes and by signing below. I hereby certify that, to the best of my knowledge, Proposer is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.
5. Proposer does not unlawfully discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Proposer does not discriminate against any business certified under
RFGP S-44300-0001737/6312 Page 1 of 3
OPIOID SETTLEMENT COMMUNITY GRANT
DOCUMENT F – PROPOSER AKNOWLEDGEMENTS
AND COMPLIANCES
ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owned or an emerging small business. If applicable, Proposer has, or will have prior to Grant Agreement execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into a Grant Agreement with an anticipated Grant Agreement price of $150,000 or more with an Proposer that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.
6. Proposer complies with ORS 652.220 and does not unlawfully discriminate against any of Proposer’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class.
“Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.
Proposer’s continuing compliance constitutes a material element of this Grant Agreement and a failure to comply constitutes a breach that entitles Agency to terminate this Grant Agreement for cause.
Proposer may not prohibit any of Proposer’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Proposer may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.
7. Proposer is not engaged in the provision of broadband Internet access service, or if at any time Proposer is engaged in or may engage in the provision of broadband Internet access service Proposer is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Grant Agreement.
8. Proposer and Proposer’s employees, agents, and subcontractors are not included on:
A. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or
B. the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/
RFGP S-44300-0001737/6312
OPIOID SETTLEMENT COMMUNITY GRANT
DOCUMENT F – PROPOSER AKNOWLEDGEMENTS
AND COMPLIANCES
https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.sam.gov/portal/ https://www.sam.gov/portal https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx
9. Proposer certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Proposer, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFGP. If any changes occur with respect to Proposer’s status regarding conflict of interest, Proposer shall promptly notify the State in writing.
10. Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFGP) and this Proposer Acknowledgements & Compliances are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.
11. Proposer understands that any statement or representation it makes in response to this RFGP, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Grant Agreement being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.
12. Proposer acknowledges these certifications are in addition to any certifications required in the Grant Agreement and at the time of Grant Agreement execution.
Authorized Signature Date
(Printed Name and Title)
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OPIOID SETTLEMENT COMMUNITY GRANT
DOCUMENT F – PROPOSER AKNOWLEDGEMENTS
AND COMPLIANCES
| Legal Business Name: |
| Address: |
| State of Incorporation: |
| Name: |
| Telephone: |
| Email: |
| Printed Name and Title: |
| Date: |
| Signature1_es_:signer:signature: |
| City, State, Zip: |
| Entity Type: |
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