Enclosure_8_-_Minimum_Qualifications_and_Certification_of_Compliance_Form.pdf

Enclosure 8 - Minimum Qualifications and Certification of Compliance Form

Proposers must complete the form and certify by marking the sections accordingly.

No = Proposer is unable to comply with term/provision. Proposer will identify the specific objections and provide a reason in the provided area below.

Yes = Proposer can comply with provision and has no objections.

Yes No Minimum Qualifications ☐ ☐ Proposer is legally authorized to conduct business in the State of California.

Attach completed W9 signed within the last year.

☐ ☐ Neither the proposer nor its principles, and/or named subcontractors are identified on the list of Federally debarred, suspended or other excluded parties located at https://sam.gov/content/exclusions.

Yes No Provisions shown in V.A of the RFP ☐ ☐ Proposer certifies its commitment and ability to comply with the minimum qualifications as set forth in the section V.A of the RFP.

• Proposer has a minimum of three years’ experience operating an interim housing program that serves transitional age youth, either as the sole population or as a portion of the adult population. Years of experience do not need to be consecutive.

• Proposer must list any current licensure, HIPAA, and discrimination claims against you/ your organization and those having occurred in the past five years, including any resulting in claims or legal judgments against you/your organization.

Yes No Enclosure 1 – County Standard Agreement Terms and Conditions ☐ ☐ Proposer is able and willing to enter into an agreement with the County using the County’s

Standard Terms and Conditions as shown in Enclosure 1- Standard Agreement Template and Attachments. Attach red-lined version to request changes. Requested changes will be reviewed and discussed during negotiations.

In the table below, provide the specific clause/provision and reason for non-compliance. Additional lines may be added if necessary.

Minimum Qualification/Special Provision, Standard Contract Term or Condition

Reason

1) 2) 3) 4) 5)

Proposing Agency’s Authorized Signer (Name) Signature https://sam.gov/content/exclusions https://sam.gov/content/exclusions