Enclosure_8_-_Minimum_Qualifications_and_Certification_of_Compliance_Form.pdf
PDF 486 KB Posted
- Attached to
- Youth Interim Housing Program
- Solicitation number
- 2026-COH-RFP-00071
- Issued by
- San Mateo County, California
About this file
This document is an Enclosure 8 - Minimum Qualifications and Certification of Compliance Form for a county procurement process involving an interim housing program for transitional age youth. The form requires proposers to certify their compliance with several key qualifications, including being legally authorized to conduct business in California, not being on federal debarment lists, and having a minimum of three years' experience operating an interim housing program serving transitional age youth. Proposers must also disclose any current or past five-year licensure, HIPAA, and discrimination claims against their organization.
The form mandates that proposers indicate their ability to enter into an agreement using the County's Standard Terms and Conditions, with the option to attach a red-lined version proposing changes for negotiation. Proposers are required to attach a completed W9 form signed within the last year and demonstrate their commitment to the minimum qualifications outlined in the RFP. The document provides a structured approach for potential providers to confirm their eligibility and readiness to participate in the county's interim housing program, with clear instructions for marking compliance or non-compliance with various provisions.
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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
| Reason2: |
| Reason3: |
| Reason4: |
| Reason5: |
| Proposing Agencys Authorized Signer Name: |
| Check Box1: Off |
| Check Box3: Off |
| Check Box5: Off |
| Check Box6: Off |
| Check Box8: Off |
| Check Box9: Off |
| Check Box10: Off |
| Check Box11: Off |
| Reason1: |
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