Exhibit E - Vendor Disclosure Statement.pdf
PDF 41 KB Posted
- Attached to
- CMS #211060 RFQ Pre-Disaster DRR
- Solicitation number
- RFQ NLAA 2027000003 5
- Issued by
- Denver County, Denver City, Colorado
About this file
This is a Vendor Disclosure Statement form (Exhibit E) required by the State of Colorado under Colorado Revised Statute 24-102-206 for all state contracts and solicitations for services executed after August 3, 2007. The form applies to the CMS #211060 RFQ Pre-Disaster DRR contract opportunity in Colorado and must be completed by vendors to disclose whether contract performance or any subcontract work will occur outside the United States or the State of Colorado.
Vendors must indicate whether services will be performed outside the U.S. or Colorado and, if so, identify the specific countries and states where work will be conducted. If performance outside these geographic boundaries is anticipated, vendors must explain why such arrangement is necessary or advantageous. The form exempts certain contracts related to Medicare, the Colorado Medical Assistance Act, the Children's Basic Health Plan Act, and the Colorado Indigent Care Program. Completed forms must be signed by an authorized representative with printed name, title, and date, and returned to the contracting agency at the address specified in the solicitation documents.
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Text version
DPA SB-228 VDS Form Updated 2/14/2008
EXHIBIT E
VENDOR DISCLOSURE STATEMENT
Contract Performance Outside the United States or Colorado
Colorado Revised Statute 24-102-206
Company Name:________________________. Contract or Purchase Order Number:________________ (Contract or PO to be entered after award)
To the extent the vendor has not disclosed the following information in the Statement of Work, this form shall be completed and returned to the contracting agency. This applies to all state contracts and solicitation for services executed after August 3, 2007.
1. Are any services under the contract or any subcontracts anticipated to be performed outside the United States or Colorado?
Yes No
If “No”, please sign the form.
If “Yes”, please complete the following three questions:
2. Where will the services be performed under the contract, including any subcontracts?
(List country(ies) and/or state(s).
3. Explain why it is necessary or advantageous to go outside of the United States or the State of Colorado to perform the contract or any subcontracts.
Not required for contracts to which the State is a party under:
• Medicare
• The “Colorado Medical Assistance Act”, Articles 4 to 6 of Title 25.5 CRS
• The “Children/s Basic Health Plan Act”, Article 8 of Title 25.5, CRS
• The “Colorado Indigent Care Program”, Part I of Article 4 of Title 25.5, CRS
Signature: Printed Name
Title: Date:
RETURN THIS FORM WITH TO THE ADDRESS BELOW
Return to: ______________________________
RETURN THIS FORM WITH TO THE ADDRESS BELOW
File details come from the government source that posted it. Updated .