Exhibit G - Mandatory Requirements and Eligibility Certification.docx

Exhibit G – Mandatory Requirements and Eligibility Certification Completion of this Exhibit fulfills the Demonstration of Compliance requirement for both Applicant Eligibility Type and Legal Authority/Regulatory Compliance, as described in the RFA IBEH__________________ All applicants must complete and submit this Exhibit as part of their proposal.

Failure to submit a completed Exhibit G, or failure to meet any mandatory requirement, may result in the application being deemed nonresponsive and disqualified from further evaluation.

E. Application Content

1. Mandatory Criteria

i. Applicant Eligibility Type Applicants must select ONE (1) and only one of the following organizational types by checking the appropriate box below. Failure to select an option will result in the application being deemed nonresponsive.

☐ Local Government Agency (e.g., county, municipality, or law enforcement department) ☐ Nonprofit Organization. If a nonprofit organization is selected, the applicant must provide documentation of an executed partnership agreement or Memorandum of Understanding (MOU) with a local law enforcement agency or judicial entity.

☐ Executed MOU or partnership agreement attached. Please attach your agreement with your response. Name of partnering law enforcement agency or judicial entity:__________________________________________________________

ii. Legal Authority and Regulatory Compliance Certification By signing below, the applicant certifies that the organization:

· Is legally authorized to operate within the State of Colorado;

· Complies with all applicable federal and state laws and regulations governing behavioral health services and criminal justice diversion or deflection programs; and

· Has the authority to enter into a contract with the State of Colorado, if selected for award.

The applicant understands that BHA may request additional documentation to verify eligibility, legal authority, or compliance status.

Authorized Certification I certify that the information provided in this Exhibit is true, complete, and accurate to the best of my knowledge. I understand that misrepresentation or failure to meet mandatory requirements may result in disqualification of the application or termination of an award.

Authorized Representative Name: _______________________________________ Title: _______________________________________________________________ Organization Name: _________________________________________________ Signature: ___________________________________________________________ Date: _______________________________________________________________