financial_qualification_form~4.pdf

Doc 3

Contracting Qualification Form

Responding to (RFR) #: ____________________ Issued by EOHHS Agency: ____________________________

I. Information for Primary Organization:

Primary Organization Name: _____________________________________FEIN #: _______________________

____ Check here, if the primary organization is a “non-contracting parent” entity and attach the Supplement (Page 2) for the child/affiliate organization information.

Organization Type (check one): ___ Non Profit ___ For Profit ___ Governmental Entity (Go to Sec II, #3 below)

Organization’s Corporate Address: Chief Executive Officer:

Number/Street City State Zip First Name Last Name

Contact Person: First Name Last Name Title Telephone # E-mail Address

II. Submission Materials - Covering the primary organization and all affiliated entities as required by instructions (link opens to instructions, PDF or RTF):

1. Financial/Audit Information: Required for all commonly controlled, affiliated or related entities. See the instructions for details. Fiscal Year End: ____________

Submission Type (Choose those that apply):

____ Compilation Report ____ IRS Form 990 - Return of Organization Exempt ____ Review Report from Income Tax ____ Audit Report ____ Letter/Line of Credit in Name of Organization ____ Uniform Financial Report (UFR) ____ Form PC - Mass. Office of the Attorney General, Division of ____ Corrective Action Plan (CAP) Public Charities

2. Additional Submission Requirements (All items must be provided, except as noted in item 3 below):

____ a) Federal Employer ID # (FEIN) Documentation / W-9 ____ d) Board/Principals Information ____ b) Terms & Conditions for Human and Social Services ____ e) Organizational Chart Contracting ____ c) Articles of Organization/Corporate Bylaws

3. Exemption: If the submission is for a Governmental Entity, please check here ____. Only items 2a and 2b must be provided.

III. Related Party Disclosure Certification The signatory below represents that all required related party disclosures have been made in a complete and accurate manner and that all pricing and procurement requirements pertaining to related party relationships have been fulfilled in compliance with 808 CMR 1.00 and the supplemental guidance material promulgated by the Operational Services Division of the Commonwealth. If applicable, please attach a separate document describing any current related party transactions.

IV. Federal Disclosure, Tax and Other Compliance Certification Under the penalties of perjury, the signatory below certifies that neither the organization nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation by any Federal or state department or agency that the organization complies with the laws and regulations relating to State and Federal Taxes and with all other requirements of the Terms and Conditions for Human and Social Services contracting and that all qualification submission information and attachments are true and complete to the best of my knowledge and signatory’s knowledge and belief. The certification line below must be signed and dated by the authorized signatory for each organization covered by this submission. The signatory for the Primary Organization should sign below on this page. The signatory for each additional organization should sign on the supplemental page(s) covering information for child/affiliate organizations.

Authorized Signature: ________________________________________________ Date: ____________________

FOR PPA INTERNAL USE:

Qualification Status: _________________________________________ Early Termination Date if Conditional or Provisional: ______________

Audit Opinion: __________________________ Findings: ____________________________________________________________________

Comments: _________________________________________________________________________________________________________ PPA Approval: _____________________________________________________ Date: _________________

Doc 3

Supplement to Contracting Qualification Form (Complete this section for each affiliated organization. This page may be copied as required.)

Primary Organization Name: ____________________________________ FEIN #: _______________________

Child/Affiliate Organization Name: _______________________________ FEIN #: _______________________

Organization Type (check one): ___ Non Profit ___ For Profit ___ Governmental Entity

Organization’s Corporate Address: Chief Executive Officer:

Number/Street City State Zip First Name Last Name

Contact Person: First Name Last Name Title Telephone # E-mail Address

Related Party Disclosure Certification The signatory below represents that all required related party disclosures have been made in a complete and accurate manner and that all pricing and procurement requirements pertaining to related party relationships have been fulfilled in compliance with 808 CMR 1.00 and the supplemental guidance material promulgated by the Operational Services Division of the Commonwealth. If applicable, please attach a separate document describing any current related party transactions.

Federal Disclosure, Tax and Other Compliance Certification Under the penalties of perjury, the signatory below certifies that neither the organization nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation by any Federal or state department or agency that the organization complies with the laws and regulations relating to State and Federal Taxes and with all other requirements of the Terms and Conditions for Human and Social Services contracting and that all qualification submission information and attachments are true and complete to the best of my knowledge and signatory’s knowledge and belief. The certification line below must be signed and dated by the authorized signatory for each organization covered by this submission. The signatory for each additional organization should sign on the supplemental page(s) covering information for their child/affiliate organizations.

Authorized Signature ________________________________________________ Date _______________

Child/Affiliate Organization Name: ________________________________FEIN #: _______________________

Organization Type (check one): ___ Non Profit ___ For Profit ___ Governmental Entity

Organization’s Corporate Address: Chief Executive Officer:

Number/Street City State Zip First Name Last Name

Contact Person: First Name Last Name Title Telephone # E-mail Address

Related Party Disclosure Certification The signatory below represents that all required related party disclosures have been made in a complete and accurate manner and that all pricing and procurement requirements pertaining to related party relationships have been fulfilled in compliance with 808 CMR 1.00 and the supplemental guidance material promulgated by the Operational Services Division of the Commonwealth. If applicable, please attach a separate document describing any current related party transactions.

Federal Disclosure, Tax and Other Compliance Certification Under the penalties of perjury, the signatory below certifies that neither the organization nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation by any Federal or state department or agency that the organization complies with the laws and regulations relating to State and Federal Taxes and with all other requirements of the Terms and Conditions for Human and Social Services contracting and that all qualification submission information and attachments are true and complete to the best of my knowledge and signatory’s knowledge and belief. The certification line below must be signed and dated by the authorized signatory for each organization covered by this submission. The signatory for each additional organization should sign on the supplemental page(s) covering information for their child/affiliate organizations.

Authorized Signature ________________________________________________ Date _______________