HC_CELLWAN_ATTACHMENT_B_PRICING_FORM2.pdf

Attachment B — Pricing Form Hattiesburg Clinic RFP No. [HC-RTG-2026-WAN] | Tertiary Cellular WAN Service for Rural Clinic Sites

Bidder Information

Company (legal name): UEI (SAM.gov):

Contact name / title: Email:

Phone: Carrier / network:

Amounts in U.S. dollars, excluding taxes and government fees. Gray fields calculate automatically. Enter 0 for any line not applicable.

A. Year 1 Recurring Service Unit price Qty Months Extended (USD)

A1 Cellular data service, per line / month Standby data plan per SOW 4.1

A2 Static IP / private APN, per line / month Enter 0 if included or not needed

A3 Equipment rental / management, per site / mo Enter 0 if equipment is purchased (B1)

A4 Other recurring costs (describe in Notes)

Subtotal A — Year 1 Recurring

B. One-Time Costs Unit price Qty Extended (USD)

B1 Cellular modem / router, per site Enter 0 if carrier-provided at no cost

B2 Activation / installation, per site

B3 Other one-time costs (describe in Notes)

Subtotal B — One-Time Costs

C. Year 1 Total Amount (USD)

C1 Year 1 Total, before taxes (Subtotal A + Subtotal B)

C2 Estimated taxes and government fees Sales tax and telecom surcharges; describe in Notes

C3 YEAR 1 GRAND TOTAL (C1 + C2)

Attachment B — Pricing Form Hattiesburg Clinic RFP No. [HC-RTG-2026-WAN] | Tertiary Cellular WAN Service for Rural Clinic Sites

D. Years 2 and 3 (before taxes; subject to availability of funds) Amount (USD)

D1 Year 2 — total annual recurring cost (all sites)

D2 Year 3 — total annual recurring cost (all sites)

36-Month Total, before taxes (C1 + D1 + D2)

E. Unit Rates Amount (USD)

E1 Data overage, per GB (if applicable)

E2 Additional site — monthly service per line

E3 External / high-gain antenna, installed, per site

E4 Early termination charge per line if Years 2–3 are not funded

F. Service Details

Data plan type / allowance (pooled, per line, GB):

Number of sites with confirmed usable coverage (of 67):

Priority / preemption available (Y/N, describe):

Proposal valid through (date):

G. Pricing Notes, Assumptions and Exclusions

H. Certification The undersigned certifies that the prices above are complete for all requirements of the Scope of Work, were arrived at independently, and will remain firm for the validity period stated. Any cost not listed will not be paid by the Clinic.

Authorized signature:

Printed name / title:

Date:

Signature may be applied digitally, or the completed form may be printed, signed and scanned.

Supplemental carrier quotes may be attached but do not replace this form.