proposal_intent_response_sheet_form1.doc

PROPOSAL INTENT RESPONSE SHEET

RFP No.: HHS-ASPR-16-100-SOL-00006 RFP Title: Emergency Prescription Assistance Program – Long Term Please review the attached Request for Proposal. Furnish the information requested below and return this page ASAP . Your expression of intent is not binding but will greatly assist us in planning for proposal evaluation.

[ ] DO INTEND TO SUBMIT A PROPOSAL

[ ] DO NOT INTEND TO SUBMIT A PROPOSAL FOR THE FOLLOWING REASONS:

Company/Institution Name (print):

Address (print):

Project Director's Name (print):

Title (print):

Telephone Number E-mail Address (print clearly):

Name of individual to whom electronic proposal instructions should be sent:

Name:

Title:

Telephone Number:

E-Mail Address:

RETURN VIA FAX OR E-MAIL TO:

United States Department of Health & Human Services (HHS)

Office of the Secretary (OS)

Assistant Secretary for Preparedness & Response (ASPR)

Office of Acquisitions Management, Contracts & Grants (AMCG)

Attn:

RoShawn K. Simpson

Senior Contracting Officer