E.1_Prime_Proposal_Checklist.doc

HHSM-500-2015-RFP-0113

Exhibit E.1

Prime Contractor Proposal Checklist You are requested to complete the following checklist to allow CMS to more readily identify various aspects of your proposal. Please check the appropriate items and provide an explanation, if necessary.

1) Company name, address, point of contact, email and telephone number

2) If a newly formed company, provide name and address of parent companies forming the new entity:

a. __________________ b.__________________

3) List of proposed subcontractors (if applicable):

a. _____________________________________

b. _____________________________________

c. _____________________________________

4) In accordance with the North American Industry Code 541219, indicate the business size of the prime entity/company.

□ Large Business

□ Small Business – check additional categories as applicable:

____ Disadvantaged

____ Woman-owned

____ Veteran-owned

____ HUBZone

____ (8)a

5)

TIN # _______________

6) DUNS# _______________

7) Cage Code _____________

8) Productive Hours for Exempt and Non-Exempt Employees ________