E.1.A UPIC Subcontractor Proposal Checklist.doc

HHSM-500-2015-RFP-0122

Exhibit E.1.A

Subcontractor Proposal Checklist UPIC Each subcontractor to a prime contractor shall complete the following checklist for the UPIC IDIQ/Jurisdiction 1 task order proposal. This submission will allow CMS to more readily identify various aspects of your proposal. Please check the appropriate items and provide an explanation, if necessary.

1) Prime Offeror’s Name: _________________________________

2) Subcontractor company name, address, point of contact and telephone number

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

a. __________________ b.__________________

4) List of proposed subcontractors (if applicable):

a. _____________________________________

b. _____________________________________

c. _____________________________________

5) In accordance with the North American Industry Code 541990, indicate the business size of the prime entity/company.

□ Large Business

□ Small Business – if so, please indicate size standard for the NAICS above:

6) TIN # _______________

7) DUNS# _______________

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

9) Number of FTEs and Hours Proposed:

TASK ORDER 0001 – JURISDICTION 1

TOTAL PROPOSED FTEs:

Task Order 0001

OY1

Direct

Indirect

Subs

Total

TASK ORDER 0001 – TOTAL PROPOSED HOURS:

Task Order 0001

OY1

Direct

Indirect

Subs

Total