E.1 UPIC Prime Proposal Checklist.doc

HHSM-500-2015-RFP-0122

Exhibit E.1

Prime Proposal Checklist UPIC The 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) Company name, address, point of contact 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 541990, indicate the business size of the prime entity/company. If the NAICS above does not fit with the subcontract requirement, provide the appropriate NAICS and why it was chosen.

□ Large Business

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

5) Interested in receiving task order 0001 for Jurisdiction 1: __yes ___ no

Other Jurisdictions of interest:

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