IFB_Solicitation_Attachments.pdf

BID/BIDDER CERTIFICATION SHEET

(Page 1 of 2)

This sheet must be signed and returned along with all the Required Attachments and must bear a certified digital signature or scanned wet signature of a person authorized to bind the Bidder’s firm.

The signature affixed hereon and dated certifies compliance with all the requirements of this bid document. The signature below authorizes the verification of this certification.

An Unsigned Bid/Bidder Certification Sheet May Be Cause for Rejection

1. Organization/Company Name 2. Telephone Number 2a. Fax Number

3. Address

Indicate your organization type:

4. Sole Proprietorship 5. Partnership 6. Corporation Indicate the applicable employee and/or corporation number:

7. Federal Employee ID No. 8. California Corporation

9. Indicate applicable license and/or certification information:

10. Bidder’s Name (Print) 11. Title

12. Signature 13. Date

14. Are you certified with the Department of General Services, Office of Small Business and Disabled Veteran Certification (OSDC) as:

a. Small Business Enterprise Yes No If yes, enter certification number:

b. Disabled Veteran Business Enterprise

NOTE: A copy of your Certification is required to be included if either of the above items is checked “Yes”.

Date application was submitted to OSDS, if an application is pending:

Yes No If yes, enter your service code below:

ATTACHMENT 2

(Page 2 of 2)

Completion Instructions for Bid/Bidder Certification Sheet

Complete the numbered items on the Bid/Bidder Certification Sheet by following the instructions below.

Item Numbers Instructions 1, 2, 2a, 3 Must be completed. These items are self-explanatory.

Check if your firm is a sole proprietorship. A sole proprietorship is a form of business in which one person owns all the assets of the business in contrast to a partnership and corporation. The sole proprietor is solely liable for all the debts of the business.

Check if your firm is a partnership. A partnership is a voluntary agreement between two or more competent persons to place their money, effects, labor, and skill, or some or all of them in lawful commerce or business, with the understanding that there shall be a proportional sharing of the profits and losses between them. An association of two or more persons to carry on, as co-owners, a business for profit.

Check if your firm is a corporation. A corporation is an artificial person or legal entity created by or under the authority of the laws of a state or nation, composed, in some rare instances, of a single person and his successors, being the incumbents of a particular office, but ordinarily consisting of an association of numerous individuals.

7 Enter your Federal Employee Tax Identification Number.

Enter your corporation number assigned by the California Secretary of State’s Office. This information is used for checking if a corporation is in good standing and qualified to conduct business in California.

Indicate applicable license and/or certification information that your firm possesses and that is required for the type of services being procured.

10, 11, 12, 13 Must be completed. These items are self-explanatory.

If certified as a Small Business Enterprise, place a check in the "yes" box, and enter your certification number on the line. If certified as a Disabled Veteran Business Enterprise, place a check in the "Yes" box and enter your service code on the line. If you are not certified, place a check in the "No" box. If your certification is pending, enter the date your application was submitted to OSDC.

BIDDER DECLARATION

To view the form, click on the heading. Contact the Contract Services Team at:

m_ContractSupport@cdcr.ca.gov to request a hard copy.

ATTACHMENT 3

https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd05-105.pdf mailto:m_ContractSupport@cdcr.ca.gov

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS FORM

To view the form, click on the heading. Contact the Contract Services Team at:

m_ContractSupport@cdcr.ca.gov to request a hard copy.

ATTACHMENT 4

https://www.energy.ca.gov/sites/default/files/2025-10/03_IFB-25-001_TIS_Attachment-03-DVBE-STD_843.pdf

DARFUR CONTRACTING ACT CERTIFICATION

ATTACHMENT 5

To view the form, click on the heading. Contact the Contract Services Team at:

m_ContractSupport@cdcr.ca.gov to request a hard copy.

https://www.dgs.ca.gov/-/media/CBAFDC111B6C43B09496B8391E11F394.ashx

CALIFORNIA CIVIL RIGHTS LAWS CERTIFICATION

ATTACHMENT 6

To view the form, click on the heading. Contact the Contract Services Team at:

m_ContractSupport@cdcr.ca.gov to request a hard copy.

https://www.dgs.ca.gov/-/media/Divisions/OLS/Forms/CALIFORNIA-CIVIL-RIGHTS-LAWS-ATTACHMENT.ashx

CONTRACTOR CERTIFICATION CLAUSES

ATTACHMENT 7

To view the form, click on the heading. Contact the Contract Services Team at:

m_ContractSupport@cdcr.ca.gov to request a hard copy.

https://www.dgs.ca.gov/-/media/Divisions/OLS/Resources/CCC-042017.pdf?la=en&hash=4DE3E4DC414511AE378794200BA43EBF91C758EE

IRAN CONTRACTING ACT

ATTACHMENT 8

To view the form, click on the heading. Contact the Contract Services Team at:

m_ContractSupport@cdcr.ca.gov to request a hard copy.

https://dgs.ca.gov/-/media/A7EE965578CA4CC1A63087423C7BED0C.ashx

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

California Correctional Health Care Services (CCHCS) Direct Care Contracts Section/Contract Support Team

P.O. Box 588500 N/A (916) 691-0698

Elk Grove CA 95758 m_ContractSupport@cdcr.ca.gov

Print Form Reset Form

ATTACHMENT 9

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.

Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification Number The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Section 4 – Payee Residency Status Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at time of death.

A trust is a resident if at least one trustee is a California resident.

o For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

Section 5 – Certification Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signe e can provide a power of attorney documented for the individual.

Section 6 – Paying State Agency This section must be completed by the state agency/department requesting the STD 204.

Privacy Statement Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of this form.

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

Rev. 05/1/2021

Form to be completed by Vendor.

LEGAL NAME OF BUSINESS

DBA

FEIN OR SSN NUMBER

BUSINESS PHYSICAL ADDRESS

STREET

CITY

STATE ZIP

REMIT TO INFORMATION

(WHERE YOU WANT YOUR PAYMENTS SENT. ADDRESS MUST MATCH REMIT TO ADDRESS ON INVOICE.)

COMPANY NAME

STREET(P.O. Box)

CITY

STATE ZIP

CONTACT INFORMATION

SALES CONTACT PERSON ACCOUNTING CONTACT PERSON

TITLE TITLE

PHONE PHONE

FAX FAX

SALES E-MAIL ADDRESS

WEB-SITE ADDRESS:

PURCHASING INFORMATION

SERVICE TYPE OF SERVICE PROVIDED:

COMMODITY TYPE OF PRODUCT PROVIDED:

SUPPLEMENT VENDOR PAYEE DATA RECORD FORM

ATTACHMENT 10

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

Rev. 05/1/2021

SUPPLEMENT VENDOR PAYEE DATA RECORD FORM

BUSINESS DESIGNATION

(Fill out only if registered with the Dept. of General Services)

SMALL BUSINESS (SB) CERTIFICATION # - EXPIRATION DATE

MICRO BUSINESS (MB) CERTIFICATION # - EXPIRATION DATE

DVBE BUSINESS CERTIFICATION # - EXPIRATION DATE

SMALL BUSINESS PUBLIC WORK CERTIFICATION # - EXPIRATION DATE

NP VETERAN SERVICE AGENCY CERTIFICATION # - EXPIRATION DATE

NON-PROFIT RECOGNITION CERTIFICATION # - EXPIRATION DATE

TAX INFORMATION

(Fill out if you expect a 1099 at the end of the year)

WITHHOLDING TAX INFORMATION

TYPE OF RECIPIENT (PLEASE SELECT ONE/ SHOULD

MATCH SECTION 3 OF STD 204)

RENTS CORPORATION (REGULAR)------------- (SELECT “ALL OTHERS” ON 204)

ROYALTIES MEDICAL CORPORATION---------- (SELECT “MEDICAL” ON 204)

OTHER INCOME (PRIZED, AWARDS) LEGAL CORPORATION----------------- (SELECT “LEGAL” ON 204)

FISHING BOAT PROCEEDS NON-PROFIT CORP.----- (SELECT “EXEMPT(N. PROF)” ON 204)

MEDICAL AND HEALTHCARE PAYMENTS LLC C-CORPORATION --------- (SELECT “ALL OTHERS” ON 204)

NONEMPLOYEE COMPENSATION LLC S-CORPORATION--------- (SELECT “ALL OTHERS” ON 204)

SUBSTITUTE PAYMENTS (DIVIDENDS/INTEREST) LLC PARTNERSHIP --------------------- (SELECT “PARTNERSHIP” ON 204)

DIRECT SALES SINGLE MEMBER LLC ----- (SELECT “SOLE PROP, INDIV LLC” ON 204)

CROP INSURANCE PROCEEDS TAX EXEMPT ORG. --------------------- (OTHER THAN NON PROFIT CORP.)

EXCESS GOLDEN PARACHUTE PAYMENTS INDIVIDUAL/ SOLE PROP-- (SELECT “SOLE PROP, INDIV LLC” ON 204)

GROSS PROCEEDS PAID TO AN ATTORNEY ESTATE------------------------------------------------- (SELECT “ESTATE” ON 204)

STATE TAX WITHHELD QUALIFIED INTERMEDIARY

ARTIST OR ATHLETE

GOVERNMENT OR INT. ORGANIZATION

NOMINEE

FIDUCIARY

AUTHORIZES FOREIGN AGENT

TYPE OF RECIPIENT UNKNOWN

PRIVATE FOUNDATION

STOP! Only fill out this section if your company has sold their receivables to another company

FACTORING VENDOR (WHEN A VENDOR SELLS RECEIVABLES TO A THIRD PARTY) ATTACH COPY OF THE

LETTER FROM VENDOR NOTIFIYING CDCR OF THE ASSIGNMENT

COMPANY NAME

DBA

STREET(P.O. Box)

CITY

STATE ZIP

CERTIFICATE OF GOOD STANDING

Provide a copy of your organization’s Certificate of Good Standing from the California Secretary of State.

ATTACHMENT 11

California Department of Corrections and Rehabilitation (CDCR)/ California Correctional Health Care Services (CCHCS) Rate Sheet

IFB Number: SD26-00005 Exhibit B-1

ENDODONTIC DENTAL SPECIALTY SERVICES

Contractor must be able to provide services to all institutions awarded below. Subcontractors may be required to comply with the terms of this Agreement. If subcontractors are used, subcontractor information must be submitted. If additional subcontractors are added during the term of the contract, an updated subcontractor/consultant list must be submitted.

Contractors with multiple Agreements for the same service at the same institution shall be obligated to provide service(s) at the rate specified in Contractor’s primary Agreement (i.e., Agreement resulting from the prior bid) until all obligations under that Agreement (e.g., rate per procedure) are satisfied before the rate in any subsequent Agreement(s) can be used. The only exception to this provision occurs when the rate in a subsequent Agreement is lower than those of the primary Agreement; the State then has the sole right to determine which rate will be applied. The rates listed below are in effect for the term of the Agreement, including any extension of the term through a formal amendment.

For any procedures not listed on the Exhibit B-2 – Standardized Fees, Contractor will be reimbursed Usual, Customary, and Reasonable (UCR) fees for pre-approved procedure(s) at the percent (%) bid for the region(s) in which the UCR fee of Current Dental Terminology (CDT) procedure(s) is performed. Contractor's bid percentage of CDCR’s/CCHCS’s Standardized Fees and rank for each region is noted below:

REGION 1

California Medical Facility (CMF), California State Prison – Sacramento (SAC), San Quentin Rehabilitation Center (SQ), California State Prison – Solano (SOL), Folsom State Prison (FSP), High Desert State Prison (HDSP), Mule Creek State Prison (MCSP), Pelican Bay State Prison (PBSP).

Bid Rate Cap Percent (%) Bid of

CDCR/CCHCS Standardized Fees.

120%

REGION 2

California Men's Colony (CMC), Central California Women's Facility (CCWF), Correctional Training Facility (CTF), Salinas Valley State Prison (SVSP), Sierra Conservation Center (SCC), Valley State Prison (VSP), California Health Care Facility (CHCF), Pleasant Valley State Prison (PVSP).

Bid Rate Cap Percent (%) Bid of

CDCR/CCHCS Standardized Fees.

120%

CDCR/CCHCS

Rate Sheet

IFB Number: SD26-00005 Exhibit B-1

REGION 3

Avenal State Prison (ASP), California Correctional Institution (CCI), California State Prison – Corcoran (COR), California State Prison – Los Angeles County (LAC), California Substance Abuse & Treatment Facility (SATF), Kern Valley State Prison (KVSP), North Kern State Prison (NKSP), Wasco State Prison (WSP).

Bid Rate Cap Percent (%) Bid of

CDCR/CCHCS Standardized Fees.

120%

REGION 4

California Institution for Men (CIM), California Institution for Women (CIW), Calipatria State Prison (CAL), Centinela State Prison (CEN), Ironwood State Prison (ISP), Richard J. Donovan Correctional Facility (RJD).

Bid Rate Cap Percent (%) Bid of

CDCR/CCHCS Standardized Fees.

120%

In accordance with Exhibit A – Scope of Work, Section 7 – Cancellation, payments will be as follows:

Due to institutional operational factors and security conditions that may restrict patient movement, off‑site medical appointments may, at times, be delayed or cancelled. CDCR/CCHCS may cancel or modify scheduled appointments by telephone, email, and/or fax up to twenty‑four (24) hours prior to the scheduled reporting time without incurring liability. If CDCR/CCHCS cancels or modifies an appointment less than twenty‑four (24) hours before the scheduled reporting time, CDCR/CCHCS shall pay a cancellation fee of no more than Fifty Dollars ($50.00) for each scheduled appointment hour.

SD26-00005 Rate Sheet.pdf