LCA DQ Appendix B, PII Cert.pdf

This is a Personal Identifying Information (PII) Certification form required by the State of Colorado's Health Care Policy and Financing (HCPF) for the Local Contact Agency - In-Reach Counseling solicitation (Solicitation #DQ UHAA 2026000469). The certification is executed under penalty of perjury by an authorized representative of a third-party entity or organization seeking access to PII through a database or automated network. The certifying organization attests that it has not and will not use or disclose any Personal Identifying Information as defined by Colorado Revised Statutes 24-74-102(1) for the purpose of investigating, participating in, cooperating with, or assisting Federal Immigration Enforcement, including the enforcement of civil immigration laws and the Illegal Immigration and Immigrant Responsibility Act (codified at 8 U.S.C. §1325 and 1326), except as required by Federal or State law or to comply with court-issued subpoenas, warrants, or orders.

The certification requires completion by an individual with full legal authority to bind the organization, who must provide their signature, printed name, title, and date of execution. The form also requires the legal name of the organization and serves as a compliance document pursuant to Colorado Revised Statutes 24-74-105, ensuring that any entity accessing PII through state databases or automated networks adheres to strict limitations on the use and disclosure of such information in relation to immigration enforcement activities.