Mathematica_Offer_and_Acceptance_Form.pdf

Request for Proposal Solicitation No.

BPM001998

Description:

Data Management Services

Arizona Department of Administration

State Procurement Office 100 N 15th Ave., Suite 402

Phoenix, AZ 85007

PART 3 of the Solicitation Documents Template version 4.0 (16-NOV-2018)

SECTION 3-B: Offer Forms Page 1 of 36 3

A v a i l a b l e o n l i n e a t : A P P . A Z . g o v

Attachment 1 Offer and Acceptance Form

SUBMISSION OF OFFER: Undersigned hereby offers and agrees to provide Workers' Compensation Cost Containment, Claim Management and Administration Services in compliance with the Solicitation indicated above and our Offer indicated by the latest dated version below:

Initial Offer:

1. 11/20/2019 MG

Date initial

Revised Offers:

2. x x 3. x x 4. x x date #1 initial date #1 initial date #1 initial

5. x x 6. x x 7. x x date #4 initial date #5 initial date #6 initial

Best and Final Offer:

8. x x Date initial

Mathematica Policy Research, Inc x Offeror company name Signature of person authorized to sign Offer

1100 First Street, NE, 12th Floor Matt Gillingham, Vice President

Address Printed name and title

Washington, DC 20002-4221 Pamela Tapscott

City | State | ZIP Contact name and title

22-2112296 rfpcenter@mathematica-mpr.com (202) 484-3294

Federal tax identifier (EIN or SSN) Contact Email Address Contact phone number

CERTIFICATION: By signature in the above, Offeror certifies that it:

1. will not discriminate against any employee or applicant for employment in violation of Federal Executive Order 11246, [Arizona] State

Executive Order 2009-

2. has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted offer. Failure to provide a valid signature affirming the stipulations required by this clause will result in rejection of the Offer. Signing the Offer with a false statement will void the

3. complies with A.R.S. § 41-

4. is not debarred from, or otherwise prohibited from participating in any contract awarded by federal, state, or local government.

ACCEPTANCE OF OFFER: State hereby accepts the initial Offer, Revised Offer, or Best and Final Offer identified by the latest date and number at the top of this form (the Accepted Offer). Offeror is now bound (as Contractor) to carry out the Work under the attached Contract, of which the Accepted Offer forms a part. Contractor is cautioned not to commence any billable work or to provide any material or perform any service under the Contract until Contractor receives the applicable Order or written notice to proceed from Procurement Officer.

State’s Contract No. is: ________________ The effective date of the Contract is: __________ Contract awarded _________ Date Date

Procurement Officer Signature Procurement Officer Printed Name

MG /2 /20