ODMR 2627-0005 Attachment A - Required Offeror Information.pdf

ODMR 2627-0005

PROVIDER REIMBURSEMENT TECHNICAL ASSISTANCE

ATTACHMENT A – REQUIRED OFFEROR INFORMATION

Attachment A1

REQUIRED OFFEROR INFORMATION

Purpose: ODM requires the following information from Offerors who submit Proposals to this RFP, in order to facilitate the development of the Contract (or finalization of a purchase) with the selected Offeror. ODM reserves the right to reject an Offeror’s Proposal if it fails to provide this information fully, accurately, and by the deadline set by ODM. Failure to provide such required supplier information may result in immediate disqualification of Offeror’s Proposal.

Instructions: Provide the following information regarding the Offeror submitting the Proposal. Offerors may either print this attachment, complete and sign, or may provide the required information and certifications (each fully re-stated from this attachment) on their letterhead as the opening pages of their Proposal. It is mandatory that the information provided is certified with an original signature (in blue ink) from a person with authority to represent the Offeror. Offerors are to provide the completed and signed information and certifications as the cover pages of their original application submitted to

ODM.

IMPORTANT: If the RFP specified a maximum page limit for Proposals, the attachment of any required certifications, other documents, or additional pages needed to fully provide the information requested here will NOT be counted against that page limit.

1. ODM RFP# and TITLE:

2. Proposal Submission Due Date:

3. Offeror Name: (legal name of Offeror to whom Contract/purchase payments will be made):

4. Offeror Corporate Address:

5. Offeror Remittance Address: (or “same” if same as number 4 above):

6. Print or type the following information for the Offeror’s representative/contact person authorized to answer questions on the Proposal/application:

Offeror’s Representative Name and Title:

Offeror’s Representative Phone # and Email Address:

7. Is this Offeror an Ohio certified MBE? Yes No. If yes, attach a copy of current certification to Proposal/application.

8. Offeror agrees to affirm they will be in compliance with ORC Section 125.111 prior to be awarded a Contract.

9. Offeror Employee Information:

Total Number of Employees Nationwide: _______ % of Women Employees in Ohio: ________

Total Number of Employees in Ohio: _______ % of Minority Employees Nationwide: ________

% of Women Employees Nationwide: ________ % of Minority Employees in Ohio: ________

Attachment A2

ETHICS CERTIFICATION AND MANDATORY AFFIRMATIONS

Offeror must carefully review and complete each section below and provide its signature and date at the bottom to complete its attestation.

1. I, _________________________________________ (authorized Offeror representative), certify on behalf of __________________________ (Name of Offeror or grantee) that, as a vendor seeking to do business with the State of Ohio (which includes all contracts for goods and services, except for purchases made using the State of Ohio’s Payment Card Program that cost less than $1,000) that:

(1) I have reviewed and understand Ohio ethics and conflict of interest laws, as found in

Chapter 102 and Sections 2921.42 and 2921.43 of the Ohio Revised Code; and

(2) I acknowledge that failure to comply with this certification is, by itself, grounds for termination of this Contract or grant with the State of Ohio.

2. I have read the ODM Contract Model attached to the RFP, and if awarded a Contract, I will not

_____ (or) I will _____ (check one) request changes to the standard language and have identified the requested changes in Attachment G. (All requested changes to the Contract Model language is subject to ODM approval.)

3. I, (authorized Offeror representative), hereby affirm that this Proposal accurately represents the capabilities and qualifications of (name of Offeror or grantee), and I hereby affirm that the Cost Proposal (Attachment C) to ODM for the performance of services and/or provision of goods covered in this Proposal in response to the ODM RFP is a firm fixed price, inclusive of all incidental as well as primary costs. (Failure to provide the proper affirming Attachment C may result in the disqualification of Offeror’s Proposal.)

4. I, (authorized Offeror representative), hereby attest that I understand that this Proposal and all information included in this Proposal is subject to ORC Section 9.28 and 149.43 regarding public records, and that the Proposal submission may be posted in its entirety on the internet for public viewing after an award of a contract is made.

I attest that if this proposal contains trade secret or proprietary information (as described in the RFP), the Proposal meets the requirements set forth in the RFP for submission of a redacted version and detailed legal explanation of any redactions.

5. I, (authorized Offeror representative), hereby attest that our organization will maintain the confidentiality of information and records in accordance with state and federal laws, rules, and regulations. As a condition of receiving a Contract from ODM, our company, and any subcontractor(s), will be required to comply with 42 U.S.C. §§ 1320d through 1320d-8, and the implementing regulations found at 45 CFR § 164.502(e) and § 164.504(e) regarding disclosure of protected health information under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Protected Health Information (PHI) is information received by our organization from or on behalf of ODM that meets the definition of PHI as defined by HIPAA and the regulations promulgated by the

United States Department of Health & Human Services, specifically 45 CFR § 164.501 and any amendments thereto.

6. I, (authorized Offeror representative), hereby attest that our organization will disclose whether our company or any proposed subcontractor has received a formal claim for breach of contract. For purposes of this disclosure, “formal claims” means any claims for breach that have been filed as a lawsuit in any court, submitted for arbitration (whether voluntary or involuntary, binding or not), or assigned to mediation. If any such claims are disclosed, our company shall fully explain the details of those claims, including the allegations regarding all alleged breaches, any written or legal action resulting from those allegations, and the results of any litigation, arbitration, or mediation regarding those claims, including terms of any settlement.

7. I, (authorized Offeror representative), hereby attest that our organization will disclose whether our organization and any of the proposed subcontractor(s) have been the subject of any adverse regulatory or administrative governmental action (federal, state, or local) with respect to performance. It will be fully explained, in detail, the nature of the governmental action, the allegations that led to the governmental action, and the results of the governmental action including any legal action that was taken against Offeror by the governmental agency.

8. I, (authorized Offeror representative), hereby attest that our organization will affirm to be in compliance with ORC Section 125.111 prior to being awarded a Contract.

I attest that this information is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to disqualification, penalties, administrative discipline, or legal processes.

Authorized Offeror Representative Signature Date

Attachment A3

LOCATION OF BUSINESS AND OFFSHORE DECLARATION FORM

Location of Business Declaration: Offerors responding to any ODM RFP must certify that no public funds shall be spent on services provided/performed offshore by completing, signing, and returning this “Location of Business and Offshore Disclosure Form.” FAILURE TO PROPERLY COMPLETE, SIGN, AND RETURN THIS FORM MAY RESULT IN DISQUALIFICATION OF THE OFFEROR FROM CONSIDERATION

FOR AWARD OF THIS ODM CONTRACT.

Offeror affirms that Offeror has read and understands the applicable Executive Orders regarding the prohibitions of performance of offshore services, locating State data offshore in any way, or purchasing from Russian institutions or companies. The Executive Order is available at the following website:

(https://governor.ohio.gov/media/executive-orders).

The Offeror shall provide all the name(s) and location(s) where services under this Contract will be performed and where data is located, in the spaces provided below or by attachment. Failure to provide this information may result in no award. If the Offeror will not be using subcontractors, indicate "Not Applicable" in the appropriate spaces.

1. Principal location of business of Offeror:

(Address) (City, State, Zip)

Name/Principal location of business of subcontractor(s):

(Name) (Address, City, State, Zip)

2. Location where services will be performed by Offeror:

(Address) (City, State, Zip)

Name/Location where services will be performed by subcontractor(s):

https://governor.ohio.gov/media/executive-orders

3. Location where state data will be stored, accessed, tested, maintained or backed-up, by Offeror:

(Address) (Address, City, State, Zip)

Name/Location(s) where state data will be stored, accessed, tested, maintained or backed-up by subcontractor(s):

4. Location where services to be performed will be changed or shifted by Offeror:

(Address) (Address, City, State, Zip)

Name/Location(s) where services will be changed or shifted to be performed by subcontractor(s):

(Name) (Address, City, State, Zip)

Offeror also affirms, understands, and agrees that Offeror and its subcontractors are under a duty to disclose to the State any change or shift in location of services performed by Offeror or its subcontractors before, during, and after execution of any contract with the State. Offeror agrees it shall so notify the State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the Contract, unless a duly signed waiver from the State has been attained by the Offeror to perform the services outside the United States.

On behalf of the Offeror, I acknowledge that I am duly authorized to execute this Affirmation and Disclosure Form and have read and understand that this form is a part of any contract that Offeror may enter into with the State and is incorporated therein.

Signature

Date

Offeror’s Name Address (Principal place of business)

Printed name of individual authorized to sign on behalf of entity

City, State, Zip

Attachment A4

OFFEROR’S CORPORATE STRUCTURE AND FINANCIAL INFORMATION

Offeror must provide the information requested in the table. If the response is not applicable to the Offeror, please indicate “N/A” in the table.

Name of Parent Company

(if applicable) <Response>

Industry (NAICS) (North American Industry Classification System)

<Response>

Type of Legal Entity <Response>

Company Ownership (e.g., private / public, joint venture)

<Response>

Number of Full Time Employees <Response>

Last Fiscal Year Company Revenue <Response>

Last Fiscal Year Company Net Income

<Response>

% of Revenue from State and Local Government Clients in the United States

<Response>

Number of Years in Business <Response>

Number of Years Offeror has been Providing the Type of Services Specified in the RFP

<Response>

Number of Employees Providing the Type of Services Specified in the RFP

<Response>

Headquarters in the USA <Response>

Locations in the USA <Response>

Attachment A5

EXISTING BUSINESS RELATIONSHIPS WITH OHIO

Describe any existing or recent (within the last five (5) years) business relationships the Offeror or any of its affiliates or proposed subcontractors has with ODM, the State of Ohio, or any of the State’s counties.

Attachment A6

BUSINESS DISPUTES

As used in this Attachment A6:

“Identify” means to state the caption or case name, the case number, the jurisdiction, the year when the matter began, how the matter resolved (if it has been resolved), and a short and concise description of the claims.

“Related entities” means Offeror’s current or former parent company (if any) and current or former subsidiary or subsidiaries (if any) in which the Offeror holds or has held a controlling share or interest.

Disclosures for any parent company and any subsidiary should be only for the time period when the parent or subsidiary has or had the aforesaid corporate relationship with the Offeror.

“And/or” should be read conjunctively or disjunctively to give each sentence the most expansive meaning and scope possible.

Offeror must do all of the following:

1) Provide information for all service contracts/clients related to the work requested in this RFP during the last three (3) years that are pending litigation or Terminated for Cause or Convenience.

2) Identify all state and federal disciplinary, securities, or law enforcement actions against the Offeror and/or related entities that were commenced at any time during the last fifteen years.

3) Identify all litigation and administrative proceedings against the Offeror and/or related entities that involve claims of $100,000 or more and that was commenced at any time during the last ten years.

4) Identify all litigation and administrative proceedings against the Offeror and/or related entities that included claims of employment discrimination or antitrust with respect to the Offeror’s sourcing activities and that were commenced at any time during the last five years.

At its sole discretion, ODM may request the opinion or case decision associated with some or all of the disclosures.

If the Offeror uses subcontractors, associated companies, or consultants that will be involved in any phase of this Project, each of these entities will submit this information as part of the Offeror’s response.