OPD-2026-19 - Library of Attachments.docx

Library of Attachments

RFP OPD-2026-19

Annual Certification of OPWDD’s Consolidated Fiscal Report

Attachment 1

Document Submission Checklist and Attestation OPWDD reserves the right to disqualify any proposals that do not contain the mandatory items specified for this Solicitation and the resulting Contract. Bidders should use the following checklist as a guide when submitting proposals and include all required documents (mark the box to indicate inclusion of the document):

Document Submission Checklist and Attestation

Bid Quote Sheet / Cost Proposal

Contractor Information Sheet

Encouraging the Use of New York Subcontractors and Suppliers

New York State Business Usage Form

Non-Collusive Bidding Certification

References

Vendor Responsibility Questionnaire Certification

Consultant Disclosure Reporting Requirements – Contractor Instructions and Form A

Vendor Assurance of No Conflict of Interest or Detrimental Effect

Procurement Lobbying Law Certification of Compliance

Equal Employment Opportunity Staffing Plan

MWBE Utilization Plan

SDVOB Utilization Plan

Sexual Harassment Prevention Policy Certification

Executive Order 177 Anti-Discrimination Certification

Certification Under Executive Order No. 16

Gender-Based Policy and the Workplace Certification

Technical Proposal Response Form

Mandatory Notice of Intent to Bid

ATTESTATION:

By signing and checking “yes” below, the Bidder hereby attests that they meet all minimum qualifications as outlined in section 1.9 of this RFP:

1.9. Bidder Minimum Qualifications

Any Bidder submitting a proposal in response to this RFP must meet the minimum qualifications listed below. Information demonstrating these qualifications must be incorporated into the Bidder’s Administrative Proposal.

These qualifications are Pass/Fail; Bidders failing to meet the minimum qualifications as indicated below will result in a Bidder’s ineligibility for the proposal evaluation process.

1.9.1. Bidder must be a public accounting firm that employs and/or can provide Certified Public Accountants (CPAs) licensed in New York State.

1.9.2. Bidder must be able to perform the duties as outlined in the scope of work (see section 2) in accordance with the independence provisions contained in Generally Accepted Government Auditing Standards (GAGAS) Chapter 3 (See Section 1.7).

1.9.3. A minimum of five years of professional auditing experience

1.9.4. Bidder must not currently hold, nor have a pending contract with OPWDD for, any of the following services.

· Auditing of Medicaid Service Documentation; or

· Ad hoc accounting, auditing, or consulting services.

In addition, the successful Bidder will not be eligible to bid on future procurement opportunities for these services for the duration of awarded contract:

THE BIDDER MEETS ALL MINIMUM QUALIFICATIONS:

☐ Yes ☐ No

The Bidder hereby attests that they have read, understand, and are willing to comply with the scope and requirements of this Solicitation. The Bidder also affirms that, to the best of their knowledge, the contents of their submitted proposal are truthful and accurate, meeting all mandatory requirements as presented.

PRINTED NAME: _______________________________________

AUTHORIZED SIGNATURE: ____________________________________ DATE: _________________ RFP OPD-2026-19 Annual Certification of OPWDD’s Consolidated Fiscal Report Attachment 3 NYS Office for People With Developmental Disabilities Contractor Information Sheet

BIDDER NAME

ADDRESS

PRINTED NAME

TITLE

EMAIL ADDRESS

PHONE #

NYS VENDOR ID

FEDERAL ID (FEIN) #

IF THE BIDDER USES, OR HAS USED IN THE PAST TEN YEARS, ANY OTHER BUSINESS NAME, FEIN, OR DBA PLEASE PROVIDE: _____________________________________________________________________________________________

Number of Years in Business: _______ Number of Years of Experience Providing Solicited Service: _____

PLEASE CHECK THE APPROPRIATE BOX:

|_| None of the above

Form submitted to show compliance with New York State Workers Compensation Insurance requirements:

CE-200____ or C-105.2____ or U-26.3____ or SI-12____ or GSI-105.2____

Form submitted to show compliance with New York State Disability Benefits Insurance requirements:

CE-200____ or DB-120.1____ or DB-155____

Attachment 4 Encouraging the Use of New York Subcontractors and Suppliers New York State businesses have a substantial presence in State contracts and strongly contribute to the economies of the state and the nation. In recognition of their economic activity and leadership in doing business in New York State, Bidders for this contract for commodities, services or technology are strongly encouraged and expected to consider New York State businesses in the fulfillment of the requirements of the contract. Such partnering may be as subcontractors, suppliers, protégés or other supporting roles.

Bidders need to be aware that all authorized users of this contract will be strongly encouraged, to the maximum extent practical and consistent with legal requirements, to use responsible and responsive New York State businesses in purchasing commodities that are of equal quality and functionality and in utilizing services and technology. Furthermore, Bidders are reminded that they must continue to utilize small, minority and women-owned business, consistent with current State law.

Utilizing New York State businesses in State contracts will help create more private sector jobs, rebuild New York’s infrastructure, and maximize economic activity to the mutual benefit of the contractor and its New York State business partners. New York State businesses will promote the contractor’s optimal performance under the contract, thereby fully benefiting the public sector programs that are supported by associated procurements.

Public procurements can drive and improve the State’s economic engine through promotion of the use of New York businesses by its contractors. The State therefore expects Bidders to provide maximum assistance to New York businesses in their use of the contract. The potential participation by all kinds of New York businesses will deliver great value to the State and its taxpayers.

Bidder can demonstrate their commitment to the use of New York state businesses by responding to the question below:

Will New York State Businesses be used in the performance of this contract? |_| YES |_| NO

If yes, complete Attachment 4A – New York State Business Usage Form to provide identifying information about New York State Businesses that will be used in the performance of this contract.

Contractor Name: _____________________________________________________________ Printed Name: _______________________________________________________ Title: _______________________________________________________________ Authorized Signature: _________________________________________________ Date: ___________

This form must be signed by an authorized executive or legal representative.

Attachment 4A New York State Business Usage Form

If you answered “Yes” to either questions 2 or 4, please provide identifying information below:

Subcontractor or Supplier Check applicable certification type:

Estimated Contract Amount and Brief Description of Services/Commodity

Company Phone # Location/Address where Services will be Performed

Name:

EIN:

☐NYS-Certified MBE ☐ NYS-Certified WBE ☐ NYS-Certified SDVOB ☐ None of the above Estimated Amount: $_____

Description:

Name:

☐NYS-Certified MBE ☐ NYS-Certified WBE ☐ NYS-Certified SDVOB ☐ None of the above Estimated Amount: $_____

Name:

☐NYS-Certified MBE ☐ NYS-Certified WBE ☐ NYS-Certified SDVOB ☐ None of the above Estimated Amount: $_____

Name:

☐NYS-Certified MBE ☐ NYS-Certified WBE ☐ NYS-Certified SDVOB ☐ None of the above Estimated Amount: $_____

Name:

☐NYS-Certified MBE ☐ NYS-Certified WBE ☐ NYS-Certified SDVOB ☐ None of the above Estimated Amount: $_____

Attachment 5 Non-Collusive Bidding Certification Required by Section 139-D of the State Finance Law (Page 1 of 3)

SECTION 139-D, Statement of Non-Collusion in bids to the State:

BY SUBMISSION OF THIS BID, BIDDER AND EACH PERSON SIGNING ON BEHALF OF BIDDER CERTIFIES, AND IN THE CASE OF JOINT BID, EACH PARTY THERETO CERTIFIES AS TO ITS OWN ORGANIZATION, UNDER PENALTY OF PERJURY, THAT TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF:

[1] The prices of this bid have been arrived at independently, without collusion, consultation, communication, or agreement, for the purposes of restricting competition, as to any matter relating to such prices with any other Bidder or with any competitor;

[2] Unless otherwise required by law, the prices that have been quoted in this bid have not been knowingly disclosed by the Bidder and will not knowingly be disclosed by the Bidder prior to opening, directly or indirectly, to any other Bidder or to any competitor; and [3] No attempt has been made or will be made by the Bidder to induce any other person, partnership or corporation to submit or not to submit a bid for the purpose of restricting competition.

A BID SHALL NOT BE CONSIDERED FOR AWARD NOR SHALL ANY AWARD BE MADE WHERE [1], [2], [3] ABOVE HAVE NOT BEEN COMPLIED WITH; PROVIDED HOWEVER, THAT IF IN ANY CASE THE BIDDER(S) CANNOT MAKE THE FOREGOING CERTIFICATION, THE BIDDER SHALL SO STATE AND SHALL FURNISH BELOW A SIGNED STATEMENT WHICH SETS FORTH IN DETAIL THE REASONS THEREFORE:

[AFFIX ADDENDUM TO THIS PAGE IF SPACE IS REQUIRED FOR STATEMENT.]

Subscribed to under penalty of perjury under the laws of the State of New York, this _______ day of ___________, 20____ as the act and deed of said corporation of partnership.

(Page 2 of 3)

IF BIDDER IS A PARTNERSHIP, COMPLETE THE FOLLOWING:

IF BIDDER IS A CORPORATION, COMPLETE THE FOLLOWING:

President:

Secretary:

Treasurer:

President:

Secretary:

Treasurer:

IF BIDDER IS A LIMITED LIABILITY COMPANY (LLC), COMPLETE THE FOLLOWING:

NAMES OF MEMBERS LEGAL RESIDENCE

(Page 3 of 3)

Identifying Data

Street City, Town, etc.

Telephone: __________________________ Title__________________________

If applicable, Responsible Corporate Officer:

Name: ______________________________ Title__________________________

Signature: _______________________________________________________________

Joint or combined bids by companies or firms must be certified on behalf of each participant.

City, State City, State

Attachment 7 Vendor Responsibility Questionnaire Certification Vendors are encouraged to file the required Vendor Responsibility Questionnaire online via the New York State VendRep System. To enroll in and use the New York State VendRep System, see the VendRep System Instructions available at https://www.osc.ny.gov/state-vendors/vendrep/vendrep-system or go directly to the VendRep System online at https://onlineservices.osc.state.ny.us. For direct VendRep System user assistance, the Office of the State Comptroller Help Desk may be reached at 866-370-4672 or 518-408-4672 or at https://www.osc.ny.gov/online-services/get-help.Vendors may opt to file a paper questionnaire; the appropriate questionnaire form can be obtained from the VendRep https://www.osc.ny.gov/state-vendors/vendrep/vendor-responsibility-forms, or vendors may contact the authorized contact at OPWDD or the Office of the State Comptroller Help Desk for a copy of the paper form.

Vendors enrolled in the online VendRep System are also reminded to recertify existing questionnaires every six months or whenever changes that affect their business entity occur.

Vendor Responsibility Certification Please check the appropriate box indicating what mechanism has been utilized to submit the Vendor Responsibility Questionnaire; the Questionnaire is to be submitted/certified prior to the bid due date.

Bidder is to indicate the format utilized by checking the appropriate box:

|_| On-Line Certified Format (Preferred) or |_| Hard Copy, Paper Format Note: If utilizing a hard copy, paper format, that hard copy must be included with the bid quote submission. If utilizing the online format, the Vendor Responsibility Questionnaire must be certified by the bid due date. Failure to provide the required Vendor Responsibility Questionnaire may result in the bid being rejected for not meeting the minimum mandatory requirement.

Vendor Registration Requirement The New York State Vendor Management Unit (VMU) relies on State Business Units to obtain a completed Substitute Form W-9 for any vendor not already registered. Any vendor that wants to do business with New York State must complete a Substitute Form W-9, which may be accessed on the NYS Office of the State Comptroller’s Web site at the following link: https://www.osc..ny.gov/vendors/forms/ac3237s_fe.pdf.

Submit the completed form with the required bid documentation. For more information about NYS Vendor Management, please access the NYS Office of State Comptroller's website using the following link: http://www.osc..ny.gov/state-vendors.

Attachment 8

Consultant Disclosure Reporting Requirements - Contractor Instructions

Pursuant to New York State Finance Law Section 163(4)(g), state agencies must require all contractors, including subcontractors, that provide consulting services for State purposes pursuant to a contract to submit an annual employment report for each such contract, such report to include for each employment category within the contract: (i) the number of employees employed to provide services under the contract, (ii) the number of hours they work, and (iii) their total compensation under the contract. Consulting services are defined as analysis, evaluation, research, training, data processing, computer programming, engineering, environmental, health, and mental health services, accounting, auditing, paralegal, legal, or similar services.

Contractors selected for award on the basis of a procurement issued by the Office of the State Comptroller (OSC) (Request for Proposals, Mini-Bid, or Invitation for Bids) must complete Form A, State Consultant Services – Contractor’s Planned Employment from Contract Start Date through the End of the Contract Term upon notification of award. The completed Form A must include information for all employees that will be providing services under the contract, whether employed by the contractor or by a subcontractor.

Contractors selected for award are also required to complete Form B, State Consultant Services Contractor’s Annual Employment Report annually for each year of the contract term, on a State fiscal year basis. The first report is due on May 15 for the period April 1 through March 31.

Form A must be submitted to OPWDD as the contracting agency, and Form B must be submitted to OPWDD (as the contracting agency), the Department of Civil Service (DCS), and the Consultant Reporting Section of the Bureau of Contracts at OSC, at the addresses provided in these instructions.

Form A, State Consultant Services – Contractor’s Planned Employment from Contract Start Date through the End of the Contract Term (attached) and Form B, State Consultant Services Contractor’s Annual Employment Report (located in the RFP/IFB).

INSTRUCTIONS: FORM A

Upon notification of contract award, use Form A, State Consultant Services Contractor’s Planned Employment From Contract Start Date Through the End of the Contract Term, attached to these instructions, to report the necessary planned employment information prospectively from the start date through the end of the contract term. This is a one-time reporting requirement.

Complete Form A for contracts for consulting services in accordance with the following:

• Employment category: the specific occupation(s), as listed in the O*NET occupational classification system, which best describe the employees anticipated to be providing services under the contract.

(Note: Access the O*NET database, which is available through the US Department of Labor’s Employment and Training Administration, on-line at https://www.onetonline.org/ to find a list of occupations.)

• Number of employees: the total number of employees in the employment category anticipated to be employed to provide services under the contract, including part-time employees and employees of subcontractors.

• Number of hours to be worked: the total number of hours anticipated be worked by the employees in the employment category.

• Amount payable under the contract: the total amount payable by the State to the State contractor under the contract, for work by the employees in the employment category, for services provided during the Report Period.

Submit completed Form A within 48 hours of notification of selection for award to OPWDD (as the contracting agency) at the address listed below.

NYS OPWDD

44 Holland Avenue, 5th Fl.

Albany, NY 12229

Attachment 8A State Consultant Services Contractor’s Planned Employment FORM A

OSC Use Only:

Reporting Code:

Category Code:

Date Contract Approved:

FORM A

New York State Consultant Services Contractor's Planned Employment

From Contract Start Date Through The End Of The Contract Term

State Agency Name: NYS Office for People With Developmental Disabilities

Name of person who prepared this report:

Preparer's Signature:

Date Prepared: / /

(Use additional pages, if necessary)

Page of

1. (Note: Access the O*NET database, which is available through the US Department of Labor’s Employment and Training Administration, on-line at https://www.onetonline.org/ to find a list of occupations.)

Attachment 9

Vendor Assurance of No Conflict of Interest or Detrimental Effect

The Firm offering to provide services pursuant to this Contract, as a contractor, joint venture contractor, subcontractor or consultant, attests that its performance of the services outlined in this Contract does not and will not create a conflict of interest with nor position the Firm to breach any other contract currently in force with the State of New York.

Furthermore, the Firm attests that it will not act in any manner that is detrimental to any State project on which the Firm is rendering services. Specifically, the Firm attests that:

1. The fulfillment of obligations by the Firm, as proposed in the response, does not violate any existing contracts or agreements between the Firm and the State.

2. The fulfillment of obligations by the Firm, as proposed in the response, does not and will not create any conflict of interest, or perception thereof, with any current role or responsibility that the Firm has with regard to any existing contracts or agreements between the Firm and the State.

3. The fulfillment of obligations by the Firm, as proposed in the response, does not and will not compromise the Firm’s ability to carry out its obligations under any existing contracts between the Firm and the State.

4. The fulfillment of any other contractual obligations that the Firm has with the State will not affect or influence its ability to perform under any contract with the State.

5. During the negotiation and execution of any contract, the Firm will not knowingly take any action or make any decision which creates a potential for conflict of interest or might cause a detrimental impact to the State as a while including, but not limited to any action or decision to divert resources from one State project to another.

6. In fulfilling obligations under each of its State contracts, the Firm will act in accordance with the terms of each of its State contracts and will not knowingly take any action or make any decision which might cause a detrimental impact to the State as a whole, including but not limited to any action or decision to divert resources from one State project to another.

7. No former officer or employee of the State who is now employed by the Firm, nor any former officer or employee of the Firm who is now employed by the State, has played a role with regard to the administration of this contract procurement in a manner that may violate Section 73(8)(a) of the State Ethics Law; and

8. The Firm has not and shall not offer to any employee, member or director of the State any gift, whether in the form of money, service, loan, travel, entertainment, hospitality, thing or promise, or in any other form, under circumstances in which it could reasonably be inferred that the gift was intended to influence said employee, member or director, or could reasonably be expected to influence said employee, member or director, in the performance of the official duty of said employee, member or director, or was intended as a reward for any official action on the part of said employee, member or director.

Firms should note that the State recognizes that conflicts may occur in the future because a Firm may have existing or new relationships. The State will review the nature of any such new relationship and reserves the right to terminate the contract for cause if, in its judgment, a real or potential conflict of interest cannot be cured.

Legal Entity Name:

By (signature):

Name (print/type):

Title:

Date:

Attachment 10

Procurement Lobbying Law Certification of Compliance

1. CONTACTS – Contractor affirms that it understands and agrees to comply with the procedures on procurement lobbying restrictions regarding permissible contacts in the restricted period for a procurement contract in accordance with State Finance Law §§ 139-j and 139-k. |_|I agree

2. BIDDER/OFFERER DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS – Pursuant to Procurement Lobbying Law, State Finance Law § 139-j.

(a) Has any Governmental Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into a procurement contract in the previous four years? |_|Yes |_|No If yes, please answer the following questions:

i. Was the basis for the finding of non-responsibility due to a violation of State Finance Law § 139-j?

If yes, please provide details regarding the finding of non-responsibility:

Governmental Entity: ____________________________________________________________________________ Date of Finding of Non-Responsibility: ______________________________________________________________ Basis of Finding of Non-Responsibility: ______________________________________________________________

(b) Has any governmental agency terminated or withheld a procurement contract with the above-named individual or entity due to the intentional provision of false or incomplete information? |_|Yes |_|No If yes, please provide details below:

Governmental Entity: ____________________________________________________________________________ Date of Termination or Withholding of Contract: _______________________________________________________ Basis of Termination of Withholding: ________________________________________________________________

3. TERMINATION CLAUSE – Contractor certifies that all information provided to the Agency with respect to State Finance Law §§ 139-j and 139-k is complete, true and accurate. If found to be in violation of State Finance law §§ 139-j and 139-k, the contract will result in termination. |_|I agree Legal Entity Name: _______________________________________________________________________________ Contractor Address: ______________________________________________________________________________ By (signature): _______________________________________________________________________________________________________ I understand that my signature represents that I am signing and responding to both certifications listed above.

Name (print/type): _______________________________________________________________________________ Title: Date: Email Address: _________________________________________________________________________

Attachment 11

Equal Employment Opportunity Staffing Plan Solicitation/Program Name:

Report includes:

□ Work force to be utilized on this contract

□ Total work force

□ Contractor

□ Subcontractor Subcontractor’s name: ________________________________

Bidder Address:

Enter the total number of employees for each classification in each of the EEO-Job Categories identified

EEO-Job Category

Total Work force Work force by Gender Gender

Total Male (M) Total Female (F) Total X (X) White

(M) (F) (X) Black

(M) (F) (X) Hispanic

(M) (F) (X) Asian

(M) (F) (X) Native American

(M) (F) (X) Disabled

(M) (F) (X) Veteran

(M) (F) (X)

Officials/ Administrators

Professionals

Technicians

Sales Workers

Office/Clerical

Craft Workers

Laborers

Service Workers

Temporary Apprentices

Totals

EMAIL ADDRESS:

DATE:

General instructions: All Offerors and each subcontractor identified in the bid or proposal must complete an EEO Staffing Plan (04-10) and submit it as part of the bid or proposal package. Where the work force to be utilized in the performance of the State contract can be separated out from the contractor’s or subcontractor’s total work force, the Bidder shall complete this form only for the anticipated work force to be utilized on the State contract. Where the work force to be utilized in the performance of the State contract cannot be separated out from the contractor’s or subcontractor’s total work force, the Bidder shall complete this form for the contractor’s or subcontractor’s total work force.

Instructions for completing:

1. Enter the Solicitation number or RFP number that this report applies to along with the name and address of the Bidder.

2. Check off the appropriate box to indicate if the Bidder completing the report is the contractor or a subcontractor.

3. Check off the appropriate box to indicate if the work force being reported is just for the contract or the Bidder’s total work force.

4. Enter the total work force by EEO job category.

5. Break down the total work force by gender and enter under the heading ‘Work force by Gender’

6. Break down the total work force by race/ethnic background and enter under the heading ‘Work force by Race/Ethnic Identification’. Contact the Designated Contact(s) for the solicitation if you have any questions.

7. Enter information on disabled or veterans included in the work force under the appropriate headings.

8. Enter the name, title, phone number and email address for the person completing the form. Sign and date the form in the designated boxes.

RACE/ETHNIC IDENTIFICATION

Race/ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. For the purposes of this report, an employee may be included in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. However, no person should be counted in more than one race/ethnic group. The race/ethnic categories for this survey are:

· WHITE (Not of Hispanic origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

· BLACK a person, not of Hispanic origin, who has origins in any of the black racial groups of the original peoples of Africa.

· HISPANIC/LATINO a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

· ASIAN & PACIFIC ISLANDER a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.

· NATIVE AMERICAN/ALASKAN NATIVE a person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.

OTHER CATEGORIES

· DISABLED INDIVIDUAL any person who:

· has a physical or mental impairment that substantially limits one or more major life activity(ies)

· has a record of such an impairment; or

· is regarded as having such an impairment.

· VIETNAM ERA VETERAN a veteran who served at any time between and including January 1, 1963 and May 7, 1975.

· GENDER Male, Female, or X

Attachment 12

Solicitation#

INSTRUCTIONS: This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each NYS Certified Minority and Women-owned Business Enterprises (MWBE) under the contract. By submission of this Plan, the Bidder/Contractor commits to good faith efforts in the utilization of MWBE subcontractors and suppliers as required by the MBE/WBE goals contained in the Solicitation/Contract. Making false representations or including information evidencing a lack of good faith as part of, or in conjunction with, the submission of a Utilization Plan is prohibited by law and may result in penalties including, but not limited to, termination of a contract for cause, loss of eligibility to submit future bids, and/or withholding of payments. Firms that do not perform commercially useful functions may not be counted toward MWBE utilization. Attach additional sheets if necessary.

Bidder/Contractor Name:

NYS Vendor ID:

MBE %

Bidder/Contractor Address (Street, City, State and Zip Code):

WBE %

Contract Description/Title:

CONTRACTOR INFORMATION

Prepared by (Signature):

Name and Title of Preparer:

Telephone Number:

Date:

Email Address:

IF UNABLE TO MEET THE MBE AND WBE GOALS SET FORTH IN THE SOLICITATION/CONTRACT BIDDER/CONTRACTOR MUST SUBMIT A REQUEST FOR WAIVER (FORM BDC 333)

MWBE Subcontractor/Supplier Name:

MWBE Certification: |_| MBE |_| WBE (If firm is dual certified please select one only)

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be determined put estimated % of work under the contract or value TBD based on contractual spending): $ or %

MWBE Subcontractor/Supplier Name:

MWBE Certification: |_| MBE |_| WBE (If firm is dual certified, please select one only)

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be determined put estimated % of work under the contract or value TBD based on contractual spending): $ or %

Submit Completed Plan To: NYS Office for People With Developmental Disabilities Division of Fiscal Policy and Management 44 Holland Ave, 5th Floor Albany NY 12229 email: mwbe@opwdd.ny.gov

ADDITIONAL SHEET

MWBE Subcontractor/Supplier Name:

MWBE Certification: |_| MBE |_| WBE (If firm is dual certified please select one only)

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be determined put estimated % of work under the contract or value TBD based on contractual spending): $ or %

MWBE Subcontractor/Supplier Name:

MWBE Certification: |_| MBE |_| WBE (If firm is dual certified please select one only)

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be determined put estimated % of work under the contract or value TBD based on contractual spending): $ or %

MWBE Subcontractor/Supplier Name:

MWBE Certification: |_| MBE |_| WBE (If firm is dual certified please select one only)

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be determined put estimated % of work under the contract or value TBD based on contractual spending): $ or %

MWBE Subcontractor/Supplier Name:

MWBE Certification: |_| MBE |_| WBE (If firm is dual certified please select one only)

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be determined put estimated % of work under the contract or value TBD based on contractual spending): $ or %

MWBE Subcontractor/Supplier Name:

MWBE Certification: |_| MBE |_| WBE (If firm is dual certified please select one only)

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be determined put estimated % of work under the contract or value TBD based on contractual spending): $ or %

Attachment 13 SDVOB Contractor Utilization Plan

INSTRUCTIONS: This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each NYS Certified Service-Disabled Veteran-Owned Business (SDVOB) under the contract. By submission of this Plan, the Bidder/Contractor commits to making good faith efforts in the utilization of SDVOB subcontractors and suppliers as required by the SDVOB goals contained in the Solicitation/Contract. Making false representations or providing information that shows a lack of good faith as part of, or in conjunction with, the submission of a Utilization Plan is prohibited by law and may result in penalties including, but not limited to, termination of a contract for cause, loss of eligibility to submit future bids, and/or withholding of payments. Firms that do not perform commercially useful functions may not be counted toward SDVOB utilization. Attach additional sheets if necessary.

Bidder/Contractor Name:

NYS Vendor ID:

Bidder/Contractor Address (Street, City, State and Zip Code):

Contract Description/Title:

CONTRACTOR INFORMATION

Prepared by (Signature):

Name and Title of Preparer:

Telephone Number:

Date:

Email Address:

If unable to meet the SDVOB goals set forth in the solicitation/contract, bidder/contractor must submit a request for waiver on the SDVOB Waiver Form.

SDVOB Subcontractor/Supplier Name:

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ or %

SDVOB Subcontractor/Supplier Name:

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ or %

FOR OPWDD USE ONLY

NAME (Please Print):

SDVOB %/$

Date Received:

Date Processed:

Comments:

NYS CERTIFIED SDVOB SUBCONTRACTOR/SUPPLIER INFORMATION: The directory of New York State Certified SDVOBs can be viewed at: Division of Service-Disabled Veterans' Business Development (ny.gov) Note: All listed Subcontractors/Suppliers will be contacted and verified by OPWDD.

ADDITIONAL SHEET

SDVOB Subcontractor/Supplier Name:

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ or %

SDVOB Subcontractor/Supplier Name:

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ or %

SDVOB Subcontractor/Supplier Name:

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ or %

SDVOB Subcontractor/Supplier Name:

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform)): $ or %

SDVOB Subcontractor/Supplier Name:

Please identify the person you contacted:

Federal Identification No.:

Telephone No.:

Address:

Email Address:

Detailed Description of work to be provided by subcontractor/supplier:

Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ or %

Attachment 14 Sexual Harassment Prevention Policy Certification

State Finance Law § 139-l requires bidders on state procurements to certify that they have a written policy addressing sexual harassment prevention in the workplace and provide annual sexual harassment prevention training to all its employees and that such policy, at a minimum, meets the requirements of State Labor Law § 201-g.

By submission of this bid, each bidder and each person signing on behalf of any bidder certifies, and in the case of a joint bid each party thereto certifies its own organization, under penalty of perjury, that the bidder has and has implemented a written policy addressing sexual harassment prevention in the workplace and provides annual sexual harassment prevention training to all its employees. Such policy shall, at a minimum, meet the requirements of State Labor Law § 201-g.

Please mark the applicable box (select one) below and complete the following sections, as required.

|_| The Contractor certifies its compliance with State Finance Law § 139-I.

|_| The Contractor cannot certify its compliance with State Finance Law § 139-I.

Legal Entity Name:

By (signature):

Name (print/type):

Title:

Date:

If the Contractor cannot make the above certification, the Contractor must provide a statement detailing the reasons:

Attachment 15

Executive Order 177 Anti-Discrimination Certification

The New York State Human Rights Law, Article 15 of the Executive Law, prohibits discrimination and harassment on the basis of age, race, creed, color, national origin, sex, pregnancy or pregnancy-related conditions, sexual orientation, gender identity, disability, marital status, familial status, domestic violence victim status, prior arrest or conviction record, military status, or predisposing genetic characteristics.

The Human Rights Law may also require reasonable accommodation for persons with disabilities and pregnancy-related conditions. A reasonable accommodation is an adjustment to a job or work environment that enables a person with a disability to perform the essential functions of a job in a reasonable manner. The Human Rights Law may also require reasonable accommodation in employment on the basis of Sabbath observance or religious practices.

Generally, the Human Rights Law applies to:

· all employers of four or more people, employment agencies, labor organizations, and apprenticeship training programs in all instances of discrimination or harassment.

· employers with fewer than four employees in all cases involving sexual harassment; and

· any employer of domestic workers in cases involving sexual harassment or harassment based on gender, race, religion, or national origin.

In accordance with Executive Order No. 177, the Bidder hereby certifies that it does not have institutional policies or practices that fail to address the harassment and discrimination of individuals on the basis of age, race, creed, color, national origin, sex, sexual orientation, gender identity, disability, marital status, or other protected status under the Human Rights Law.

Executive Order No. 177 and this certification do not affect institutional policies or practices that are protected by existing law, including but not limited to the First Amendment of the United States Constitution, Article 1 Section 3 of the New York State Constitution, and Section 296(11) of the New York State Human Rights Law.

Legal Entity Name:

By (signature):

Name (print/type):

Title:

Date:

Attachment 16 Certification Under Executive Order No. 16 Prohibiting State Agencies and Authorities from Contracting with Businesses Conducting Business in Russia Executive Order No. 16 provides that “all Affected State Entities are directed to refrain from entering into any new contract or renewing any existing contract with an entity conducting business operations in Russia.” The complete text of Executive Order No. 16 can be found at Executive Order 16 Prohibiting State Agencies and Authorities from Contracting with Businesses Conducting Business in Russia | Office of General Services (ny.gov).

The Executive Order remains in effect while sanctions imposed by the federal government are in effect. Accordingly, vendors who may be excluded from award because of current business operations in Russia are nevertheless encouraged to respond to solicitations to preserve their contracting opportunities in case the sanctions are lifted during a solicitation or even after award in the case of some solicitations.

Is Vendor an entity conducting business operations in Russia, as defined above? Please answer by checking one of the following boxes:

|_| 1. No, Vendor does not conduct business operations in Russia within the meaning of Executive Order No. 16.

|_| 2.a. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16 but has taken steps to wind down business operations in Russia or is in the process of winding down business operations in Russia. (Please provide a detailed description of the wind down process and a schedule for completion) |_| 2.b. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16 but only to the extent necessary to provide vital health and safety services in Russia or to comply with federal law, regulations, executive orders, or directives. (Please provide a detailed description of the services being provided or the relevant laws, regulations, etc.)

|_| 3. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16.

The undersigned certifies under penalty of perjury that they are knowledgeable about the Vendor’s business and operations and that the answer provided herein is true to the best of their knowledge and belief.

Vendor Name (Legal Entity): ________________________________________________________ By (signature): ___________________________________________________________________ Name (print/type): ________________________________________________________________ Title: ____________________________________________________________________ Date: __________________________________________

Attachment 17

Gender-Based Policy and the Workplace Certification

New York State Finance Law §139-M requires bidders on competitive state procurements to certify that they have a written policy addressing gender-based violence and the workplace and that such policy meets the following minimum requirements:

· Share Information: Employers must provide information regarding gender-based violence where employees can see and access it, including displaying the NYS Domestic and Sexual Violence Hotline information and a gender-based violence and the workplace poster.

· Refer Employee-Survivors to Services: The policy must require that the employer refer employees who disclose current or past victim status to the NYS Domestic and Sexual Violence Hotline and/or a local service provider. For bidders outside of New York State, referrals should be made to a local provider or statewide hotline. While referrals are required to be provided by the employer, it is not required for the employee to access services.

· Prohibit Retaliation: The policy must clearly state that discrimination or retaliation against employees who identify as victims or survivors of gender-based violence is prohibited.

· Comply with Laws: Ensure your policy follows State law. For employers based in New York State, this means that the policy must follow the SAFE Leave Act, New York State Human Rights Law, and any other relevant laws and regulations.

· Offer Implementation Support: The Office for the Prevention of Domestic Violence (OPDV) is able to assist employers in developing and implementing this policy. Employers must provide information to supervisors and human resources, where available, about this technical assistance from OPDV. OPDV can be contacted at workplace@opdv.ny.gov.

By submission of this certification, each person signing on behalf of any organization certifies, and in the case of a joint submission each party thereto certifies its own organization, under penalty of perjury, that they have and have implemented a written policy addressing gender-based violence and the workplace.

Organization’s signature below certifies its compliance with State Finance Law §139-M.

Organization: __________________________________________ By (signature): ____________________________________

Name (Please Print): _______________________________ Title: ____________________________________________ Date: ____________________

If the organization cannot make the above certification, they must provide a statement with their bid detailing the reasons therefor:

Attachment 18

TECHNICAL PROPOSAL RESPONSE FORM

FORM INSTRUCTIONS

Please complete and submit this form as your Technical Proposal Response. While additional data may be presented, each section below should be completed. The response should present a level of detail sufficient to assure OPWDD of the information’s accuracy. Responses entered into the Technical Proposal can receive a total of 100 points.

Per Section 4 of the RFP, the purpose of the Technical Proposal is to establish the qualifications, competence, and capacity of the Bidder to perform the services contained in the RFP. The Technical Proposal must demonstrate that the Bidder will be able to provide the services described in this RFP.

Bidders…