PROPONENT_FORMS_-_RFP_063-2496202-DM_(9.28.23).docx

REQUEST FOR PROPOSAL

FOR

WELFARE-TO-WORK ASSESSMENT SERVICES

County of Orange Social Services Agency

September 28, 2023

RFP #063-2496202-DM

PROPONENT FORMS

Proponents are responsible to manually insert and/or adjust page breaks so that the submitted proposal is formatted with each Form beginning at the top of a new page.

FORM A – PROPOSAL COVER PAGE

Social Services Agency Request for Proposal (RFP) Title: WTW ASSESSMENT SERVICES

RFP # 063-2496202-DM

Proposal Due Date/Time: October 30, 2023 4:00 p.m. (Pacific Time) Attention: Desiree Mor 500 N. State College Blvd., Suite 100 Orange, CA 92868

PROPONENT: [entered by Proponent]

☐ The undersigned read, understood, and agree to all statements, terms and conditions, Forms, and Attachments in the RFP referenced above. The signature(s) below are in accordance with RFP Subparagraph 2.1, Signature Requirements.

Proponent’s Name (as it appears on W-9 form)

An unsigned proposal may be subject to rejection.

FORM B - REQUIRED DOCUMENTS CHECKLIST

Name of Proponent: ________________________________________________

INSTRUCTIONS:

Submit the following documents in the order listed on this form, in accordance with Subparagraph 2.4, Proposal Package. Proponent will indicate on this checklist whether or not all items requested have been included.

Required Documents

Form A – Proposal Cover Page

Form B – Required Documents Checklist

Form C – Organization Profile

Form D – Organization Experience

Form E – Services to be Provided

Form F – Assessment Instruments

Form G – Unit Price of Assessments

Form H – Board of Directors/Advisory Board

Form I – Statement of References

Form J – Organization Litigation

Form K – Proponent Certifications

Form L –Disabled Veteran Business Enterprise (DVBE) Certification Requirements

Form M – Levine Act Campaign Contribution Disclosure Form

Organizational Structure and Chart (1)

Certificates of Insurance (2)

Articles of Incorporation (3)

Signature Authorization Resolution/Documentation (4)

Current/valid copy(s) of organization license(s) to do business in California (5)

Financial Statements (6) [If applicable]

(1) Organizational Structure, Including Organizational Chart

Proponent must provide information regarding existing and/or proposed local organizational structure within Orange County and, where applicable, outside Orange County. If Proponent’s headquarters is located outside of Orange County, Proponent must define the relationship between the existing or proposed Orange County organization and the main headquarters. The chart must identify the relationship of the proposed services/program to the overall organization and identify the reporting relationship of each proposed staff position.

(2) Per Subparagraph 1.12, Insurance Requirements, attach evidence your organization has or can obtain all required insurance.

(3) If your organization is incorporated, attach Articles of Incorporation (executed by the Secretary of State), Bylaws, and Amendments.

(4) If applicable, and in accordance with Subparagraph 2.1, Signature Requirements, attach a board or corporate resolution, or other documentation, demonstrating the legal authority of the signatory to bind the organization.

(5) As applicable, attach current business or professional licenses or certificates required by the nature of the contract work to be performed and held by the Proponent.

(6) Financial Statements

Proponent (excluding government agencies) shall provide a complete financial statement based upon an audit that is not more than eighteen (18) months old from the proposal submission deadline, certified by an independent certified public accountant. These statements should clearly identify the financial condition of the Proponent's business entity as well as that of its corporate structure, if applicable. The financial statement will be used in determining the Proponent's financial condition, including the working capital position that would permit the Proponent to perform a contract of the size indicated by this RFP. All required financial statements must be prepared in conformity with Generally Accepted Accounting Principles (GAAP).

FORM C – ORGANIZATION PROFILE

Name of Proponent (as shown on IRS W-9 form):

Doing Business As (if applicable):

Proponent Address:

Proponent Business Telephone:

Proponent Website Address: ☐ None

Primary Proposal Contact Person (Name and Title):

Primary Contact Person Address:

Primary Contact Person Telephone and Email:

Secondary Proposal Contact Person (Name and Title):

Secondary Contact Person Telephone and Email (1):

Legal Business Status of Organization – check all that apply

If incorporated, list the state where incorporated:

Employer Identification Number (EIN): or

Tax Identification Number (TIN):

DUNS Number:

How many years has your organization conducted business under its present name?

How many years did your organization conduct business under a prior business name?

List name(s) and dates as applicable for two (2) items above:

Does your organization (excluding government agencies) hold a controlling interest in any other organization, or is it owned or controlled by any other person or organization? ☐ No ☐Yes If yes, explain.

Does your organization (excluding government agencies and individuals who will personally perform the contracted service) hold financial interests in any other business? ☐ No ☐Yes If yes, explain.

List the names of persons with whom your organization (excluding government agencies) has been associated in business as partners or business associates in the last five (5) years.

(1) Communication sent via email to the primary proposal contact will also be sent to secondary proposal contact.

FORM D – ORGANIZATION EXPERIENCE

Name of Proponent: _______________________________________________________

PART A

PART A INSTRUCTIONS: In correlation with this RFP complete the following tables in the order presented. One (1) of the two (2) options under each table description must be checked. Begin with the most current experience. Limit your response to this Part A of Form D to no more than three (3) pages utilizing the same table format. Pages that exceed the page limit will not be evaluated or scored.

Table One: Experience with the County of Orange

|_| Yes - See Below |_| No Experience with the County of Orange

Proponent must list all contracts and briefly describe services it has provided in the past five (5) years for the County of Orange. In particular, Proponent must describe experience in providing services that are the same as or similar to those services being requested in the RFP. Add additional tables as necessary.

#1 #2 #3 Awarding Agency

Name and Brief Description of Services

Dollar Amount of Contract

Service Beginning and End Dates

Population Served

Location of Services (City, County & State)

Table Two: Experience with other than the County of Orange

|_| Yes - See Below |_| No Experience with other than the County of Orange

Proponent must briefly describe all services provided in the past five (5) years, for entities other than County of Orange. In particular, Proponent must describe experience in providing services that are the same as or similar to those services being requested in the RFP. Add additional tables as necessary.

Awarding Agency

Name and Brief Description of Services

Service Beginning and End Dates

Dollar Amount of Contract

Population Served

Location of Services (City, County & State)

Table Three: Failure to Complete Contracts

|_| Yes - See Below |_| No Failure to Complete Contracts

Proponent must state if it has failed or refused to complete a contract. If affirmative, Proponent must provide explanation for every instance. The definition of “failure or refusal to complete a contract” includes any contract that meets one (1) or more of the following criteria: (1) The contractor terminated the contract early; (2) The contracting agency terminated the contract with cause as defined in the terminated contract; and/or (3) Terms of the contract were not fulfilled in their entirety, including meeting all goals and/or deliverables as described in the contract, with the exception of any requirements waived by the contracting agency. Add additional tables as necessary.

Awarding Agency

Name and Brief Description of Services

Service Beginning and End Dates

Dollar Amount of Contract

Population Served

Location of Services (City, County & State)

Explanation

PART B

PART B INSTRUCTIONS: Proponent must answer all of the following questions regarding its experience. Answer all of the following questions in the order presented, restating the number and question before each response. If a question does not apply to your organization, answer with a full negative response rather than stating "Not Applicable." Begin with the most current experience. Limit your response to this Part B to no more than eight (8) pages. Pages that exceed page limit will not be evaluated or scored.

1. In reference to services included above in Part A, describe your organization’s experience in providing services that are the same or similar to services required in this RFP. Include experience in the following four (4) categories.

a. Development

b. Implementation

c. Management

d. Evaluation

2. Describe successful outreach efforts and techniques your agency used to engage clients that are similar to the target population described in this RFP.

3. Describe a minimum of two (2) challenges and/or barriers management encountered in the delivery of services included in Part A and how these were resolved. Specify what adjustments and/or improvements were made to service delivery as a result of what was learned.

4. Describe how your organization monitored its performance related to previous contracts and/or services and how management addressed those concerns.

5. Describe your organization’s experience in providing services to the population that is the same or similar to those described in this RFP.

6. From your response to Part A, identify the most successful service you have provided, and how it relates directly to the requirements specified in this RFP for Assessment Services. Include the number of clients provided services, detail of services meeting or exceeding service expectation, areas where services did not meet service expectations and how these weaknesses were evaluated and strengthened.

7. Describe what resources and/or methods you have utilized in recruiting for Assessment positions or similar projects where recruitments were involved. Indicate factors and action plan to attract the most qualified candidates, the outcomes of such recruitments and what changes were made to better the process.

FORM E – SERVICES TO BE PROVIDED

Name of Proponent: ________________________________________________________________________

INSTRUCTIONS: Answer all of the following questions in the order presented, restating the number and question before each response. If a question does not apply to your organization, answer with a full negative response rather than stating "Not Applicable." Limit your response to this Form E to no more than twelve (12) pages. Pages that exceed page limit will not be evaluated or scored.

Part A – Direct Services to be Provided Responses to the following questions will be scored.

Population To Be Served (Attachment A, Paragraph 1):

1. Describe your organization’s approach for providing services to CalWORKs WTW Clients as described in Paragraph 1 of Attachment A.

Outcome Objectives (Attachment A, Paragraph 3):

2. Describe your organization’s approach to meeting performance outcome objectives as required in Paragraph 3 of Attachment A, including, but not limited to, the following:

a) Details of evaluation factors and processes.

b) Frequency with which specific evaluation processes will occur.

c) Who will be responsible for developing and executing an action plan if outcomes are off-target.

Hours of Operation (Attachment A, Paragraph 4):

3. Describe your organization’s ability to provide services beyond the minimum service days and hours specified in Subparagraph 4.1 of Attachment A.

General Requirements (Attachment A, Paragraph 5):

4. Describe your strategy to engage the client in an interactive and engaging manner, including how you will successfully distinguish the program’s purpose, and alleviate any stigmas concerning being assessed. Include how you will encourage participants to attend the scheduled assessment, including any outreach efforts, and how you will address situations when a scheduled assessment is missed, as required in Subparagraphs 5.1 through 5.9 of Attachment A.

5. Describe the proposed cultural and linguistic capabilities of your service delivery plan, including, but limited to:

A. How you will deal with illiteracy, as required in Subparagraph 5.7 of Attachment A.

B. The languages in which you will test and indicate your ability to add other languages as designated by SSA, as required in Subparagraph 5.16 of Attachment A.

6. Describe how your organization will utilize technology to administer Assessment Instruments as appropriate. Include in your answer, how your organization will offer any remote or virtual Assessments when available as required in Subparagraph 5.17 of Attachment A.

Service Requirements (Attachment A, Paragraph 6):

7. Describe any unique and/or innovative features of your proposal that would enhance your organization’s ability to provide quality services to this target population, as required in Subparagraphs 6.1.1 through 6.1.17 of Attachment A.

8. Describe how you will evaluate English and non-English speaking clients with suspected learning disabilities. Include your plan to provide a diagnosis when formal documentation of an accommodation is needed, or when the client presents significant or multiple impairments, as required in Subparagraphs 6.2.1 through 6.2.4 of Attachment A.

9. Describe the Learning Disability Assessment instruments that will be utilized by your organization, as required in Subparagraph 6.3 of Attachment A.

10. Describe your organization’s plan to provide sufficient bilingual staffing for translation services, as required in Subparagraph 6.4.3 of Attachment A.

Meetings and Trainings (Attachment A, Paragraph 7):

11. Describe your organization’s approach to attendance and participation in meetings and trainings, as required in Paragraph 7 of Attachment A.

Reports (Attachment A, Paragraph 8):

12. Describe your organization’s process and system to be used to maintain records, collect data, and provide reports as required in Paragraph 8 of Attachment A.

Case Records (Attachment A, Paragraph 9):

13. Describe how your organization will maintain records for each client referred, as required in Paragraph 9 of Attachment A.

Staffing Requirements (Attachment A, Paragraph 11)

14. Describe your organization’s policies and procedures to recruit, hire and retain staff, as required in Paragraph 11 of Attachment A.

Handling Complaints (Attachment A, Paragraph 12)

15. Describe how your organization will handle client complaints, as required in Paragraph 12 of Attachment A.

Quality Assurance/Quality Control (Attachment A, Paragraph 13):

16. Present a comprehensive Quality Control Plan to be utilized by your organization as a self-monitoring tool to ensure required services are provided as specified in Paragraph 13 of Attachment A. The Quality Control Plan shall include, but not be limited to, the following:

a) The method for ensuring the services, deliverables, and requirements of Attachment A are being provided at or above the level of quality per this RFP.

b) The method for providing case reviews, a clear description of issues that arise, and corrective action taken to resolve identified problems.

c) Items/areas to be inspected on either a scheduled or unscheduled basis, how often inspections will be accomplished, and the title of the individual(s) who will perform the inspections.

d) Specific methods for identifying and preventing deficiencies in the quality of service performed, before the level of performance becomes unacceptable.

e) Method for continuing services in the event of a strike by the Contractor’s employees.

*Please note the Quality Control Plan is not included in the page limitation for Attachment E.

Performance Monitoring (Attachment A, Paragraph 14)

17. Describe your organization’s plan to provide client satisfaction surveys upon completion of Assessment Services, as required in Subparagraph 14.6 of Attachment A.

Assessment Disputes (Attachment A, Paragraph 15)

18. Describe how your organization will handle Assessment disputes, as required in Paragraph 15 of Attachment A.

Third Party Assessments (Attachment A, Paragraph 16)

19. Describe your organization’s process for receiving client requests for third party Assessments, as described in Paragraph 16.

Part B – Management of Direct Services to be Provided Responses to the following questions will be scored.

20. Describe how your organization ensures effective management and administrative services of day-to-day operations. Include:

a. Description of the span of control for all management and supervisory positions to be involved in the delivery of services under the resulting contract.

b. Description of existing and/or proposed organizational structure within, and where applicable, outside Orange County.

c. Relationship between the existing or proposed Orange County organization and Proponent’s headquarters, if located outside of Orange County.

21. Describe the method(s) your organization will use to self-evaluate the management of services to be provided.

22. Identify all project start-up activities necessary to begin service delivery on the effective date of the resulting contract.

23. Describe how management keeps informed of effective practices, which are based on current theory, research, and evaluation data for the purpose of positively impacting service delivery in the resulting contract.

Part C – Responses to the following questions will not be scored and will not be counted toward the page limit described above in the instructions for this form.

24. If subcontractor(s) are to be used for the provision of any service element, provide:

a. Name(s) of all subcontractor(s)

b. Procurement process and schedule

c. Subcontractor(s) responsibilities and/or tasks

d. Minimum qualifications for subcontractor’s key personnel to provide services under the resulting contract

e. proponent’s contractual relationship with subcontractor(s)

f. costs

25. If subcontractor(s) will be utilized, but are not identified at this point, provide detailed strategy to determine subcontractor(s).

26. Describe other location(s) your organization will offer WTW Assessment Services at, in addition to the locations required in Paragraph 10 of Attachment A.

FORM F – ASSESSMENT INSTRUMENTS

Name of Proponent: ________________________________________________________

a. How the instrument is a reliable indicator of the participant’s work history and his or her vocational skills and aptitudes, knowledge and abilities, and identification of personal-social traits, needs, and aspirations for change.

b. How the instrument is sensitive to learning problems, literacy, language, and socio-cultural issues that may distort the quality of the assessment process.

c. How the instrument provides fair and accurate results.

d. How the instrument will be used to ensure CalWORKs WTW program objectives are met as stated in Subparagraph 1.1 of this RFP.

A. Assessments Instruments Pursuant to Subparagraph 6.1 of Attachment A.

Name of Instrument:

a.

b.

c.

d.

Type (e.g., paper & pencil, audio, online, computer assisted):

Characteristics (what it measures, purpose or function):

Language Availability of Assessment Instruments:

Minimum Reading Proficiency Level Required for Each Language:

Estimated time required per referred participant to complete each instrument:

B. Learning Disability Assessment Instruments Pursuant to Section Subparagraph 6.2 & 6.3 of Attachment A.

Name of Instrument:

a.

b.

c.

d.

Type (e.g., paper & pencil, audio, online, computer assisted):

Characteristics (what it measures, purpose or function):

Language Availability of Assessment Instruments:

Minimum Reading Proficiency Level Required for Each Language:

Estimated time required per referred participant to complete each instrument:

FORM G – UNIT PRICE OF ASSESSMENTS AND TRANSLATION SERVICES

Name of Proponent: ______________________________________________________

FIXED PRICING ON ASSESSMENTS AND TRANSLATION SERVICES

Provide unit prices for all Assessments and Translation Services listed below. Unit price must include all costs related to completing Assessments, Learning Disability Assessments and Outside Translation Services as described in Attachment A, Scope of Work:

ASSESSMENTS

LEARNING DISABILITY ASSESSMENTS

TRANSLATION SERVICES

RATE PER MINUTE

Proponents warrant that the proposed fixed prices listed above are fair, reasonable, and commensurate with the prices offered by Proponent to other government entities that purchase similar services.

FORM H – BOARD OF DIRECTORS/ADVISORY BOARD

INSTRUCTIONS: Proponent must provide the following information regarding its Board of Directors and/or Advisory Board, as applicable. Indicate whether there are any vacancies. Use additional copies of this page as needed.

Name:

Name:

Current Office:

Current Office:

Occupation:

Occupation:

Address:

Address:

City/Zip:

City/Zip:

Telephone:

Telephone:

Name:

Name:

Current Office:

Current Office:

Occupation:

Occupation:

Address:

Address:

City/Zip:

City/Zip:

Telephone:

Telephone:

Name:

Name:

Current Office:

Current Office:

Occupation:

Occupation:

Address:

Address:

City/Zip:

City/Zip:

Telephone:

Telephone:

FORM I – STATEMENT OF REFERENCES

Name of Proponent: ________________________________________________________________________

INSTRUCTIONS: Proponent must provide names and addresses of three (3) current references. A minimum of two (2) of the references must be from organizations with whom the proponent has had a contractual relationship for similar scope of services for some period during the past five (5) most recent years. NOTE: References from current or former SSA employees are not permitted.

Organization’s Name:

Address:

Contact Name and Title

Current Contact Phone and Email:

Brief Description of Contracted Services Provided or Nature of Relationship:

Organization’s Name:

Address:

Contact Name and Title

Current Contact Phone and Email:

Brief Description of Contracted Services Provided

Organization’s Name:

Address:

Contact Name and Title

Current Contact Phone and Email:

Brief Description of Contracted Services Provided

FORM J – ORGANIZATION LITIGATION

Name of Proponent: ___________________________________________________________

INSTRUCTIONS: Check YES or NO to the following questions. If a YES answer is checked, please explain fully the circumstances and include discussion of the type of program involved as well as the potential impact on this program, if funded. Include court jurisdiction and case number where applicable.

Response Section (Use extra pages, as necessary)

Proponent must specify any current and/or past litigation proceedings and indicate status.

Completed By: ___________________________________________

Name and Title: ___________________________________________

FORM K – PROPONENT CERTIFICATIONS

Model Contract

It is understood that the only contract terms and conditions that will be applicable to this solicitation and resultant contract(s) are those issued by the County of Orange, as they now exist or may be hereafter amended. Proponent acknowledges that she/he has read and agrees to all terms and conditions in the Model Contract and the requirements of this solicitation and indicates concurrence below. Any exceptions to the terms and conditions in the Model Contract must be clearly stated in response to this solicitation in the space provided below entitled “Exceptions.” In addition, Proponent must provide a redlined (using tracked changes) of alternate language. Any exception must include the details of the exception and the reasons for it. Exceptions will not be evaluated or scored during the evaluation process but will be used as a point of departure for contract negotiations with the selected Proponent. The County reserves the right to disqualify Proponents taking exception to the terms and conditions in the Model Contract. Proponents taking exception after notice of award may be disqualified from award of contract as determined by County.

☐ Organization acknowledges the terms and conditions as stated in the Model Contract to this RFP will be included in the resultant contract and does not take any exceptions.

☐ Organization acknowledges the terms and conditions as stated in the Model Contract to this RFP will be included in the resultant contract and takes the exceptions noted below.

Exceptions: Enter response(s) here, if applicable.

(Signature Required) Printed Name Date

Certificates of Insurance

Proponent certifies, by signing below, its willingness and ability to provide the required insurance coverage, certificates, and endorsements as set forth in the terms and conditions of the Model Contract.

(Signature Required) Printed Name Date

Conflict of Interest

Disclose any financial, business, or other relationship with the County of Orange, any other entity that the Orange County Board of Supervisors governs*, or any Orange County board member, officer, or employee, which could affect or influence award of the contract for the services you propose to provide.

Proponent must certify either Option 1 or 2 below:

1. Proponent certifies current/past financial, business, or other relationship with the above exists/existed as follows:

Use Additional Pages as Necessary

(Signature Required) Printed Name Date

OR

2. Proponent certifies that no relationship with the above exists/existed as outlined above.

(Signature Required) Printed Name Date

*Orange County Board of Supervisors govern: All Assessment Districts, All Community Facilities Districts, All Reassessment Districts, Housing and Community Development Commission, Housing Successor Agency to the Orange County Development Agency, In-Home Supportive Services Public Authority, Industrial Development Authority For Orange County, Local Redevelopment Authority Marine Corp Air Station (MCAS) El Toro, Orange County Financing Authority, Orange County Flood Control District, Orange County Housing Authority, Orange County Housing Authority Acting As the Housing Successor Agency, Orange County Public Financing Authority, Orange County Special Financing Authority, South Orange County Public Financing Authority, and the Successor Agency to the Orange County Development Agency

Name/Ownership Changes

Proponent must certify either Option 1 or 2 below:

1. Proponent certifies past company name changes and/or ownership changes for Proponent’s firm and any proposed subcontractor firm, as follows:

a. Proponent shall provide detailed information regarding any company name changes (including legal business names) in the past seven (7) years.

b. Proponent shall provide detailed information regarding any company ownership changes (including legal business names) in the past seven (7) years.

(Signature Required) Printed Name Date

2. Proponent certifies that Proponent or any proposed subcontractors have not had any company name changes or ownership changes in the past seven (7) years.

FORM L - DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) CERTIFICATION REQUIREMENTS

1) To participate as a DVBE the following requirements must be met:

A. A business must be certified with DGS as a DVBE - https://caleprocure.ca.gov/pages/sbdvbe-index.aspx

B. DVBE Certification must be valid at the date/time solicitation is closed, and it shall remain in effect at the time of contract award. County reserves the right to verify and/or reject incomplete documents.

C. Complete and sign the Affirmation form attached herein. The signed Affirmation form and the DVBE Certification are required and must be returned with the solicitation response in order to compete as a DVBE.

2) DVBE Preference provides for the following:

A. Request for Proposal – RFP

An extra five percent (5%) shall be applied to the tallied score of each certified DVBE to obtain the final score. If the final score of any DVBE matches the final score of a non-DVBE, preference shall be given to the certified DVBE. If two or more DVBEs have the same final score, the County shall determine the contract award based on the County’s best interest.

Disabled Veteran Business Enterprise (DVBE) Affirmation

DVBE Certification Requirements: To be certified as a Disabled Veteran Business Enterprise, a business must meet the following requirements:

1) Must be certified as a DVBE by the State of California Department of General Services (DGS); and

2) DGS DVBE requirements must be valid at the time of bid/proposal submittal.

Please specify if DVBE preference applies to your business by checking below:

☐ DVBE

I, certify that ______________________, (legal company/business name) is certified as a DVBE and currently meets the respective Certification Requirements set forth above.

_____________________________ Print Name

_____________________________ Authorized Signature

___________________ Title

___________________ Date

Please check below:

· State of California DVBE Certification attached

County Use Only

Solicitation Number:

Solicitation Description:

File Folder Number:

FORM M – LEVINE ACT

CAMPAIGN CONTRIBUTION DISCLOSURE FORM

Application or Solicitation Number:

Application or Solicitation Title:

Was a campaign contribution, regardless of the dollar amount, made to any member of the Orange County Board of Supervisors or to any County Agency Officer within the preceding 12 months by the applicant, or, if applicable, any of the applicant’s proposed subcontractors or the applicant’s agent or lobbyist?

Yes ____ No_____

If no, please sign and date below.

If yes, please provide the following information:

Applicant’s Name:

Contributor or Contributor Firm’s Name:

Contributor or Contributor Firm’s Address:

Is the Contributor:

Note: Under California law as implemented by the Fair Political Practices Commission, campaign contributions made by the Applicant and the Applicant’s agent/lobbyist who is representing the Applicant in this application or solicitation must be aggregated together to determine the total campaign contribution made by the Applicant.

Identify the Board of Supervisors Member(s) and County Agency Officer(s) to whom you, your subcontractors, and/or agent/lobbyist made campaign contributions, the name of the contributor, the dates of contribution(s) in the preceding 12 months and dollar amount of the contribution. Each date must include the exact month, day, and year of the contribution.

Name of Board of Supervisors Member or County Agency Officer:

Name of Contributor:

Date(s) of Contribution(s):

Amount(s):

(Please add an additional sheet(s) to identify additional Board Members or County Agency Officer to whom you, your subconsultants, and/or agent/lobbyist made campaign contributions)

By signing below, I certify that the statements made herein are true and correct. I also agree to disclose to the County any future contributions made to Board Members or County Agency Officers by the applicant, or, if applicable, any of the applicant’s proposed subcontractors or the applicant’s agent or lobbyist after the date of signing this disclosure form, and within 12 months prior to and following the approval, renewal, or extension of the requested license, permit, or entitlement to use.

Date Signature of Applicant

ORANGE COUNTY BOARD OF SUPERVISORS

AND COUNTY AGENCY OFFICERS

Board of Supervisors

Donald P. Wagner, Chairman, Third District Andrew Do, Vice Chairman, First District Vicente Sarmiento, Second District Doug Chaffee, Fourth District Katrina Foley, Fifth District

County Agency Officers Claude Parrish, Assessor Andrew Hamilton, Auditor-Controller-Elect Hugh Nguyen, Clerk-Recorder Todd Spitzer, District Attorney-Public Administrator Don Barnes, Sheriff-Coroner Shari A. Freidenrich, Treasurer-Tax Collector

WTW Assessment Services Page 47 of 30 RFP # 063-2496202-DM, September 28, 2023

WTW Assessment Services Page 56 of 30 RFP # 063-2496202-DM, September 28, 2023

EXHIBIT

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