RFGA 6030 Attachment A fillable corrected.pdf

RFP #6030 Sample Grant Agreement

ATTACHMENT A – APPLICANT INFORMATION AND CERTIFICATION SHEET

Legal Name of Applicant

Address: City, State, Zip:

State of Incorporation: Entity Type:

Contact Name: Telephone: Email:

Oregon Business Registry Number (if required):

Any individual signing below hereby certifies they are an authorized representative of Applicant and that:

1. Applicant understands and accepts the requirements of this RFGA. By submitting an Application, Applicant agrees to be bound by the Grant Agreement terms and conditions in Attachment D and as modified by any Addenda, except for those terms and conditions that OHA has reserved for negotiation, as identified in the RFGA.

2. Applicant acknowledges receipt of any and all Addenda to this RFGA.

3. Application is a Firm Offer for 180 days following the Closing.

4. If awarded a Grant Agreement, Applicant agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Grant Agreement.

5. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

6. Applicant does not unlawfully discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Applicant does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owns or an emerging small business.

7. Applicant complies with ORS 652.220 and does not unlawfully discriminate against any of Applicant’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class. “Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.

8. Applicant’s continuing compliance constitutes a material element of a Grant Agreement and a failure to comply constitutes a breach that entitles OHA to terminate the Grant Agreement for cause.

9. Applicant may not prohibit any of Applicant’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Applicant may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

10. Applicant is not engaged in the provision of broadband Internet access service, or if at any time Applicant is engaged in or may engage in the provision of broadband Internet access service Applicant is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Grant Agreement.

RFP #6030 Sample Grant Agreement

11. Applicant and Applicant’s employees, agents, and subcontractors are not included on:

A. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at:

https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or

B. the government wide exclusions lists in the System for Award Management found at:

https://www.sam.gov/

12. Applicant certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Applicant, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFGA. If any changes occur with respect to Applicant’s status regarding conflict of interest, Applicant shall promptly notify the State in writing.

13. Applicant certifies that all contents of the Applicant (including any other forms or documentation, if required under this RFGA) and this Application Certification Sheet are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.

14. Applicant understands that any statement or representation it makes, in response to this RFGA, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under a Grant Agreement being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

15. Applicant acknowledges these certifications are in addition to any certifications required in the Grant Agreement and Program Description in Attachment D at the time of Grant Agreement execution.

Authorized Signature Date

(Printed Name and Title) https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.sam.gov%2F&data=05%7C02%7CTammy.HURST%40odhsoha.oregon.gov%7C41ce6f0073134e86881808dd9271c448%7C658e63e88d39499c8f4813adc9452f4c%7C0%7C0%7C638827739503148698%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=ARyW5GrKKKed%2FpSgA5T0Su4XHw6aYSPsuR%2FMpT3gHtk%3D&reserved=0