RFGAAttC - Applicant Information and Certification Sheet.docx

RFGA # S-44300-00010881 for Culturally AttC and Linguistically Specific Behavioral Health Services

ATTACHMENT C — APPLICANT INFORMATION

AND CERTIFICATION SHEET

Legal Name of Applicant:

Address:

City, State, Zip:

Entity Type:

State of Incorporation:

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:

Applicant understands and accepts the requirements of RFGA# S-44300-00010881 (“the RFGA”).

By submitting an Application, Applicant agrees to be bound by the Sample Grant Agreement terms and conditions in Attachment D and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFGA.

Applicant acknowledges receipt of all Addenda to the RFGA.

If awarded a Grant Agreement , Applicant agrees to perform the allowable program activities set forth in the final negotiated Program Description of the Grant Agreement .

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.

To the best of the undersigned’s knowledge, Applicant has not discriminated against and will not discriminate against minority, women or emerging small business enterprises certified under ORS 200.055 in obtaining any required subcontract.

Applicant will not request funding for expenditures already funded by any other agency or department of the State of Oregon or the federal government, or by private insurance.

If Applicant is receiving Medicaid Administrative Claiming (MAC) or Medicaid outreach, enrollment and education funds, Applicant must demonstrate that funding shall not be used for the same activities and that separate financial tracking processes exist, distinguishing the funding sources and uses from each other.

Applicant certifies that Applicant shall not expend grants funds under any Grant Agreement issued from this RFGA # S-44300-00010881 on healthcare services if any other funding source for the services shall be obtained or sought from private health insurance, Medicaid, Medicare, or any other federal or state government funding source by Applicant to cover the cost of those services and Applicant understands and agrees that this certification will be included in Grant Agreement awarded under this RFGA.

If Applicant is awarded a Grant Agreement under this RFGA, Applicant’s performance of the Program activities described in Applicant’s Application under the Grant Agreement shall, to the best of Applicant’s knowledge, create no actual or potential conflict of interest, as defined by ORS 244, for Applicant or any of Applicant’s Key Persons, and creates no other violation of ORS Chapter 244 for Applicant’s employees, agents, or contractors. If any changes occur with respect to Applicant’s status regarding an actual or potential conflict of interest, Applicant will promptly notify the Agency in writing.

If Applicant is awarded a Grant Agreement under this RFGA, Applicant agrees to comply with all the Terms and Conditions included in the attached Notice of Award (NOA) for Award Number: 1B08TI083963-01 as are applicable to subrecipients of funds awarded under that NOA.[footnoteRef:1]. If any changes occur with respect to Applicant’s status regarding conflict of interest, Applicant shall promptly notify the State in writing. [1: A copy of the Federal Notice of Award #1B08TI083963-01 re: Substance Abuse Prevention and Treatment Block Grant Funding referenced above is provided for Applicants’ review as Attachment G for this RFGA in the Attachments for OregonBuys Bid # S-44300-00010881]

Applicant understands and agrees that the parties may negotiate the final Program Activities, Reporting Requirements and Budget to be included in any Grant Agreement awarded to Applicant.

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

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 the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/ 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.

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

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 Contract 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.

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)