RFGP 6264-0 Attachment A.pdf
PDF 99 KB Posted
- Solicitation number
- S-44300-00018385
- Issued by
- Oregon
About this file
RFGP 6264-0 Attachment A – Proposer Information and Certification Sheet
This document is a proposer information and certification sheet for a Request for Grant Proposals (RFGP) issued by Oregon for the GLS Youth Suicide Prevention & Early Intervention funding opportunity, which targets Local Public Health Authorities (LPHAs), Local Mental Health Authorities (LMHAs), and Community Mental Health Programs (CMHPs). The form requires proposers to provide basic organizational information including legal name, address, current agreement number, and primary contact details. Proposers must certify their understanding and acceptance of the RFGP requirements, acknowledge receipt of all addenda, and confirm that their proposal constitutes a firm offer valid for 180 days following the closing date. The certification sheet also requires proposers to verify compliance with state tax laws under Oregon Revised Statutes (ORS 305.620 and ORS chapters 316, 317, and 318) and affirm the truthfulness and accuracy of all proposal contents prepared independently and without collusion or fraud.
The document emphasizes that any false statements, misrepresentations, or material omissions in the proposal may constitute a false claim under the Oregon False Claims Act (ORS 180.750-180.785), exposing proposers to associated liabilities and penalties. Proposers must acknowledge that the certifications required on this form are in addition to any certifications mandated under their current funding agreements with the state. The form is designed for organizations seeking funding to build capacity for youth suicide prevention and early intervention services in jurisdictions experiencing suicide burdens higher than the national average of 10.5 per 100,000 among youth aged 10-24 years.
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Other files
| File | Type | Posted |
|---|---|---|
| RFGP 6264-0 Attachment C.docx | DOCX document | |
| RFPG 6264-0 final tlh.pdf | ||
| RFGP 6264-0 Attachment D.docx | DOCX document | |
| RFGP 6264-0 Attachment B.pdf |
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RFGP 6264-0 tlh Attachment A Page 1 of 2
ATTACHMENT A — PROPOSER INFORMATION AND CERTIFICATION SHEET
Legal Name of Proposer:
Address: City, State, Zip:
Current LPHA or Tribal Agreement #:
Contact Name: Telephone:
Email:
Any individual signing below hereby certifies they are an authorized representative of Proposer and that:
1. Proposer understands and accepts the requirements of this RFGP. By submitting a Proposal, Proposer agrees to that any funds that will be awarded will be awarded through the current LMHA, CMHP or LPHA Agreement.
2. If awarded a funding, Proposer agrees to perform the scope of work and meet the performance standards set forth in the Program Element Description in the current Agreement.
3. Proposer acknowledges receipt of any and all Addenda to this RFGP.
4. Proposal is a Firm Offer for 180 days following the Closing.
5. I have knowledge regarding Proposer’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Proposer 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. Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFGP) and this Proposal Certification Sheet are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.
7. Proposer understands that any statement or representation it makes, in response to this RFGP, 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 the Current 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.
8. Proposer acknowledges these certifications are in addition to any certifications required in the Current Agreement.
Authorized Signature Date
(Printed Name and Title)
| ATTACHMENT A — PROPOSER INFORMATION AND CERTIFICATION SHEET |
| Legal Name of Proposer: |
| Address: City, State, Zip: |
| Current LPHA or Tribal Agreement #: |
| Contact Name: Telephone: |
| Email: |
| Date: |
| Printed Name and Title: |
| Contact Name: |
| Business Name: |
| Physical Address: |
| Agreement Number: |
| Phone Number: |
| email address: |
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