RFP 170-4437-25 Attachment G Responsibility Inquiry Draft.docx
DOCX document 93 KB Posted
- Solicitation number
- S-17000-00015408
- Issued by
- Marion County, Oregon
About this file
This is a Responsibility Inquiry form (Attachment G) for Oregon's Request for Proposal 170-4437-25, issued by the State Treasury. The form is designed to evaluate contractor responsibility and financial capability prior to contract award for marketing services related to Oregon's retirement savings program. Proposers must complete this form to demonstrate their ability to perform contractual obligations, including assessment of financial resources, personnel, equipment, and facility capabilities. The form requires contractors to certify their experience with similar contracts completed within budget and timeline constraints over the past five years, and to disclose any contract performance issues or legal disputes.
The form requires proposers to provide detailed explanations regarding contract performance history, any criminal charges or civil litigation involving company principals or major subcontractors within the past three years, and any financial distress indicators such as contract terminations, creditor lawsuits, bankruptcy filings, or cash flow difficulties. Additionally, proposers must identify all required licenses, registrations, and proof of insurance coverage relevant to the work. For companies with 50 or more full-time employees and contracts exceeding $500,000, a Pay Equity Certificate from the Department of Administrative Services must be attached. An authorized representative must certify under penalty of perjury that all responses are complete, accurate, and truthful. Failure to promptly provide requested documentation or demonstrate responsibility may result in a finding of non-responsibility and contract rejection.
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Attachment G Responsibility Inquiry
Proposer Proposer Legal Business Name:
| Request: |
| 170-4437-25 |
Responsibility Determination Treasury will determine your Responsibility if you are selected to be awarded a contract under this Request. Prior to the execution of a Contract, you must complete this form. Treasury may require other documentation to determine Responsibility including, but not limited to, recent profit-and-loss history, current balance statements and cash flow information, assets-to-liabilities ratio, including number and amount of secured versus unsecured creditor claims, availability of short and long-term financing, bonding capacity, insurability, credit information, materials and equipment, facility capabilities, personnel information, record of performance under previous contracts, etc. Failure to promptly provide requested information or clearly demonstrate Responsibility may result in a finding of non-responsibility and rejection.
Provide the following information
1. Mark the statement that best describes your company’s ability to fully perform a contract under this Request. My company:
| |_| | Has the appropriate financial, material, equipment, facility and personnel resources and expertise, necessary to meet all contractual responsibilities. |
| |_| | Has the ability to obtain the appropriate financial, material, equipment, facility and personnel resources and expertise, necessary to meet all contractual responsibilities. |
| |_| | Does not have, nor the ability to obtain, the appropriate financial, material, equipment, facility and personnel resources and expertise, necessary to meet all contractual responsibilities. (If you marked this statement, you do not need to complete the rest of the form). |
2. Within the last five years and based on the cost and time available under your company’s control, please complete the following statements. My company:
a. Completed contracts of a similar nature within the time and budget allotted.
b. Completed contracts of a similar nature outside the time and budget allotted.
c. Completed contracts that were subject to a contract claim by any party.
Please complete Item 2 under the explanations section if your company had contracts that were outside the time and budget allotted or a party made a contract claim.
3. Within the last three years, my company (including a partner or shareholder owning 10 percent or more of my company or a major subcontractor receiving 10 percent or more of a total contract amount) has been charged, indicted, convicted, or subject to a civil lawsuit or judgement in connection with (check all that apply, if any):
| |_| | Obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract. |
| |_| | Violation of Federal or state antitrust statutes relating to the submission of bids or Proposals. |
| |_| | Embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property? |
Please complete Item 3 under the explanations section if you marked one or more of the statements above.
4. Within the last three years, my company (check all that apply, if any):
| |_| | Has had one or more contracts terminated by any government agency for default within the last three years. |
| |_| | Has had 0ne or more lawsuits filed against it by creditors or involving contract disputes within the last three years. |
| |_| | Has had one or more outstanding or pending judgements. |
| |_| | Experienced distress or having difficulty security financing. |
| |_| | Did not have sufficient cash flow to fund day-to-day operations under its Proposal. |
| |_| | Filed a bankruptcy action, filed for reorganization, made a general assignment of assets for the benefit of creditors, or had an action for insolvency instituted against it. |
Please complete Item 4 under the explanations section if marked one or more of the statements above.
5. Check if the following statements apply:
| |_| | My company has 50 or more full-time workers. |
| |_| | The estimated contract price exceeds $500,000. |
If you checked both boxes, attach a copy of a Pay Equity Certificate issued by the Department of Administrative Services. (See Section 1[E] of the Request for more information).
6. Attach copies of all the required licenses and registrations identified in this paragraph:
a.
7. Attach proof of insurance for the following required lines of coverage:
a.
Explanations
| Item 2 |
| Provide an explanation of each instance your company had contracts that were outside the time and budget allotted for reasons under your control, or a party made a contract claim. |
[Insert your response here]
| Item 3 |
| Provide an explanation of each instance including the jurisdiction, date of indictment, charge, or judgement, and the names and summary of charges or allegations. |
[Insert your response here]
| Item 4 |
| Provide an explanation of each instance related to each box you checked. If you checked a box relating to any legal action, include the filing date, jurisdiction, type of action, ultimate resolutions, and dates or judgement or dismissal, if applicable. |
[Insert your response here]
Authorized Representative By my signature below and on behalf of my company, I hereby certify that to the best of my knowledge and belief that the responses provided on this form are complete, accurate, and are not misleading.
Authorized Representative Printed Name
Title
Authorized Signature
Date
Attachment G Responsibility Inquiry 170-4437-25 image1.png image2.png
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