RFR Attachment 7 - Mandatory Forms and Certifications~2.docx

Attachment 1 – Mandatory Forms and Certifications

RFR ATTACHMENT 7 – MANDATORY FORMS AND CERTIFICATIONS

Schedule 1: Certification of Bidder’s Qualifications and Contract Readiness

Name of Bidder: _________________________________________________________

Certification:

The undersigned certifies that the Bidder will be ready to begin performance of responsibilities described in this RFR by the date listed in Section 5.1 therein, and that the Bidder is able to perform all services and responsibilities at the cost stated in the Bidder’s cost response and by the dates specified herein.

The undersigned certifies that no Bidder interest will conflict in any manner or degree with the performance of services required under the Agreement.

Signature

Printed Name of Signatory

Title

Date

Schedule 2: Certification of Key Personnel

The undersigned certifies that the Key Personnel identified in the Bidder’s response are benefitted employees, consultants or under obligation to the Bidder such that they will be available to work on this project according to the proposed project plan, and that they shall not be reassigned during the term of the agreement without the prior written approval of the Health Connector.

Signature

Printed Name of Signatory

Title

Date

Schedule 3: Certification with Regard to Subcontractors

The undersigned acknowledges its understanding that it will not be relieved of any legal obligations under any Agreement resulting from this RFR as a result of any contracts with subcontractors, that it shall be fully responsible for the partner's or subcontractor's performance, and that all partnership agreements, subcontracts and other agreements or arrangements for reimbursement will be in writing, will contain terms consistent with all terms and conditions of the Agreement, and must be reviewed and approved (with the exception of financial terms, which may be withheld) prior to execution.

Signature

Printed Name of Signatory

Title

Date

Schedule 4: Certification with Regard to Financial Condition

A check in the box to the right of each item indicates an affirmative response to the certification.

If one or more of the above boxes are not checked, please explain in the space provided below or attach a clearly labeled separate sheet.

Signature

Printed Name of Signatory

Title

Date

Schedule 5: Request for Taxpayer Identification Number and Certification (W-9)

Schedule 6: Certification Regarding Debarment and Suspension

Name of Bidder: _________________________________________________________ hereby certifies that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in this or any other transaction by any federal department or agency, or any department or agency of any state of the United States.

Signed and executed this _____ day of ___________, 2024:

CERTIFYING ORGANIZATION

Organization Name

By:___________________________________

Signature

image1.emf form_w-9.pdf

Form W-9 (Revised April 2022) Massachusetts Substitute Form W-9

Request for Taxpayer Identification Number and Certification

▶ Online instructions at: macomptroller.org/wp-content/uploads/instructions_w-9.pdf

Give this Form to the requestor or the department you are doing business with.

1 Business name/Taxpayer (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name/dba, if different from above.

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.

Check only one of the following seven boxes.

4 Exemptions (codes apply only to certain entities, not individuals;

see instructions on Page 4):

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate Exempt payee code (if any):

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership ▶ ___________________

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Exemption from FATCA reporting code (if any):

(Applies to accounts maintained outside the U.S.) Other (see instructions) ▶

5 Legal Address (number, street, and apt. or suite no.) See instructions. Requester’s name and address (optional)

6 City, state, and ZIP code

7 Remittance Address (if different from Legal Address)

Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN).

However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, on Page 5. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, on Page 5.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number to Give the Requester for guidelines on whose number to enter.

Social security number or Employer identification number

DUNS Number Please confirm with the state agency if this is required for vendors receiving federal funds.

Unique Entity Identifier (SAM) As of April 4, 2022, all vendors that receive federal grant funds must submit their Unique Entity Identifier registered in the System of Awards Management (SAM).

Part II Certification Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You check the following box if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, on Page 5.

Item 2 does not apply.

5. I am an active Commonwealth of Massachusetts state employee: (check one)

If yes, I certify compliance with the Massachusetts State Ethics Commission requirements at https://www.mass.gov/ethics.

Yes No

Sign Here

Signature of U.S. person ▶ Date ▶

Massachusetts Substitute Form W-9 (Rev 4-2022)

Pr in t o r t yp e.

Se e Sp ec ifi c In st ru ct io ns o n pa ge https://macomptroller.org/wp-content/uploads/instructions_w-9.pdf

1 Business nameTaxpayer as shown on your income tax return Name is required on this line do not leave this line blank:

2 Business namedisregarded entity namedba if different from above:

Federal Tax Classification: Off

LLC:

Other (See Instructions):

code if any:

Exempt payee code if any:

5 Legal Address number street and apt or suite no See instructions:

6 City state and ZIP code:

Requesters name and address optional:

7 Remittance Address if different from Legal Address:

Social Security Number # 1:

Social Security Number # 2:

Social Security Number # 3:

Social Security Number # 4:

Social Security Number # 5:

Social Security Number # 6:

Social Security Number # 7:

Social Security Number # 8:

Social Security Number # 9:

Employer Identification Number # 9:

Employer Identification Number # 8:

Employer Identification Number # 7:

Employer Identification Number # 6:

Employer Identification Number # 5:

Employer Identification Number # 4:

Employer Identification Number # 3:

Employer Identification Number # 2:

Employer Identification Number # 1:

DUNS Number Please confirm with the state agency if this is required for vendors receiving federal funds:

Unique Entity Identifier SAM As of April 4 2022 all vendors that receive federal grant funds must submit their Unique Entity Identifier registered in the System of Awards Management SAM:

Item 2 does not apply: Off

I am an active Commonwealth of Mass State Employee: Off

Sign Here:

Date: