Sample Exhibit 3 - Certification Statement for Corporation or Independent Contractor.docx
DOCX document 35 KB Posted
- Attached to
- Primary Care Patient Experience Surveys
- Solicitation number
- RFP-1-2023
- Issued by
- Oregon
About this file
This document is a Certification Statement for Corporation or Independent Contractor from Multnomah County, specifically related to a potential contract for Primary Care Patient Experience Surveys. The form requires contractors to certify their business structure (corporation, LLC, partnership, or sole proprietorship) and confirm their status as an independent contractor by meeting specific criteria, such as having a separate business location, bearing service-related risk, providing services to multiple clients, making significant financial investments, or having hiring/firing authority.
The certification is part of a procurement process for the Multnomah County Health Department's Integrated Clinical Services, which is seeking a supplier to conduct professional patient survey sampling, tabulation, and reporting services. Contractors must verify legal compliance, including obtaining necessary licenses and registrations, and demonstrate their independence as a service provider. The document requires the contractor's signature, title, and date, and mandates that at least three of six listed independent contractor characteristics must be checked to establish their professional status.
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Text version
EXHIBIT 3
MULTNOMAH COUNTY CONTRACT
Contract No. Sample contract – Do not submit Certification Statement for Corporation or Independent Contractor Contractor Must Complete A AND B below:
Not valid unless signed.
A. CONTRACTOR IS A CORPORATION, LIMITED LIABILITY COMPANY, OR A PARTNERSHIP.
I certify under penalty of perjury that Contractor is a (check one):
☐ Corporation ☐ Limited Liability Company ☐ Partnership ☐ Non-Profit Corporation authorized to do business in the State of Oregon ☐ NOT APPLICABLE – See section B.
B. CONTRACTOR IS A SOLE PROPRIETOR WORKING AS AN INDEPENDENT CONTRACTOR.
Contractor certifies under penalty of perjury, that the following statements are true:
1. If CONTRACTOR is providing services under this Contract for which registration is required under ORS Chapter 671 (architects and landscape contractors) or 701 (construction contractors), CONTRACTOR has registered as required by law.
2. CONTRACTOR is free to determine and exercise control over the means and manner of providing the service, subject to the right of the County to specify the desired results.
3. CONTRACTOR is responsible for obtaining all licenses or certifications necessary to provide the services.
4. CONTRACTOR is customarily engaged in providing services as an independent business. CONTRACTOR is customarily engaged as an independent contractor if at least three of the following statements are true.
NOTE: Check all that apply. You must check at least three (3) to establish that you are an independent contractor.
☐ A. CONTRACTOR’s services are primarily carried out at a location that is separate from CONTRACTOR’s residence or primarily carried out in a specific portion of the residence which is set aside as the location of the business ☐ B. CONTRACTOR bears the risk of loss related to the services provided under this Contract.
☐ C. CONTRACTOR provides services to two or more persons within a 12-month period or Contractor routinely engages in business advertising solicitation or other marketing efforts reasonably calculated to obtain new contracts for similar services.
☐ D. CONTRACTOR makes a significant financial investment in the business.
☐ E. CONTRACTOR has authority to hire additional persons to provide the services and has authority to fire such persons.
☐ F. NOT APPLICABLE – See section A.
Contractor Signature: __________________________________ Date: ____________ Title: ________________________________________________
06/21/2021 CAO Exhibit 3 Page 1 of 1
File details come from the government source that posted it. Updated .