VendorSummary_+_BoardStaffVolunteer.pdf

PDF 505 KB Posted Mar 26, 2024

Attached to: Family Interaction Services State and local contract opportunity
Solicitation number: 425008-CBB
Issued by: Dane County, Mattoon Village, Wisconsin

About this file

Written by GovTribe AI · Jul 1, 2025

This document is a Vendor Summary and Board/Staff/Volunteer Descriptors form for a potential vendor applying for a Family Interaction Services contract with Dane County, Wisconsin. The form is a comprehensive application that collects detailed information about the organization's business structure, fiscal practices, governing board, staff demographics, and certifications. It appears to be part of a procurement process for providing family interaction services, specifically designed to support children in out-of-home care by facilitating face-to-face interactions with their parents.

The application requires extensive organizational details, including business establishment date, accounting practices, board composition, and staff diversity metrics. The form includes sections on legal status, fiscal information (such as accounting principles and audit practices), board governance (with spaces to list board members' details), and staff/board demographic characteristics. The applicant must provide information on gender, age, race, ethnicity, and disability status for both staff and board members. Additionally, the form allows the organization to indicate if it qualifies as a Minority Business Entity (MBE), Woman Owned Business Entity (WBE), or Disabled Veteran Business (DVB), which may provide advantageous consideration in the contract evaluation process.

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Other files for this state and local contract opportunity

Other files attached to Family Interaction Services, newest first.
File	Type	Posted
Family_Interaction_Services.pdf	PDF	Apr 8, 2024
425008_Family_Interaction_Services_-_ABC_COMPANY_Cost_Proposal.xlsx	XLSX spreadsheet	Apr 5, 2024

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Applicant Summary and Signature Page

Organization legal name:

Mailing address:

(if P.O. Box, include street address)

Telephone:

Fax number:

Name of chief admin/contact:

E-mail address of chief admin:

Website:

Legal status Private Non-Profit Private For-Profit Other (LCC, LLP, Sole Proprietor)

Federal EIN:

RFP number and title:

Contact person:

Contact phone number:

Contact e-mail address:

I hereby attest that all statements made in this application and any attachments are true and correct to the best of my knowledge.

Signature of legal representative/organization head: _____________________________

Title: ____________________________

Printed name: __________________________

Date: ______________________________

Section 1. Applicant Information

Business Information

Date business originally established:

Number of years under current ownership:

How many years have you been doing business under your present firm or trade name?

Please list other names under which this business may have operated:

Fiscal Information

If you are working with an accounting firm to handle fiscal operations, how long have you worked with this firm?

Provide the following information on the employees in your organization who will have primary fiscal responsibilities such as billing and claiming, payroll, etc.

Name Job Title % of time spent per week on fiscal duties

If less than 100%, describe other duties

Please provide information on the accounting/auditing practices of your organization. Please note that this information is not scored.

a. Agency maintains accounting records in accordance with the Generally Accepted Accounting Principles (GAAP). GAAP is the general guidelines and principles, standards and detailed rules, plus industry practices that exist for financial reporting.

If you are unsure or you do not know, please check No.

Yes No

b. Agency maintains a uniform double entry accounting system which is compatible with cost accounting and generally accepted accounting principles.

Yes No

c. Agency maintains a cost allocation plan with costs allocated in a manner consistent with these plans.

Yes No

d. Agency audit is performed annually by an independent, outside party in accordance with generally accepted auditing standards.

Yes No

e. Has the most recent audit revealed any significant or ongoing concerns? Yes No

Legal Information Please attach a detailed explanation for any YES responses below.

Has the applicant or any owner been involved in any lawsuits or judgements in the last five (5) years or have any lawsuits pending?

Yes No

Has the applicant or any owner been involved in any bankruptcy or insolvency proceedings or have any proceedings pending?

Yes No

Section 2: Agency Governing Board

a. How many Board meetings has your governing board or Board of Directors scheduled for the current calendar year?

b. How many meetings were held in the prior calendar year?

Please list your current Board of Directors or you agency’s governing body. Include name, address, primary occupation, term information, and board office held.

Board President’s Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service

Board Vice-President’s Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service

Board Secretary’s Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service

Board Treasurer’s Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service

Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service

Board Member Name Contact Address Contact E-mail

Occupation Representing Current Term of Office from __ to __ Total Years of Service

Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service

Section 3: Staff/Board/Volunteer Descriptors State of Wisconsin Certifications Minority Business Entity (MBE) (51% owned, controlled and actively managed by minorities)

Yes

Woman Owned Business Entity (WBE) (51% owned, controlled and actively managed by women)

Yes

Disabled Veteran Business (DVB) (51% owned, controlled and actively managed by disabled veterans)

Yes

Indicate the number and percentage of the following characteristics for your Agency’s current staff and board. Report total number of volunteers.

Descriptor Staff Board

Number Percent Number Percent

Total

Gender

Male

Female

Not listed/prefer not to say

Age

Less than 18 Years

18-59 Years

60 and Older

Race

White

Black or African-American

American Indian and Alaskan Native

Asian

Native Hawaiian and Other Pacific Islander

Some Other Race

Two or More Races

Ethnicity

Hispanic or Latino (of any race)

Not Hispanic or Latino

Persons with Disabilities

Volunteers

Form for RFP_demo.pdf

Section 3: Staff/Board/Volunteer Descriptors

State of Wisconsin Certifications

RFP Attachments.pdf

Applicant Summary and Signature Page

Section 1. Applicant Information

Business Information

Fiscal Information

Legal Information

Section 2: Agency Governing Board

Section 3: Staff/Board/Volunteer Descriptors

State of Wisconsin Certifications

Attachment A: VENDOR INFORMATION

Attachment B: DESIGNATION OF CONFIDENTIAL AND PROPRIETARY INFORMATION

NumberNot listedprefer not to say:

PercentNot listedprefer not to say:

NumberNot listedprefer not to say_2:

PercentNot listedprefer not to say_2:

NumberHispanic or Latino of any race:

PercentHispanic or Latino of any race:

NumberHispanic or Latino of any race_2:

PercentHispanic or Latino of any race_2:

NumberNot Hispanic or Latino:

PercentNot Hispanic or Latino:

NumberNot Hispanic or Latino_2:

PercentNot Hispanic or Latino_2:

Organization legal name:

Mailing address if PO Box include street address:

Telephone:

Fax number:

Name of chief admincontact:

Email address of chief admin:

Website:

Private NonProfit: Off

Private ForProfit: Off

Other LCC LLP Sole Proprietor: Off

Federal EIN:

RFP number and title:

Contact person:

Contact phone number:

Contact email address:

Title:

Printed name:

Date:

Date business originally established:

Number of years under current ownership:

How many years have you been doing business under your present firm or trade name:

Please list other names under which this business may have operated:

If you are working with an accounting firm to handle fiscal operations how long have you worked with this firm:

NameRow1:

Job TitleRow1:

of time spent per week on fiscal dutiesRow1:

If less than 100 describe other dutiesRow1:

NameRow2:

Job TitleRow2:

of time spent per week on fiscal dutiesRow2:

If less than 100 describe other dutiesRow2:

NameRow3:

Job TitleRow3:

of time spent per week on fiscal dutiesRow3:

If less than 100 describe other dutiesRow3:

undefined: Off

undefined_2: Off

undefined_3: Off

undefined_4: Off

undefined_5: Off

undefined_6: Off

undefined_7: Off

undefined_8: Off

undefined_9: Off

undefined_10: Off

undefined_11: Off

undefined_12: Off

undefined_13: Off

a How many Board meetings has your governing board or Board of Directors scheduled for the current calendar year:

b How many meetings were held in the prior calendar year:

Board Presidents Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service:

Board VicePresidents Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service:

Board Secretarys Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service:

Board Treasurers Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_2:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_3:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_4:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_5:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_6:

Board Member Name Contact Address Contact Email:

Board Member Name Contact Address Contact Email_2:

Occupation Representing Current Term of Office from to Total Years of Service:

Occupation Representing Current Term of Office from to Total Years of Service_2:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_7:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_8:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_9:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_10:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_11:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_12:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_13:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_14:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_15:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_16:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_17:

Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_18:

undefined_14: Off

undefined_15: Off

undefined_16: Off

NumberTotal:

NumberTotal_2:

NumberMale:

PercentMale:

NumberMale_2:

PercentMale_2:

NumberFemale:

PercentFemale:

NumberFemale_2:

PercentFemale_2:

NumberLess than 18 Years:

PercentLess than 18 Years:

NumberLess than 18 Years_2:

PercentLess than 18 Years_2:

Number1859 Years:

Percent1859 Years:

Number1859 Years_2:

Percent1859 Years_2:

Number60 and Older:

Percent60 and Older:

Number60 and Older_2:

Percent60 and Older_2:

NumberWhite:

PercentWhite:

NumberWhite_2:

PercentWhite_2:

NumberBlack or AfricanAmerican:

PercentBlack or AfricanAmerican:

NumberBlack or AfricanAmerican_2:

PercentBlack or AfricanAmerican_2:

NumberAmerican Indian and Alaskan Native:

PercentAmerican Indian and Alaskan Native:

NumberAmerican Indian and Alaskan Native_2:

PercentAmerican Indian and Alaskan Native_2:

NumberAsian:

PercentAsian:

NumberAsian_2:

PercentAsian_2:

NumberNative Hawaiian and Other Pacific Islander:

PercentNative Hawaiian and Other Pacific Islander:

NumberNative Hawaiian and Other Pacific Islander_2:

PercentNative Hawaiian and Other Pacific Islander_2:

NumberSome Other Race:

PercentSome Other Race:

NumberSome Other Race_2:

PercentSome Other Race_2:

NumberTwo or More Races:

PercentTwo or More Races:

NumberTwo or More Races_2:

PercentTwo or More Races_2:

NumberPersons with Disabilities:

PercentPersons with Disabilities:

NumberPersons with Disabilities_2:

PercentPersons with Disabilities_2:

NumberVolunteers:

File details come from the government source that posted it. Updated Jul 1, 2025.