ATTACHMENT 1
OFFEROR REPRESENTATIONS AND CERTIFICATIONS
FAILURE OF THE OFFEROR TO COMPLETE AND SIGN THIS FORMMAYRESULT IN REJECTION
OF THE SUBMITTED OFFER
The undersigned, having full knowledge of the specifications for the goods or services specified herein, offers and agrees that this offer shall be irrevocable for at least 30 calendar days after the date offers are due or as stated in the solicitation, and if accepted, to furnish any and/or all goods or services as described herein at the prices offered and within the time specified.
OFFEROR NAME:
ADDRESS:
TELEPHONE NUMBER: FAX NUMBER:WEBSITE:
DATE/STATE OF INCORPORATION:
BUSINESS DESIGNATION: Corporation Sole Proprietor Partnership
S Corporation Non-Profit Government
Other
MWESB CERTIFICATION: Number Minority Owned Woman Owned Emerging, Small N/A
ASSURANCES – The Offeror attests that:
- The person signing this offer has the authority to submit an offer and to represent Offeror in all phases of this procurement process;
- The information provided herein is true and accurate;
- The Offeror is a resident proposer, as described in ORS 279A.120, of the State of ______, [insert State]and has not discriminated against any minority, women, or emerging small business enterprises in obtaining any required subcontracts, in accordance with ORS 279A.110;
"Resident bidder" means a bidder that has paid unemployment taxes or income taxes in this state during the 12 calendar months immediately preceding submission of the bid, has a business address in this state and has stated in the bid whether the bidder is a "resident bidder". ORS 279A.120 (1)(][b);
- Any false statement may disqualify this offer from further consideration or be cause of contract termination; and
- The Offeror will notify the Department Contracts Officer within 30 days of any change in the information provided on this form.
CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS – TheOfferorcertifies to the best of its knowledge and belief that neither it nor any of its principals:
1.Are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from submitting bids or proposals by any federal, state or local entity, department or agency;
2.Have within a five-year period preceding the date of this certification been convicted of fraud or any other criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) contract, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
3.Are presently indicted for or otherwise criminally charged with commission of any of the offenses enumerated in paragraph 2. of this certification;
4.Have, within a five-year period preceding the date of this certification had a judgment entered against contractor or its principals arising out of the performance of a public or private contract;
5.Have pending in any state or federal court any litigation in which there is a claim against contractor or any of its principals arising out of the performance of a public or private contract; and
6.Have within a five-year period preceding the date of this certification had one or more public contracts (federal, state, or local) terminated for any reason related to contract performance.
Where Offeror is unable to certify to any of the statements in this certification, Offeror shall attach an explanation to their offer. The inability to certify to all of the statements may not necessarily preclude Offeror from award of a contract under this procurement.
SIGNATURE OF AUTHORIZED PERSON
Signature Date
Print Name & Title
Contact Person for this procurement:
Phone Email
ATTACHMENT 2 A
PROPOSAL COVER PAGE
FOR PROVIDER QUALIFICATIONS
REQUEST FOR PROGRAMMATIC QUALIFICATION
For
RFPQ No. R11-10339
Domestic Violence Victim Services
A continuously open procurement
PROPOSALS DUE:SEE COVER PAGE OF RFPQ FOR DETAILS.
PROVIDER QUALIFICATION
By submitting this Proposal, Proposer certifies that, if found to be a Qualified Provider, Proposer will attend the optional Oral Evaluations to clarify questions regarding their subsequent Proposals for any and all Service Categories submitted.
By submitting this Proposal, Proposer certifies that, if Proposer is affiliated with a religious organization, services will be provided in a wholly secular manner.
Proposers Name:
Authorized Signature:
Authorized Signer’s Title:
ATTACHMENT 2 B
PROPOSAL COVER PAGE
FOR SERVICE AREA QUALIFICATION
REQUEST FOR PROGRAMMATIC QUALIFICATIONS
For
RFPQ No. R11-10339
Domestic Violence Victim Services
A continuously open procurement
PROPOSALS DUE:SEE COVER PAGE FOR DETAILS
SERVICE AREA QUALIFICATION
Proposer:
Please Identify OnlyONE (1) Service Area Being Proposed By This Proposal
R11-10339 Domestic Violence Victim ServicesPage 1 of 9
Emergency Services
Category 2.1 – Emergency Shelter
Category 2.2 – 24/7 Crisis Line
Category 2.3 – Comprehensive
Non-Facility-Based
Transitional Housing
Category 3.0 – Transitional Housing
Target Outreach Populations
Category 4.1 – African American / African
Category 4.2 – Latina / Hispanic
Category 4.3 – Native Americcan / Alaskan Native
Category 4.4 – Russian Speaking Immigrants or Refugees
Category 4.5 – Asian and other Immigrants or Refugees
Category 4.6 – Sexual Minorities including Gay, Lesbian, Bi-Sexual, or Transgendered Individuals
Category 4.7 – Other
(Not Currently Funded)
Community Based Services (CBS)
Category 5.1 – Court House Restraining Order
Category 5.2 – Legal Services
CBS Co-Located Services
Category 5.3.1 – DVERT Advocacy Services General Population
Category 5.3.2 – DVERT Advocacy Services Spanish-Speaking Victim/Survivor
Category 5.3.3 – Safe Start Advocacy Services General Population
Category 5.3.4 – Safe Start Advocacy Services Spanish-Speaking Victim/Survivor
Category 5.3.5 – Safe Start Parent-Child Specialist Services
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ATTACHMENT 3
EXCEPTIONS TO TERMS AND CONDITIONS
Reference: Section 4.2.1.
Required if Proposer has exceptions to contract terms and conditions
ATTACHMENT 4
MEMORANDUM OF UNDERSTANDING
Reference: See Section 1.3
If Proposer is submitting proposal as a Lead Agency (Proposer) providing services through a consortium, a signed or draft copy of the working agreement or Memorandum of Understanding (MOU) between the Proposer and all the participating members of the consortium must accompany the response to this RFPQ.
ATTACHMENT 5
FISCAL BUDGET AND AUDIT DOCUMENTS
Reference: See Section 2.4.1 Fiscal Requirements
Proposer to insert Full Budget and most recent Financial Audit for Category 1 and/or Proposed Budget and 15% Match Requirements for Categories 2-5 as required.
ATTACHMENT 6
ELECTRONIC LINKS AND ADDRESS REFERENCE
Cover Page – Procurement Analyst Email Address
Cover Page – Purchasing Website for Multnomah County
Section 2.1 – Recommendations planning process meeting of June 23, 2010
Section 2.3.1 Item 4 – Training Requirements for DV Victim Advocacy
Section 3.5.1 Item 2 – Safety, Confidentiality, and Training
Section 2.3.1 Item 5 – Confidentiality and Safety for Victims/survivors and
Violence Against Women Act (VAWA) &
Section 3.5.1 Item 2 – Safety, Confidentiality, and Training and
Violence Against Women Act (VAWA)
Section 2.4.1 Item 5 – Office of Management and BudgetCircular A-122
Section 2.2 Item 10 – County PUR-8 Sustainability Practices Website
Section 3.5.1 Item 5 – County Recycling Website
ATTACHMENT 7
SAMPLE MULTNOMAH COUNTY CONTRACT
Reference: See Section 1.15
NOTE: A FULLCOPY OF THIS DOCUMENT IS AVAILABLE
ELECTRONICALLY FROM PURCHASING
See the Purchasing website at and click on the “Current Bid and Proposal Opportunities” heading – scroll down to Procurement R11-10339.
Printed copies may also be obtained upon request to the assigned
Procurement Analyst. Request your copy by contacting:
Procurement Analyst: Lisa Emery
503.988.5111, Extension 25881
attachment 8
NO BID / COMMENT FORM
Solicitation #: R11-10339
Solicitation Name: Domestic Violence Victim Services
Prospective Bidder or Proposer:
If you determine not to submit a bid or proposal in response to this solicitation, or have comments to provide regarding our solicitation process, please complete and return this form for our records so that we may consider your response.
“My firm has declined to submit a response for the following reason(s)(please check all reasons applicable that apply and explain below):
We do not offer this commodity and/or service or an equivalent
Insufficient time to respond to the solicitation
Too busy / our schedule would not permit us to perform
Project’sbudget estimate is too low / inadequate
Bid Pages/evaluation questions too complicated (please indicate specific issues below)
Instructions not clear (please indicate specific issues below)
Other (please explain)
Remarks:______
______
______
______
Attach additional page(s) if necessary
Company Name:Optional: Would you like us to contact you regarding this form? If so, please provide:
Contact Name: ______Phone #: ______
Thank you for your assistance. Please send this form via email, mail or fax to:
Multnomah County Purchasing
Attn: Lisa Emery
501 SE Hawthorne Blvd., Suite 400
Portland OR 97214
Fax: 503-988-3252
Email:
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