State in Which Organized/Incorporated
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PROVIDER NAME
ADDRESS
CONTACT PERSON POSITION
TELEPHONE ( )
STATE IN WHICH ORGANIZED/INCORPORATED
TYPE OF CORPORATION
ASSURANCES & CERTIFICATIONS
1. Sign here to certify that, under penalty of perjury, your provider agency has completed this Request for Proposal independent of any outside influence which may result in your receiving privileged information about this RFP.
Authorized Signature Date
2. Sign here to certify that this RFP factually represents your administrative capabilities and proposed services and if approved, you agree to abide by the terms and conditions of the Provider Agreement (Attached).
Authorized Signature Date
3. Sign here to certify that if your agency is approved, you agree to provide services at the rate described in this RFP, Section III.
Authorized Signature Date
1 4. Please check the status of your agency (check all that apply).
□ Minority-owned □ Woman-owned □ Small Business □ Non-profit organization □ Current Contractor □ Previous Contractor, but not □ New/Prospective Contractor current □ Other (please specify) □ “Certified” or “certification in process” with State Office of Minority and Women Business Assistance (SOMWBA).
5. Is your agency currently under Federal or State debarment? □ Yes □ No If yes, please explain.
6. Check every box below for which you have a written policy. Sign to certify that the checked documents are on file at your agency.
□ Personnel Policies □ Affirmative Action Policy □ Non-discrimination in Hiring Policy (Agencies who receive more □ Non-discrimination Service Delivery than $50,000 in business Policy during the last fiscal year.) □ Policy Regarding Client Confidentially □ Uniform Financial in Statement and Auditor’s Report (UFR), if your agency does more than $100,000 in business with the state.
Authorized Signature Date
2 7. Sign here to certify that you have read the terms and conditions of the Request for Proposal and the terms and conditions defined in the attached Provider Agreement and that if you are selected by Elder Services of Berkshire County, Inc. as a Purchased Service Provider, you will abide by those terms and conditions.
Authorized Signature Date
8. Sign here to certify that your agency has purchased sufficient liability insurance and secured all required licenses, certifications, permits and accreditation.
Authorized Signature Date
For most other services, rates approved by the Executive Office of Elder Affairs will apply to this RFP. In certain instances, Elder Services of Berkshire County, Inc. will negotiate the rate.
A. For providers who are submitting rates for Elder Services to negotiate and/or approve, please include cost factors and units of service used to develop the rate.
Sign here to certify that your agency’s rate and development of the rate is as accurate as possible relating to all costs included in this rate.
Authorized Signature Date
3 IV REFERENCE SECTION
The following definitions apply to terms used in this proposal packet:
Small Business – means a business concern which is independently owned and operated, not dominant in its field of operation and based on unique aspects of Massachusetts industry, would be defined as a “small business” under applicable federal law.
Minority Business – means a private profit-making or private non-profit making entity doing business in Massachusetts which provides goods or services and which is owned or controlled by one or more minority persons. “Minority”, meaning a person who is American Indian, Black, Asian, Hispanic or Cape Verdean.
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