CALIFORNIA DEPARTMENT OF REHABILITATION
AMERICAN RECOVERY AND REINVESTMENT ACT 2009
STIMULUS FUNDS – SERVICE PROVIDER PROJECTS
HUMBOLDT AND DEL NORTE COUNTIES
RFP #11-01-05
REQUEST FOR PROPOSAL
Notice to Prospective Proposers
TABLE OF CONTENTS
I. SCHEDULE OF EVENTS................................................................................. 2
II. PURPOSE OF REQUEST FOR PROPOSAL .................................................... 2
III. DESCRIPTION OF PROJECT FUNDING ACTIVITIES .................................... 3
IV. MINIMUM QUALIFICATIONS FOR PROPOSALS ........................................... 6
V. CLARIFICATION OF RFP REQUIREMENTS ................................................... 6
VI. PROJECT DESCRIPTION REQUIREMENTS ................................................. 7
VII. SUBMISSION OF PROPOSAL ....................................................................... 8
VIII. EVALUATION AND AWARD........................................................................ 10
RFP EVALUATION SYSTEM AND RATING FACTORS ........................................ i
The Department of Rehabilitation (DOR) will award federal stimulus funds from the
American Recovery and Reinvestment Act (ARRA) of 2009. DOR Community
Rehabilitation Program (CRP) Service Providers are invited to review and respond
to this Request for Proposal (RFP) entitled Stimulus Funds – Service Provider
Projects: Humboldt and Del Norte Counties. In submitting your proposal, you
must comply with the instructions found herein.
All agreements entered into with the State of California will include the General
Terms and Conditions and Contractor Certification Clauses, and also include the
applicable Federal language requirements, assurances, and certifications. All
awards are contingent upon passage of the State of California budget and
authorized spending authority.
In the opinion of the DOR, this RFP is complete and without need of explanation.
However, if you have questions, or should you need any clarifying information
regarding the RFP and its submittal process, the contact for this RFP is:
Sandy Cook
Contracts and Procurement Section (C&PS)
Statewide Contract and Grants Administrator
Department of Rehabilitation
(916) 558-5688
Please note that no verbal information given will be binding upon DOR unless the
questions and answers are published by DOR on its website.
Any written questions regarding this RFP may be submitted in writing according to
Section I. Schedule of Events listed in this RFP to:
Email address: crdssinfo@dor.ca.gov
or FAX at (916) 558-5446
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I. SCHEDULE OF EVENTS
RFP Release Date
(January 28, 2011)
Written Question Submittal Deadline
(February 4, 2011 by 5:00 pm)
Pre-Proposal Teleconference
(February 9, 2011 at 1:00 pm)
Final Date for Proposal Submission
(Hard Copy)
(February 16, 2011 by 4:00 pm)
Final Date for Proposal Submission
(E-Copy)
(February 16, 2011 by 4:00 pm)
Post Notice of Intent to Award*
(February 28, 2011 by 5:00 pm)
(February 28 – March 4, 2011)
Notice of Appeals Deadline*
(April 1, 2011 – September 30, 2011)
Anticipated Contract Term Dates*
* All dates after the Final Date for Proposal Submission are tentative and subject
to change by DOR written notification to all Proposers.
II. PURPOSE OF REQUEST FOR PROPOSAL
The American Recovery and Reinvestment Act of 2009 (ARRA) appropriates
significant new funding for Vocational Rehabilitation projects to help individuals
with disabilities, especially those individuals with the most significant disabilities,
prepare for, obtain, and maintain employment.
The DOR has received funding from the ARRA in order to further meet its mission
and goals. DOR has set aside a total of $400,000 to award project funded
contracts of up to $200,000 (Two Hundred Thousand dollars) per award, to CRPs
for a short-term period that ends on September 30, 2011.
The purpose of this RFP and resulting project funded contracts is to use ARRA
funding:
 To advance California and local economic recovery through the
maintenance and creation of jobs, in accordance with the ARRA guidelines.
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 Implement projects to create jobs, improve job placement and/or result in a
greater capacity in support of improved outcomes, which will provide
services to Californians.
 To use one-time funds to invest in a project that has long term, sustainable
results.
 Contingent upon DOR’s need for the service in a particular area/location.
 Consistent/aligned with the DOR Strategic and State Plans that works with
stakeholders to provide employment, independence and equality for
individuals with disabilities. (The DOR Strategic and State Plans may be
viewed at http://www.dor.ca.gov/index.htm)
CRP’s must comply with reporting requirements as described by DOR in
accordance with the requirements of the ARRA as administered by the
Rehabilitation Services Administration.
III. DESCRIPTION OF PROJECT FUNDING ACTIVITIES
The overall goals of the ARRA are to stimulate the economy short term and invest
in education and other essential public services to ensure long-term economic
health for the State of California.
CRPs shall submit a single proposal only (1 in total) for project funded contract
activities to:
A. Meet the ARRA purposes listed above in Section II. Purpose of Request for
Proposal outlined above
AND
B. Provide the following four DOR authorized services as outlined in the
“Description of Services” below:
1. Assessment Services
a. Comprehensive Vocational Evaluation
b. Situational Assessment (SA)
c. Vocational Assessment (VA)
2. Employment Services
3. Job Coaching - Individual
4. Personal, Vocational and Social Adjustment
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CRPs will not be required to provide any in-kind or cash match in order to receive
funding; however, funding is contingent upon passage of the State of California
budget and authorized spending authority.
Description of Services
Provide DOR authorized Assessment Services, Employment Services, Job
Coaching (Individual) and Personal, Vocational and Social Adjustment services in
accordance with the Community Rehabilitation Program Guide to Certification and
Vendorization, to DOR consumers located in the Humboldt County and Del Norte
County areas, who are not receiving services through a DOR cooperative/case
service contract. The Community Rehabilitation Program Guide to Certification
and Vendorization can be accessed on the Internet at
http://www.dor.ca.gov/public/forms.htm.
Expected Goals/Outcomes: A CRP awarded a contract is expected to provide
authorized Assessment Services, ES, Job Coaching and PVSA services to a
reasonable number of DOR consumers during the contract period, and will
achieve successful employment of 30% of those consumers receiving ES
services, resulting in a positive competitive outcome per DOR closure criteria.
For purposes of this RFP, “reasonable” will be determined by the DOR, taking into
consideration the short-term period of the contract, the contract award amount and
the service capacity of the proposer.
Proposals must contain measurable goals and outcomes, including the number of
DOR consumers to be served and number of successful employment outcomes
per DOR closure criteria to be achieved during the project funding period and, a
detailed plan for carrying out project goals and objectives and resulting services to
DOR consumers to achieve the expected outcomes.
Sustainability of the service delivery project beyond the contract period will be a
significant factor in awarding funding as part of this RFP. The following fee-forservice rates for authorized Assessment Services, ES, Job Coaching and PVSA
services under the current Uniform Fee Structure for DOR CRP Providers is
provided for planning purposes beyond the contract period:
ASSESSMENT SERVICES
Comprehensive Vocational Evaluation
Case Service Code: 14
Rate: $180 per day - individual service
Situational Assessment
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Case Service Code: 14
Rate: $40 per hour - individual service
$55 per day - group service of 2-4 hours
$110 per day - group service of 5 or more hours
Vocational Assessment
Case Service Code: 14
Rate: $40 per hour-individual service
TRAINING SERVICES
Personal, Vocational, Social Adjustment
Case Service Code: 38
Rate: $40 per hour - individual service
$20 per hour - group classes of one hour per class
JOB RELATED SERVICES
Employment Services Benchmarks
Package Service: $2200 per consumer
Case Service Code: 69
 Intake
Rate: $300 per consumer
 Employment Preparation
Rate: $700 per consumer
 Job Development & Placement
Rate: $700 per consumer
 Employment Retention Services
Rate: $500 per consumer
Job Coaching - Individual
Case Service Code: 71
Rate: Hourly rates determined by Regulation
Currently $30.82 per hour
Note: Proposals submitted must not include any project funded contract activity
except that of Assessment Services, ES, Job Coaching (Individual) and PVSA.
Services supplementary to these services will not be funded through this RFP.
District Identified Needs Locations
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The DOR Redwood Empire District has identified Humboldt County and Del Norte
County as areas where a need for Assessment Services, ES, Job Coaching
(Individual) and PVSA exists.
Note: CRP proposers located outside of the district identified needs locations who
meet the minimum qualifications contained in Section IV. Minimum Qualifications
for Proposals may apply to provide the "above" consumer services and in the
above identified needs locations.
IV. MINIMUM QUALIFICATIONS FOR PROPOSALS
A CRP proposer must be:
1) A CRP that is certified by the Internal Revenue Service (IRS) as a 501(c)(3)
corporation and domiciled in the State of California and/or bordering states of
California; and
2) A non-profit corporation in good standing and authorized to do business in the
State of California (California Secretary of State certification; and
3) DOR-certified in accordance with the Community Rehabilitation Program Guide
to Certification and Vendorization, which can be accessed at:
http://www.dor.ca.gov/public/forms.htm.
Note: A proposer who meets the above minimum qualifications can also be a CRP
that provides services through a cooperative service/case service contract.
However, their proposal shall only be for projects that meet these RFP activity
requirements as listed, and must not duplicate and serve DOR consumers that
are currently being served under a DOR cooperative/case service contract.
V. CLARIFICATION OF RFP REQUIREMENTS
In addition to this RFP, DOR provides two other opportunities for CRPs to obtain
information about this RFP:
1. Written Questions Regarding the RFP
The deadline to submit written questions regarding this RFP are subject to times
and dates listed in Section I. Schedule of Events. Questions received after the
date and time listed will not be addressed. Written questions should include the
individual's name, firm name, and address, and must reference RFP #11-01-05.
DOR will receive written questions to which the answers will be addressed in the
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Pre-Proposal Teleconference at the times and date listed in item #2 of this
Section.
Written questions must be sent to:
Email address: crdssinfo@dor.ca.gov or fax (916) 558-5446
Subject Line: RFP #11-01-05
It is the responsibility of the Proposer to inquire about an expected addendum if
the addendum is not received.
2. Pre-Proposal Teleconference
Proposers are encouraged but not required to participate in DOR’s Pre-Proposal
Teleconference. The teleconference will allow potential proposers the opportunity
to receive information regarding proposal requirements and parameters, and the
opportunity to ask any technical questions regarding the RFP process. The
questions will become part of the Q&A document.
Teleconference Schedule
Wednesday, February 9, 2011
Time: 1:00 pm – 2:30 pm
Call in number: 1-877-601-3608, Participant Pass Code: 5633429
Proposers may utilize California Relay Service at 711 or their preferred Video
Relay Service to access the teleconference.
VI. PROJECT DESCRIPTION REQUIREMENTS
1) The “PROJECT DESCRIPTION” is divided into the following sections:
A. Organization Description (3 pages)
B. Project Summary (8 pages)
C. Implementation Plan (4 pages)
D. Budget Narrative and DR 801A Service Budget (8 pages)
E. All Attachments (attachments do not count toward stated page limits)
2) The Project Description must be presented in MS Word format using Arial,
font size 14, and shall not exceed 23 pages (single-sided) in length.
Additional attachments do not count toward the 23-page limit. The proposal
will be evaluated on the basis of completeness, clarity of presentation, and
adequacy of the degree to which it complies with the RFP.
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VII. SUBMISSION OF PROPOSAL
Proposals should be submitted based on the Attachment 1 Required
Attachment Check List.
1) Proposals should provide straightforward and concise descriptions of the
proposer’s ability to satisfy the requirement of this RFP. The proposal must be
complete and accurate. Omissions, inaccuracies or misstatements will be
sufficient cause for rejection of a proposal.
2) The proposal package should be prepared in the least expensive method.
3) All proposals must be submitted under sealed cover to the Department of
Rehabilitation by the dates and times shown in Section I. Schedule of Events.
Proposals received after the date and time will not be considered.
4) A minimum of “six” hard copies, one (1) original with signature, and five (5)
copies, of the proposal must be submitted.
5) One (1) electronic copy of the proposal must be sent via email as a Microsoft
Word document, subject to times and dates listed in Section I. Schedule of
Events. Email the electronic copy to:
Email Address: crdssinfo@dor.ca.gov
Subject: RFP #11-01-05
Electronic copies of proposals must be accessible to individuals using
assistive technology devices, e.g., screen readers.
6) The original proposal must be marked "ORIGINAL COPY". All documents
contained in the original proposal package must have original signatures and
must be signed by a person who is authorized to bind the proposing firm. All
additional proposal sets may contain photocopies of the original package.
7) The proposal envelopes must be plainly marked with the RFP number and
title, the firm name and address, and "DO NOT OPEN”.
Mail or deliver proposals (U.S. Postal Service deliveries, hand deliveries,
UPS, express mail and/or Federal Express) to the following address as
follows:
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Department of Rehabilitation-RFP #11-01-05
Attention: Service Provider Projects
Sandy Cook, C & PS Statewide Contracts and Grants Administrator
721 Capitol Mall, Sacramento, CA 95814
DO NOT OPEN
Proposals must be physically received in the C&PS subject to times and
dates listed in Section I. Schedule of Events (postmarks will not be
accepted). If the proposal is made under a fictitious name, business title,
or doing business as (dba), the legal name of Proposer must also be
provided. Proposals not submitted under sealed cover and marked as
indicated will be rejected.
8)
All proposals, including the electronic copy, shall include the documents
identified in Attachment 1: Required Attachment Check List, except as noted
in item 7) above regarding financial statements. Proposals that do not include
these required attachments shall be deemed non-responsive. A nonresponsive proposal is one that does not meet the basic requirements.
9)
Proposals must be submitted for the performance of all the services described
herein. Any deviation from the work specifications will not be considered and
will cause a proposal to be rejected.
10) A proposal may be rejected if it is conditional or incomplete, or if it contains
any alterations of form or other irregularities of any kind. The State may reject
any or all proposals and may waive any immaterial deviation in a proposal.
The State's waiver of immaterial deviation shall in no way modify the RFP
document or excuse the Proposer from full compliance with all requirements if
awarded the agreement.
11) Costs incurred for developing proposals and in anticipation of award of the
agreement are entirely the responsibility of the Proposer and shall not be
charged to the State of California.
12) An individual who is authorized to bind the proposing firm contractually shall
sign the Attachment 2: Proposal/Proposer Certification Sheet. The signature
must indicate the title or position that the individual holds in the firm. An
unsigned proposal will be rejected.
13) A Proposer may withdraw its proposal by submitting a written withdrawal
request to the State, signed by the Proposer. A Proposer may thereafter
submit a new proposal prior to the proposal submission deadline. Proposals
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may not be withdrawn without cause subsequent to proposal submission
deadline.
14) The awarding agency may modify the RFP prior to the date fixed for
submission of proposals by the issuance of an addendum to all parties who
received a proposal package.
15) The awarding agency reserves the right to reject all proposals. The agency is
not required to award an agreement. All awards are contingent upon passage
of the State of California budget and authorized spending authority.
16) Before submitting a response to this solicitation, Proposers should review,
correct all errors and confirm compliance with the RFP requirements.
17) Where applicable, a Proposer should carefully examine work sites and
specifications. No additions or increases to the agreement amount will be
made due to a lack of careful examination of work sites and specifications.
18) The State does not accept alternate contract language from a prospective
contractor. A proposal with such language will be considered a counter
proposal and will be rejected. The State’s General Terms and Conditions
(GTC) are not negotiable.
19) No oral understanding or agreement shall be binding on either party.
VIII. EVALUATION AND AWARD
A. Proposal Evaluation
At the time of opening, each proposal will be checked for the presence or absence
of required information in conformance with the submission requirements of this
RFP. Proposal evaluation and screening for attachments will be in accordance
with Appendix 1: RFP Evaluation System and Rating Factors. The evaluation
process will consist of two phases: Phase 1 - Administrative Screening, and
Phase 2 - Technical Review and Scoring. Multiple contracts may be awarded until
the funding for this RFP has been exhausted. However, in the event additional
ARRA funding beyond $400,000 becomes available for this RFP, the DOR
reserves the right to continue awards to eligible scored proposals that were not
able to be originally funded under the base award amount of $400,000.
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Phase 1- Administrative Screening - Pass/Fail
The Administrative Screening will be a Pass/Fail review of all eligible proposals to
determine which proposals have met RFP requirements in accordance with RFP
Evaluation System and Rating Factors. Proposals that pass ALL of the criteria in
the Phase 1- Administrative screening will be deemed responsive and submitted
to an Evaluation Panel for the Phase 2 -Technical Review and Scoring. Those
proposals that do not pass will be deemed non-responsive and will be rejected
from further consideration.
Phase 2 – Technical Review and scoring - Maximum Possible Points = 100
Proposals deemed responsive will be scored by a minimum of three (3) but not
more than (5) panel members selected by the DOR. Scoring will be in accordance
with the Phase 2 - Technical Review and Scoring criteria as indicated in the RFP
Evaluation System and Rating Factors. Proposals must score 70 points or above
to be considered for funding.
1) Tie Breakers - In the event of a tie score, the tiebreaker will be conducted by a
random drawing conducted by DOR contract staff.
2) Rounding of Decimal Point Scores - Decimal point scores shall be rounded to
the nearest whole number. (For example: 20.3 will be 20).
3) Final awards – Final scores will be determined based on an average of the
consensus scores of panel members. The DOR will prioritize all responsive
and responsible proposals, with the highest scored proposal considered for
funding first, then all subsequent proposals prioritized in order according to
score.
B. Award and Appeal
1) Notice of the Intent to Award shall be posted in a public place in the office of
Department of Rehabilitation, and also at www.bidsync.com, for five (5)
working days prior to the official awarding the contract(s).
2) If any Proposer, during the five working day Intent to Award notice period,
files an appeal with the Department of Rehabilitation on the grounds that the
(appealing) Proposer would have been awarded the contract had the agency
correctly applied the evaluation standard in the RFP, or if the Proposer
followed the evaluation standards and scoring methods in the RFP, the
agreement shall not be awarded until either the appeal has been withdrawn
or the Department of Rehabilitation has decided the matter.
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3) During the five (5) working days Intent to Award period, the appealing
Proposer shall file with the Department of Rehabilitation a detailed statement
specifying the grounds for the appeal. The Proposer must submit any appeal
by certified or registered mail.
4) Upon resolution of the appeal and award of the contract. Contractor must
complete and submit to the awarding agency any revisions to the Payee
Data Record (STD 204), used to determine if the Contractor is subject to
state income tax withholding pursuant to California Revenue and Taxation
Code Sections 18662 and 26131. This form can be found on the Internet at:
http://www.osp.dgs.ca.gov/StandardForms/Automated+Standard+eForms.ht
m
5) No payment shall be made unless a completed STD 204 is submitted to the
awarding agency.
C. Disposition of Proposals
1) Upon proposal opening, all documents submitted in response to this RFP
will become the property of the State of California, and will be regarded as
public records under the California Public Records Act (Government Code
Section 6250 et seq.) and subject to review by the public.
2) Proposal packages may be returned only at the Proposer’s expense, unless
such expense is waived by the awarding agency.
D. Agreement Execution and Performance
1) Service shall start on the date set by the awarding agency and the
Contractor, after all approvals have been obtained and the agreement is fully
executed. Should the Contractor fail to commence work at the agreed upon
time, the awarding agency, upon five (5) days written notice to the
Contractor, reserves the right to terminate the agreement.
In addition, the Contractor shall be liable to the State for the difference
between Contractor's Proposal price and the actual cost of performing work
by another Contractor.
2) All performance under the agreement shall be completed on or before the
termination date of the agreement.
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3) ARRA funds must be spent with an unprecedented level of transparency and
accountability. DOR reserves the right to reallocate ARRA funds away from
contract recipients who are underutilizing said funds by at least 10% through
the second quarter of funding. All redirected contract project funds may be
reallocated to other RFP contract awarded recipients to ensure ARRA
funding is fully maximized.
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APPENDIX 1
RFP EVALUATION SYSTEM AND RATING FACTORS
SERVICE PROVIDER PROJECTS RFP #11-01-05
INSTRUCTIONS FOR PROPOSAL EVALUATION
A responsive and responsible proposal is one that meets or exceeds the RFP requirements.
Phase 1 - Administrative Screening: The DOR staff will complete the Administrative
Screening. Proposals that meet the Phase 1- Administrative Screening requirements as
indicated on page ii will be forwarded to the Evaluation Panel for the Phase 2 - Technical
Review and Scoring.
Phase 2 - Technical Review and Scoring: Proposals will be evaluated as described under
Program Description and the Budget Narrative and Proposed Budget. Each panel member
will individually evaluate and numerically score the technical components of the proposal
against the stated criteria and the degree to which it complies with the RFP requirements. A
responsive and responsible proposal must have an overall minimum score of 70 points to be
eligible for award.
Proposals should be written in a narrative format and include a brief project abstract.
Proposals should describe the project services to be provided, how those services are
aligned with the priorities listed in this RFP, fiscal effectiveness of the project, the number of
jobs (staff and contractors) that will be created or retained during the project period, and
finally, identify the needs assessment for the particular location to be proposed. Job creation
for the purposes of this proposal will include staff hired by the project, to include
subcontractors and suppliers. Jobs retained for the purposes of this proposal will include
staff positions previously identified to be eliminated but which were retained through the use
of ARRA funding. This information is not intended to be all-inclusive and other significant
details about the proposal should be included accordingly. The proposal should give the
review team a concrete understanding of the service delivery needs the project intends to
address and the solutions given by the proposer, including a description of the process for
evaluating the results.
The following criteria will be used when considering the extent to which a Proposal is
successful in addressing the necessary components in the project description.
i
APPENDIX 1
PROPOSAL EVALUATION SCORING WORKSHEET
FOR SERVICE PROVIDER PROJECTS RFP #11-01-05
Phase 1 Administrative
Screening
Phase 2 Technical Review and Scoring
= Pass/Fail
= Maximum Points 100
PHASE 1 - ADMINISTRATIVE SCREENING (PASS/FAIL)
Evaluator Name (Printed):
Evaluator Signature:
Proposer’s Name/Identifier:
Phase 1 - Administrative Screening
All items indicated must be checked ”yes” in order to PASS and move to the Phase 2
Technical Review and Scoring
YES
NO
 Six (6) Proposal Copies
yes
no
(1 original signed and 5 copies)
 One Email Copy of Proposal
yes
no
 Required Attachment Check List – (Attachment 1
completed)
yes
no
Meets Minimum Requirements
 Internal Revenue Service (IRS) 501(c)(3) Letter
 California Secretary of State certification “active” status
 DOR-certified (or eligible for certification)
Project Description (within 15 pages)
 A. Organizational Description (3 pages)
- Organizational chart of key staff and project team
- Full resumes of CRP’s major key staff
- Duty statement for each project team member
 B. Project Summary (8 pages)
 C. Implementation Plan (4 pages)
 D. Budget Narrative and Proposed Budget (DR 801A) (8 pages)
PASS
If no, provide brief statement:
ii
yes
yes
yes
no
no
no
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no
APPENDIX 1
PROPOSAL EVALUATION CRITERIA SCORING WORKSHEET
FOR SERVICE PROVIDER PROJECTS RFP #11-01-05
PHASE 2 -TECHNICAL REVIEW AND SCORING (100 points)
Evaluator Name (Printed):
Evaluator Signature:
Proposer’s Name/Identifier:
For each item listed, the reviewer will assign the following point value:
Missing - 0 points
Proposal fails to address the component or the Proposer does not describe
any experience related to the component. Information is missing.
Insufficient information- 1 Point
Proposal minimally addresses the component, but one or more major
considerations of the component are not addressed, or so limited that it results
in a low degree of confidence in the Proposer’s ability to perform identified
activities.
Minimally meets criteria- 2 points
All considerations of the component are addressed adequately, but one or
more minor considerations may not be addressed. There is minimal degree of
confidence in the Proposer’s ability to perform identified activities based on the
information submitted.
Meets expectations - 3 points
The component is fully developed, comprehensive and has no deficiencies.
There is an acceptable degree of confidence in the Proposer’s ability to
perform identified activities based on the information submitted.
Exceeds expectations - 4 points
The proposal clearly addresses each component sufficiently to generate the
highest degree of confidence in the Proposer’s ability to perform identified
activities based on the information submitted.
iii
APPENDIX 1
ORGANIZATIONAL DESCRIPTION
Not to Exceed 3 Pages
24 POINTS POSSIBLE
Organizational description is designed for DOR to understand how the award
will be properly utilized based upon past history of the organization that reflects
its trustworthiness and success. The description must provide the following:
Score each item # below rate a value of 0-4 pts:
1. Concise description of the history of the CRP and
provide relevant experiences in providing proposed
project activities.
2. Describes individuals currently being served, including
any special languages or disability groups.
3. Description of how the CRP is financially
sound/solvent.
4. An organization chart of key staff and the proposed
project team.
5. Full resumes of key staff and key subcontractor for
proposed project.
6. Clearly defined duty statements for all positions to be
funded by the project.
SUBTOTAL
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Enter Score:
APPENDIX 1
PROJECT SUMMARY
Not to Exceed 8 Pages
32 POINTS POSSIBLE
Project Summary must describe all of the following:
Score each item# below rate a value of 0-4 pts:
Enter Score:
1. Describes how the CRP qualifies to provide the
project activities described under Purpose of RFP.
2. Describes how the proposed project fulfills an
identified need for individuals with disabilities and
identifies all service location(s).
3. Describes how the project is consistent and aligns
with the DOR Strategic Plan and State Plan for
Vocational Rehabilitation http://www.dor.ca.gov/.
4. Describes all locations where services will be
provided.
5. Describes clear and obtainable deliverables to
meet RFP objectives. Proposal contains
measurable goals and outcomes of the number of
DOR consumers to be served and for ES, the
number of successful employment outcomes per
DOR closure criteria to be achieved during the
project funding period.
6. Describes how the project model will be
sustainable after the contract period is over.
7. Describes long-range benefits that will exist after
the contract project period is ended, and how the
project will contribute to local economic recovery
including the creation or maintenance of jobs.
8. Describes how the CRP will ensure a tracking
methodology of the number of jobs (staff and
contractors) that will be created or retained during
the contract project period.
SUBTOTAL
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APPENDIX 1
IMPLEMENTATION PLAN
Not to Exceed 4 Pages
12 POINTS POSSIBLE
Implementation plan describes how the project will be carried out clearly
describing the following:
Score each item# below rate a value of 0-4 pts:
1. Identifies all major tasks and activities and its
responsible personnel.
2. Identifies task implementation, desired goals and
objectives to include a proposed method of evaluating
success and cost effectiveness of the project.
3. Identifies appropriate timelines and dates for
milestones, benchmarks and/or outcomes. Has articulated
specific outcomes to be achieved by the contract project
activities.
SUBTOTAL
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Enter Score:
APPENDIX 1
PROPOSED BUDGET NARRATIVE AND DR 801A
Not to Exceed 8 pages
32 POINTS POSSIBLE
Proposed Budget: A budget narrative and a completed DR 801A cost format
are required. Budget details must identify a concise description and justification
of the costs associated to carry out the contract project activities as listed in the
RFP. Each line item cost is justified and explains the related cost to the
contract project activities for the following:
Score each item# below rate a value of 0-4 pts:
1. Personnel, Equipment or Operating line item costs
are referenced in the Budget Narrative, clearly
identified, justified in a fiscally efficient manner as
appropriate, and aligned with the DR 801A Service
Budget.
2. Salaries and benefits include full-time equivalency
(FTE) based on a 40 hr workweek, salary rates, and
personnel classifications w/ percentage of personnel
time charged to the contract project activities.
3. Indirect costs are clearly identified, include detailed
math formulas/calculations to justify indirect costs,
and does not exceed 15% of total budget.
4. Line items are detailed (i.e., no miscellaneous
items are included). Major Equipment costs over
$5,000 per item referenced in the Budget Narrative is
itemized.
5. All costs are allowable, realistic, and applicable to
project proposed. Proposed Budget does not exceed
amount to be awarded per the RFP.
6. Describes how the CRP will ensure transparency in
reporting and fiscal accountability.
7. Details about cost ensure project funds will not be
used to supplant other existing services
8. Proposer has submitted copies of proposed payroll
activities records used to track time spent on the
project.
SUBTOTAL
vii
Enter Score:
ATTACHMENT 1
REQUIRED ATTACHMENT CHECK LIST
SERVICE PROVIDER PROJECTS RFP #11-01-05
A complete bid or bid package will consist of the items identified below.
Complete this checklist to confirm the items in your bid. Place a check mark or “X” next to
each item that you are submitting to the State. For your bid to be responsive, all required
attachments must be returned. This checklist must be returned with your bid package.
Attachment #
Name/Description
Attachment 1
Required Attachment Check List
Attachment 2
Proposal/Proposer Certification Sheet
Attachment 3
PROJECT DESCRIPTION:
A. Organizational Description (3 pages) and the following
attachments:
1) Organizational chart
2) Resumes of major key staff or major key subcontractors
3) Duty statements for all positions/subcontractors to be
funded by the project
4) Financial Statements (needs two month cash flow)
B. Project Summary (8 pages)
C. Implementation Plan (4 pages)
Attachment 4
D. Budget Narrative and DR 801A Proposed Budget
(8 pages)
Attachment 5
Attachment 6
Attachment 7
Attachment 8
Attachment 9
Payee Data Record (Std.204)
Contractor Certification Clauses CCC-307
Darfur Contracting Act Certification Form
Federal Funded Assurances/Certifications
Certification regarding Lobbying, Debarment, Suspension and
Other Responsibility Matter: and Drug-Free Workplace
Requirement
Proof of Non-Profit status from the Internal Revenue Service
(IRS), Certification of Good Standing from CA Secretary of State,
Attachment 10
ATTACHMENT 2
PROPOSAL/PROPOSER CERTIFICATION SHEET
SERVICE PROVIDER PROJECTS RFP #11-01-05
This Proposal/Proposer Certification Sheet must be completed, signed and
returned along with all the "required attachments" as an entire package in
duplicate with original signatures. The proposal must be transmitted in a sealed
envelope in accordance with RFP instructions.
Do not return Sections I. through VI. of the RFP - Proposal Information, nor the
“Sample Agreement” at the end of this RFP.
 Place all required attachments behind this certification sheet.
 The signature affixed hereon and dated certifies compliance with all the
requirements of this proposal document. The signature below authorizes
the verification of this certification.
An Unsigned Proposal/Proposer Certification Sheet may be cause for rejection
1. Company Name:
2. Telephone Number:
3. Fax Number:
4. Address:
5. City, State Zip Code:
6. County:
Indicate your organization type
7. Public:
8. Private Non-Profit
Indicate the applicable corporation number
9. Federal Employee ID No. (FEIN):
10. California Corporation No.:
Indicate Contact information
11. Proposer’s Name (Print):
12. Title:
13. Email Address:
14. Signature:
15. Date:
ATTACHMENT 3
PROJECT DESCRIPTION - Microsoft Word format, 14 font
SERVICE PROVIDER PROJECTS RFP #11-01-05
PROJECT DESCRIPTION
A.
Organization Description (3 pages) and Attachments
B.
Project Summary (8 pages) and Attachments
C.
Implementation Plan (4 pages)
D.
See Attachment 4 for Budget Narrative and Proposed Service Budget
- DR 801A (8 pages).
Proposed Budgets must be submitted in this format:
 For Personnel, identify each line item as P1, P2, etc.
 For Operating, identify eachline item as O1, O2, etc.
 For Subcontracting, identify each line item as S1, S2, etc.
 For Major Equipment, identify each line item as E1, E2, etc.
Please identify if equipment for reporting purposes of your
organization is less than $5,000 and considered major
equipment
 If the proposed budget line items are determined as unallowable
in accordance to this RFP, your proposal will be rejected.
ATTACHMENT 4- INSERT EXCEL DR 801A
SERVICE PROVIDER PROJECTS RFP #11-01-05
Note: EXPENDITURES AND LINE ITEMS NOT ALLOWED
Expenses and line items such as, but not limited to, the following are unallowable
expenditures and will NOT be paid under the ARRA contract:






















Automotive vehicles
Awards or trophies
Bad debts
Commute mileage
Construction (new or otherwise) and/or remodeling, alteration, improvement, or repair of
privately-owned property.
Contingency fund for reserves
Entertainment
Expenses which are described as “miscellaneous” or “etc.”
Fines and penalties
Food/refreshments (including bottled water or water service)
Fundraising and investment management
Goods and services for personal use (i.e., PDA, cell phone)
Indirect costs that exceed 15% as identified on the DR 801A
Indirect costs additionally budgeted as a direct line item expense, if an indirect cost rate
is already used
Interest
Lobbying activities
Out-of-State travel
Petty cash
Real Property
Relocation expenses
Severance pay
Volunteer or other recognition
OMB Circular A-122 cost principles also include additional unallowable expenses that may
not be included in this section. Refer to the applicable OMB Circular for your organization for
more information. Go to http://www.whitehouse.gov/omb/circulars/index.html
ATTACHMENT 4 BUDGET NARRATIVE and COST JUSTIFICATION
COST JUSTIFICATION SHALL INCLUDE AN EXPLANATION/OR FORMULA OF THE
COSTS AS IT RELATES TO THE PROJECT AGREEMENT
SERVICE PROVIDER PROJECTS RFP #11-01-05
PERSONNEL
Personnel: List each staff member (or proposed staff), their pay per hour and number of hours per year dedicated to
program. Include supervision personnel and/or support costs, if any
Fringe Benefits: List, for each staff member (or proposed staff), the benefits provided, percent paid by the
Contractor/Subgrantee and the percent paid by the staff. Explain how the benefits are determined. If using a fringe benefit
rate, explain how this percentage is justified or approved by your organization.
OPERATING EXPENSES
Rent & Utilities: List amounts paid for rent or mortgage and the associated utilities (electric, gas, water and trash pickup)
used by program/project staff.
Operating Services: List amounts for telephone, alarm, janitorial, landscaping, internet, insurance and other operating
services used by program/project staff. Maintenance agreements may be included.
Travel: Indicate the amount requested for staff travel. Provide an explanation of the travel costs as it relates to the
agreement.
Staff Development: Show estimated costs for training and education of staff involved in the project. Review the typical
type of training allowable to staff, include conference travel.
Minor Equipment: Indicate the cost of non-expendable personal property that has a useful life of more than one year with
a per unit cost of $4,999 or less. Include a detailed description of minor equipment to be purchased with price information.
Explain the purpose of the equipment as it relates to the proposed project.
Materials and Supplies: Include the cost of consumable supplies and materials used during the program period. Describe
types of items and justify need for items.
General Administrative Costs: Administrative costs may also include that portion of salaries and benefits of the project’s
director and other administrative staff not attributable to the time spent in support of a specific project.
MAJOR EQUIPMENT
Major Equipment: Indicate the cost of non-expendable personal property that has a useful life of more than one year with
a per unit cost of $5,000 or more. Include a detailed description of equipment to be purchased with price information.
Explain the purpose of the equipment as it relates to the proposed program.
SUBCONTRACTORS
Consortium Partners: If consortium partners assist this project, List each staff member (or proposed staff), resumes, their
pay per hour and number of hours per year dedicated to program. Include supervision personnel and/or support costs, if
any. Include sample proposed collaboration partnering agreement. Note: Consortium partners must meet the minimum
requirements as the prime awardee. The Consortium agreement must be submitted with the final approved agreement.
Subcontractors: If subcontractors are hired for pay to assist this project. List each subcontractor, their pay per hour and
number of hours per year dedicated to program/project. Indicate how subcontractors will be selected.
Professional & Outside Services: If professional consultants/services costs are proposed in the budget, define how the
costs for these services were determined and the justification for the services related to the project services. Temporary
personnel services, payroll services may be included.
INDIRECT COSTS: Indirect costs must be determined according to Federal OMB Circulars for Non-profits. Include a
narrative that describes the methodology or a copy an approved indirect cost.
ATTACHMENT 5
PAYEE DATA RECORD (STD 204)
FOR SERVICE PROVIDER PROJECTS RFP #11-01-05
The selected Contractor must submit a Payee Data Record (STD 204). This
form must be included in the proposal as a required attachment. The form is
provided separately. It can also be obtained at
http://www.documents.dgs.ca.gov/osp/pdf/std204.pdf.
ATTACHMENT 6
CONTRACTOR CERTIFICATION CLAUSES (CCC-307)
CERTIFICATION
I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to
legally bind the prospective Contractor to the clause(s) listed below. This certification is made under
the laws of the State of California.
Contractor/Bidder Firm Name (Printed)
Federal ID Number
By (Authorized Signature)
Printed Name and Title of Person Signing
Date Executed
Executed in the County of
CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the nondiscrimination program
requirements. (Gov. Code §12990 (a-f) and CCR, Title 2, Section 8103) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the requirements of the Drug-Free
Workplace Act of 1990 and will provide a drug-free workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession or use of a
controlled substance is prohibited and specifying actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free workplace;
3) any available counseling, rehabilitation and employee assistance programs; and,
4) penalties that may be imposed upon employees for drug abuse violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug-free workplace policy statement; and,
2) agree to abide by the terms of the company's statement as a condition of employment on the Agreement.
Failure to comply with these requirements may result in suspension of payments under the Agreement or termination of the
Agreement or both and Contractor may be ineligible for award of any future State agreements if the department determines
that any of the following has occurred: the Contractor has made false certification, or violated the certification by failing to
carry out the requirements as noted above. (Gov. Code §8350 et seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor certifies that no more than one (1) final
unappealable finding of contempt of court by a Federal court has been issued against Contractor within the immediately
preceding two-year period because of Contractor's failure to comply with an order of a Federal court, which orders
Contractor to comply with an order of the National Labor Relations Board. (Pub. Contract Code §10296) (Not applicable to
public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO REQUIREMENT: Contractor hereby certifies
that Contractor will comply with the requirements of Section 6072 of the Business and Professions Code, effective January
1, 2003.
Contractor agrees to make a good faith effort to provide a minimum number of hours of pro bono legal services during each
year of the contract equal to the lessor of 30 multiplied by the number of full time attorneys in the firm’s offices in the State,
with the number of hours prorated on an actual day basis for any contract period of less than a full year or 10% of its
contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for legal services, and may be taken
into account when determining the award of future contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an expatriate corporation or subsidiary of an
expatriate corporation within the meaning of Public Contract Code Section 10286 and 10286.1, and is eligible to contract
with the State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of apparel, garments or corresponding accessories, or the
procurement of equipment, materials, or supplies, other than procurement related to a public works contract, declare under
penalty of perjury that no apparel, garments or corresponding accessories, equipment, materials, or supplies furnished to
the state pursuant to the contract have been laundered or produced in whole or in part by sweatshop labor, forced labor,
convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop
labor, or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive
forms of child labor or exploitation of children in sweatshop labor. The Contractor further declares under penalty of
perjury that they adhere to the Sweatfree Code of Conduct as set forth on the California Department of Industrial Relations
website located at www.dir.ca.gov, and Public Contract Code Section 6108.
b. The Contractor agrees to cooperate fully in providing reasonable access to the Contractor’s records, documents, agents
or employees, or premises if reasonably required by authorized officials of the contracting agency, the Department of
Industrial Relations, or the Department of Justice to determine the Contractor’s compliance with the requirements under
paragraph (a).
7. DOMESTIC PARTNERS: For contracts over $100,000 executed or amended after January 1, 2007, the Contractor
certifies that Contractor is in compliance with Public Contract Code section 10295.3.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of California.
1. CONFLICT OF INTEREST: Contractor needs to be aware of the following provisions regarding current or former state
employees. If Contractor has any questions on the status of any person rendering services or involved with the
Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
1). No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee
receives compensation or has a financial interest and which is sponsored or funded by any state agency, unless the
employment, activity or enterprise is required as a condition of regular state employment.
2). No officer or employee shall contract on his or her own behalf as an independent Contractor with any state agency to
provide goods or services.
Former State Employees (Pub. Contract Code §10411):
1). For the two-year period from the date he or she left state employment, no former state officer or employee may enter
into a contract in which he or she engaged in any of the negotiations, transactions, planning, arrangements or any part of
the decision-making process relevant to the contract while employed in any capacity by any state agency.
2). For the twelve-month period from the date he or she left state employment, no former state officer or employee may
enter into a contract with any state agency if he or she was employed by that state agency in a policy-making position in
the same general subject area as the proposed contract within the 12-month period prior to his or her leaving state service.
If Contractor violates any provisions of above paragraphs, such action by Contractor shall render this Agreement void.
(Pub. Contract Code §10420)
Members of boards and commissions are exempt from this section if they do not receive payment other than payment of
each meeting of the board or commission, payment for preparatory time and payment for per diem. (Pub. Contract Code
§10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: Contractor needs to be aware of the provisions which require every
employer to be insured against liability for Worker's Compensation or to undertake self-insurance in accordance with the
provisions, and Contractor affirms to comply with such provisions before commencing the performance of the work of this
Agreement. (Labor Code Section 3700)
3. AMERICANS WITH DISABILITIES ACT: Contractor assures the State that it complies with the Americans with
Disabilities Act (ADA) of 1990, which prohibits discrimination on the basis of disability, as well as all applicable regulations
and guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the Contractor's name as listed on this
Agreement. Upon receipt of legal documentation of the name change the State will process the amendment. Payment of
invoices presented with a new name cannot be paid prior to approval of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the contract contracting agencies will be verifying
that the Contractor is currently qualified to do business in California in order to ensure that all obligations due to the state
are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any transaction for the purpose of financial
or pecuniary gain or profit. Although there are some statutory exceptions to taxation, rarely will a corporate Contractor
performing within the state not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of California) must be in good standing in order to be
qualified to do business in California. Agencies will determine whether a corporation is in good standing by calling the
Office of the Secretary of State.
6. RESOLUTION: A county, city, district, or other local public body must provide the State with a copy of a resolution,
order, motion, or ordinance of the local governing body which by law has authority to enter into an agreement, authorizing
execution of the agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the Contractor shall not be: (1) in violation of any
order or resolution not subject to review promulgated by the State Air Resources Board or an air pollution control district;
(2) subject to cease and desist order not subject to review issued pursuant to Section 13301 of the Water Code for violation
of waste discharge requirements or discharge prohibitions; or (3) finally determined to be in violation of provisions of
federal law relating to air or water pollution.
8. PAYEE DATA RECORD FORM STD. 204: all Contractors that are not another state agency or other governmental entity
must complete this form.
ATTACHMENT 7
DARFUR CONTRACTING ACT CERTIFICATION FORM
RFP NUMBER #11-01-05
NOTE: YOUR BID OR PROPOSAL WILL BE DISQUALIFIED UNLESS YOUR BID OR PROPOSAL
INCLUDES THIS FORM WITH EITHER PARAGRAPH # 1 OR # 2 INITIALED OR PARAGRAPH # 3
INITIALED AND CERTIFIED.
Darfur Contracting Act of 2008 (Act) was passed and signed into law to preclude State agencies generally from
contract Contracting with “scrutinized” companies that do business in the African nation of Sudan (of which the
Darfur region is a part). (Public Contract Code sections 10475-10481, et seq.; Stats. 2008, Ch. 272).
Pursuant to Public Contract Code section 10478, if a bidder or proposer currently or within the previous three
years has had business activities or other operations outside of the United States, it must certify that it is not a
“scrutinized” company as defined in Public Contract Code section 10476.
You must initial only one of the following three paragraphs below as applicable, complete certification and sign
if initialed Paragraph # 3:
1.
_____
Initials
We do not currently have, or we have not had within the previous
three years, business activities or other operations outside of the United States.
OR
2.
_____
Initials
We are a scrutinized company as defined in Public Contract Code
section 10476, but we have received written permission from the Department of
General Services (DGS) to submit a bid or proposal pursuant to Public Contract Code
section 10477(b). A copy of the written permission from DGS is included with our bid
or proposal.
OR
3.
_____
Initials
+ certification
below
We currently have, or we have had within the previous three years,
business activities or other operations outside of the United States,
but we certify below that we are not a scrutinized company
as defined in Public Contract Code section 10476.
CERTIFICATION For # 3.
I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally
bind the prospective proposer/bidder to the clause listed above in # 3. This certification is made under the
laws of the State of California.
Proposer/Bidder Firm Name (Printed)
Federal ID Number
By (Authorized Signature)
Printed Name and Title of Person Signing
Date Executed
Executed in the County and State of
ATTACHMENT 8
FEDERAL FUNDED ASSURANCES/CERTIFICATIONS
When reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0040), Washington DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT
TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact
the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional
assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant I certify that the applicant:
Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including
funds sufficient to pay the non-Federal share of project cost) to ensure proper planning, management, and completion of
the project described in this application.
Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any
authorized representative, access to and the right to examine all records, books, papers, or documents, related to the
award; and will establish a proper accounting system in accordance with generally accepted accounting standards or
agency directives.
Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the
appearance of personnel or organizational conflict of interest, or personal gain.
Will initiate and complete the work within the applicable timeframe after receipt of approval of the awarding agency.
Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728-4763) relating to prescribed standards for
merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM’s Standards
for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
Will comply will all Federal statutes relating with nondiscrimination. These include but are not limit to: (a) Title VI of the Civil
Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of
the Education Amendments of 1972, as amended (20 U.S.C. 1681-1683, and 1685-1686), which prohibits discrimination
on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107),
which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as
amended, relating to nondiscrimination on the basis of drug abuse (f) the Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis
of alcohol abuse of alcoholism; (g) 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee;
3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of
1968 (42 U.S.C. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing (i) any
other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made;
and (j) the requirements of any other nondiscrimination statutes(s) which may apply to the application.
Will comply, or has already complied, with the requirements of Titles II and III of the uniform Relocation Assistance and
Real Property Acquisition Policies Act of 1970 (PL 91-646) which provide for fair and equitable treatment of persons
displaced or whose property is acquired as a result of Federal or Federally assisted programs. These requirements apply
to all interests in real property acquired for project purposes regardless of Federal participation in purchases.
Standard Form 424B (Rev.7-97) Front
Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. 1501-1508 and 7324-7328), which limit the
political activities of employees whose principal employment activities are funded in whole or in part with Federal funds.
Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. 276a to 276a-7), the Copeland Act (40
U.S.C.276c and 18 U.S.C. 874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333), regarding
labor standards for federally assisted construction subagreements.
Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection
Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to
purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more.
Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive
Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO
11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency
with the approved State management program developed under the Coastal Zone Management Act of 1972 (16
U.S.C.1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the
Clear Air Act of 1955, as amended (42 U.S.C 7401 et seq.; (g) protection of underground sources of drinking water under
the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the
Endangered Species Act of 1973, as amended, (P.L. 93-205).
Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1721 et seq.) related to protecting components or
potential components of the national wild and scenic rivers system.
Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966,
as amended (16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and
Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).
Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related
activities supported by this award of assistance.
Will comply with the Laboratory Animal Welfare Act of 1966 (PL 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to
the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this
award of assistance.
Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.), which prohibits the use of leadbased paint in construction or rehabilitation of residence structures.
Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and OMB Circular No. A-133, Audits of States, Local Governments, and Non-Profit Organizations.
Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing
this program.
Signature of Authorized Certifying Official
Title
Applicant Organization Name
Date Submitted
Standard Form 424B (Rev. 7-97) Back
ATTACHMENT 9
CERTIFICATION REGARDING LOBBYING, DEBARMENT, SUSPENSION AND OTHER
RESPONSIBILITY MATTER: AND DRUG-FREE WORKPLACE REQUIREMENTS
For Federal-Funded Programs
Applicants should refer to the regulations cited below to determine the certification to which they are required to attest.
Applicants should also review the instructions for certification included in the regulations before completing this form.
Signature of this form provides for compliance and certification requirements under 34 CFR Part 82, New Restrictions on
Lobbying, and 29 CFR Part 98, Government-wide Debarment and Suspension (Nonprocurement).
LOBBYING
A. As required by Section 1352, Title 31 of the U.S. Code, and implemented at 34 CFR Part 82, for persons entering into
a Contract or cooperative agreement over $100,000, as defined as 35 CFR Part 82 Sections 82, 105 and 82.110, the
applicant certifies that:
No Federal appropriated funds have been paid or will b paid, by or on behalf of the Contractor, to any person for
influencing or attempting to influence an officer or employee of Congress, or an employee of a Member of Congress in
connection with the making of any Federal Contract, the entering into any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any Federal Contract or cooperative agreement.
If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with a Federal Contract or cooperative agreement, the Contractor
shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.
The undersigned shall require that the language of this certification be included in the award documents for all awards at all
tiers including subcontracts, contracts under Contracts and cooperative agreements, and subcontracts) and that all sub
recipients shall certify and disclose accordingly.
DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS
As required by Executive Order 12549, Debarment and Suspension and implemented at 34 CFR Part 85, for prospective
participants in primary covered transactions, as defined at 34 CFR Part 85, Sections 85.105 and 85.110.
The applicant certifies that it and its principals:
Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered
transactions by any Federal department or agency:
Have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against
them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction: violation of Federal or State antitrust statutes or
commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or
receiving stolen property.
Are not presently indicated for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local)
with commission of any of the offenses enumerated in paragraph (1)(b) of this certification: and
Have not within a three-year period preceding this application had one or more public transactions (Federal, State, or local)
terminated for cause or default: and
B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an
explanation to this application.
Drug-Free Workplace (Contractor other than Individuals)
As required by the Drug-Free workplace Act of 1988, and implemented at 34 CFR Part 85, Subpart F, for Contractors, as
defined at 34 CFR Part 85, Sections 85.605 and 85.620.
The applicant certifies that it will or will continue to provide a drug-free workplace by:
Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a
controlled substance is prohibited in the Contractor’s workplace and specifying the actions that will be taken against
employees for violation of such prohibitions.
Establishing an on-going drug-free awareness program to inform employees about the following:
The dangers of drug abuse in the workplace;
The Contractor’s policy of maintaining a drug-free workplace;
Any available drug counseling, rehabilitation, and employee assistance programs; and
The penalties that may be imposed upon employee for drug abuse violations occurring in the workplace. Making it a
requirement that each employee to be engaged in the performance of the Contract be given a copy of the statement
require by paragraph (a)
Notifying the employee in the statement required by paragraph (a) that as a condition of employment under the Contract,
the employee will:
Abide by the terms of the statement; and
Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no
later than five calendar days after such conviction;
Notifying the agency, in writing, within 10 calendar days after receiving notice under subparagraph (dx2) from an employee
or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice including
positions titles to Director, Contracts and contracts Service, U.S. Department of Education, 400 Maryland Avenue, S.W.
(Room 3124, GSA Regional Office Building No. 3) Washington, DC 202-2-4571. Notice shall include the Contract/Contract
identification number(s) of each affected contract/Contract.
Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with respect to any
employee who is so convicted.
Taking appropriate personnel action against such an employee, up to and including termination, consistent with the
requirements of the Rehabilitation Act of 1973, as amended; or
Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for
such purposes by a Federal, State, or local health, law enforcement or other appropriate agency;
Making a good faith effort to continue to maintain a drug-free workplace through implementation or paragraphs (a), (b), (c),
(d), (e), and (f).
B. The Contractors may insert in the space provided below the site(s) for the performance or work done in connection
with the specific Contract.
Place of Performance (Street address, city, county, state, zip code)
Check
if there are workplaces on file that are not identified here.
DRUG FREE WORKPLACE (CONTRACTOR WHO ARE INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented at 34 CFR Part 85, Subpart F, for Contractors, as
defined at 34 CFR Part 85, Section 85.605 and 85.610.
As a condition of the Contract, I certify that I will not engage in the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance in conducting any activity with the Contract; and
If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any Contract activity, I will
report the conviction, in writing, with 10 calendar days of the conviction to: Director, Contracts and contracts Service, U.S.
Department of Education, 400 Maryland Avenue, S.W. (Room 3124, GSA Regional Office Building No. 3) Washington, DC
202-2-4571. Notice shall include the Contract/Contract identification number(s) of each affected contract/Contract.
As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above
certification.
Contract/Contract Applicant/Institution Name
Contract/Contract Award Number
Printed Name of Authorized Representative
Title
Signature
Date
ATTACHMENT 10
PROOF OF CORPORATE STATUS DOCUMENTS
SERVICE PROVIDER PROJECTS RFP #11-01-05
These documents must be included in the proposal as a required attachment.
A. NON-PROFIT STATUS (IRS LETTER)
B. CA SECRETARY OF STATE CERTIFICATION OF GOOD STANDING