Certification and Assurances

MOBILE VANS OPERATED BY FREE HEALTH CLINICS
MOBILE VAN _RFA 02022024

Under the penalties of perjury of the State of Connecticut, we make the following certifications and assurances as a required element of our Application  for RFA.

We affirm the truthfulness of these facts and acknowledge our current and continued compliance with these certifications and assurances as part of our Application and any resulting contract award with the Department.

1.  We declare that all answers and statements made in this application are true and correct.

2.		We certify that the prices and/or cost data contained in our Application: (a) have been determined independently, without consultation, communication or agreement with others for the purpose of restricting competition, and (b) have not been and will not be knowingly disclosed by the Respondent, directly or indirectly, to any other Respondent or competitor before contract award, except to the extent that we have joined with other individuals or organizations for the purpose of preparing and submitting a joint Application  or unless otherwise required by law.

3.   Our Application  is a firm offer for a period of 180 days following receipt, and it may be accepted by the Department without further negotiation (except where obviously required by lack of certainty in key terms) at any time within the 180-day period. In the case of a protest, the Respondent’s Application  will remain valid for 210 days or until the protest is resolved, whichever is later.

4.   We have not been assisted by any current or former Department employee whose duties relate (or did relate) to this procurement and who assisted in other than his or her official, public capacity.

If there are any exceptions to these assurances or we have been assisted, we will identify on a separate page attached to this document everyone by:  (a) name, (b) current address and telephone number, (c) current or former position with the Department, (d) dates of employment with the Department, and (e) detailed description of the assistance provided by that individual.

5.  We acknowledge that the Department will not reimburse us for any costs incurred in the preparation of our Application.  All Applications become the property of the Department and we claim no proprietary right to the ideas, writings, items, or samples.

6.   We acknowledge that any resulting contract awards will incorporate Special Terms and Conditions, Statement of Work, and General Terms and Conditions substantially like the sample contract attached to the procurement document.

7.   We will comply with these or substantially similar Special Terms and Conditions, Statement of Work, and General Terms and Conditions if awarded a contract, and will negotiate in good faith any changes or modifications.

8.   We acknowledge that if awarded a contract with the Department, we are required to comply with all applicable state and federal civil rights and other laws.  Failure to comply may result in contract termination.  We agree to submit additional information about our nondiscrimination policies, at any time, if requested by the department.

9.  I authorize the Department to conduct a reference check with my present and/or previous employer(s) and with any entity with which I have contracted. This also serves to authorize my present and/or previous employer(s), or entities with which I have contracted, to provide reference information to the Department By providing such authorization, I release the Department, its employees, and agents, and my present and/or previous employer(s), or entities with which I have contracted, from all claims or potential claims I may have regarding all information released to or by the Department.

10. We certify that we have a current Connecticut Business License and agree to promptly provide a copy of the license if we are awarded a contract.

11. We made no attempt, nor will make any attempt, to induce any other person or firm to submit, or not submit, a Application  for the purpose of restricting competition.

12. We acknowledge and authorize the Department to conduct a financial assessment and/or background check of our organization if the Department considers such action necessary or advisable.

13.  We acknowledge that we will deliver services to the Agency the cost proposed in the RFA and within the timeframes therein.

14.  We acknowledge that we will seek prior approval from the Agency before making any changes to the location of services.

15.  We  acknowledge,  that  neither  the  Respondent  of  any  official  of  the  organization  nor  any subcontractor the Respondent of any official of the subcontractor organization has received any notices of debarment or suspension from contracting with the State of CT or the Federal Government.

16. We acknowledge that neither the Respondent of any official of the organization nor any subcontractor to the Respondent of any official of the subcontractor’s organization has received any notices of debarment or suspension from contracting with other states within the United States.

17. We acknowledge our obligation to notify the Department of any changes in the certifications and assurances above.

Legal Name of Organization:   	

Authorized Signatory	Date