As an authorized representative of the Respondent, having carefully examined the Request for Qualifications, propose to furnish services in accordance therewith as set forth in the attached response.I further agree that this response will remain in effect for not less than sixty (60) calendar days from the date that responses are received by the County, and that this response may not be withdrawn or modified during that time.I hereby certify that this response is genuine and not a false or collusive response, or made in the interests or on behalf of any person not therein named; and I have not directly or indirectly induced or solicited any Contractor or supplier on the above work to put in a false response or any person or corporation to refrain from submitting a response; and that I have not in any manner sought by collusion to secure to myself an advantage over any other contractor(s) or person(s).In order to induce the County to consider this response, the Respondent irrevocably waives any existing rights which it may have, by contract or otherwise, to require another person or corporation to refrain from submitting a response to or performing work or providing supplies to Pierce County, and Respondent further promises that it will not in the future directly or indirectly induce or solicit any person or corporation to refrain from submitting a response or response to or from performing work or providing supplies to Pierce County.

By submitting a response, I agree that all documents, reports, proposals, submittals, working papers, or other materials prepared by the Respondent pursuant to this response shall become the sole and exclusive property of the County, and the public domain, and not property of the Respondent. The Respondent shall not copyright, or cause to be copyrighted, any portion of items submitted to the County in response to this procurement.

I confirm I have reviewed the content of the following attachments included under this RFQ: Sample Agreement and any other documents as identified as "sample" in the Attachments section and acknowledge I understand and agree to these requirements should my organization receive a contract as a result of this response.

By submitting a response, I understand and agree that if awarded funding from this RFQ, the organization must be able to meet all insurance requirements based on services being purchased, prior to contract execution, and types of insurances may include, but are not limited to:Commercial General Liability Insurance: Required on all contracts. Standard levels are $1M occurrence/$2M aggregate (may be higher/lower, depending on value of contract and type of service).Commercial Automobile Liability Insurance: Required when the Contractor uses owned, rented, or leased automobiles to complete the services as required per the contract. Higher coverages may be required for fleet/large passenger vehicles. Workers Compensation Insurance: As required by Washington State.Professional Liability or Errors and Omissions Insurance: If the Contractor provides services such as analysis, consulting, counseling, daycare, legal, medical, nursing, pastoral, medical, or other services that require professional licensing.Abuse and Molestation: If the Contractor will be working directly with youth under the age of 18, elderly, disabled or other vulnerable populations.Cyber/Privacy and Security Insurance: If the Contractor is doing work that could give the Contractor access to personal or sensitive information from within the County's network or on the Contractor's personal computer, or lead to breaches of security, leading to a loss of privacy or identity theft.Crime/Employee Dishonesty Insurance: If the Contractor is in the custody or control of Pierce County funds such as cash, credit cards, checks or physical property.Other insurance(s) applicable to services being purchased: Such as Excess or Umbrella Liability Insurance if the contract is in excess of $500,000.In addition:Pierce County shall be named as an "Additional Insured" which must be provided in the insurance endorsement; andInsurance requirements also apply to any subcontractors hired by the main Contractor to deliver services, where applicable.Please see "Exhibit D" in the SAMPLE AGREEMENT under attachments to see full insurance requirements. If you have questions regarding insurance requirements, please submit them through the “Question & Answer” section of the RFQ.

As an authorized representative of the Respondent, I certify to the best of my knowledge and belief that the organization 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 response 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 indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; andHave not within a three-year period preceding this response had one or more public transactions (Federal, State, or local) terminated for cause or default.Does not employ any person nor contracts with any person or agency excluded from participation in federal health care programs under either 42 U.S.C. 1320a-7 (§§1128 or 1128A Social Security Act) or debarred or suspended.By checking the confirmation, I understand that a false statement on this certification may be grounds for rejection of this response or termination of any award. In addition, under 18 USC Sec. 1001, a false statement may result in a fine of up to $10,000 or imprisonment for up to 5 years, or both.

Pierce County is now collecting Risk Assessment documentation through this form. Agencies MUST complete the Risk Assessment and submit related documentation through the form at LEAST every six months. Upon completion of the form submission, you will receive a confirmation email. The confirmation email is REQUIRED as part of this application. You MUST re-submit the form if any of the following conditions apply since the previous submission: It has been more than six months.There has been a change in leadership (ED/CEO/CFO).There has been a loss or reduction of funding of 20% or more of the agency's total budget. I understand and agree that my organization has completed the Risk Assessment form within the last six months and/or has updated the Risk Assessment form submission if any of the above conditions apply.I understand the results of the Risk Assessment shall be utilized to determine the potential financial risk and stability of the organization prior to the County making any award and that completing the risk assessment does not guarantee an award.

Once you have submitted the Pre-Award Financial Risk Assessment Form, you will receive an email confirmation. Save the email confirmation as a .PDF and UPLOAD HERE.WARNING: Failure to provide evidence of an acceptable and up-to-date Risk Assessment may be cause for the application to be disqualified from competition.

Please provide the name and title of the individual authorized to execute a contract on behalf of the organization.

Please provide the legal name, any d/b/a names, years in business, local address, billing address if different, email address, and phone number of the organization making the response.

Please provide the Employee Identification Number (EIN).

Must choose at least two (2) answers: Profit status (1 or 2) and organizational structure (3, 4, 5, or 6).

Please provide the name, phone, and email for:Executive Director/CEO/PresidentFinancial Manager/CFOContract Manager

Please provide the organization's UBI number. WARNING: Failure to provide a UBI number will be cause for the application to be disqualified from competition.

An organization must have, at the time of submission, an active UEI number when the funding for the procurement is identified as federal. Please list your UEI as issued by Sam.gov. Funding may or may not create a subrecipient relationship between the organization and the County. WARNING: Failure to provide a valid and active UEI number may result in the disqualification of the application from further consideration.

Select the services the organization is proposing to provide.

I certify that, if my organization is selected under this RFQ, my organization will comply with all applicable federal and Washington State laws, regulations, and standards governing the implementation of Health-Related Social Needs (HRSN) services, including, but not limited to, the authorities and standards identified in Section 1.4.5, Policy Compliance.

Please upload a current DSHS contract for each service for which you are applying.

I certify that, if my organization is selected under this RFQ, my organization will serve the entire geographic area of Pierce County.