request for proposals for polk county consolidated human services agency (chsa) · 2019-03-13 ·...

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REQUEST FOR PROPOSALS

FOR POLK COUNTY

CONSOLIDATED HUMAN SERVICES AGENCY (CHSA)

Interested Vendors should submit their proposals by March 29, 2019 to the attention of:

Joshua Kennedy, Director Polk County – Consolidated Human Services Agency

Mail: PO Box 308 Columbus, NC 28722

Phone: (828) 894-2114 Email: [email protected]

Any late proposals will be returned unopened.

Vendors should submit clearly marked with the service being bid:

Example: “Food Services for Polk County Senior Services”

mailto:[email protected]

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REQUEST FOR PROPOSALS

Polk County Consolidated Human Services Agency (CHSA), hereinafter referenced as CHSA, will receive request for proposals (RFP) for the below listed services. It is the intent of this RFP to establish one or more contracts with responsible and reliable Contractors for 1 to 3 years starting July 1, 2019. The contract(s) will be cost reimbursement with fixed rates or amounts, all work will be priced and pre-approved prior to the start of the work efforts. Interested parties may obtain a complete copy of the Requests for Proposal by contacting:

Joshua Kennedy, Director

Polk County – Consolidated Human Services Agency Mail: PO Box 308

Columbus, NC 28722 Phone: (828) 894-2114

Email: [email protected]

Proposals are due by 5PM EDT, on March 29, 2019. Proposals submitted after this date will not be considered and will be returned unopened. Issuance of this Request for Proposal does not commit the CHSA to award a contract, to pay any costs incurred in preparation of a proposal or to procure or contract for related services or supplies. The CHSA reserves the right to accept or reject any or all proposals, to waive minor technicalities and informalities and to make an award deemed in its own best interest. All Contractors must certify they are not on the federal or state list of ineligible Contractors. The Comptroller General’s federal list of ineligible Contractors is located at the web site www.epls.gov. The state list of debarred organizations can be found on the State’s Purchase and Contract web site www.doa.state.nc.us/pandc/. The successful Contractor(s) shall be required to comply with all applicable local, state and federal laws and regulations including Equal Employment Opportunity. Disadvantaged Business Enterprises will be afforded full opportunity to submit proposals and compete for subcontracting work and will not be discriminated against on the basis of race, color, religion, sex, national origin, or disability. DBE Contractors must be certified and registered on the NCDOT Directory: https://apps.dot.state.nc.us/vendor/directory.

mailto:[email protected]

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The following is the solicitation schedule: March 17, 2019 ................. Issuance of RFP. CHSA issues this RFP. March 29, 2019 ................. Proposal Submission Due Date. April 1, 2019 ...................... Evaluation. During this period, the Evaluation Committee will

conduct a full detailed evaluation of Proposals and References.

May1-June 3, 2019 .......... Award Notification Period

SELECTION CRITERIA

This procurement will be conducted using either informal or formal (sealed) competitive proposal procedures. It is the intent of the CHSA to conduct technical evaluations of proposals received, hold Contractor site visits and / or interviews, conduct negotiations with one or more Contractors, and select one or more Contractors, with the goal of promoting fairness and competition. All proposals will be evaluated by the CHSA personnel who will determine which proposals are responsive and rank them according to the evaluation criteria. Please Contact Joshua Kennedy, CHSA Director to be sent an email attachment of any additional information requested. Polk County reserves the right to accept or reject any or all proposals, to waive minor technicalities and informalities and to make an award deemed in its own best interest as provided in N.C.G.S. 143-129(b). The following criteria will be used to evaluate the proposals. Criteria & Weight Proposal Response – how well the issues are addressed ............................................ 25 Qualifications and Experience ....................................................................................... 25 References .................................................................................................................... 25 Costs ............................................................................................................................. 25

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INSTRUCTIONS TO PROPOSERS SUBMITTAL REQUIREMENTS

The information included in this document is designed to assist with responding to the RFP by indicating the desires of the procuring agency. All respondents must accurately and completely fill out the Response Form. Respondents to this RFP may only communicate with the designated contact listed in this RFP regarding the RFP and/or selection process. All communication shall be in writing. The proposal will be valid for a period of 120 days from submission. All submitted proposals must adhere to the following guidelines:

1. Be typed on 8 1/2" by 11" paper 2. Mail to the address on Page 1, in SEALED packages clearly marked with service

for bid. EXAMPLE “Vehicle Maintenance Services for the CHSA” 3. Be received by the close of business (5PM EDT) the due date

SUBMISSION PACKET CHECKLIST

The checklist below is provided to help proposers with compilation of documents requested in this RFP.

Check (√) INCLUDED IN PACKET Sign Off as Complete

_____ A. Response Form _____ B. Certificates of Insurance _____ C. Form of Proposal and Acknowledgement of Addenda _____ D. Required Submissions from Appendices _____ E. Submission of Packet Checklist Completed _____ One (1) original printed document and a CD (or other electronic format) of completed and signed proposal response

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SERVICES AND PRODUCTS AVAILABLE FOR BID All Attachments and Sections are required unless otherwise noted.

CHSA DIVISION ITEM/SERVICE

Business Services Facility Cleaning Services

Economic Services Legal Services – Child Support Enforcement

Senior Services Food/Congregate Meal Supplies

Social Services Adult Guardianship Services

Legal Services – Adult Services, Child Services and Family Services

Transportation Services Maintenance

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SCOPE OF SERVICES/WORK Congregate Meal Supplies

Polk Consolidated Human Services Agency – Senior Services Division provides congregate

meals and home delivered meals to residents in Polk County. The division serves roughly

38,000 meals a year. Please see the below meal design for details. The CHSA is accepting

bids for food supplies vendor.

Meal Design

Meals are designed by our staff and approved by a dietitian to meet 1/3 of the Recommended

Daily Allowances (RDA) for Adults. Each meal provides at least 700 calories and the sodium

content does not exceed 1,300mg per meal. Each meal includes:

3 ounces of protein (meat, fish, poultry, and/or beans)

Two ½ cup servings of fruits and/or vegetables; fresh and raw- vitamin C rich foods are

served at least twice a week

Two servings of whole grain or enriched grain products such as rice and breads

Dairy- ½ pint of milk no less than 400mg of calcium from combined menu items

No more than 30% of the total calories per meal are fats

No Service on Polk County Holidays

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SCOPE OF SERVICES/WORK Legal Services – Adult Services, Child Services and Family Services

Polk Consolidated Human Services Agency provides a number of services requiring legal

review and representation. The contractor will service the Polk County Consolidated Human

Services Agency as Special Attorney for Human Services matters as provided for under NC

General Statute 108A-16 through 108A-18. This contract is established as part of the total

duties referred to under the cited General Statutes and relates to use of an Attorney in assisting

the Agency with legal matters specific to the Social Services Block Grant Programs

administered by the Agency. Activities include providing legal services including but not limited

to the following programs: Adoption (028), Foster Care (128), Child Protection (228), Adult

Protection (204) and Guardianship (107). Optional elements include only reimbursable

expenses related to attendance at the County Attorney’s Conference seminars and professional

meetings as specified in the attorney guide of the fiscal manual and per-diem from County

Policy.

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SCOPE OF SERVICES/WORK Child Support Services

Polk Consolidated Human Services Agency is responsible for the enforcement of child support

in Polk County. Contractors shall meet the below scope of work as well as IRS publication 1075

Section 4.7.1 and Exhibit 7 Safeguarding Contract Language

A. The CHSA Will:

1. Prepare and transmit referrals to the Contractor on appropriate cases pursuant to

Title IV-D. Such referrals shall be made through the NC FAST (North Carolina

Families Accessing Services through Technology) System interface. Such referrals

will contain the name of the recipient, names of the children and the associated

absent parent, if known, such identifying information as is available to assist in the

location and support enforcement process, pertinent known legal information relative

to marital status and orders for support, the amount of the family's assistance grant,

available data relative to the absent parent's whereabouts and employment, and any

other available information that may relate to the support process. In the absence of

NC Fast, DSS workers will provide written referrals containing available information.

2. Provide office space without charge for use by Contractor in conducting its duties

under this Contract.

3. Upon receipt by the County of each invoice for court filing fees resulting from the

services under this Contract (the "Court Filing Fees"), which the Polk County Clerk of

Courts (the "County Clerk") shall deliver to the County, the County shall:

a. Forward such invoice for Court Filing Fees (the "Court Filing Fees Invoice") to

the Contractor

b. Following review of such Court Filing Fees Invoice by Contractor, resolution

of any discrepancies in it by Contractor, and notice of the correct amount of

such County Filing Fees Invoice from Contractor, pay the County Clerk one

hundred percent (100%) of such correct amount.

4. Monitor Contractor performance through assigned State consultant review and

monthly reports provided by Contractor.

5. Impose a financial penalty for failure to timely submit an acceptable Corrective Action

Plan. (The imposition of such a penalty does not preclude the County’s right to

terminate the Agreement during the assessment of the penalty.) The penalty shall

initially be assessed by withholding 20% of the next monthly payment due the

Contractor and, for each subsequent month of failure to submit a corrective action

plan, an additional 35% will be withheld.

6. Impose a financial penalty for failure to correct the cited deficiencies with the

corrective action period, such penalty not to preclude contract termination. The

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penalty shall initially be assessed by withholding 20% of the payment due for each of

the next 3 months and will increase 10% for each subsequent quarter in which there

is a continued failure to meet the standard.

B. The Contractor Will:

1. Establish and maintain a child support enforcement program in Polk County that

complies with the provisions of Title IV, Part D) of the Social Security Act, as

amended; Title 45 of the Code of Federal Regulations; Article 9, Chapter 110 of the

North Carolina General Statutes, as amended; State laws and regulations, and to be

totally responsible and accountable for the proper operation of such program for all

current, ongoing, and back log cases in Polk County.

2. Provide all child support enforcement services following standard and accepted child

support practices, policies and procedures and in doing so pursuing the best interest

of the child(ren) for whom support is sought.

3. Furnish all necessary personnel, materials services and travel and otherwise perform

all activities and actions necessary or incidental to the accomplishment of the tasks

specified in this contract. Personnel and facilities assigned to the contract will not be

used in other business without written approval of the Contract Administrator (unless

so specified in this contract). Contractor shall cover salary, benefits, insurance and

all other operating expenses for personnel and provide the County a copy of the

certificate of insurance.

4. Provide testimony, evidence and support necessary for the establishment of

paternity, establishment and enforcement of child support orders, and the review and

modification of support orders pursuant to federal and state laws, in civil, criminal

and administrative forums. The choice of forum shall be based on the facts of each

case, the judgment of legal counsel, and the best interest of the child.

5. Bring all court actions in the manner as prescribed by N.C. Gen. Stat. §110.130.1

and to notify the appropriate County official in a timely fashion of any judicial or

administrative decision or settlement agreement that negatively affects the County's

or State's interests. Contractor agrees not to enter any settlement that results in the

County's or State's loss of revenue. Contractor may appeal from any judicial or

administrative order and shall cooperate with the State in the event the State

chooses to appeal. In the event that the Contractor thinks that a decision needs to be

appealed, the Contractor shall consult with the appropriate County official prior to

filing a Notice of Appeal. The County will notify the Contractor within 30 days of

signing this agreement as to the name of the appropriate County official.

6. Utilize the State's automated system that affects the Child Support Enforcement

Program. Any additional automation needs deemed necessary to assist Contractor in

carrying out its responsibilities shall be the responsibility of Contractor. The

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Contractor shall retain all rights to such software developed by the Contractor, at the

Contractor's expense, to assist Contractor in carrying out its duties under this

Agreement. Software developed by the Contractor at public expense shall be owned

by the County. Such software, including source code, shall be returned to the County

at the time of contract termination. As the Contractor staff will be utilizing and

accessing County information technology including computers and email addresses,

all Contractor staff will be required to review and sign the Polk County Information

Technology Acceptable Usage Policy.

7. Reimburse the County for any monthly copy overages attributable to the County-

owned copier used by contractor staff and to provide one toner cartridge each year.

8. Immediately respond to the State IV-D agency's central office on any requests for

case status or information. Such response shall contain sufficient information

regarding the status of the case to permit the State to reply to the inquiring party.

9. Return all case and automated files to the County at the time of contract termination.

10. Be responsible for the proper training and management of staff assigned to the

project.

11. Ensure that the child support office administrator and/or staff attend any meetings

sponsored by the County and/or State, at which attendance is requested, upon

timely notice. Timely notice means at least 15 days advance notice. The Contractor

shall make every effort to comply if less than 15 days’ notice is provided.

12. Upon the request of any State or County Official, the Contractor shall make case files

immediately available for audit or case review sampling purposes. The Contractor

shall comply with any corrective action as set forth in any non-compliance letter

received from the County, State, or Federal government within 30 days of receiving

the letter.

13. Revise and or clarify within fifteen (15) working days any Corrective Action Plan that

the County or State determines to be unacceptable in addressing deficiencies.

14. Provide, on a monthly basis, statistical information relative to the caseload and

services in such a manner and format as prescribed by the County.

15. Cooperate fully with the data collection and evaluation activities carried out by the

County in connection with the services performed under this contract.

16. Develop, with input from the County, a customer satisfaction survey that will be used

to determine the customer satisfaction level and to cooperate with the county in

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answering customer complaints related to Child Support Enforcement in a timely

manner.

17. Provide relevant information immediately and file proofs of claim with the bankruptcy

court on behalf of the County in a timely manner in the event the Contractor receives

notice that an obligor has filed a bankruptcy petition.

18. Collect and return to the County any fees required to be charged under State or

federal law regulation or policy.

19. Comply fully with the aforementioned and all other provisions of Title IV, Part D of the

Social Security Act, as amended, Title 45 of the Code of Federal Regulations, North

Carolina General Statutes, and the program instructions issued by the County.

20. The Contractor shall cooperate, to the fullest extent allowed by law, with other

County, State and federal entities. This provision also covers other entities operating

Child Support Enforcement Programs pursuant to Title IV, Part D of the Social

Security Act as amended.

21. The Contractor shall ensure that a child support enforcement worker is available

during all normal working hours. The Contractor may assign multiple individuals to

provide this full-time service. A child support worker will be on site five days each

week except when reporting to court, meetings or conferences unless contractor

notifies the County of extenuating circumstances.

22. The Contractor agrees that the place of this Contract, its site and forum, shall be in

the State Courts of North Carolina in Polk County, North Carolina, and in said County

and State shall all matters, whether sounding in Contract or tort relating to the

validity, construction, interpretation, and enforcement of this Contract be determined.

23. The Contractor shall provide the County with a copy of its annual audit report when

the report is completed by the Contractor's external accounting firm.

24. Following receipt of each Court Filing Fees invoice from the County, the Contractor

shall:

a. Review such Court Filing Fees Invoice for discrepancies, resolve any

discrepancies in it, and provide notice to the County of the correct amount of

such County Filing fees invoice; and

b. Reimburse the County for thirty-four percent (34%) of such correct amount.

25. To meet or exceed, by June 30, 2019, the following performance goals for the Child

Support Enforcement Program as determined by the state of North Carolina:

a. Total Collections

b. Percent of caseload under order

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c. Percentage of current support collected

d. Percent of arrears collected

e. Percent of paternity established

f. Any other metric or goal outlined for child support enforcement by HB 630

MOU for fiscal year 2018-2019 and following. See MOU for details

26. Abide by IRS Publication 1075 Section 4.7.1 and Exhibit 7 Safeguarding Contract

Language (attached).

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SCOPE OF SERVICES/WORK Facility Cleaning Services

Polk Consolidated Human Services Agency is responsible for the cleaning of several county

owned or rented facilities: Human Services Building (231 Wolverine Trail, Mills Springs, NC

28756) and Green Creek Community Center-Gym (534 Coxe Rd, Columbus, NC 28722).

Schedules are listed below.

Human Services Buidling

Frequency Location Task

Each visit (3 times per week)

Bathrooms Clean & Sanitize toilets & sinks

Replace paper & soap products

Empty Trash

Clean mirrors

Sweep & mop

Halls Vacuum as needed

Water Fountains Clean & Sanitize

Entrance & Lobby Vacuum Clean Glass Doors & Reception window Clean chairs, tables & children’s toys Empty trash cans Sweep outside entrance as needed

Kitchen & Staff Break Room Empty Trash, wipe down tables & counters, scrub sink, sweep & mop as needed

Family Visitation Empty Trash

Wipe down tables and furniture if necessary

Check to see if needs sweeping or vacuuming

Small Conference Room / Large Training Room

Check Trash Vacuum and wipe down tables as needed Organize chairs

Commons / Mail area Empty Trash Vacuum

Copier & Storage Rooms Vacuum, Dust & Empty Trash

Filing Rooms Empty trash

Shower Clean & sanitize shower stall as needed Sweep & mop as needed

Weekly Filing Rooms Vacuum & Dust

Interview office Dust & vacuum

Back Entrance Clean Glass Doors Sweep outside entrance Clean couch and bench if necessary

Individual offices Vacuum as needed

All but individual offices Dust Baseboards

Kitchen & Staff Break Room Remove appliances & wipe down entire surface

Commons / Mail Area Remove all items from counter & wipe down entire surface

Bathrooms Wipe down stall doors & walls Pour Bleach down drains

Copier & Storage Rooms Empty Recyclables & trash (Thursdays)

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Green Creek Center

Frequency Location Task

Each visit (1 times per week)

Bathrooms Clean & Sanitize toilets & sinks

Replace paper & soap products

Empty Trash

Clean mirrors

Sweep & mop

All Areas Rented

Sweep and Mop Clean chairs, and tables Empty trash cans

Kitchen & Staff Break Room

Empty Trash, wipe down tables & counters, scrub sink, sweep & mop as needed

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SCOPE OF SERVICES/WORK Transportation Maintenance Services

TECHNICAL SPECIFICATIONS

PROJECT AND BACKGROUND OF SYSTEMS

The key elements of this maintenance program include, a comprehensive preventive maintenance schedule, full utilization of standard warranty coverage and customer service responsiveness. Contractors work collaboratively with staff to maximize cost efficiencies, minimize unscheduled repairs and downtime and ensure quality service while providing mechanically sound, safe, reliable and clean vehicles. Attention is always focused on balancing costs and providing effective service. The following table lists the fleet to be included in this contract. Please note that as vehicles are replaced or expansion occurs vehicles may be substituted, deleted, or added to the fleet. The maintenance classification will relate directly to the Preventive Maintenance Schedule that will be discussed later in this document. The maintenance plan required by the Federal Transit Administration and the North Carolina Department of Transportation is included in the attachments.

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FLEET CHARACTERISTICS (Fleet Inventory vehicles)

VEH # YEAR/MODEL LICENSE VIN NUMBER TYPE Current Mileage

TIRE SIZE Total

Monthly Mileage

2 2011 Ford 66693V 1FTDS3EL2BDA71308 12 Pass Conversion 139308 245/75R/16 1304

6 2011 Ford (Lift) 66632V 1FTDS3EL6BDB31669 8 Pass (2 Wheel Chairs) 154955 245/75R16 641

15 2011 Ford 66692V 1FTDS3EL4BDB31668 12 Pass Conversion 109045 245/75R16 2712

16 2011 Ford 66691V 1FTDS3EL4BDA71309 12 Pass Conversion 146192 245/17R16 2021

18 2012 Dodge Caravan 66673V 2C4RDGBGXCR374009 5 Pass with Chair Ramp 98798 235/60R16 1975

19 2014 Ford (Lift) 61052V 1FTDS3EL5EDA38663 8 Pass (2 Wheel Chairs) 87152 245-75-R16 2892

20 2014 Ford (Lift) 61053V 1FTD53EL7EDA38664 8 Pass (2 Wheel Chairs) 81315 245-75-R16 2483

21 2014 Dodge Caravan 71642V 2C4RDGCG7ER4233443 7 Pass Mini Van 77329 225-65-R17 3008

22 2015 Ford Chassis (Lift) 79146V 1FDEE3FLXFDA34549

8 Pass (2 Wheel Chairs) 49210 225-75R16 1307

23 2015 201 F 550 Bus 80115V 1FDGF5GY5FEC91818 21 Pass (2 Wheel Chairs) 19796

225/70R19.5 1176

24 2015 Ford E450L 81469V 1FDFE4FS7GDC05096 19 Pass (2 Wheel Chairs) 28578 225/75R16 2615

25 2015 Dodge Caravan 82681V 2C4RDGCG2GR136790 7 Pass Mini Van 39130 225-65-R17 2599

26 2016 Nissan Pathfinder 84868V 5N1AR2MM6GC634095 7 Pass Crossover 33870 235-65R-18 2074

27 2016 Mobility Transit Van (MTV) 350 88201V 1FTBW3XM6GKB25021

12 Passenger Conversion 14597

235/65R-16C 2062

28 2017 Ford (lift) 95082V 1FTBW3XM7HKA50251 7 Pass (2 Wheel Chairs) 955

235/65R-16C 798

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29 2017 Ford (lift) 95084V 1FTBW3XM9HKA50252 7 Pass (2 Wheel Chairs) 1299

235/65R-16C 831

2008 Dodge/Daimler Van

1D8HN44H78B184964 7 Pass Mini Van 93672 P225/65R16

109 2009 Ford Focus 1FAHP34N19W136692 5 Passenger Car 113572 P195/60R15



2013 Ford Escape 1FMCU9GX8DUB16453 5 Passenger Car 73867 P235/55R17

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SCOPE OF WORK WITH STATED DELIVERABLES

Unless otherwise specified herein, the contractor shall provide all supplies, personnel, equipment, tools, materials, supervision, and other items or services necessary to perform the management and operation of motor vehicle maintenance functions as defined in this Scope of Work. All supplies and materials shall be of a type and quality that conform to THE CHSA specifications and standards. All supplies, materials, and equipment to be used in the performance of work described herein are subject to the approval of THE CHSA.

The contractor must submit to THE CHSA a work order identifying the work to be performed prior to start of service.

The contractor shall not use any materials, chemicals, or compounds which THE CHSA determines would be unsuitable for the intended purpose or harmful to the vehicles being serviced.

The following is a list of products THE CHSA requires for vehicle maintenance purposes. Each product submitted must be identified with one of these categories. It is desirable that vendors be able to supply the greatest number of all services listed below.

The vendor must give all THE CHSA maintenance requests top priority attention.

The vendor will provide the following items: o Professional Welding Services o Exhaust Services to include Catalytic Converter Services o Alignment Equipment capable up to a 213” wheel base and 19,500 lbs o Up to date diagnostic scanning equipment o Tire Pressure Monitoring Equipment with reprogrammable capability o Tire Equipment to properly remove, replace and balance tires o Brake Lathe Machine Capable of Turning Rotors and Drums o The Ability to look up Technical Service Bulletin Recalls o Coolant Flush Machines o Transmission Flush Machines o The Ability to Work Directly with the Vehicle Manufacturers

The contractor shall provide intermediate maintenance, preventive maintenance and scheduled inspections/tests; repair/replace unserviceable parts, assemblies, subassemblies and components; refinish, fabricate parts, make modifications; repair accessories and auxiliary equipment, and body and structural repair.

Vehicle Maintenance normal hours of operation shall be continuous from 8:00 AM to 5:00PM daily, Monday through Friday

The contractor shall provide oncall response within 60 minutes for weekends, holidays, and after normal duty hours for emergency vehicle repair. This work shall be continuous 24 hours a day, 7 days a week until completed, unless approved by THE CHSA.

Recognized Holidays for Polk County Offices. Except for work categorized as emergency, the contractor is not required to provide all services on the federal holidays.

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NOTE: Any of the above holidays falling on a Saturday or Sunday shall be observed on the date designated by Polk County Government. (List of recognized Holidays available at the county office).

The contractor shall maintain all vehicles to the standards required by THE CHSA mandatory directives and manuals. THE CHSA manuals available in email format upon request.

The contractor shall accomplish scheduled preventive maintenance, concurrent and special inspections, tests, and calibration.

The contractor shall be responsible for installation or transfer of vehicle accessories and special equipment as approved by THE CHSA. The contractor shall be responsible for repairs and parts after installation which should fall under warranty.

The contractor shall provide, issue, and add all replenishment fluids/ lubricants to include; engine oils, transmission, brake and hydraulic fluids, gear lubricants, and coolants that meet the standards set forth by THE CHSA directives and manuals. THE CHSA manuals available in email format upon request.

The contractor shall provide repair and replacement of vehicle and equipment tires in accordance with THE CHSA directives and manuals. Disposal of unserviceable tires shall be the contractor's responsibility in accordance with approved environmental procedures.

The contractor shall maintain strict control of all accountable documents. This includes logs and registers required by THE CHSA. These documents will be made available to THE CHSA upon request.

The contractor shall ensure that employees have current and valid professional certifications before operating county vehicles. Vehicle Operations drivers must be licensed by the appropriate State to operate vehicles used in the performance of this contract on federal, state, and local highway systems.

The contractor shall provide motor vehicle and equipment repair parts equal to or exceeding the quality of replacement parts supplied by the original equipment manufacturer.

Commercially purchased or contractor rebuilt parts may be used if they equal or exceed the quality of the original parts.

THE CHSA may award multiple contracts for each maintenance activity.

For cost and service efficiencies, THE CHSA prefers to have a single Contractor that is able to perform all services. However, if necessary, Contractors may subcontract specialty work to subcontractors who have been approved prior to the start of work. The Contractor shall be responsible for all costs associated with doing business with its subcontractors unless otherwise mutually agreed upon with THE CHSA.

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Service Facility Location and Contacts A Contractor Information Sheet is included. Proposers must submit this form with their proposal. When information on the form changes, a new form should be submitted. The form includes the facility location and primary and secondary contact information. PREVENTIVE MAINTENANCE SERVICE The description of preventive maintenance activities follows: Preventive maintenance is a term used to describe the performance of regularly scheduled maintenance procedures of a vehicle to prevent the possibility of malfunctions. THE CHSA will maintain all vehicles and wheel chair lifts in the best possible operational conditions. This will be accomplished by adhering to and/or exceeding the manufacturer’s recommended minimum maintenance requirements. THE CHSA will contact the Contractor to schedule any maintenance service. At the time of the contact, the Contractor will provide an estimated price for the service. The Contractor is responsible for communicating any noted inspection deficiencies to THE CHSA BEFORE the repairs are performed. Part of the communication will include an estimate for the additional activities. Please note that all fluids needed for topping off, reservoirs or oil changes shall be included in the quoted price of the preventive maintenance service. Each week, THE CHSA will provide a pre schedule of the PM Services that are approaching their mileages. THE CHSA and Contractor will mutually agree on a schedule for the week to accomplish the maintenance.

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PREVENTIVE MAINTENANCE SCHEDULE In addition to the following schedule: REGULAR

Wash vehicle interior and exterior – determine need by the amount of use and road conditions. (Salt used for clearing roads and chloride compounds used to control dust on unpaved roads may require more frequent washes.

Clean the windshield wiper blades as required. UNSCHEDULED

Replace: o Alternator o Starter motor o Windshield wiper motor o Windshield wiper blades o O2 sensor o Exhaust components: muffler, manifolds, pipes, hangers and clamps,

headlamps, turn signal bulbs, brake lights and marker lights. o Vehicle interior fittings, seat materials o Wheelchair lift components o Wheelchair restraint components

EVERY YEAR

Vehicle Inspection

Flush radiator

Replace coolant

Service air conditioner

Replace all hoses; more often if necessary. MILEAGE SPECIFIC

In dusty areas, the air filter should be replaced every 10,000 miles.

PVC valve and brake pad replacements and engine tuneups may need to be performed more often than suggested in this schedule.

PM Description

Preventive maintenance (PM) service is scheduled at 5000 miles or six (6) months, whichever comes first. The preventive maintenance schedule matches the Original Equipment Manufacturer’s (OEM’s) recommendations and is documented in THE CHSA maintenance plan.

The majority of vehicles receive an “A” or “B” service on an alternating basis. For example: the vehicles receive an “A service” at 5,000 miles, “B service” at 10,000 miles, then “A service” again at 15,000 miles, etc. The “C”, “D”, and “E” services will always be performed in conjunction with an “A” or “B service”.

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The “A” shall be inspected and maintained for a minimum 5,000-mile performance increment.

The “B” PM Service shall include ALL items on the “A” PM Checklist, plus the items specified under the “B” PM Service. This service shall be maintained for a minimum 10,000-mile performance increment. This service shall be performed every 10,000-15,000 miles.

The “C” PM Service shall be performed in conjunction with an “A” or a “B” PM Service.

The “D” PM Service, or “tune-up” service. It shall be performed in conjunction with the “B” PM Service that is scheduled between 50,000 and 60,000 miles but not to exceed four (4) years.

The “E” PM Service or “coolant system” service shall also be performed in conjunction

with an “A” or “B” PM Service at 50,000-mile increments

Repair Service

As a result of PM Service, the Contractor may make recommendations for repair service. Contractors shall support their recommendations for repair work by using diagnostic statistics, accepted performance standards, vehicle history records, mileage, etc. The Contractor shall obtain prior authorization before completing any work that is the result of PM Service. All repair service, other than emergencies, will be scheduled by THE CHSA.

The required turnaround time for PM Service plus routine repair services done as a result of the PM shall not exceed two (2) business days or a mutually agreed time frame.

Warranty Service

Completion of warranty work revealed as a result of PM Service shall not exceed five (5) business days from the date the vehicle is received by the warranty dealer. If special circumstances require extended down times, the specific schedule will be mutually determined between The CHSA and the Contractor / Warranty Dealer.

Contracted service facilities shall be familiar with all manufacture and after-market warranties. It is the responsibility of the Contractor to identify and notify THE CHSA of service that is covered by any warranty. The CHSA will make the final determination to

exercise the warranty or not based on costs, nature of the work to be done, convenience, and customer service.

THE CHSA shall be responsible for coordinating all warranty work with the Contractor.

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Emergency Service

If a vehicle has a breakdown or is involved in an accident after hours and cannot be driven, the CHSA shall have the vehicle towed to either the System's or the Contractor’s facility.

Service Procedures

a. Communications

THE CHSA will assign a contact person to coordinate services including: daily scheduling of vehicle drop-off and pick up, authorization of any service as a result of PM work, update of vehicle work status, review of invoices, etc.

The Contractor will provide contact information for a primary and secondary

contact, as provided on the Contractor form.

The CHSA will call the on a daily basis when vehicles have been delivered for services. The Contractor shall anticipate the calls and be prepared to provide accurate and timely information to THE CHSA on vehicle status including but not limited to:

Vehicle status.

Which vehicles are ready by vehicle number.

Which vehicles are being serviced and/or require authorization for repair.

Which vehicles require warranty service.

Estimated completion date of vehicles under repair.

Description of repairs.

THE CHSA and Contractor will discuss the following information at a minimum: Vehicles coming in for service including estimated cost and arrival time.

Type of PM Service to be done.

Significant mechanical problems vehicle is having – as relayed by driver.

Service work Authorization.

b. Billing Requirements

A detailed work order / invoice will be provided when the vehicle is returned. On a monthly basis, the Contractor shall prepare and submit a summary invoice with detailed work orders attached. Both of these documents should minimally include:

Vehicle #, Work Order #, Work Order Date, Work Order Costs, Sales Tax, Tire Fee, Hours, Hours Cost, Total Cost

Each summary invoice will contain the following statement, a signature of person preparing the invoice and be dated:

o This information is true and accurate to the best of my knowledge and ability.

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Administration

Upon contract award, THE CHSA will meet with the Contractor to review procedures for

monitoring contract performance. In general, the Contractor shall anticipate that THE

CHSA will use standard industry rate publications for cost and performance time

guidelines, obtain second opinions of service work at random, and schedule on-site

visits with shop management to review service performance. Contract renewal

meetings shall be held prior to the end of the contract period expiration. At that time,

THE CHSA will offer a contract extension or may notify the Contractor of its intent not to

renew.

THE CHSA Vehicle Maintenance Schedule

THE CHSA Vehicle Maintenance Schedule A B C D E

Description 5000 15000 60000 105000 120000

Shocks/struts: other suspension components;

leaks/damage X X X X X

Brake system: lines; hoses; parking brake; wheel end

play/noise, X X X X X

Inspect brake pads & rotors; replace/machine if

necessary X X X X X

Engine cooling system: hoses and clamps X X X X X

Fluids/level/lines: transmission; filter; power steering;

axle X X X X X

Battery: secure; terminals clean; performing properly,

replace as needed X X X X X

Inspect, replace as needed, accessory drive belt(s) X X X X X

Rotate tires; inspect for wear and tear X X X X X

Tires; tread; wear; wheel lugs; hubcaps; valve cores

condition X X X X X

***** other items ***** X X X X X

Change oil; replace oil filter; use oem recommended

oil X X X X X

Inspect wheels for end play and noise X X X X X

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THE CHSA Vehicle Maintenance Schedule A B C D E

Description 5000 15000 60000 105000 120000

Brake master cylinder full / no leaks X X X X X

Inspect cabin air filter, if equipped X X X X X

Transmission fluid full / no leaks X X X X

Lubricate front axle and u joints X X X X

Inspect half shaft dust boots; if equipped X X X X

Inspect steering linkage; driveshaft; ball/u-joints;

lubricate X X X X

Replace cabin air filter (if equipped) X X X X

Change fuel filter X X

Change transmission fluid and replace filter X X

Replace wheel bearing grease; grease 4x2 wheel

bearing seals X X

Replace climate-controlled seat filter (if equipped) X X

Inspect spark plugs; replace as necessary X X

Change motorcraft premium gold engine coolant X

Replace rear axle fluid on dana axles; synthetic

lubricant X

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LIFT MAINTENANCE 1 YR Coolant Flush Perform lift maintenance at scheduled intervals according to number of cycles or elapsed time, whichever comes first. Correct any potentially dangerous situations at once. WHEELCHAIR LIFE MAINTENANCE SCHEDULE 2 Weeks or 50 Cycles

Outboard roll stop hinge (6 places) * light oil

Outboard roll stop springs (3) * light oil

4 Weeks or 100 cycles * Perform all procedures listed in previous section(s) also

Transition plate hinge * light oil

Platform fold axles * light oil

Handrail(s) pivot points (option) * light oil

1 Year or 1250 Cycles * Perform all procedures listed in previous section(s) also

Inspect cotter pins on platform fold axles (2) Replace if needed

Inspect gas spring mounting hardware Tighten or replace if needed

Inspect roll stop for proper operation. Replace defective parts Roll Stop must snap to vertical (UP) And/or relubricate. position.

Inspect platform locking channels Resecure or replace Mounting hardware for securement (8 carriage bolts)

Inspect handrail(s) for proper operation Replace defective parts And/or relubricate

Hydraulic Fluid (Pump) – check level Use Type A transmission Fluid (* See Systems Description for specifications Check fluid level with platform lowered fully. Fill the reservoir to within ½” from the top of the reservoir (breather cap hole)

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Manual Backup Pump (option) Release valve must be tight. Check for proper operation. Tighten or replace leaky or Faulty hydraulic fittings. Check hydraulic fluid level. (*See Systems Descriptions for Priming and Flushing Procedures).

Chain Adjustment: Must have equal Adjust if needed. *See Tension and proper platform height Roller Chain Assemblies In Systems Descriptions

GENERAL INSPECTION

Remove header cover and inspect:

Cylinder clevis lock nut and cylinder Tighten or replace if needed. Note: mounting hardware Clevis lock nut must be replaced If loosened or removed.

Hydraulic hoses, fitting and connections Resecure, replace or correct for wear, leaks or other damage as needed.

Chains, chain bolts, UHMW rollers, axles Resecure, realign, replace or and mounting hardware for wear, correct as needed. misalignment or other damage.

Inspect power cable. Resecure, repair or replace.

Make sure lift operates smoothly. Realign horseshoe tubes, Apply Light Grease or Otherwise correct as needed.

Mounting Check to see that the lift is Securely anchored to the Vehicle and there are no Loose bolts, broken welds Or stress fractures.

Decals Replace if worn, missing or Illegible.

Sun Grip Replace if worn or missing.

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Mandatory Insurance Requirements The Contractor shall provide Certificates of Insurance to THE CHSA. Any changes in the coverage of these policies must be communicated sixty (60) days prior to the change.

Worker Compensation – Statutory minimum limits: G.S. 97 Workman’s Compensation Act requires any employer with employs three or more employees to carry workman’s compensation coverage. Employer’s liability with a minimum of $100,000 combined single limit per accident, $100,000 each employee for bodily injury by disease and $500,000 policy limit bodily injury by disease.

Garage Keeper’s Legal Liability: Minimum limits $1,000,000 per occurrence

Garage Liability: Minimum limits $1,000,000 per occurrence

Commercial General Liability: Minimum $1,000,000 combined single limit of Bodily Injury and Property Damage per occurrence including the following coverage:

o Contractual Liability, Premises and Operations, Independent Contractors, Completed

o Operations and Product Liability, Personal Injury o Automobile Liability: Minimum $1,000,000 combined single limit of Bodily

Injury and Property Damage per occurrence including the following: owned automobiles, hired automobiles, nonhired automobiles

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SCOPE OF SERVICES/WORK Guardianship Services

Polk County Consolidated Human Services Agency is responsible for guardianship

services of residents deemed incompetent arising from Mental Health / Developmental

Disabilities / Substance Abuse issues as determined by the Polk County Clerk of Court.

A. The CHSA will:

1. Thoroughly assess Adult Protective Services reports and Guardianship

Evaluations requests to determine if an appointed guardian is in the best

interest of an individual

2. Coordinate with Contractor to develop a plan of care for the individual

3. Keep Contractor informed of any changes to the regulations governing the

guardianship;

4. Make reimbursement payment to Contractor for services purchased for

eligible individuals

5. Review on a monthly basis the services provided by Contractor to the

individual

6. Make face-to-face contact with the individual on a quarterly basis.

B. Contractor will:

1. Provide adult guardianship case management services to Polk County

residents / individuals identified and appointed to them on behalf of Polk

County Department Consolidated Human Services Agency (CHSA) to include

but not be limited to:

a. Coordinate with the CHSA to develop a plan of care for the Individual

b. Decide where the individual will live based on their individual

preferences, needs and resources

c. Assure that the individual receives good care including arranging for

any appropriate training, education, employment habilitation or

rehabilitation they may need;

d. Give consent or approval for the individual to receive any needed

services (medical, dental, legal, psychological, etc.) and petition the

Clerk of Court to seek the Clerk’s agreement with the guardian’s

decision

e. Take reasonable care of the individual’s personal belongings

f. Take any legal action needed to protect the individual

2. Comply with all requirements of the Order of Appointment entered by the

Clerk of Court and will fulfill the duties as set forth in Chapter 35A of the North

Carolina General Statutes

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3. Conduct at least monthly face-to-face contact with the individual unless

specifically agreed upon as documented in writing by the CHSA that the

contact may be less frequent

4. Maintain ongoing notes and documentation related to the work conducted

with and on behalf of the individual

5. Provide the CHSA written quarterly progress reports related to the work

conducted with and on behalf of the individual

6. Provide at its sole expense, legal counsel when required to fulfill its statutory

duties

7. Provide all reports required by the clerk of court

8. Copy CHSA with yearly status report when sent to the clerk of court and will

include but not be limited to the following:

a. A report of a recent medical and dental examination of the ward by one

or more physicians or dentists;

b. A copy of the most recent assessment completed by Contractor which

identifies the individual’s current condition, needs and development

9. Warrant that each employee providing guardianship case management

services to Polk County individuals is duly and currently certified as a

registered guardian with the NC Guardianship Association and that such

certification will be maintained during the term of this agreement

10. Not subcontract any of the services provided in this agreement without prior

written approval of Polk County CHSA

11. Invoice Polk County CHSA for services purchased for eligible individuals

a. Submit invoice to Polk DSS within five days of the new month.

12. Any other metric or goal outlined for guardianship services by HB 630 MOU

for fiscal year 2018-2019 and following. See MOU for details

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Section A: Response Form (Contractor Information Sheet)

1.1 CONTRACTOR INFORMATION SHEET

Request for Verification / Notification of Information Changes Name of Business

or Individual: _____________________________________________________________________ (List name as will appear on Invoice)

Owner’s Name: ___________________________________________________________________ (Individuals: names as it appears on Social Security Card Sole Proprietorships: Name as it appears on

SS Card or EIN Notification as used below Partnerships and Corporations: Correct legal name of business)

Primary Contact: Work Phone #: ( )

Cell Phone #: ( )

Fax #: ( )

Email Address:

Secondary Contact:

Work Phone #:

( )

Cell Phone #: ( )

Mailing Address:

Number Used To File Federal Income Tax:

Federal Tax ID: -

Physical Address: MUST BE CORRECT FOR 1099 PURPOSES

DUNS # (ARRA)

Taxing County: (if NC)

Business & Individual Characteristics (Complete All): Check ALL That Apply: NCDOT Certified DBE Number of Years: Individual* MinorityOwned Bus (MBE) At this location _______yrs Sole Proprietorship* WomenOwned Business Under current ownership Federal Government Enterprise (WBE) /management: _______ yrs State Government Local Government Partnership ** Corporation (Check ALL that apply) ** Not For Profit SubChapter S Medical / Health

This information is true and accurate to the best of my knowledge and ability.

Typed Name of Person Completing this Form: ___________________________________________________

Title:__________________________________________________

Signature: _____________________________ Date:_______________________

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1.2 Shop Description (Applicable to Transportation Maintenance)

Shop Hours (M-F)

Shop Hours (Saturday)

Perform Warranty Work? Yes No Describe:

Number of Lifts

Lift Capacity (ies)

Towing Equipment

Describe

Number of Bays

Bay Sizes

Height

Length

Width Experience & Certifications If Yes, list Certification type(s):

Engine Repair Yes No

Auto Transmission Yes No

Drive Train Yes No

Steering & Suspension Yes No

Brakes Yes No

Electrical System Yes No

Heating & A/C Yes No

Federal A/C Recovery Yes No

Wheels & Tires Yes No

Hydraulic Lift Yes No

State Inspections Yes No

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1.3 Subcontractors

Any outsides contractors used for repairs, services or maintenance must be listed below. These may or may not be Disadvantaged Business Enterprises (DBEs) as listed on Appendix A. All subcontracts must include Federal Requirements and ARRA Provisions from the RFP.

1. Business

Name

Contact Name

Work Provided

Address

Phone Email

2. Business

Name

Contact Name

Work Provided

Address

Phone Email

3. Business

Name

Contact Name

Work Provided

Address

Phone Email

4. Business

Name

Contact Name

Work Provided

Address

Phone Email

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1.4 References

Provide the names and contact information of at least three (3) references that we may contact to help us get to know you as a service provider. These references should help us determine your timeliness, accuracy, cost effectiveness, and customer service.

Reference #1: Name

Phone

Relationship

Reference #2: Name

Phone

Relationship

Reference #3: Name

Phone

Relationship

1.7 Pricing

A. Proposers shall use Attachment A to enter pricing.

B. Prompt Pay Discounts: Prompt pay discount offered % - Days, Net

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ATTACHMENT A

PRICE PROPOSAL RFP

Pricing shall be paid on a cost reimbursement basis. All activities will be priced prior to the start of the work. Completed work orders / invoice will be returned when services are rendered. All work must be discussed / approved by the CHSA personnel contact for the contract prior to beginning the work.

Each Proposer can submit an offer on all work or just specific work activities by checking yes or no in the appropriate box. Cost should be provided in appropriate sections (it is acceptable to include back-up material as needed). Any or all work activities and any or all items that have been selected by the bidder may be awarded by THE CHSA.

Description Price

Fixed Base Price Flat Rate

Preventive Maintenance Activity Ability To Perform Cost

Food/Congregate Meal Supplies Yes No

Facility Cleaning Services Yes No

Legal Services – Adult Services, Child

Services and Family Services Yes No

Adult Guardianship Services Yes No

Legal Services – Child Support

Enforcement Yes No

Transportation Services – Maintenance Yes No

This information is true and accurate to the best of my knowledge and ability.

Typed Name of Person Completing this Form:

Title:

Signature:

Date:

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ATTACHMENT B

PRICE PROPOSAL RFP Vehicle Maintenance Services

Maintenance and repair service pricing shall be paid on a cost reimbursement basis. All activities will be priced prior to the start of the work. Completed work orders / invoice will be returned when the vehicle is picked up. All work must be discussed / approved by the Transit System prior to beginning the work.

Each Proposer can submit an offer on all work or just specific work activities by checking yes or no in the appropriate box. Cost should be provided in appropriate sections. Any or all work activities and any or all items that have been selected by the bidder may be awarded by THE CHSA.

All component warranties will be given to the THE CHSA. Contractor will assist the Transit System in determining the best fit based on cost and potential warranties.

Description Price

Labor Rate Per Hour Flat Rate

Manufacturer’s Suggested Retail Price (MSRP) for Parts

All parts must comply with the Buy America Provisions discussed in this RFP.

% Discount

Preventive Maintenance Activity Ability To Perform Cost

Preventive Maintenance Schedule A Yes No

Preventive Maintenance Schedule B Yes No

Preventive Maintenance Schedule C Yes No

Preventive Maintenance Schedule D Yes No

Preventive Maintenance Schedule E Yes No

Preventive Maintenance Hydraulic Lift Yes No

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Routine Maintenance Activity Ability To Perform Cost

Wash and Vacuum Yes No

Tires – set of 2 tires – Brand: _____________ Rating: _________ Size: ___________, _________, _________ Attach another page if need more space

Yes No

1. 2. 3.

Tires – set of 2 tires – Brand: _____________ Rating: _________ Size: ___________, _________, _________ Attach another page if need more space

Yes No

1. 2. 3.

Wheel Balancing and Tire Repair per tire Yes No

Towing Services within 25 miles Yes No

Towing Services 25 – 50 miles Yes No

Towing Services 25 – 50 miles Yes No

Towing Services per hour portal to portal Yes No

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Maintenance Activity – to be quoted Ability To Perform

Front Brake Reline (Both Sides) Yes No

Front Brake Overhaul (Both Sides) Yes No

Brake Rotor Replacement (One Each) Yes No

Rear Brake Reline (Both Sides) Yes No

Rear Brake Overhaul (Both Sides) Yes No

Minor EVAC and Recharge R134 AC System Yes No

Hydraulic Lift Yes No

Alignment Yes No

Battery Replacement Yes No

Fuel Injection Flush Yes No

Alternator Yes No

Fuel Pump Module Yes No

Window Motors Yes No

Shock Absorbers Yes No

Engine Rebuild Yes No

Engine (New) (see fleet list, pg 5) Yes No

Transmission / Engine Oil Cooler Lines Yes No

Transmission Rebuild Yes No

Transmission (New) (see fleet list, pg 5) Yes No

Accident Repair / Body Work Yes No

This information is true and accurate to the best of my knowledge and ability. Typed Name of Person Completing this Form:

Title:

Signature:

Date:

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PRICE PROPOSAL

Vehicle Maintenance Services

Maintenance and repair service pricing shall be paid on a cost reimbursement basis. All

activities will be priced prior to the start of the work. Completed work orders / invoice

will be returned with the vehicle is picked up. All work must be discussed / approved by

THE CHSA prior to beginning the work.

Each Proposer can submit an offer on all work or just specific work activities by

checking yes or no in the appropriate box.

All component warranties will be given to THE CHSA. Contractor will assist THE CHSA

in determining the best fit based on cost and potential warranties.

DECSCRIPTION OF PRICE

Labor Rate Per Hour Flat Rate

Wash/Vacuum Labor Rate per Hour Flat Rate

Wash/Vacuum Fee Flat Rate

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Section B: Certification Of Restrictions On Lobbying (To be submitted with all bids or offers exceeding $100,000; must be executed prior to Award) The undersigned certifies, to the best of his or her knowledge and belief, that: (Contractor)

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any persons 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 the awarding to any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. 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 this Federal contract, grant loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying", in accordance with its instructions [as amended by "Government wide Guidance for New Restrictions on Lobbying," 61 Fed. Reg. 1413 (1/19/96). Note: language in paragraph (2) herein has been modified in accordance with Section 10 of the Lobbying Disclosure Act of 1995 (P.L. 10465, to be codified at 2 U.S.C. 1601, et seq .)]

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance is placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transactions imposed by 31, U.S.C. 1352 (as amended by the Lobbying Disclosure Act of 1995). Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. [Note: Pursuant to 31 U.S.C. 1352(c)(1)(2)(A), any person who makes a prohibited expenditure or fails to file or amend a required certification or disclosure form shall be subject to a civil penalty of not less than $10,000 for each such expenditure or failure.]

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The Contractor, ___________________, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. Section A 3801 et seq., apply to this certification and disclosure, if any. _____________________________ Signature of Contractor’s Authorized Official Date__________________________ Name and Title of Contractors Authorized Official________________________ Subscribed and sworn to before me this day of , 20 , in the State of ;_____________ and the County of______________________ Notary Public My Appointment Expires

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Section C: Form of Proposal & Acknowledgement of Addenda

I understand that the CHSA reserves the right to reject this proposal, but that this proposal shall remain open and shall not be withdrawn for a period of sixty (60) days from the date of its submission. Prices submitted in response to the RFP will be valid for a minimum of 180 days from the date of proposal submission.

The price quoted in any proposal shall include all labor, materials, tools, equipment and other costs necessary to fully complete the design, manufacture, delivery and implementation of the system/service pursuant to the negotiated specifications.

Name of Company/Firm: ____________________________________________

Name & Title of Authorized Official: ___________________________________

Signature: _______________________________________________________

Date: ___/___/2010

Business Address: ________________________________________________

________________________________________________

________________________________________________

Telephone Number: (___) ___-____

Fax Number: (___) ___-____

Email Address: ________________

Acknowledgement Of Addenda Received:

Addendum No.: Date Received: ______________________



If no addenda were received, write “N/A” in each “Addendum No.” blank. Failure to acknowledge receipt of all addenda may cause the proposal to be considered non-responsive to the solicitation. Acknowledged receipt of each addendum must be clearly established.

Please attach a copy of each addendum received to this page, Section D.

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SECTION D: STATE REQUIREMENTS AND SPECIAL CONDITIONS

NC E-Verify Requirements

To ensure compliance with the E-Verify requirements of the General Statutes of North Carolina, all

contractors, including any subcontractors employed by the contractor(s), by submitting a bid, proposal or

any other response, or by providing any material, equipment, supplies, services, etc., attest and affirm

that they are aware and in full compliance with Article 2 of Chapter 64, (NCGS64-26(a)) relating to the E-

Verify requirements by executing and submitting the E-verify Affidavit included in this Invitation for Bids

as Attachment B (Must be completed for all construction contracts and all bids or quotes requiring

service or installation.)

Iran Divestment Act

N.C.G.S. 147-86.59 requires that all bids or contracts or renewals with the State of North Carolina, North

Carolina local governments, or any other political subdivision of the State of North Carolina have a

certification that the contractor is not on the Final Divestment List as created by the NC State Treasurer

pursuant to N.C.G.S. § 147-86.58. In compliance with the requirements of the Iran Divestment Act 2015

and N.C.G.S. § 147-86.55 and 147-86.59, the Contractor shall not utilize the performance of the contract

any subcontractor that is identified on the Final Divestment List.

The State Treasurer’s Final Divestment List can be found on the State Treasurer’s website:

www.nctreasurer.com/Iran and will be updated every 180 days.

Effective February 26, 2016. (See Attachment C – Must be completed with all contracts over $1,000)

http://www.nctreasurer.com/Iran

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ATTACHMENT B

STATE OF NORTH CAROLINA

COUNTY OF_______________

AFFIDAVIT OF COMPLIANCE WITH N.C. E-VERIFY STATUTES

(To be submitted with all bids)

I, _____________________________ (hereinafter the “Affiant”), duly authorized by and on behalf of _____________________________ (hereinafter the “Employer”) after being first duly sworn deposes and says as follows:

1. I am the ______________________ (President, Manager, CEO, etc.) of the Employer and possess the full authority to speak for and on behalf of the Employer identified above.

2. Employer understands that “E-Verify” means the federal E-Verify program operated by the United States Dept. of Homeland Security and other federal agencies, or any successor or equivalent program used to verify the work authorization of newly hired employees pursuant to federal law.

3. Employer employs 25 or more employees, and is in compliance with the provisions of N.C. General

Statute §64-26. Employer has verified the work authorization of its employees through E-Verify and shall retain the records of verification for a period of at least one year.

Employer employs fewer than 25 Employees and is therefore not subject to the provisions of N.C. General Statute §64-26.

4. All subcontractors engaged by or to be engaged by Employer have or will have likewise complied with the

provisions of N.C. General Statute §64-26. 5. Employer shall keep the State of North Carolina informed of any change in its status pursuant to Article 2

of Chapter 64 of the North Carolina Statutes. This _____day of _______________, 20____.

_____________________________________ Signature of Affiant

_____________________________________

Printed Name and Title State of

County of

Subscribed and sworn to before me this day of , 20 .

Notary Public

(SEAL)

My Appointment Expires

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ATTACHMENT C

STATE OF NORTH CAROLINA

COUNTY OF ______________

IRAN DIVESTMENT ACT CERTIFICATION

In accordance to N.C.G.S. 147-86.59, any contractor attempting to contract with the State of North Carolina, North

Carolina local governments, or any other political subdivision of the State of North Carolina shall certify at the time

of the bid or renewal that the assignee or contractor is not identified on a list created by the State Treasurer

pursuant to N.C.G.S. 147-86.58.

The Iran Divestment Act of 2015, G.S. 147-86.55 et seq.* requires that each contractor, prior to contracting with

the State certifies, and the undersigned on behalf of the contractor does hereby certify, to the following:

1. that the Contractor is not identified on the Final Divestment List of entities that the NC State Treasurer has determined engages in investment activities in Iran.

2. that the Contractor shall not utilize on any contract with the State agency any subcontractor that is identified on the Final Divestment List; and

3. that the undersigned is authorized by the contractor to make this certification.

The agency shall include the certification in the procurement record.

The State Treasurer’s Final Divestment List can be found on the State Treasurer’s website at the address:

https://www.nctreasurer.com/inside-the-department/OpenGovernment/Pages/Iran-Divestment-Act-

Resources.aspx

and will be updated every 180 days. For questions about the Department of State Treasurer’s Iran Divestment

Policy,

please contact Meryl Murtagh at [email protected] or (919) 814-3852.

* Note: Enacted by Session Law 2015-118 as G.S.143C-55 et seq., but has been renumbered for codification at the

direction of the Revisor of Statutes.

______________________________________________ ________________________________

Contractor Signature Date

______________________________________________ ________________________________

Printed Name Title

State of

County of

Subscribed and sworn to before me this day of , 20 .

Notary Public

My Appointment Expires

https://www.nctreasurer.com/inside-the-department/OpenGovernment/Pages/Iran-Divestment-Act-Resources.aspx

https://www.nctreasurer.com/inside-the-department/OpenGovernment/Pages/Iran-Divestment-Act-Resources.aspx

request for proposals for polk county consolidated human services agency (chsa) · 2019-03-13 ·...

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