ࡱ> bd_`ay  kbjbj y{{! 444tp<&"":J"J"J"  $`0Q40J"J"444ZJ"4J" 4 446(JJ"0hARjF0b`x8444004 :  APPENDIX B SOQ APPLICATION  Table of Contents SOQ Checklist 85 Exhibit 1 Partners Organization Questionnaire/Affidavit 87 Exhibit 2 Description of Current Operations 90 Exhibit 3 Organizations Plan To Provide CalFresh Application Assistance Services 92 Exhibit 4 Certification of No Conflict of Interest 94 Exhibit 5 Organizations EEO Certification 95 Exhibit 6 Familiarity With The County Lobbyist Ordinance Certification 96 Exhibit 7 Potential Partners References 97 Exhibit 8 Potential Partners List of Contracts 98 Exhibit 9 Potential Partners List of Terminated Contracts 99 Exhibit 10 Attestation of Willingness to Consider GAIN/GROW Participants 100 Exhibit 11 Los Angeles County Contractor Employee Jury Service ProgramCertification Form & Application for Exception 101 Exhibit 12 Charitable Contributions Certification 102 Exhibit 13 Certification of Compliance with the Countys Defaulted Property Tax Reduction Program 103 Exhibit 14 Signature Page of Cooperative Agreement 104 Exhibit 15 Background and Security Investigation Certification 105 _________________________ CONTRACTOR NAME SOQ CHECKLIST EXHIBIT PAGE 1. PARTNERS ORGANIZATION QUESTIONNAIRE/AFFIDAVIT  ___ to___2. DESCRIPTION OF CURRENT OPERATIONS___ to___3.PLAN TO PROVIDE CALFRESH APPLICATION ASSISTANCE SERVICES  ___ to___4.CERTIFICATION OF NO CONFLICT OF INTEREST ___ to___5.CONTRACTORS EEO CERTIFICATION ___ to___6.FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATION  ___ to___7.PROSPECTIVE CONTRACTOR REFERENCES ___ to___8.PROSPECTIVE CONTRACTOR LIST OF CONTRACTS ___ to___9.PROSPECTIVE CONTRACTOR LIST OF TERMINATED CONTRACTS  ___ to___10.ATTESTATION OF WILLINGNESS TO CONSIDER GAIN/GROW PARTICIPANTS  ___ to___11.LOS ANGELES COUNTY CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM CERTIFICATION FORM & APPLICATION FOR EXCEPTION  ___ to___12.CHARITABLE CONTRIBUTIONS CERTIFICATION ___ to___13.CERTIFICATION OF COMPLIANCE WITH THE COUNTYS DEFAULTED PROPERTY TAX REDUCTION PROGRAM ___ to ___ 14. SIGNATURE PAGE OF COOPERATIVE AGREEMENT  ___ to___15.BACKGROUND AND SECURITY INVESTIGATION CERTIFICATION ___ to ___ SOQ CHECKLIST (CONTINUED) ATTACHMENTS  PAGE1.ARTICLES OF INCORPORATION AS FILED WITH SECRETARY OF STATE  ___ to___2.CERTIFICATE OF GOOD STANDING WITH STATE OF CALIFORNIA OR STATE OF INCORPORATION  ___ to___3.STATEMENT OF DOMESTIC (OR FOREIGN) STOCK CORPORATION AS FILED WITH CALIFORNIA SECRETARY OF STATE, AND STATEMENT WHICH INCLUDES THE NAMES OF CORPORATE OFFICERS  ___ to___4. IRS LETTER GIVING TAX EXEMPT STATUS___ to___5.COPY OF MINUTES OF BOARD OF DIRECTORS MEETING OR RESOLUTION GRANTING AUTHORITY TO SUBMIT THE SOQ AND EXECUTE THE COOPERATIVE AGREEMENT TO THE PERSON SIGNING  ___ to___6.COPIES OF THREE MOST RECENT YEARS FINANCIAL STATEMENTS  ___ to___7.COPY OF MOST RECENT FILING UNDER REGISTRY OF CHARITABLE TRUSTS  ___ to___8. PENDING LITIGATION AND JUDGMENTS ___ to___9.PROOF OF INSURANCE OR INSURABILITY ___ to___ PARTNERS ORGANIZATION QUESTIONNAIRE/AFFIDAVIT Please complete, date and sign this form and include it in Section A.1 of the SOQ. The person signing the form must be authorized to sign on behalf of and to bind the applicant in a Master Agreement. 1. If your firm is a corporation, state its legal name (as found in your Articles of Incorporation) and State of incorporation: _______________________________________________ _______________ Legal Name State/Year Inc. 2. If your firm is doing business under one or more DBAs, please list all DBAs and the County(s) of registration: Name County of Registration Year became DBA _______________________ _________________________ _________________ _______________________ _________________________ _________________ 3. Is your firm wholly or majority owned by, or a subsidiary of, another firm? ____ If yes, Name of parent firm: _______________________________________________________ State of incorporation or registration of parent firm:_______________________________ 4. Please list any other names your firm has done business as within the last five (5) years. Name Year of Name Change ________________________________________________ ________________________________________________________________________ 5. Indicate if your firm is involved in any pending acquisition/merger, including the associated company name. If not applicable, so indicate below. ________________________________________________________________________ ________________________________________________________________________ 6. Indicate the Supervisorial District to be served (mark only one): ( First ( Second ( Third ( Fourth ( Fifth 7. Applicant acknowledges and certifies that it meets and will comply with all of the Minimum Qualifications listed in Paragraph 1.5 - Minimum Qualifications, of this Request for Statement of Qualifications (RFSQ), as listed below. ( Yes ( No Has significant interaction with low-income families, individuals, children or parents with children who represent the target population for the Food Stamp Program.  ( Yes ( No Is a bona fide non-profit corporation as determined by the Internal Revenue Service and has a federal tax ID #. ( Yes ( No Has a premises located in Los Angeles County. List addresses of premises: ________________________________________ ________________________________________ ( Yes ( No Has operated in Los Angeles County for the past three years as one or more of the following: Faith-Based Organization such as a church, synagogue, mosque or temple; Community-Based Organization providing health and human services; or Parent-Teacher Association. ( Yes ( No Project staff (including volunteers) have no record of conviction for fraud, welfare fraud, embezzlement, sex crimes, forgery or theft. ( Yes ( No Have project staff fluent in English. ( Yes ( No Has no record of unsatisfactory performance, lack of integrity or poor business ethics, as required by California Operations Manual Section 23-601.243; and ( Yes ( No Completed and submitted all of the required SOQ Exhibits and Attachments in the proper format as specified in Section 3.7. Applicant further acknowledges that if any false, misleading, incomplete, or deceptively unresponsive statements in connection with this SOQ are made, the SOQ may be rejected. The evaluation and determination in this area shall be at the Directors sole judgment and his/her judgment shall be final. Corporations Name: ____________________________________________________________________________ Address: ____________________________________________________________________________ ____________________________________________________________________________ e-mail address:_____________________________ Telephone number:_________________ Fax number: ______________________________  On behalf of _______________________________ (Applicant/Corporations name), I ___________________ (Name of Applicants authorized representative), certify that the information contained in this Partners Organization Questionnaire/Affidavit is true and correct to the best of my information and belief. ______________________________________ __________________________ Signature Internal Revenue Service Employer Identification Number _________________________________________ ___________________________ Title County WebVen Number ______________________________________ Date  DESCRIPTION OF CURRENT OPERATIONS _____________________________ CONTRACTOR NAME Briefly describe the items below as they pertain to the Contractors current operations: The geographic region and community served: A demographic description of the population served by the Contractor (such as ethnicity, languages spoken, economic status and special circumstances and/or barriers and challenges faced by the service population). The Contractors mission and a description of the services currently provided by the Contractor:  DESCRIPTION OF CURRENT OPERATIONS  _____________________________ CONTRACTOR NAME Briefly describe the items below as they pertain to the Contractors current operations: Contractors (and/or key staff) experience with outreach for government benefits/programs, (such as Healthy Families, Medi-Cal, or the CalFresh Program) or other health and human services programs: Experience of the Contractor (and/or key staff) working with low-income families and individuals. CONTRACTORS PLAN TO PROVIDE CALFRESH APPLICATION ASSISTANCE SERVICES ___________________________________ CONTRACTORS NAME Describe the Contractors plan to provide CF Application Assistance services (use additional sheets if necessary): Key Staff Provide Names, relevant experience and education, CalFresh Application duties: Use of Volunteers Describe how volunteers will be used by your agency in this project. Provide the job description, training and methods for recruitment and management of volunteers. Identifying and outreaching to potential CF applicants Describe approach to be used (e.g., application clinics, notices in church bulletins, etc.).  CONTRACTORS PLAN TO PROVIDE CALFRESH APPLICATION ASSISTANCE SERVICES __________________________________ CONTRACTORS NAME Describe the Contractors plan to provide CF Application Assistance services (use additional sheets if necessary): Assisting CF Applicants and Follow-Up Describe how the Contractor will assist applicants with the CalFresh Application, collecting the required supporting documents, and following up with applicants to ensure complete applications. Record Keeping Describe the Contractors record keeping system, and means to maintain confidentiality of applicants information. Oversight and Quality Assurance Describe by whom and how the CalFresh Project will be managed by the Contractor. Describe methods to ensure quality services are provided. Estimated number of Households to be served. a. Number of families/individuals provided with CalFresh Program and Application Assistance information/outreach: __________ per month b. Number of families/individuals assisted with CalFresh Applications: __________ per month.  CERTIFICATION OF NO CONFLICT OF INTEREST  The Los Angeles County Code, Section 2.180.010, provides as follows: CONTRACTS PROHIBITED Notwithstanding any other section of this Code, the County shall not contract with, and shall reject any proposals submitted by, the persons or entities specified below, unless the Board of Supervisors finds that special circumstances exist which justify the approval of such contract: Employees of the County or of public agencies for which the Board of Supervisors is the governing body; Profit-making firms or businesses in which employees described in number 1 serve as officers, principals, partners, or major shareholders; Persons who, within the immediately preceding 12 months, came within the provisions of number 1, and who: Were employed in positions of substantial responsibility in the area of service to be performed by the contract; or Participated in any way in developing the contract or its service specifications; and 4. Profit-making firms or businesses in which the former employees, described in number 3, serve as officers, principals, partners, or major shareholders. Contracts submitted to the Board of Supervisors for approval or ratification shall be accompanied by an assurance by the submitting department, district or agency that the provisions of this section have not been violated. ____________________________________________________ Vendor Name ____________________________________________________ Vendor Official Title ____________________________________________________ Officials Signature CONTRACTORS EEO CERTIFICATION ____________________________________________________________________________ Contractor Name ___________________________________________________________________________ Address ____________________________________________________________________________ Internal Revenue Service Employer Identification Number GENERAL In accordance with provisions of the County Code of the County of Los Angeles, the Contractor certifies and agrees that all persons employed by such firm, its affiliates, subsidiaries, or holding companies are and will be treated equally by the firm without regard to or because of race, religion, ancestry, national origin, or sex and in compliance with all anti-discrimination laws of the United States of America and the State of California. CERTIFICATION YES NO Contractor has written policy statement prohibiting discrimination in all phases of employment. ( ) ( ) Contractor periodically conducts a self-analysis or utilization analysis of its work force. ( ) ( ) Contractor has a system for determining if its employment practices are discriminatory against protected groups. ( ) ( ) When areas are identified in employment practices, Contractor has a system for taking reasonable corrective action to include establishment of goal and/or timetables. ( ) ( ) ___________________________________________ ________________________ Signature Date ___________________________________________ Name and Title of Signer (please print) FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATION The Contractor certifies that: it is familiar with the terms of the County of Los Angeles Lobbyist Ordinance, Los Angeles Code Chapter 2.160; that all persons acting on behalf of the Contractor have and will comply with it during the proposal process; and it is not on the Countys Executive Offices List of Terminated Registered Lobbyists. Contractor Name: ________________________ By:__________________________________ Date:___________________ Signature _______________________________________ Print Name & Title POTENTIAL PARTNERS REFERENCES Contractors Name: _____________________________ List up to ten references which are familiar with the Contractors operations and are not either an employee or parishioner of the Contractor and can provide verification that the Contractor meets the Minimum Qualifications and/or can provide verification of the current operations of the Contractor stated in this solicitation. 1. Name of Firm/Individual Address Contact Person Telephone # Fax # ( ) ( )  Relationship . # of Years  2. Name of Firm/Individual Address Contact Person Telephone # Fax # ( ) ( )  Relationship # of Years  3. Name of Firm/Individual Address Contact Person Telephone # Fax # ( ) ( )  Relationship . # of Years  4. Name of Firm/Individual Address Contact Person Telephone # Fax # ( ) ( )  Relationship . # of Years  5. Name of Firm/Individual Address Contact Person Telephone # Fax # ( ) ( )  Relationship # of Years POTENTIAL PARTNERS LIST OF CONTRACTS Contractors Name: _____________________________ List of all entities for which the Contractor has provided service within the last five years. The list must include all contracts with public entities. Use additional sheets if necessary, if any. 1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.  2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.  3. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.  4. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.  5. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.  POTENTIAL PARTNERS LIST OF TERMINATED CONTRACTS Contractors Name: _____________________________ List all contracts that have been terminated within the past ten years (if any). If none, write None under number 1. 1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. Reason for Termination:  2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. Reason for Termination:  3. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. Reason for Termination:  4. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. Reason for Termination:  5. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )  Name or Contract No. Reason for Termination:  ATTESTATION OF WILLINGNESS TO CONSIDER GAIN/GROW PARTICIPANTS As a threshold requirement for consideration for contract award, Potential Partner shall demonstrate a proven record for hiring GAIN/GROW participants or shall attest to a willingness to consider GAIN/GROW participants for any future employment opening if they meet the minimum qualifications for that opening. Additionally, Vendor shall attest to a willingness to provide employed GAIN/GROW participants access to the Vendors employee mentoring program, if available, to assist these individuals in obtaining permanent employment and/or promotional opportunities. Potential Partners unable to meet this requirement shall not be considered for contract award. Potential Partner shall complete all of the following information, sign where indicated below, and return this form with any resumes and/or fixed price bid being submitted: Potential Partner has a proven record of hiring GAIN/GROW participants. ______YES (subject to verification by County) ______NO Potential Partner is willing to consider GAIN/GROW participants for any future employment openings if the GAIN/GROW participant meets the minimum qualifications for the opening. Consider means that Vendor is willing to interview qualified GAIN/GROW participants. ______YES ______NO Potential Partner is willing to provide employed GAIN/GROW participants access to its employee-mentoring program, if available. ______YES ______NO ______N/A (Program not available) Potential Partner Contractor: ______________________________________ Signature: _______________________________________________________ Print Name: ______________________________________________________ Title: ________________________________________ Date: _____________ Tel.#: _______________________________ Fax #: _________________  COUNTY OF LOS ANGELES CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM CERTIFICATION FORM AND APPLICATION FOR EXCEPTION The Countys solicitation for this Request for Statement of Qualifications is subject to the County of Los Angeles Contractor Employee Jury Service Program (Program), Los Angeles County Code, Chapter 2.203. All Partners, whether a contractor or subcontractor, must complete this form to either certify compliance or request an exception from the Program requirements. Upon review of the submitted form, the County department will determine, in its sole discretion, whether the Partner is excepted from the Program. Company Name:Company Address:City: State: Zip Code:Telephone Number:Solicitation For ____________ Services:If you believe the Jury Service Program does not apply to your business, check the appropriate box in Part I (attach documentation to support your claim); or, complete Part II to certify compliance with the Program. Whether you complete Part I or Part II, please sign and date this form below. Part I: Jury Service Program is Not Applicable to My Business My business does not meet the definition of contractor, as defined in the Program, as it has not received an aggregate sum of $50,000 or more in any 12-month period under one or more County contracts or subcontracts (this exception is not available if the contract itself will exceed $50,000). I understand that the exception will be lost and I must comply with the Program if my revenues from the County exceed an aggregate sum of $50,000 in any 12-month period. My business is a small business as defined in the Program. It 1) has ten or fewer employees; and, 2) has annual gross revenues in the preceding twelve months which, if added to the annual amount of this contract, are $500,000 or less; and, 3) is not an affiliate or subsidiary of a business dominant in its field of operation, as defined below. I understand that the exception will be lost and I must comply with the Program if the number of employees in my business and my gross annual revenues exceed the above limits. Dominant in its field of operation means having more than ten employees and annual gross revenues in the preceding twelve months, which, if added to the annual amount of the contract awarded, exceed $500,000. Affiliate or subsidiary of a business dominant in its field of operation means a business which is at least 20 percent owned by a business dominant in its field of operation, or by partners, officers, directors, majority stockholders, or their equivalent, of a business dominant in that field of operation. My business is subject to a Collective Bargaining Agreement (attach agreement) that expressly provides that it supersedes all provisions of the Program. OR Part II: Certification of Compliance My business has and adheres to a written policy that provides, on an annual basis, no less than five days of regular pay for actual jury service for full-time employees of the business who are also California residents, or my company will have and adhere to such a policy prior to award of the contract. I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct. Print Name:Title:Signature:Date:CHARITABLE CONTRIBUTIONS CERTIFICATION _____________________________________________________________________ Company Name ______________________________________________________________________ Address ______________________________________________________________________ Internal Revenue Service Employer Identification Number ______________________________________________________________________ California Registry of Charitable Trusts CT number (if applicable) The Nonprofit Integrity Act (SB 1262, Chapter 919) added requirements to Californias Supervision of Trustees and Fundraisers for Charitable Purposes Act which regulates those receiving and raising charitable contributions. Check the Certification below that is applicable to your company. ( Potential Partner or Contractor has examined its activities and determined that it does not now receive or raise charitable contributions regulated under Californias Supervision of Trustees and Fundraisers for Charitable Purposes Act. If Vendor engages in activities subjecting it to those laws during the term of a County contract, it will timely comply with them and provide County a copy of its initial registration with the California State Attorney Generals Registry of Charitable Trusts when filed. OR ( Potential Partner or Contractor is registered with the California Registry of Charitable Trusts under the CT number listed above and is in compliance with its registration and reporting requirements under California law. Attached is a copy of its most recent filing with the Registry of Charitable Trusts as required by Title 11 California Code of Regulations, sections 300-301 and Government Code sections 12585-12586. ___________________________________________ ____________________________ Signature Date ___________________________________________ Name and Title of Signer (please print)  CERTIFICATION OF COMPLIANCE WITH THE COUNTYS DEFAULTED PROPERTY TAX REDUCTION PROGRAM Company Name:Company Address:City: State: Zip Code:Telephone Number: Email address:Solicitation/Contract For ____________ Services: The Proposer/Bidder/Contractor certifies that: % It is familiar with the terms of the County of Los Angeles Defaulted Property Tax Reduction Program, Los Angeles County Code Chapter 2.206; AND To the best of its knowledge, after a reasonable inquiry, the Proposer/Bidder/Contractor is not in default, as that term is defined in Los Angeles County Code Section 2.206.020.E, on any Los Angeles County property tax obligation; AND The Proposer/Bidder/Contractor agrees to comply with the Countys Defaulted Property Tax Reduction Program during the term of any awarded contract. - OR - % I am exempt from the County of Los Angeles Defaulted Property Tax Reduction Program, pursuant to Los Angeles County Code Section 2.206.060, for the following reason: ________________________________________________________________________________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct. Print Name:Title:Signature:Date: Date: ___________________ AUTHORIZATION OF AGREEMENT FOR CALFRESH APPLICATION ASSISTANCE SERVICES IN WITNESS WHEREOF, the Board of Supervisors of the County of Los Angeles has caused this Agreement to be executed by the Director, of the Department of Public Social Services or designee, and Contractor has caused this Cooperative Agreement to be executed in its behalf by its duly authorized officer, this _________ day of ________________, 20__. COUNTY OF LOS ANGELES By___________________________ Sheryl L. Spiller, Director Department of Public Social Services CONTRACTOR By:_____________________________ Date: ____________________ (Signature) Printed:__________________________ Title: __________________________ APPROVED AS TO FORM: _____________________ John Krattli County Counsel By________________________ Date: ______________________ Deputy County Counsel  BACKGROUND AND SECURITY INVESTIGATION CERTIFICATION Potential Partners Name Address GENERAL CERTIFICATION At the discretion and request of County, all Contractors personnel performing work on this contract resulting from this RFSQ, must undergo and pass, to the satisfaction of County, a background and security investigation as a condition of beginning and continuing work under the Contract. POTENTIAL PARTNER'S SPECIFIC CERTIFICATIONS The Contractor conducts a preliminary background Yes ( No ( investigation on each employee/volunteer. 2. The Contractor prohibits the hiring of any employees/volunteers Yes ( No ( with prior convictions of fraud, welfare fraud, embezzlement, sex crimes, forgery or theft. A Live Scan screening will be conducted on each Yes ( No ( employee/volunteer. Authorized Officials Printed Name and Title Authorized Officials Signature Date  !./BFPQRU]j     ! # K L O W h r y z }  " # & . 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