Form 1 "Contractor's Organization Questionnaire/Affidavit" - Los Angeles County, California

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REQUIRED FORMS - FORM 1
CONTRACTOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT
Please complete, date and sign this form and include it in Section A of the SOQ. The person signing the form
must be authorized to sign on behalf of the Contractor and to bind the applicant in a Master Contract.
Organization Name:
Address:
Organization Telephone:
Facsimile:
E-Mail Address of
Organization Contact
Person:
THIS STATEMENT OF QUALIFICATIONS IS BEING SUBMITTED FOR THE FOLLOWING PROGRAM(S):
Foster Family Agency Foster Care Services (DCFS Children)
Foster Family Agency Foster Care Services (Probation Children)
Group Home Foster Care Services (DCFS Children)
Group Home Foster Care Services (Probation Children)
1.
If your organization is a corporation, state its legal name (as found in your Articles of Incorporation) and
State of incorporation:
_______________________________________________
____________
________
Name
State
Year Inc.
2.
If your organization is a partnership or a sole proprietorship, state the name of the proprietor or managing
partner:
_____________________________________
If your organization is doing business under one or more DBA’s, please list all DBA’s and the County(s)
3.
of registration:
Name
County of Registration
Year became DBA
_____________________________________
_________________
______________
_____________________________________
_________________
______________
4.
Is your organization wholly or majority owned by, or a subsidiary of, another agency? ___________
If yes, Name of parent organization: __________________________________________________
Page 1 of 4
REQUIRED FORMS - FORM 1
CONTRACTOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT
Please complete, date and sign this form and include it in Section A of the SOQ. The person signing the form
must be authorized to sign on behalf of the Contractor and to bind the applicant in a Master Contract.
Organization Name:
Address:
Organization Telephone:
Facsimile:
E-Mail Address of
Organization Contact
Person:
THIS STATEMENT OF QUALIFICATIONS IS BEING SUBMITTED FOR THE FOLLOWING PROGRAM(S):
Foster Family Agency Foster Care Services (DCFS Children)
Foster Family Agency Foster Care Services (Probation Children)
Group Home Foster Care Services (DCFS Children)
Group Home Foster Care Services (Probation Children)
1.
If your organization is a corporation, state its legal name (as found in your Articles of Incorporation) and
State of incorporation:
_______________________________________________
____________
________
Name
State
Year Inc.
2.
If your organization is a partnership or a sole proprietorship, state the name of the proprietor or managing
partner:
_____________________________________
If your organization is doing business under one or more DBA’s, please list all DBA’s and the County(s)
3.
of registration:
Name
County of Registration
Year became DBA
_____________________________________
_________________
______________
_____________________________________
_________________
______________
4.
Is your organization wholly or majority owned by, or a subsidiary of, another agency? ___________
If yes, Name of parent organization: __________________________________________________
Page 1 of 4
REQUIRED FORMS - FORM 1
CONTRACTOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT
State of incorporation or registration of parent organization: ________________________________
5.
Please list any other names your organization has done business as within the last five (5) years.
Name
Year of Name Change
_________________________________________________________
__________________
_________________________________________________________
__________________
6.
Indicate if your organization is involved in any pending acquisition/merger, including the associated
company name. If not applicable, so indicate below.
______________________________________________________________________________
______________________________________________________________________________
Prospective Contractor acknowledges and certifies that it meets and will comply with all of the Minimum
Qualifications listed in Section 2.0 General Information, Sub-section 2.4 Prospective Contractor’s Minimum
Qualifications, of this Request for Statement of Qualifications (RFSQ), as listed below.
Check the appropriate boxes:
 Yes  No Sub-paragraph 2.4.1.1
Prospective Contractor must not have any unresolved issues
stemming from non-compliance with any County, State, or out-of-
state government agency or department.
 Yes  No Sub-paragraph 2.4.1.2
Prospective Contractor must have licensure through the State of
California Department of Social Services (CDSS) Community Care
Licensing Division (CCLD) for each program it is attempting to
qualify, and must provide a copy for each program and each site.
 Yes  No Sub-paragraph 2.4.1.3
Prospective Contractor must provide a copy of their organization’s
Non-Profit Corporation Status letter from the Internal Revenue
Service.
 Yes  No Sub-paragraph 2.4.1.4
Prospective Contractor must provide a copy of their organization’s
Non-Profit Determination letter from the State of California
Franchise Tax Board.
 Yes  No Sub-paragraph 2.4.1.5
Prospective Contractor must provide a certified copy of their
organization’s Statement of Information by Domestic Non-Profit
from the California Secretary of State.
 Yes  No Sub-paragraph 2.4.1.6
Prospective Contractor must demonstrate fiscal viability through
the organization’s financial
a review and evaluation of
documents:
Page 2 of 4
REQUIRED FORMS - FORM 1
CONTRACTOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT
Organizations must be in compliance with applicable laws
and regulations pertaining to financial audits, including but not
limited to the California Government Code Section 12586, the
California Department of Social Services (CDSS), Manual of
Policies and Procedures, Division 11, Chapter 11-400,
Section 11-405 et seq., and the Office of Management and
Budget (OMB) Super-Circular.
Organizations responding to this RFSQ are required to submit
audited financial statements and single audits reflecting the
three most recent years for which the organization was
required to conduct financial and single audits.
Any
organization that submits fewer than three audited financial
statements and single audits must indicate why they were
exempt from the applicable audit requirements for each year
that no audit was conducted.
Organizations submitting less than three audited financial
statements and single audits may be required to submit
additional documents at County’s request. Organizations that
have not been required to undergo a financial and single
audit under the applicable laws and regulations must submit a
copy of their current budget, balance sheet, and profit and
loss statement.
 Yes  No Sub-paragraph 2.4.1.7
Prospective Contractor must meet insurance requirements for the
programs it is attempting to qualify as specified in Appendix F,
Sample FFA Master Contract or Appendix H, Sample GH Master
Contract, Part I, Section 5.0, General Insurance Requirements
and Section 6.0 Insurance Coverage Requirements.
Prospective Contractors attempting to qualify a FFA program must meet these additional requirements:
 Yes  No Sub-paragraph 2.4.2.1
Provide a copy of their organization’s Foster Family Agency
Treatment Rate Notification letter from CDSS Foster Care
Funding and Rates Bureau or a formal letter requesting a support
letter from the County of Los Angeles to obtain a CDSS FFA rate.
Organizations that submit a request for a support letter under this
minimum qualification, during the submission period, must submit
their Foster Family Agency Treatment Rate Notification letter from
CDSS Foster Care Funding and Rates Bureau prior to contract
execution. Only organizations that demonstrate they operate the
program effectively and efficiently and that are determined by
DCFS to meet the level of care and services for AFDC-FC
children placement will receive a support letter from the County of
Los Angeles.
Page 3 of 4
REQUIRED FORMS - FORM 1
CONTRACTOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT
 Yes  No Sub-paragraph 2.4.2.2
Be dually licensed for foster family agency and adoption services
or
CONTRACTOR
shall
have
completed
a
subcontract/Memorandum of Understanding (MOU), signed by
authorized parties, with a licensed agency to provide adoption
services including adoption home studies for their certified foster
homes prior to contract execution. Contractor shall provide a copy
of the organization’s Adoption license issued by CDSS CCLD.
 Yes  No Sub-paragraph 2.4.2.3
Prospective Contractor of an FFA program must certify adherence
to requirements as specified in Appendix G, FFA Exhibits, Exhibit
A, Statement of Work - Part C Service Tasks to Achieve
Performance Outcome Goals, Section 1.0 Safety, Sub-section 1.1,
Staff Qualifications, Requirements and Duties.
Prospective Contractors attempting to qualify a GH program must meet these additional requirements:
 Yes  No Sub-paragraph 2.4.3.1
Provide a current AFDC-FC rate letter (RCL 10 and above) from
CDSS Foster Care Funding and Rates Bureau for each GH
service delivery site to be covered under this Contract. If the
organization’s name and/or address does not match the California
Secretary of State Statement of Information, the organization must
additionally provide a copy of the letter from the CDSS Foster
Care Funding and Rates Bureau acknowledging the change in the
organization’s name and/or address.
 Yes  No Sub-paragraph 2.4.3.2
Prospective Contractor of a GH program must certify adherence to
the staffing requirements as specified in Appendix I, GH Exhibits,
Exhibit A, Statement of Work, Part A, Section 5.0, Staff
Qualifications, Requirements, and Duties.
 Yes  No Sub-paragraph 2.4.3.3
Meet this additional requirement if the GH program is RCL 14:
Provide a copy of the certification letter issued by the State
Department of Mental Health or a County Mental Health
Department to provide the mental health treatment component of
RCL 14 programs.
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 Director’s sole judgment and his/her judgment shall be final.
On behalf of _______________________________ (Contractor’s name), I __________________________
(Name of Contractor’s authorized representative), certify that the information contained in this Contractor’s
Organization Questionnaire/Affidavit is true and correct to the best of my information and belief.
_________________________________________
_________________________________
Signature and Date
IRS Employer Identification Number
_________________________________________
_________________________________
Title
California Business License Number
Page 4 of 4

Download Form 1 "Contractor's Organization Questionnaire/Affidavit" - Los Angeles County, California

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