Request for Proposal Checklist

Proposal

Submission

Forms

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IV – A[MANDATORY PROPOSAL SUBMISSION]

Request for Proposal Checklist

THIS CHECKLIST MUST BE COMPLETED AND SUBMITTED WITH YOUR PROPOSAL:

Please initial below, indicating that your proposal includes the itemized document.

A PROPOSAL SUBMITTED WITHOUT THE FOLLOWING DOCUMENTS IS CAUSE FOR REFUSAL.

INITIAL BELOW

• One (1) original paper hard copy, ten (10) paper hard copies, and one (1) electronic copy of the Word and Excel application forms with the required scanned PDF attachments on a CD or Thumb Drive. Please include all information and affirmative statements as required in the section entitled “Standard Requirements of Technical Proposal.”

• Documentation Checklist

• Non-Collusion Affidavit

• Americans with Disabilities Act

• Proposer Signature Page

• Non-Profit 501 C 3 Letter (for non-profit organizations only)

• Business Registration Certificate For Profit (for-profit companies only)

• Current Insurance Certificate

• Attest to the Union County Insurance Requirements

• Affirmative Action Requirement

• Affidavit of No Conflict of Interest

• Stockholder Disclosure Certification (for-profit companies only)

• Certification of Lobbying & Debarment

• Disclosure of Investment Activities in Iran

Note: N.J.S.A 52:32-44 provides that the County shall not enter into a contract for goods or services unless the other party to the contract provides a copy of its business registration certificate and the business registration certificate of any Subcontractors at the time that it submits its proposal. The contracting party must also collect the state use tax where applicable.

THE UNDERSIGNED HEREBY ACKNOWLEDGES THE ABOVE LISTED REQUIREMENTS

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IV – BUNION COUNTY ONE-TIME GAP PROGRAM RFP

DOCUMENTATION CHECKLIST (MANDATORY PROPOSAL SUBMISSION)

THE FOLLOWING INFORMATION MUST BE SUBMITTED. (PLEASE INDICATE THE PAGE WHERE THE INFORMATION MAY BE FOUND.)

Section IV-D Americans with Disabilities Act(mandatory proposal submission)

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IV – C[MANDATORYPROPOSAL SUBMISSION]

Union County One-Time GAP Funds

(Rev. 4/24/01)

NON-COLLUSION AFFIDAVIT

STATE OF ______

COUNTY OF ______

I______of the City of ______in the County of ______and the State of ______, of full age, being duly sworn according to law, on my oath depose and say that: I am ______of the firm of ______, the organization making the Proposal for the above named project, and that I executed the said Proposal with full authority so to do; that said Proposer has not, directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free, competitive bidding in connection with the above named project; and that all statements contained in said Proposal and in this Affidavit are true and correct, and made with full knowledge that the COUNTY OF UNION, NEW JERSEY relies upon the truth of the statements contained in said Proposal and in the statements contained in the affidavit in awarding the contract for the said project.

I further warrant that no person or selling agency has been employed or retained to solicit or secure such contract upon an agreement or understanding for a commission, percentage, brokerage or contingent fee, except bona fide employees or bona fide established commercial or selling agencies maintained by ______(N.J.S.A. 52:34-15).

(NAME OF CONTRACTOR)

______

(SIGN NAME HERE)

Subscribed and sworn to before(Original signature only; Black or Blue ink

me this ______day of ______, 20____.required; stamped signature not accepted)

______

Name of Notary (Printed, Typed, or Stamped with Ink Stamp)

Notary Public of the State of ______

(Printed, Typed, or Stamped with Ink Stamp)

My Commission expires ______

(Printed, Typed, or Stamped with Ink Stamp)

NOTE TO NOTARY: WHEN COMPLETING THIS JURAT, ALL NOTARIES MUST:

1. Original signature. 2. Stamp of name/date commission expires or typed or handwritten of that same informationAND 3. Impressed seal.

NOTE: The person who signed the Proposer Signature Page (Form B) should sign this form also.

WARNING: FAILURE TO FULLY ACCURATELY AND COMPLETELY COMPLETE THIS AFFIDAVIT OF NON-COLLUSION MAY RESULT IN PROPOSAL REJECTION.

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IV – D[MANDATORYPROPOSAL SUBMISSION]

AMERICANS WITH DISABILITIES ACT

EQUAL OPPORTUNITY FOR INDIVIDUALS WITH DISABILITIES

The Contractor and the County of Union (hereafter “Owner”) do hereby agree that the provisions of Title II of the Americans With Disabilities Act of 1990 (the “Act”) (42 U.S.C. S12.101 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs and activities provided or made available by public entities, and the rules and regulations promulgated pursuant thereunto, are made a part of this contract. In providing any aid, benefit, or service on behalf of the Owner pursuant to this contract, the Contractor agrees that the performance shall be in strict compliance with the Act. In the event the Contractor, its agents, servants, employees, or Subcontractors violate or are alleged to have violated the Act during the performance of this contract, the Contractor shall defend the Owner in any action or administrative proceeding commenced pursuant to this Act. The Contractor shall indemnify, protect, and save harmless the Owner, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The Contractor shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the Owner’s grievance procedure, the Contractor agrees to abide by any decision of the Owner which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the Owner, or if the Owner incurs any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the Contractor shall satisfy and discharge the same at its own expense.

The Owner shall, as soon as practicable after a claim has been made against it, give written notice thereof to the Contractor along with full and complete particulars of the claim. If any action or administrative proceeding is brought against the Owner or any of its agents, servants, and employees, the Owner shall expeditiously forward or have forwarded to the Contractor every demand, complaint, notice, summons, pleading, or other process received by the Owner or its representatives.

It is expressly agreed and understood that any approval by the Owner of the services provided by the Contractor pursuant to this contract will not relieve the Contractor of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the Owner pursuant to this paragraph.

It is further agreed and understood that the Owner assumes no obligation to indemnify or save harmless the Contractor, its agents, servants, employees and Subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the Contractor expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the Contractor’s obligations assumed in this Agreement, nor shall they be construed to relieve the Contractor from any liability, nor preclude the Owner from taking any other actions available to it under any other provisions of this Agreement or otherwise at law.

Name ______

(please print or type)

Signature ______Date ______

PROPOSER’S NAME: ______

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IV-E PROPOSAL SUBMISSION (MANDATORY PROPOSAL SUBMISSION)

I. IDENTIFICATIONPAGE

The name of the organization and address listed in Section A below should be the official legal name and mailing address. Contract recipients will be paid with the information listed below.

A.ORGANIZATION:

ADDRESS:

TELEPHONE #: FAX #:

B.SIGNATORY: TITLE:

TELEPHONE: EMAIL ADDRESS:

1. PROGRAM SITE/SERVICE LOCATION:

D.PROGRAM CONTACT PERSON FOR CONTRACT:

TITLE: TELEPHONE:

EMAIL ADDRESS:

E.FINANCIAL REPRESENTATIVE FOR CONTRACT:

TITLE: TELEPHONE:

EMAIL ADDRESS:

F.CERTIFIED TRAINING/LICENSED PROGRAM: ___ YES ___ NO

G.TITLE OF PROGRAM:

H.POPULATION TO BE SERVED:

I.DESIGNATED FUNDING SOURCE: Union County One-Time GAP Funding

J.AMOUNT OF GAPFUNDS REQUESTED:$______

K.ELIGIBLE SERVICE/FUNDING PERIOD: August 21, 2015 – December31, 2015(tentative dates)

L.SUMMARY OF CONTRACT SERVICES: (insert concise description)

M.AUTHORIZING SIGNATURES (The undersigned reviewed and approved proposal):

______

Proposer/Agency Executive Director SignatureAgency Executive Director Name (Please print)

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II. PROGRAMPURPOSE (There is no page limit to this section. However, please complete each section clearly and concisely.)

A.STATEMENT OF NEED

• Indicate Need for Proposed Program (e.g. research, statistics, demographics)
• If requesting funds for an existing program, clearly explain how the GAP funds will be used (e.g. increase over the current service levels provided, addition of a new service component, etc.)
• Identify GAP eligible service category(ies) and corresponding activity (see Attachment 1).

B. PROGRAM GOALS

• Identify the program mission – what the program ultimately hopes to accomplish.

C.PROGRAM OBJECTIVES/SERVICE ACTIVITIES

• List series of program activities to accomplish Goals.
• There should be one objective for each measurement listed below in Section F.

D.PROCEDURES AND METHODS/PROGRAM DESIGN

• Describe how individuals will access services - include intake procedures

Service Accessibility and Cultural Competency

• Describe how the agency meets the needs of persons with disabilities. What is in place to provide services to persons with disabilities?
• Does the proposed program have bilingual staff? Describe what measures have been implemented to develop cultural competency.
• Describe all aspects of service delivery and monitoring
• Describe the conclusion of service delivery and the procedure and timeframe for measuring attainment of program goals (Program Evaluation)

E.CASE PLAN OUTLINE FOR PROPOSED GAP SERVICES

• ATTACH a descriptive Case Plan Outline that details the complete planning tool that is used to move a client through the stabilization process. Describe implementing step-down assistance if needed. Be as specific as possible.
• This section will indicate the level of comprehensive services offered by the Proposer. More details will be disclosed on documentation and expectations of the program as the contracting process begins.

F. MEASUREMENTS: PROPOSED LEVEL OF SERVICE

• Level of Services must be measurable based upon eligible services in Attachment 1 and further descripted in Attachments 2-6.
• Measurements should be linked to Program Objectives. There should be one objective for each measurement listed above in Section C.
• Measurements should apply only to those services that will be provided with the funds requested in this proposal (do not include services paid for by any other funding sources).
• Sample Measurements: 60 short-term rental assistance payments, as a result 30 people were able to retain housing; 20 persons received 5 detoxification bed nights; 15 persons in the Union County Juvenile Detention Center received 20 substance abuse treatment and education sessions.

G.PROGRAM TIMEFRAMES FOR CLIENTS/PARTICIPANTS / FEES FOR SERVICE

• Describe the service duration of the program for participants.
• Will any fee be charged to any individuals receiving services under this proposal? If so, explain and attach a fee scale.

H. TARGET POPULATION/ELIGIBILITY CRITERIA/ADMISSION CRITERIA

• List and describe the criteria for receipt of services under the program.

I.GEOGRAPHIC AREA SERVED/GEOGRAPHIC LIMITATIONS, IF ANY

Union County residents.

J.STANDARD POLICIES AND PROCEDURES FOR EVALUATING INDIVIDUALS’ AND FAMILIES’ ELIGIBILITY FOR ASSISTANCE UNDER GAP

All persons served (documented or undocumented status)with GAP funds must be Union County residents and meet the household income eligibility (household income may not exceed 350% of the Federal Poverty Guidelines [FPG]; see Attachment 7).

Specific and general requirements for the five (5) eligible services categories relating to policies and procedures are described in Attachments 2-6.

Each funded agency will be required to document eligibility for all the information listed above and must have it available for the Union County Internal Monitoring Unit for on-site review.

III.AGENCY CAPACITY AND COLLABORATION

1. Agency Capacity

• Describe your agency’s capacity to be able to implement the program. If your current capacity cannot implement the program, explain how GAP funds will be utilized to do so in a short time frame as the contract period will be only 4.25months. It is anticipated if awarded, annual subcontracts will be developed for the next grant cycle.

1. AGENCY COLLABORATION

A collaboration of efforts, not stand alone services, is necessary to implement components of the GAP program and will be required among awarded agency(s).

• Describe how service coordination will be conducted among employment/training, emergency services, and family supportproviders and mainstream services. It is anticipated that service providers will ensure linkages to other GAP activities, other activities/services and/or mainstream services to program participants.
• For employment: describe how accessible “living wage” jobs are created, or saved, from reduction or elimination in the community through collaboration.

IV.PROGRAM BUDGET(Forms Attached)

In the original and ten copies of the proposal to be submitted to the County, please insert the budget pages (Forms A-1, A-2, A-3, and if applicable A-4) after Section II-I of the narrative. Continue the narrative portion of the proposal with Section V (If full funding cannot be provided . . .) after the budget pages.

1. UNIT COST BUDGET (A-1)

• Use Form A1
• On the top section, number and describe each service that you propose to provide. Reference the eligible services in Attachment 1.
• Example: Unit #1 – A unit is one monthly rental assistance payment not to exceed the FMR for the unit/apartment size. (Maximum allowed is 4 months including arrearages.)
• One the bottom section, next to the corresponding number, identify the unit, the number of units, the cost per unit and the total. If there is no exact unit cost, list as Actual.
• Example:Unit #1 – Rent 45 X Actual = $50,000

Unit #2 – Mortgage 7 X Actual = $10,000

Unit #3 – Case Management 52 X $110 = $5,720

B. PROGRAM BACK-UP LINE ITEM BUDGET (A-2)

• Use Form A2
• Justification must be included for each budgeted item
• Other Funds used to fund the program should be identified and included
• If fringe will be paid by the proposer, fringe needs to be listed in the “Other Funds” column and in below Other Source chart.
• Adjustments to Form A1 may be made to accommodate budget categories

C.PERSONNEL BACK-UP DETAIL FORM (A-3)

• Use Form A3
• List all personnel to be funded by this award
• IF there is a current vacancy, list the position and minimum requirements, salary, percent and proposed amount to be funded by this grant.
• Include entire Fringe Breakdown

D.CONSULTANT SERVICE AND EXPENSE FORM (A-4)

• Use Form A4, only if needed
• If this form is used, complete all columns (ie. Rate X Services/Hours = Total Cost)
• Include a rate of service. If there are state/federal maximum hourly rates, they need to be adhered to.
• Note that a consultant is not considered a third party contract or service to be subcontracted to another entity. This is not allowable through the GAP grant.

V.IF FULL FUNDING CANNOT BE PROVIDED, BE SPECIFIC AS TO HOW THIS PROPOSAL CAN BE SCALED DOWN? IF YES, HOW?

• Be specific as to where the program budget can be scaled down. Also, quantify how the adjustment in funding would affect the services proposed (decreased levels of service across the board, certain program and budget components eliminated, etc). Be specific.
• All Proposers are encouraged to consider this option due to the limited funds available and short-time contract period of 4.25 months.

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VI.GENERAL ORGANIZATION INFORMATION

A.Date of Incorporation: ______

B1.If Not for Profit Proposer: attach 501 C 3 Letter*

B2.If for Profit Proposer: attach Business Registration Certificate*

P.L. 2009, c.315, requires that effective January 18, 2010; a Contractor must receive proof of the Proposer’s business registration prior to the award of a contract. However, the proof must show that the Proposer was in fact registered with the State of New Jersey Department of the Treasury, Division of Revenue and obtained the business registration prior to the receipt of proposals.