Res 2009-064 - Laserfiche WebLink

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FORM A: FACE PAGE INSTRUCTIONS This form provides basic information about the respondent and the proposed project with the Department of State Health Services (DSHS), including the signature of the authorized representative. It is the cover page of the proposal and is required to be completed. Signature affirms the facts contained in the respondent's response are truthful and the respondent is in compliance with the assurances and certifications contained in APPENDIX A: DSHS Assurances and Certifications and acknowledges that continued compliance is a condition for the award of a contract. Please follow the instructions below to complete the face page form and return with the respondent's proposal. 1) LEGAL BUSINESS NAME - Enter the legal name of the respondent. 1A) DBA - Enter doing-business-as name if different from legal business name. 2) MAILING ADDRESS INFORMATION - Enter the respondent's complete physical address and mailing address, city, county, state, and zip code. 3) PAYEE NAME AND MAILING ADDRESS - Payee - Entity involved in a contractual relationship with respondent to receive payment for services rendered by respondent and to maintain the accounting records for the contract; i.e., fiscal agent. Enter the PAYEE's name and mailing address if PAYEE is different from the respondent. The PAYEE is the corporation, entity or vendor who will be receiving payments. 4) FEDERAL TAX IDISTATE OF TEXAS COMPTROLLER VENDOR ID/SOCIAL SECURITY NUMBER - Enter the Federal Tax Identification Number (9-digit) or the Vendor Identification Number assigned by the Texas State Comptroller (14-digit). "The respondent acknowledges, understands and agrees the respondent's choice to use a social security number as the vendor identification number for the contract, may result in the social security number being made public via state open records requests. 5) TYPE OF ENTITY - The type of entity is defined by the Secretary of State and/or the Texas State Comptroller. Check all appropriate boxes that apply. MINORITY ORGANIZATION is defined as an organization in which the Board of Directors is made up of 50% racial or ethnic minority members. If a Non-Profit Corporation or For-Profit Corporation, provide the 10-digit charter number assigned by the Secretary of State. 6) PROPOSED BUDGET PERIOD - Enter the budget period for this proposal. Budget period is defined in the RFP. 7) COUNTIES SERVED BY PROJECT - Enter the proposed counties served by the project. 8A) PROPOSED PROJECT - Check the box(es) that best represent the project(s) in your proposal. 8B) NUMBER OF ENTITIES REPRESENTED IN PROPOSAL - Enter the number of entities represented in your request. 8C) AMOUNT OF FUNDING REQUESTED - Enter the amount of funding requested from DSHS for proposed project activities. This amount must match column (1) row K from FORM I: BUDGET SUMMARY 9) PROJECTED EXPENDITURES - If respondent's projected state or federal expenditures exceed $500,000 for respondent's current fiscal year, respondent must arrange for a financial compliance audit (Single Audit). 10) PROJECT CONTACT PERSON - Enter the name, phone, fax, and e-mail address of the person responsible for the proposed project. 11) FINANCIAL OFFICER - Enter the name, phone, fax, and e-mail address of the person responsible for the financial aspects of the proposed project. 12) AUTHORIZED REPRESENTATIVE - Enter the name, title, phone, fax, and e-mail address of the person authorized to represent the respondent. Check the "Check if change" box if the authorized representative is different from previous submission to DSHS. 13) SIGNATURE OF AUTHORIZED REPRESENTATIVE - The person authorized to represent the respondent must sign in this blank. 14) DATE - Enter the date the authorized representative signed this form. Page 28 RFP# EMS/LPG - 0328.1