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%W <br /> <br />1fNO. respondent must be able to demonstrate fiscal solvency. Submit a copy of the organization's most recently <br />and?fed balance sheet, statement of income and expenses and accompanying financial footnotes. 1f an organization does <br />not have audited financial statements, submit a copy of the organizations most recent IRS Form 990 and an explanation <br />why an audited financial statement is not available. DSHS will re view the documents that are submitted and ma at its <br />SOIB diRrrPtinn M! r4 tho rirnnnenJ .,.. lfi., t . . <br />Is respondent or any member of respondent's executive management, project management, board <br />members or principal officers: <br />• Delinquent on any state, federal or other debt; <br />• Affiliated with an organization which is delinquent on any state, federal or other debt; or <br />• In default on an agreed repayment schedule with any funding organization? <br />F1 YES ®' NO <br />!f YES, please explain. (Attach no more than one additional page.) <br />9. Has the respondent had a contract suspended or terminated prior to expiration of contract or not been <br />renewed under an optional renewal by any local, state, or federal department or agency or non-profit <br />entity? <br />? YES p NO <br />If YES, indicate the reason for such action that includes the name and contact information of the local, state, or <br />federal department or agency, the date of the contract and a contract reference number, and provide copies of any <br />and all decisions or orders related to the suspension, termination, or non-ronewaf by the contracting entity. <br />10. Does this proposal include financial participation by a person orentity that has been convicted of violating <br />federal law, or been assessed a penalty in a federal civfi administrative enforcement action, in connection <br />with a contract awarded by the federal government for relief, recovery or reconstruction efforts as a result <br />of Hurricanes Rita or Katrina or any other disaster occurring after September 24, 2005, under Government <br />Code'§2155.006 and 2161.053? <br />[J YES ® NO <br />If YES, please explain. (Attach no more than one additional page.) <br />panes ,'V; nr-rl.ic_ r•..... __ ____ .