Form 1 - Contractor'S Organization Questionnaire/affidavit Page 4

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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
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