TO INCREASE COMMUITY CAPACITY OF PROVIDER MANAGED HOUSING FORINDIVIDUALS WITH ACUTE BEHAVIORAL AND/OR MEDICAL NEEDS

3 | P a g e I. Purpose and Intent This Request for Proposals (RFP) is issued by the New Jersey Department of Human Services (DHS), Division of Developmental Disabilities (Division) for the provision of capital funds to offset costs incurred in the acquisition, development and renovation of group homes that serve newly placed individuals with acute behavioral and/or medical needs. The Division has a long history of seeking to develop and expand the network of home and community-based services (HCBS). More recently, efforts have begun to focus on linking physical, behavioral, social and HCBS waiver services to improve overall health outcomes and quality of life for individuals with intellectual and developmental disabilities (IDD). Existing community-based housing is increasingly in demand for individuals with acute needs. Expanding the State’s capacity to serve this population will enhance our network of providers and increase individual choice, with the ultimate goals of strengthening

community infrastructure, reducing reliance on institutions, and ensuring individuals are supported in their homes throughout the life course. The following summarizes the anticipated RFP schedule: June 22, 2023 Notice of Funding Availability July 13, 2023 Close of Question Period – Questions on RFP due no later than 4:00 p.m. ET Rolling 45 day award period Beginning August 2023 through award of all funds, proposals received by 4:00pm ET on the 1st of each month will be reviewed and responded to by the 15th of the following month. Appeal deadline Appeals must be received within 10 business days of the Division’s response date Award lapse date Funding will lapse for successful proposals that do not meet the criteria for payment release as described in the contact scope of work on or before December 31, 2025 and will not be replaced with an alternate funding source. No extensions will be permitted. May 1, 2024 Pending availability of funds, this is the last day proposals will be accepted. 4 | P a g e II. Background and Population to be Served Under the leadership of Governor Phil Murphy, New Jersey continues to take steps to strengthen services and supports for IDDs. This RFP builds on that work and focuses on increasing community capacity and choice in housing options for individuals with IDDs who have acute behavioral and/or medical needs. IDDs are disorders that are usually present at birth and affect the trajectory of the individual's physical, intellectual, and/or emotional development. Some conditions considered to be developmental disabilities include: intellectual disabilities, cerebral palsy, autism, epilepsy, spina bifida, traumatic brain injuries and certain neurological disorders. The Division is committed to serving individuals in community settings most appropriate to their needs. To aide in this, the Division participates in the Centers for Medicare and Medicaid Services (CMS) Money Follows the Person (MFP) Program. The MFP Program enables the Division to draw down additional federal funding for eligible individuals for the first year of their HCBS enrollment. Eligible individuals are those who were residing in a qualified institution for at least 60 days prior to their move to a community setting, are Medicaid eligible at least one day prior to moving to a community setting, and are moving to a setting with four or fewer unrelated individuals. The state savings realized through participation in the MFP Program must be reinvested in efforts to rebalance the system from institutional to HCBS services. New Jersey has implemented several other initiatives to expand and enhance NJ’s HCBS system. These initiatives include increasing access to affordable and accessible housing for Medicaid-eligible individuals transitioning from institutions to the community, strengthening state Medicaid and state housing partnerships, and coordinating with community partners to improve direct supports for HCBS eligible individuals. This initiative will allow the Division to continue working in concert with providers to incentivize targeted housing for a population with complex needs. III. Who Can Apply? To be eligible for consideration, bidders must satisfy the following requirements at the time of application: • The bidder must be a non-profit, for-profit, or governmental entity; • The bidder must be licensed by the DHS Office of Program Integrity and Accountability, Office of Licensing (OOL) prior to the start of these services; • The bidder must be in good standing with OOL, including having not had a moratorium on admissions,10% or more provisional licenses, or triggered three or more risk management categories (per the DHS Risk Management System) at any time within three years preceding the time of application. https://www.state.nj.us/humanservices/staff/opia/reports.html 5 | P a g e • For a bidder that is a Division provider when this RFP is issued, that bidder must have all outstanding Plans of Correction (PoC) for deficiencies submitted to the Division and/or OOL (as appropriate) for approval prior to submission; • The bidder must be fiscally viable based upon an assessment of the bidder’s audited financial statements. If a bidder is determined, in the Division’s sole discretion, to be insolvent or to present insolvency within the twelve (12) months after bid submission, the Division will deem the proposal ineligible for this RFP; • The bidder must not appear on the State of New Jersey Consolidated Debarment Report at https://www.state.nj.us/treasury/debarred/debarsearch.htm or be suspended or debarred by any other State or Federal entity from receiving funds. • Pursuant to DHS Contract Policy and Information Manual Policy Circular 8.05, the bidder shall not have a conflict, or the appearance of a conflict, between the private interests and the official responsibilities of a person in a position of trust. Persons in a position of trust include Provider Agency staff members, officers and Governing Board Members. A bidder must have written Conflict of Interest policies and procedures that satisfy the requirements of P8.05, thereby ensuring that paid Board members do not participate in transactions except as expressly provided in the P8.05 circular; and • Pursuant to N.J.S.A. 52:32-44, a for-profit bidder and each proposed subcontractor must have a valid Business Registration Certificate on file with the Division of Revenue. This statutory requirement does not apply to nonprofit organizations, private colleges and universities, or state and municipal agencies. IV. Contract Scope of Work The Division is soliciting proposals from housing developers and/or service providers who are able to leverage capital funding from a variety of sources to quickly build new group homes for the target population. These new settings will enable individuals with high-level behavioral and/or medical needs to choose from a larger array of providers and geographic locations across the state. Bidders must be able to demonstrate significant experience and capability in developing housing, identifying appropriate individuals through outreach, and providing or linking with high-quality services. Criteria for Payment - The Division will allocate funding to the service provider in an amount up to $90,000 per home, subject to the following conditions: • Funding is available to offset costs incurred directly by providers in developing group homes licensed under N.J.A.C. 10:44A, as well as for accelerated principal payment related to the financing of such costs. This funding is in addition to funding for sprinklers and fire suppression, which the Division will also provide. • Homes eligible for this funding are limited to those with four, single-occupancy bedrooms, at least two of which will be contractually reserved for individuals with medical levels of 5 or 6, or behavioral levels 3 or 4, and/or individuals determined by the Division to have an acute need or a placement disposition challenge. https://www.state.nj.us/treasury/debarred/debarsearch.htm 6 | P a g e Reimbursement for services associated with target individuals will be through the fee-for-service system using the established fee schedule associated with the assigned tier of the individual. • Only new sites shall be considered. A new site is defined as: o A home or buildable lot that has not yet been purchased by a provider or by a housing entity/developer affiliated with a provider; or o A home that is not licensed by DHS but is already owned and requires capital investment to meet licensing standards. • Individuals moving into the homes are eligible for Division services and actively enrolled on the Community Care Program (CCP). • Funding will be secured by the Division’s standard capital agreement and promissory note, as well as a mortgage reflective of the Division’s position in the financing structure. • Reimbursement is subject to the availability of state appropriations. • Funding will not be released to a community-based provider unless the individuals seeking a community-based setting and Provider have agreed to placement, and the provider has secured 100% of the financing required to fund the entire project cost. • The Division will provide up to $5 million of state MFP rebalancing funds for this initiative, potentially over multiple allocation cycles, until all available funds have been paid out. No funding match is required, however, bidders are required to identify all other sources of funding for each project, both in-kind and monetary, that will be used to fund the entire project cost. Bidders may not fund any costs incurred for the planning or preparing of a proposal in response to this RFP from current DHS/Division contracts. Bidders may apply for allocations for up to four separate homes through this RFP. As applicable, bidders applying for more than one (1) allocation may submit a single request that identifies multiple target development towns or counties. Bidders may use one type of DHS capital funding per project/address. Should alternate capital funding become available, bidders may not apply for additional DHS capital funding for the same property. Bidders must adhere to all applicable State and Federal cost principles. Budgets should be reasonable and reflect the scope of responsibilities in order to accomplish the goals of this project. V. General Contracting Information Bidders must currently meet or be able to meet the terms and conditions of DHS contracting rules and regulations as set forth in the Standard Language Document (SLD), the Contract Reimbursement Manual (CRM), and the Contract Policy and Information Manual (CPIM). These documents are available on the DHS website at: https://www.state.nj.us/humanservices/olra/contracting/policy/ https://www.state.nj.us/humanservices/olra/contracting/policy/ 7 | P a g e Bidders are required to comply with the Affirmative Action Requirements of Public Law 1975, c. 124 (N.J.A.C. 17:27) and the requirements of the Americans with Disabilities Act of 1991 (P.L. 101-336). Budgets should be reasonable and reflect the scope of responsibilities in order to accomplish the goals of this project. All bidders will be notified in writing of the State’s intent to award a contract. All proposals are considered public information and will be made available for a defined period after announcement of the contract award and prior to final award, as well as through the State Open Public Records Act process at the conclusion of the RFP process. Funds may only be used to support services that are specific to this award; hence, this funding may not be used to supplant or duplicate existing funding streams. Actual funding levels will depend on the availability of funds, satisfactory performance. Contract commitments will be negotiated based upon representations made in response to the RFP. Failure to deliver commitments may result in termination of the contract. In accordance with DHS Policy P1.12 available on the web at https://www.state.nj.us/humanservices/olra/assets/documents/CPIManual.pdf programs awarded pursuant to this RFP will be separately clustered until the Division determines, in its sole discretion, that the program is stable in terms of service provision, expenditures, and applicable revenue generation. VI. Required Proposal Content All Proposal submissions will be evaluated based on the elements indicated below. The proposal must not exceed 20 pages (not inclusive of appendices and required attachments.) All Proposals must include responses that clearly correspond to each category as delineated below. Funding Proposal Cover Sheet: (See Attachment A) Bidder’s Organization, History, and Experience: (5 points) Provide a brief and concise summary of the bidder’s background and experience in implementing this or related types of services and explain how the bidder is qualified to fulfill the obligations of the RFP. The written narrative should include: Provide a brief and concise summary of the bidder’s background and experience in implementing this or related types of services and explain how the bidder is qualified to fulfill the obligations of the RFP. The written narrative should: https://www.state.nj.us/humanservices/olra/assets/documents/CPIManual.pdf 8 | P a g e 1. Describe the agency’s history, mission, purpose, current licenses and modalities, and record of accomplishments. Explain the work with the target population and the number of years’ experience working with the target population; 2. Describe the bidder’s background and experience in implementing program similar to those described in the project scope; 3. Describe why the bidder is the most appropriate and best qualified to implement this program in the target service area; 4. Summarize the bidder’s administrative and organizational capacity to establish and implement sound administrative practices and successfully carry out the proposed program; 5. Describe the bidder's current status and history relative to debarment by any State, Federal or local government agency. If there is debarment activity, it must be explained with supporting documentation as an appendix to the bidder's proposal; 6. Provide a description of all active litigation in which the bidder is involved, including pending litigation of which the bidder has received notice. Failure to disclose active or pending litigation may result in the agency being ineligible for contract award at the Division’s sole discretion; 7. Include a description of the bidder’s ability to provide culturally competent services; 8. Describe the bidder's plan to bring the initiative to a conclusion at the end of the contract; 9. Describe the bidder’s current status and compliance with contract commitments in regard to programmatic performance and level of service, if applicable. Project Description: (40 points) In this section, the bidder is to provide an overview of how the services detailed in the scope of work will be implemented and the timeframes involved, specifically addressing the following: 1. A proposed monthly timeline of activities for engagement and enrollment of the target population; 2. The strategies that will be used for engaging the targeted individuals; 3. The bidder’s willingness to accept individuals assigned by Division staff and any foreseen barriers in this process; 4. The plan to address targeted individual’s treatment needs based on their service profile including, but not limited to: a. Intensive behavioral supports i. PICA safe environments; ii. Prader-Willi syndrome; iii. Behavioral programming; iv. Dually diagnosed IDD/Mental Health; v. Substance abuse disorders; vi. Elopement; vii. Injurious behaviors to self/other; viii. Fire setting behaviors; 9 | P a g e ix. Sexual behaviors and registered sex offenders; x. Specialized transportation. b. Intensive medical supports i. Tube feedings; ii. Tracheostomy; iii. Repositioning; iv. Specialized transportation. 5. Description of how the proposed service will integrate the following principles into service delivery, as evidenced by specific program considerations: a. Promotion of wellness and recovery; b. Trauma informed care; c. Creation of a safe and healthy, home-like environment; and d. Demonstration of best practices. 6. The provider agency’s linkages with appropriate not-for-profit agencies or service providers in the community in which the proposed program will be located or readily accessible through public transportation, and who could serve as resources for and/or provide off-site services. Outcome(s) and Evaluations(s): (15 points) Provide the following information related to the projected outcomes associated with the proposal as well any evaluation method that will be utilized to measure successes and/or setbacks associated with this project: 1. The bidder’s detailed plan and approach to measure individual satisfaction. 2. The bidder’s measurement of the achievement of identified goals and objectives. 3. The evaluation of contract outcomes. 4. Description of all tools to be used in the evaluation. 5. Details about any outside entity planned for use to conduct the evaluation, including but not limited to the entity’s name, contact information, brief description of credentials and experience conducting program evaluation. 6. Tools and activities the bidder will implement to ensure fidelity to the evidence- based practice. Staffing: (15 points) Bidders should describe the proposed staffing structure and identify how many staff will be hired to meet the needs of the program. 1. Describe the composition and skill set of the proposed program team including staff qualifications, credentials and professional licensure. 2. Provide details of the Full Time Equivalent (FTE) staffing required to satisfy the contract scope of work. Describe proposed staff qualifications, including professional license and related experience. Details should include currently on- board or to be hired staff, with details of the recruitment effort. Identify bilingual staff. Include discussion of plan to address call outs and employee leave time. 10 | P a g e 3. Provide copies of job descriptions or resumes as an appendix – limited to two (2) pages each – for all proposed staff. 4. Identify the number of work hours per week that constitute each FTE. If applicable, define the Part Time Equivalent (PTE) work hours. 5. Description of the proposed organizational structure, including the submission of an organizational chart as an appendix to the bidder's proposal. 6. The bidder's hiring policies, including background and credential checks, as well as handling of prior criminal convictions. 7. The approach for supervision and training of staff. 8. A list of the bidder's board members and current term, including each member's professional licensure and organizational affiliation(s). The bidder's proposal must identify each board member who is also an employee of the bidder or an affiliate of the bidder. The proposal shall indicate if the Board of Directors vote on contract-related matters. 9. A list of names of consultants the bidder intends to utilize for the contract resulting from this RFP, including each consultant's professional licensure and organizational affiliation(s). Each consultant must be further described as to whether they are also a board member and, if so, whether they are a voting member. The bidder must identify all reimbursement the consultant received as a board member over the last twelve (12) months. Facilities/Equipment: (5 points) The bidder should detail its facilities where its normal business operations will be performed and identify equipment and other logistical issues including at a minimum: 1. A description of the manner in which tangible assets, i.e., computers, phones, other special service equipment, etc., will be acquired and allocated. 2. A description of the bidder’s Americans with Disabilities Act (ADA) accessibility to its facilities and/or offices for individuals with disabilities. Budget: (20 points) The Division will consider the cost efficiency of the proposed budget as it relates to the scope of work. Therefore, bidders must clearly indicate how this funding will be used to meet the program goals and/or requirements. In addition to the required Budget forms, bidders are asked to provide budget notes. 1. The budget should be reasonable and reflect the scope of responsibilities required to accomplish the goals of this project. All costs associated with the completion of the project must be delineated and the budget notes must clearly articulate the details of all proposed budget items including a description of miscellaneous expenses and other costs. 2. Budget notes that detail and explain the proposed budget methodology and estimates and assumptions made for expenses and the calculations/computations to support the proposed budget. The State's proposal reviewers need to fully understand the bidder's budget projections from the 11 | P a g e information presented in its proposal. Failure to provide adequate information could result in lower ranking of the proposal. Budget Notes, to the extent possible, should be displayed on the Excel template itself. 3. The name and address of each organization providing support and/or money to help fund the program for which the proposal is being submitted. 4. The timeline for completion of the project. Appendices The following items must be included as appendices with the bidder's proposal, limiting appendices to a total of 40 pages. Proposals that do not include all items will not be considered. 1. Proposal Cover Sheet (RFP Attachment A); 2. Bidder mission statement; 3. Organizational chart; 4. Job descriptions of key personnel; 5. Resumes of proposed personnel if currently on staff, limited to two (2) pages each; 6. A description of all pending and in-process audits identifying the requestor, the firm’s name and telephone number, and the type and scope of the audit; 7. List the board of directors, officers, and terms; 8. Copy of documentation of the bidder’s charitable registration status; 9. Original and/or copies of letters of commitment/support; 10. Department of Human Services Statement of Assurances (RFP Attachment C); 11. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions (RFP Attachment D); 12. Budget Proposal Form (RFP Attachment E); 13. Commitment to Defend and Indemnify Form (RFP Attachment F); 14. Certification of Non-Involvement in Prohibited Activities in Russia or Belarus (www.nj.gov/treasury/purchase/forms.shtml); 15. Disclosure of Investment in Iran (www.nj.gov/treasury/purchase/forms.shtml); and 16. Statement of Bidder/Vendor Ownership Disclosure (www.nj.gov/treasury/purchase/forms.shtml). The documents listed below are also required with the proposal, unless the bidder has a current contract with the Division and these documents are current and on file with the Division. 1. Most recent single audit report (A133) or certified statements (submit only two [2] copies); and 2. Any other audits performed in the last two (2) years (submit only two [2] copies). VII. Submission of Proposal Requirements The Division assumes no responsibility and bears no liability for costs incurred by the bidder in the preparation and submittal of a proposal in response to this RFP. The http://www.nj.gov/treasury/purchase/forms.shtml 12 | P a g e narrative portion of the proposal should not exceed 20 pages, be single-spaced with one (1”) inch margins, and no smaller than twelve (12) point Arial, Courier or Times New Roman font. For example, if the bidder’s narrative starts on page 3 and ends on page 23 it is 21 pages, not 20 pages. The Division will not consider any information submitted beyond the page limit for RFP evaluation purposes. The budget notes and appendix items do not count towards the narrative page limit. Proposals must be submitted no later than 4:00 p.m. ET on the submission deadline date noted in this RFP. All bidders are required to submit one (1) original and five (5) copies of the proposal narrative, budget and appendices (six [6] total proposal packages) to the following address: For U.S. Postal Service delivery: Amy Scartocci, Housing Director Department of Human Services Division of Developmental Disabilities PO Box 726 Trenton, NJ 08625-0726 OR For private delivery vendor such as UPS or FedEx: Amy Scartocci, Housing Director Department of Human Services Division of Developmental Disabilities 222 South Warren Street Trenton, NJ 08625 The bidder may mail or hand-deliver its proposal, however, the Division is not responsible for items mailed but not received by the due date. Note that U.S. Postal Service two-day priority mail delivery to the post office box listed above may result in the bidder's proposal not arriving timely and, therefore, being deemed ineligible for RFP evaluation. The bidder will not be notified that its proposal has been received. The State will not accept facsimile transmission of proposals. VIII. Review of Proposals Technical assistance regarding this RFP will be provided via the DHS web site. Potential applicants are encouraged to submit questions to the Division at DDD.RFP@dhs.nj.gov no later than 4:00 P.M. ET on “Close of Question Period” date listed above. Responses to submitted questions will be posted on the DHS website location https://www.nj.gov/humanservices/providers/grants/rfprfi/index.html. mailto:DDD.RFP@dhs.nj.gov https://www.nj.gov/humanservices/providers/grants/rfprfi/index.html 13 | P a g e There will be a review process for all timely submitted proposals. The Division will convene a review committee of public employees to conduct a review of each proposal accepted for review. The bidder must obtain a minimum score of 70 points out of 100 points for the proposal narrative and budget sections in order to be considered eligible for funding. The Division will award up to 20 points for fiscal viability, using a standardized scoring rubric based on the audit, which will be added to the average score given to the proposal from the review committee. An additional 15 points may be awarded as described in the Outcomes/Evaluation section and the Facilities/Equipment section. Thus, the maximum points any proposal can receive is 135 points which includes the combined score from the proposal narrative and budget as well as fiscal viability. In addition, if a bidder is determined, in the Division’s sole discretion, to be insolvent or to present insolvency within the twelve (12) months after bid submission, the Division will deem the proposal ineligible for contract award. Contract award recommendations will be based on such factors as the proposal scope, quality and appropriateness, bidder history and experience, as well as budget reasonableness. The review committee will look for evidence of cultural competence in each section of the narrative. The review committee may choose to visit a bidder's existing program(s), invite a bidder for interview, and/or review any programmatic or fiscal documents in the possession of the Division. The bidder is advised that the contract award may be conditional upon final contract and budget negotiation. The Division reserves the right to reject any and all proposals when circumstances indicate that it is in its best interest to do so. The Division’s best interests in this context include, but are not limited to: loss of funding; inability of the bidder(s) to provide adequate services; an indication of misrepresentation of information and/or non- compliance with State and federal laws and regulations, existing DHS contracts, and procedures set forth in DHS Policy Circular P1.04 http://www.state.nj.us/humanservices/olra/ocpm/resources/manuals/ The Division will notify all bidders of contract awards, contingent upon the satisfactory final negotiation of a contract, by the final allocation date above. IX. Appeal of Award Decisions An appeal of any award decision may be made only by a respondent to this RFP. All appeals must be made in writing and be received by the Division at the address below no later than 4:00 p.m. ET on the appeal date noted in this RFP. The written appeal must clearly set forth the basis for the appeal. Appeal correspondence should be addressed to: Jonathan Seifried, Assistant Commissioner http://www.state.nj.us/humanservices/olra/ocpm/resources/manuals/ 14 | P a g e Department of Human Services Division of Developmental Disabilities PO Box 726 Trenton, NJ 08625-0726 Or via email: DDD-CO.LAPO@dhs.nj.gov Please note that all costs incurred in connection with appeals of Division decisions are considered unallowable cost for the purpose of Division contract funding. The Division will review all appeals and render a final decision on or around March 15, 2024. Contract award(s) will not be considered final until all timely filed appeals have been reviewed and final decisions rendered. An appeal based on the determination may be filed in writing to the Assistant Commissioner within seven calendar days following receipt of the notification. An appeal of the selection process shall be heard only if it is alleged that the Division has violated a statutory or regulatory provision in the awarding of the contract. An appeal will not be heard based upon a challenge to the evaluation of a proposal. X. Post Award Required Documentation Upon final contract award announcement, the successful bidder(s) must be prepared to submit (if not already on file), one (1) original signed document for those requiring a signature or copy of the following documentation (unless noted otherwise) in order to process the contract in a timely manner, as well as any other contract documents required by DHS/Division. 1. Most recent IRS Form 990/IRS Form 1120, and Pension Form 5500 (if applicable) (submit two [2] copies); 2. Copy of the Annual Report-Charitable Organization (for information visit: https://www.state.nj.us/treasury/revenue/); 3. A list of all current contracts and grants as well as those for which the bidder has applied for from any Federal, state, local government or private agency during the contract term proposed herein, including awarding agency name, amount, period of performance, and purpose of the contract/grant, as well as a contact name for each award and the phone number; 4. Proof of insurance naming the State of New Jersey, Department of Human Services, Division of Developmental Disabilities, 726, Trenton, NJ 08625-0726 as an additional insured; 5. Board Resolution identifying the authorized staff and signatories for contract actions on behalf of the bidder; 6. Current Agency By-laws; 7. Current Personnel Manual or Employee Handbook; 8. Copy of Lease or Mortgage; 9. Certificate of Incorporation; mailto:DDD-CO.LAPO@dhs.nj.gov https://www.state.nj.us/treasury/revenue/ 15 | P a g e 10. Co-occurring policies and procedures; 11. Policies regarding the use of medications, if applicable; 12. Policies regarding Recovery Support, specifically peer support services; 13. Conflict of Interest Policy; 14. Affirmative Action Policy; 15. Affirmative Action Certificate of Employee Information Report, newly completed AA 302 form, or a copy of Federal Letter of Approval verifying operation under a federally approved or sanctioned Affirmative Action program. (AA Certificate must be submitted within 60 days of submitting completed AA302 form to Office of Contract Compliance); 16. A copy of all applicable licenses; 17. Local Certificates of Occupancy; 18. Master lease agreements, evidence of all State (non-Division), federal and local housing subsidies and resources. 19. Current State of New Jersey Business Registration; 20. Procurement Policy; 21. Current equipment inventory of items purchased with DHS funds (Note: the inventory shall include: a description of the item [make, model], a State identifying number or code, original date of purchase, purchase price, date of receipt, location at the Provider Agency, person(s) assigned to the equipment, etc.); 22. All subcontracts or consultant agreements, related to the DHS contract, signed and dated by both parties; 23. Business Associate Agreement (BAA) for Health Insurance Portability Accountability Act of 1996 compliance, if applicable, signed and dated; 24. Updated single audit report (A133) or certified statements, if differs from one submitted with proposal; 25. Business Registration (online inquiry to obtain copy at https://www1.state.nj.us/TYTR_BRC/jsp/BRCLoginJsp.jsp; for an entity doing business with the State for the first time, it may register at https://www.nj.gov/treasury/revenue); 26. Source Disclosure (EO129) (www.nj.gov/treasury/purchase/forms.shtml); and 27. Chapter 51 Pay-to-Play Certification (www.nj.gov/treasury/purchase/forms.shtml). XI. Attachments Attachment A – Proposal Cover Sheet Attachment B – Addendum to RFP for Social Service Training and Contracts Attachment C – Statement of Assurances Attachment D – Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions Attachment E – Budget Proposal Form Attachment F – Commitment to Defend and Indemnify Form https://www1.state.nj.us/TYTR_BRC/jsp/BRCLoginJsp.jsp https://www.nj.gov/treasury/revenue http://www.nj.gov/treasury/purchase/forms.shtml http://www.nj.gov/treasury/purchase/forms.shtml 16 | P a g e Attachment A – Proposal Cover Sheet Date Received STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES Division of Developmental Disabilities Proposal Cover Sheet Name of RFP Incorporated Name of Bidder: Type: Public Profit Non-Profit Hospital-Based Federal ID Number: Charities Reg. Number (if applicable) Address of Bidder: Contact Person Name and Title: Phone No.: Email Address: Total dollar amount requested: Fiscal Year End: Funding Period: From to Total number of unduplicated consumers to be served: County in which services are to be provided: Brief description of services by program name and level of service to be provided: Authorization: Chief Executive Officer (printed name): Signature: Date: 17 | P a g e Attachment B – Addendum to RFP for Social Service and Training Contracts STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ADDENDUM TO REQUEST FOR PROPOSAL FOR SOCIAL SERVICE AND TRAINING CONTRACTS Executive Order No. 189 establishes the expected standard of responsibility for all parties that enter into a contract with the State of New Jersey. All such parties must meet a standard of responsibility that assures the State and its citizens that such parties will compete and perform honestly in their dealings with the State and avoid conflicts of interest. As used in this document, "provider agency" or "provider" means any person, firm, corporation, or other entity or representative or employee thereof that offers or proposes to provide goods or services to or performs any contract for the Department of Human Services. In compliance with Paragraph 3 of Executive Order No. 189, no provider agency shall pay, offer to pay, or agree to pay, either directly or indirectly, any fee, commission, compensation, gift, gratuity, or other thing of value of any kind to any State officer or employee or special State officer or employee, as defined by N.J.S.A. 52:13D-13b and e, in the Department of the Treasury or any other agency with which such provider agency transacts or offers or proposes to transact business, or to any member of the immediate family, as defined by N.J.S.A. 52:13D-13i, of any such officer or employee, or any partnership, firm, or corporation with which they are employed or associated, or in which such officer or employee has an interest within the meaning of N.J.S.A. 52:13D-13g. The solicitation of any fee, commission, compensation, gift, gratuity or other thing of value by any State officer or employee or special State officer or employee from any provider agency shall be reported in writing forthwith by the provider agency to the Attorney General and the Executive Commission on Ethical Standards. No provider agency may, directly or indirectly, undertake any private business, commercial or entrepreneurial relationship with, whether or not pursuant to employment, contract or other agreement, express or implied, or sell any interest in such provider agency to, any State officer or employee or special State officer or employee having any duties or responsibilities in connection with the purchase, acquisition or sale of any property or services by or to any State agency or any instrumentality thereof, or with any person, firm or entity with which he is employed or associated or in which he has an interest within the meaning of N.J.S.A. 52:13D- 13g. Any relationships subject to this provision shall be reported in writing forthwith to the Executive Commission on Ethical Standards, which may grant a waiver of this restriction upon application of the State officer or employee or special State officer or employee upon a finding that the present or proposed relationship does not present the potential, actuality or appearance of a conflict of interest. 18 | P a g e No provider agency shall influence, or attempt to influence or cause to be influenced, any State officer or employee or special State officer or employee in his official capacity in any manner which might tend to impair the objectivity or independence of judgment of said officer or employee. No provider agency shall cause or influence, or attempt to cause or influence, any State officer or employee or special State officer or employee to use, or attempt to use, his official position to secure unwarranted privileges or advantages for the provider agency or any other person. The provisions cited above shall not be construed to prohibit a State officer or employee or special State officer or employee from receiving gifts from or contracting with provider agencies under the same terms and conditions as are offered or made available to members of the general public subject to any guidelines the Executive Commission on Ethical Standards may promulgate. 19 | P a g e Attachment C – Statement of Assurances Department of Human Services Statement of Assurances As the duly authorized Chief Executive Officer/Administrator, I am aware that submission to the Department of Human Services of the accompanying application constitutes the creation of a public document that may be made available upon request at the completion of the RFP process. This may include the application, budget, and list of applicants (bidder’s list). In addition, I certify that the applicant: • Has legal authority to apply for the funds made available under the requirements of the RFP, and has the institutional, managerial and financial capacity (including funds sufficient to pay the non-Federal/State share of project costs, as appropriate) to ensure proper planning, management and completion of the project described in this application. • Will give the New Jersey Department of Human Services, or its authorized representatives, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with Generally Accepted Accounting Principles (GAAP). Will give proper notice to the independent auditor that DHS will rely upon the fiscal year end audit report to demonstrate compliance with the terms of the contract. • Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. This means that the applicant did not have any involvement in the preparation of the RFP, including development of specifications, requirements, statement of works, or the evaluation of the RFP applications/bids. • Will comply with all federal and State statutes and regulations relating to non- discrimination. These include but are not limited to: 1) Title VI of the Civil Rights Act of 1964 (P.L. 88-352;34 CFR Part 100) which prohibits discrimination based on race, color or national origin; 2) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794; 34 CFR Part 104), which prohibits discrimination based on handicaps and the Americans with Disabilities Act (ADA), 42 U.S.C. 12101 et seq.; 3) Age Discrimination Act of 1975, as amended (42 U.S.C. 6101 et. seq.; 45 CFR part 90), which prohibits discrimination on the basis of age; 4) P.L. 2975, Chapter 127, of the State of New Jersey (N.J.S.A. 10:5-31 et. seq.) and associated executive orders pertaining to affirmative action and non-discrimination on public contracts; 5) federal Equal Employment Opportunities Act; and 6) Affirmative Action Requirements of PL 1975 c. 127 (NJAC 17:27). • Will comply with all applicable federal and State laws and regulations. 20 | P a g e • Will comply with the Davis-Bacon Act, 40 U.S.C. 276a-276a-5 (29 CFR 5.5) and the New Jersey Prevailing Wage Act, N.J.S.A. 34:11-56.27 et seq. and all regulations pertaining thereto. • Is in compliance, for all contracts in excess of $100,000, with the Byrd Anti-Lobbying amendment, incorporated at Title 31 U.S.C. 1352. This certification extends to all lower tier subcontracts as well. • Has included a statement of explanation regarding any and all involvement in any litigation, criminal or civil. • Has signed the certification in compliance with federal Executive Orders 12549 and 12689 and State Executive Order 34 and is not presently debarred, proposed for debarment, declared ineligible, or voluntarily excluded. The applicant will have signed certifications on file for all subcontracted funds. • Understands that this provider agency is an independent, private employer with all the rights and obligations of such, and is not a political subdivision of the Department of Human Services. • Understands that unresolved monies owed the Department and/or the State of New Jersey may preclude the receipt of this award. _______________________________ Applicant Organization Signature: CEO or equivalent ______________________________ Date Typed Name and Title 6/97