REQUEST FOR PROPOSALS FOR COURT REPORTING …



SECTION H - MBE/WBE TRACKING INFORMATIONDefinitions:A Minority Business Enterprise (MBE) is defined in the Camden County Affirmative Action Plan as "a business which is independently owned and operated and is at least 51% owned and controlled by minority group members". Minority group members are defined in the Camden County Affirmative Action Plan as "persons who are Black, Hispanic, Portuguese, Asian-American, American Indian or Alaskan Natives"A Women Business Enterprise (WBE) is defined in the Camden County Affirmative Action Plan as "a business which is independently owned and operated and is at least 51% owned and controlled by women".Using the definitions above, please check the following space which best describes your firm: Minority Business Enterprise (MBE) Women Business Enterprise (WBE) NeitherNAME OF FIRM: ________________________________________ ADDRESS: __________________________________________________________________________________________________________________________________________________________ DATE: ________________________ SECTION JCERTIFICATION REGARDING THE DEBARMENT, SUSPENSION, INELIGIBILITYAND VOLUNTARY EXCLUSION – LOWER TIER COVERED TRANSACTIONSThis certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510, titled Participants’ Responsibilities. The Regulations were published as Part VII of the May 26, 1988 Federal Register (pages 19160-19211)I am of the firm (Your Title) (Name of Your Organization)(Address of Your Organization)CHOOSE THE FOLLOWING( )A.I hereby certify on behalf of ___________________________, (Name of Your Organization)that neither it nor its principals are debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.( )B.I am unable to certify to any of the statements set forth in this certification. I have attached an explanation to this form.____________________________(Signature)____________________________ Type Name & TitleDate:_______________________INSTRUCTIONS FOR CERTIFICATION1.By signing and submitting this proposal, the prospective recipient of Federal assistance funds is providing the certification as set out below.2.The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective recipient of Federal assistance funds knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the Department of Labor (USDOL) may pursue available remedies, including suspension and/or debarment.3.The prospective recipient of Federal assistance funds shall provide immediate written notice to the person to whom this proposal is submitted if at any time the prospective recipient of Federal funds learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.4.The terms “covered transaction”, “debarred”, “suspended”, “ineligible”, “lower tier covered transaction”, “participant”, “person”, “primary covered transaction”, “principal” “proposal”, and “voluntary excluded”, as used in this clause, have the meanings as set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations.5.The prospective recipient of Federal assistance funds agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction unless authorized by the USDOL.6.The prospective recipient of Federal assistance funds further agrees by submitting this proposal that it will include the clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion – Lower Tier Covered Transactions” without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.7.A participant in a covered transaction may rely upon a certification of prospective participants in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may, but is not required to check the List of Parties Excluded from Procurement or Nonprocurement Programs.8.Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.9.Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the USDOL may pursue available remedies, including suspension and/or debarment. SECTION L - DISCLOSURE OF INVESTMENT ACTIVITIES IN IRANPART 1: CERTIFICATIONBIDDERS MUST COMPLETE PART 1 BY CHECKING EITHER BOX. FAILURE TO CHECK ONE OF THE BOXES WILL RENDER THE PROPOSAL NON-RESPONSIVE.Pursuant to Public Law 2012, c. 25, any person or entity that submits a bid or proposal or otherwise proposes to enter into or renew a contract must complete the certification below to attest, under penalty of perjury, that neither the person or entity, nor any of its parents, subsidiaries, or affiliates, is identified on the Department of Treasury's Chapter 25 list as a person or entity engaging in investment activities in Iran. The Chapter 25 list is found on the Division's website at: . Bidders must review this list prior to completing the below certification. Failure to complete the certification and return it with the RFP will render a bidder's proposal non-responsive and the RFP will be rejected. If the Director finds a person or entity to be in violation of law, s/he shall take action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring the party in default and seeking debarment or suspension of the party.PLEASE CHECK THE APPROPRIATE BOX:I certify, pursuant to Public Law 2012, c. 25, that neither the bidder listed above nor any of the bidder's parents, subsidiaries, or affiliates is listed on the N.J. Department of the Treasury's list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012 c. 25, ("Chapter 25 List"). I further certify that I am the person listed above, or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf. I will skip Part 2 and sign and complete the Certification below.ORI am unable to certify as above because the bidder and/or one or more of its parents, subsidiaries, or affiliates is listed on the Department's Chapter 25 List. I will provide a detailed, accurate and precise description of the activities in Part 2 below and sign and complete the Certification below. Failure to provide such will result in the proposal being rendered as non-responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by law.PART 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN - add additional sheets if necessary.You must provide a detailed, accurate and precise description of the activities of the bidding person/entity, or one of its parents, subsidiaries or affiliates, engaging in the investment activities in Iran outlined above by completing below:Name of Entity: ________________________; Relationship to Bidder:____________________________Description of Activities:________________________________________________________________________ ____________________________________________________________________________________Duration of Engagement: _____________________Anticipated Cessation Date:____________________Bidder/Offeror Contact Name: _____________________; Contact Phone:_________________________Sign Certification - next pageSECTION L - continuedDISCLOSURE OF INVESTMENT ACTIVITIES IN IRANBIDDER: _________________________________Certification: I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge that I am authorized to execute this certification on behalf of the bidder, that the County of Camden is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with the County to notify the County in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the County of Camden, permitting the County to declare any contract(s) resulting from this certification void and unenforceable.Full Name (Print): ____________________________________ Signature: __________________________________________ Title: ______________________________________________ Date: ______________________ATTACHMENT A-1Juvenile Justice Commission2019 Positive Youth Development and Innovative Youth Detention Alternative ServicesFunding ProposalCover SheetProposal Summary InformationIncorporate Name of Applicant:__________________________________________________________Type: Public_______ Profit_______ Non-Profit_______ Hospital-Based_______Federal ID Number: _________________________ Charities Reg. Number:___________________Address of Applicant:________________________________________________________________________________________________________________________Address of Service(s)____________________________________________________________(Attach list if necessary) ____________________________________________________________Contact Person: _________________Phone No.: __________Email:_________ FAX ___________Total dollar amount requested:_____________ Total match required:__ _______ (if applicable)Funding period: From__________ to __________Services: __________________________________________________________________________(for which funding is requested)Total number of (check one) ____duplicated ____unduplicated clients to be served: _______________Brief description of services by Program Name and Level of Service to be provided: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Brief Description of a Unit of Service:_________________________________________________________________________________________________________________________________________Cost per Unit of Service____________________Level of Service:____________________Authorization:Chief Executive Officer (Print)________________________________________________________-762000124460PLEASE CIRCLE ONE PER PROPOSAL FOR SERVICES APPLIED FOR Delinquency PreventionDiversionDetention/Detention AlternativeDispositionalReentryAfterschool/Weekend SummerArson DiversionFCIUEvening/Weekend Reporting CenterIntensive Supervision/ In-Home MSTTransitional ServicesGender SpecificAfterschool/Weekend SummerJuvenile Justice Family Partnership ProgramJuvenile Sex Offender Treatment ServicesMentoringGender Specific SeminarsGirls Advocacy ProgramAnger ManagementGang AbatementCamden County ASSET MAPPINGGang Intervention00PLEASE CIRCLE ONE PER PROPOSAL FOR SERVICES APPLIED FOR Delinquency PreventionDiversionDetention/Detention AlternativeDispositionalReentryAfterschool/Weekend SummerArson DiversionFCIUEvening/Weekend Reporting CenterIntensive Supervision/ In-Home MSTTransitional ServicesGender SpecificAfterschool/Weekend SummerJuvenile Justice Family Partnership ProgramJuvenile Sex Offender Treatment ServicesMentoringGender Specific SeminarsGirls Advocacy ProgramAnger ManagementGang AbatementCamden County ASSET MAPPINGGang InterventionSignature:______________________________________ Date___________________________ATTACHMENT A-3Logic Model 2019 Camden County Youth Service Commission: Contract Period January 1 – December 31, 2019Agency: Program Name: Contact Person:Logic Model Completed By:VisionTarget PopulationAssumptionsOutcomeServices/ActivitiesResourcesIndicatorMeasurement ToolTimeline Responsible PartiesShort-Term (engagement)Intermediate (implementation)Long Term (sustained implementation)ATTACHMENT CAFFIRMATIVE ACTION QUESTIONNAIRE Kindly complete this questionnaire in the event that your firm is awarded this contract. The necessary forms will be sent by our office, upon award. This questionnaire should be submitted with your bid.Our Company has a Federal Affirmative Action Plan Approval.YES ______NO ______if yes, submit a photo static copy of said approval.if no, submit a photo static copy of the New Jersey Certificate of Employee Information Report.NONE OF THE ABOVE ______We have neither State nor Federal Affirmative Action evidence therefore please send us Form AA-302 (Affirmative Action Employee Information Report application).(Check if applicable) _____I certified that the above information is correct to the best of my knowledge.NAME: ________________________________________________________________SIGNATURE: __________________________________________________________TITLE: ________________________________________________________________CHIEF EXECUTIVE OFFICER: ____________________________________________AGENCY: _____________________________________________________________DATE: __________________________________AN EQUAL OPPORTUNITY EMPLOYERATTACHMENT D-12019 Positive Youth Development and Innovative Youth Detention Alternative ServiceProgram Budget Summary FormPage 1 of 5Agency Name:Agency Federal I. D. #: ___ ___ - ___ ___ ___ ___ ____Address:Charities Registration #: ___ ___ ___ ___ - ___ ___ ____ ___Non-Profit Agency___ For-Profit Agency___ Public Agency____Phone:Budget Period: From ___To____ Agency Fiscal Year Ends:____Chief Executive Officer:Prepared by:Program NameReimbursable CeilingType of ServicePayment MethodProvider Agency, Contact Person & Telephone #Budget: I certify that the cost data used to prepare this contract budget is current, complete, and in accordance with the governing principles for determining costs.X_________________________________________________ (Print & Sign)ATTACHMENT D-22019 Positive Youth Development and Innovative Youth Detention Alternative ServicesContract Expense SummaryPage 2 of 5123456789BUDGET CATEGORYTOTALUNALLOWABLE COSTSGENERAL & ADMINISTRATIVE COSTSPERSONNELCONSULTANTS & PROFESSIONAL FEESMATERIALS & SUPPLIESFACILITY COSTSSPECIFIC ASSISTANCE TO CLIENTSOTHERGENERAL & ADMINISTRATIVE COST ALLOCATION>>>>>>>>>>TOTAL OPERATING COSTSEQUIPMENT TOTAL COSTLESS: REVENUENET COSTPROFITREIMBURSABLE CEILINGUNITS OF SERVICEUNIT COSTATTACHMENT D-32019 Positive Youth Development and Innovative Youth Detention Alternative ServicesPersonnelPage 3 of 5BUDGET CATEGORY: PERSONNEL123456789POSITION TITLE/NAME OF EMPLOYEEPOSITION NUMBERDATE EMPLOYEDHOURS /WEEKTOTAL COSTUNALLOWABLE COSTSGENERAL & ADMINISTRATIVE COSTSATTACHMENT D-42019 Positive Youth Development and Innovative Youth Detention Alternative ServicesOther than Personnel (i.e. equipment)Page 4 of 5123456789BUDGET CATEGORYBASIS FOR ALLOCATIONTOTAL COSTUNALLOWABLE COSTSGENERAL & ADMINISTRATIVE COSTSATTACHMENT D-52019 Positive Youth Development and Innovative Youth Detention Alternative ServicesRevenuePage 5 of 5123456789DESCRIPTONTOTALUNALLOWABLE COSTSGENERAL & ADMINISTRATIVE COSTSSUPPORTING DOCUMENTATION IS REQUIRED TO SUBSTANTIATE THE ALLOCATIONSATTACHMENT ECounty of CamdenJuvenile Justice Commission2019 Calendar of Service Days(Include one calendar for each program component)Service will be provided as followed: (fill in times)Program name/component_____________________________________________________Site Location________________________________________________________________Sunday_____________________________Monday_____________________________Tuesday_____________________________Wednesday__________________________Thursday____________________________Friday______________________________Saturday____________________________Emergency Provisions: ________________________________________________________________________________________________________________________________________________________Holiday Schedule - Service will not be provided on the following:Occasion Dates ................
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