request for proposal for professional employer ...€¦ · quote for professional employer...

Request for Proposal for Professional Employer Organization (PEO) services

18-BPA-16

Dexis Consulting Group 1412 Eye St. NW Washington, DC 20005 Tel: +1 (202) 625-9444 dexisonline.com

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TABLE OF CONTENTS

Table of Contents .......................................................................................................................................... 1

Introduction .................................................................................................................................................. 3

1.1 Purpose ............................................................................................................................................... 3

1.2 Coverage & Participation .................................................................................................................... 3

General Information ..................................................................................................................................... 3

2.1 The Organization ................................................................................................................................. 3

2.2 Chronological List of Proposal Events ................................................................................................. 3

Proposal Preparation Instructions ................................................................................................................ 4

3.1 Understanding .................................................................................................................................... 4

3.2 Good Faith Statement ......................................................................................................................... 4

3.3 Communication ................................................................................................................................... 4

3.3.1 Offeror Inquiries ............................................................................................................................... 4

3.3.2 Addenda ........................................................................................................................................... 4

3.4 Submission Instructions ...................................................................................................................... 4

3.5 Selection Criteria ................................................................................................................................. 5

3.6 Evaluation Criteria ............................................................................................................................... 5

3.7 Selection and Notification ................................................................................................................... 6

Statement of Work ....................................................................................................................................... 6

4.1 Description of Services and Deliverables ............................................................................................ 6

4.2 Case Studies ........................................................................................................................................ 8

4.3 Pricing ................................................................................................................................................ 11

4.4 Period of Performance ...................................................................................................................... 12

4.5 Content of the Offer and Submission Requirements ........................................................................ 12

Organizational Requirements ..................................................................................................................... 14

5.1 Geographic Code ............................................................................................................................... 14

5.2 License, Clearance, and Approvals .................................................................................................... 14

5.3 Small Business Requirement ............................................................................................................. 14

Additional Terms & Conditions ................................................................................................................... 14

6.1 Non-Disclosure Agreement ............................................................................................................... 14

6.2 Intellectual Property ......................................................................................................................... 14

6.3 Offerors’ Responses .......................................................................................................................... 14

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6.4. Partial Award .................................................................................................................................... 15

6.5 Liability .............................................................................................................................................. 15

6.6 No Collusion ...................................................................................................................................... 15

6.7 General Terms ................................................................................................................................... 15

6.8 Entire RFP .......................................................................................................................................... 15

Annexes ....................................................................................................................................................... 16

Annex 1: Cover Letter ............................................................................................................................. 16

Annex 2: Certifications ............................................................................................................................ 18

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INTRODUCTION

1.1 PURPOSE

The purpose of this Request for Proposal (RFP) is to invite potential vendors to submit a proposal and quote for Professional Employer Organization (PEO) services. Organizations which submit offers must provide services in at least one of the following regions.

1. Latin America and the Caribbean2. Eastern Europe3. Asia4. Africa5. Middle East

Offerors need not to provide services in all five (5) regions, or in all countries of one region, to submit a proposal. Offerors must identify the countries in which they are best suited to provide the required services. Dexis anticipates that this RFP will result in Blanket Purchase Agreements (BPA) under which fixed price (fixed rates) task orders will be issued. The anticipated BPA ceiling is USD $2,000,000. Dexis may award BPAs to multiple offerors depending on their proven local/regional expertise.

1.2 COVERAGE & PARTICIPATION

Dexis reserves the right not to enter into any Agreement, to add, remove, or edit any aspect of the statement of work, prior to the negotiation of an Agreement without prior notification or liability. Dexis is not obligated to execute an Agreement nor is it committed to pay any costs incurred in the preparation and submission of the proposals.

GENERAL INFORMATION

2.1 THE ORGANIZATION

Dexis Consulting Group is a for-profit company founded in 2001 to strengthen management systems for the U.S. Government across developing economies. Dexis provides monitoring and evaluation, program management, institutional support, project implementation, and training solutions to address some of the world’s greatest challenges.

2.2 CHRONOLOGICAL LIST OF PROPOSAL EVENTS

The following calendar summarizes important dates in the solicitation process. Offerors must strictly follow these deadlines.

RFP transmitted Deadline for written questions Answers provided to questions/clarifications (estimated) Proposal due date Agreement award (estimated)

September 5, 2019 September 16, 2019 (5:00 PM, EST)

September 20, 2019 October 4, 2019 (5:00 PM, EST)

November 13, 2019

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The dates above may be modified at the sole discretion of Dexis. Any changes will be communicated by e-mail to all prospective Offerors or posted on Devex.

PROPOSAL PREPARATION INSTRUCTIONS

3.1 UNDERSTANDING

In responding to this RFP, Offerors accept full responsibility to understand the RFP in its entirety, and in detail, including making any inquiries to Dexis as necessary to gain such understanding. Dexis reserves the right to disqualify any service provider who illustrates less than such understanding. Such disqualification shall be at no fault, cost, or liability to Dexis.

3.2 GOOD FAITH STATEMENT

All information provided by Dexis in this RFP is offered in good faith. Individual items are subject to change at any time. Dexis makes no certification that any item is without error and is not responsible or liable for any use of the information or for any claims asserted there from.

3.3 COMMUNICATION

All questions or clarifications regarding this RFP must be in writing and submitted to Oksana Zolotova at [email protected]. Questions and requests for clarification, and the responses thereto, will be circulated to all RFP recipients who have indicated an interest in this RFP.

Only written answers from Dexis will be considered official and carry weight in the RFP process and subsequent evaluation. Any answers received outside the official channel, whether received verbally or in writing, from employees or representatives of Dexis Consulting Group or any other party, will not be considered official responses regarding this RFP.

3.3.1 OFFEROR INQUIRIES

Applicable terms and conditions herein shall govern communications between Dexis and Offerors in relation to this RFP. All questions related to this RFP are to be directed in writing to:

NAME EMAIL Oksana Zolotova [email protected]

3.3.2 ADDENDA

Dexis will make a good faith effort to provide a written response to the questions or requests that require addenda per the Chronological List of Proposal Events in Section 2.2.

3.4 SUBMISSION INSTRUCTIONS

Offers must be received via email by October 4, 2019 (5:00 PM, EST). Offerors should send their offers by email to the individuals identified in Section 3.3.1, inclusive of one (1) email with the Offeror’s technical

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proposal and a separate email with the Offeror’s price proposal (10 MB limit per email). No cost information should be provided in the technical proposal, except for the cost information regarding “knowledge of local labor laws” required for the case studies.

Offers must be on company letterhead with the company’s contact name and address. The subject line of the offer transmission email must identify the RFP reference number (18-BPA-16) and the Offeror’s name.

3.5 SELECTION CRITERIA

The evaluation of each response to this RFP will be based on its demonstrated competence, compliance, format, and organization. The purpose of this RFP is to identify those suppliers that have the interest, capability, and financial strength to supply Dexis with the product and/or service identified in the Scope of Work.

3.6 EVALUATION CRITERIA

Selected firms will be identified based on the following criteria.

Evaluation Criteria Evaluation Sub-criteria Company Information, Capabilities and Service Country Presence 30 points • Did the Offeror provide proof of in-country registration for the

countries for which it proposes to provide services?• Does the Offeror have a demonstrated presence (including staff and

office) in the countries for which it proposes to provide services?• Does the Offeror have sufficient experience administering PEO

services in the region?• To what extent does the Offeror rely on local third-party vendors to

provide the required services?

NOTE: Dexis will give preference to organizations registered and with a direct presence in the proposed countries instead of organizations that rely on local third-party vendors.

Relevant Past Experience 20 points • How relevant is the Offeror’s past experience in the countries for

which the offeror proposed to provide services?

Case Studies 20 points • Does the Offeror’s response to each case study reflect realistic and

efficient on-boarding timelines and procedures, mastery of local laborlaws and employment practices, and a clear understanding of thechallenges specific to each context/situation?

Price 20 points • Did the Offeror provide pricing for all services and fees associated

with the performance of services?• Is the proposed pricing clear, reasonable, and competitive?

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• Did the offeror provide accurate and complete pricing for the casestudies selected?

References 10 points • How well was the Offeror rated through feedback provided by

previous clients?

NOTE: Dexis will solicit feedback from provided references and will review offeror experience in projects of similar scope for the countries in which the offeror claims it is best suited to provide the required services.

3.7 SELECTION AND NOTIFICATION

Offerors whom Dexis determines to possess the capacity and past performance to compete for this Agreement will be selected to move into the negotiation phase of the competition. Written notification will be provided via e-mail. Offerors not selected will not be notified.

STATEMENT OF WORK

4.1 DESCRIPTION OF SERVICES AND DELIVERABLES

The complete list of services that may be required under this BPA contract is included below. Individual task orders released under this BPA will vary in their specific scopes of work, depending on the needs of the particular in-country project that Dexis is engaging in.

The Professional Employment Organization (PEO) will provide the services listed in the table below to Dexis. Please note that recurring non-compliance with timelines will result in financial penalties and/or termination of a BPA.

Table 1: Description of Services Description Deadline

1 Provide detailed list of statutory benefits for each country NLT 10 business days following TO execution

2 Provide draft employment agreements to Dexis for review NLT 15 business days prior to employee start date

3 Provide final employment agreement to staff in all requested/required languages.

NLT 10 business days prior to employee start date. All requested changes must be made within 2 business days

4 Ensure proper application of any statutory benefits, including registration of all staff with appropriate social security and labor departments.

Within 20 business days of employment agreement execution

Provide voluntary benefits and proper enrollment Ongoing

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Description Deadline 5 Coordinate payment of tax and social security to the relevant

authorities, as required Ongoing

6 Provide proof of tax payments. As requested, NLT 5 business days following request

7 Prepare and submit monthly draft invoices to include: a. Detailed transaction list of expenses, including date, payee,

description, amount;b. Invoice summary including costs by country;c. Copy of receipts for all incurred costs;d. Fees

NLT 30 days before payment due

8 Submit final invoice to include: a. Detailed transaction list of expenses, including date, payee,

description, amount;b. Invoice summary including costs by country;c. Copy of receipts for all incurred costs;d. Fees

NLT 20 days before payment

9 Provide payslips that show correct calculations regarding tax and social security deductions and payments required to be made, including, but not limited to: salary, salary adjustments, allowances, bonuses, overtime payments, etc.

NLT COB last business day of each month (pay day)

10 Direct deposit to include accurate net pay into employee bank accounts. Recipients may not incur fees for receiving direct deposits.

NLT COB last business day of each month for all staff

11 Provide weekly updates to Dexis on the status of funding requests, compliance with local labor laws, and any other updates that could affect workflow.

NLT Monday COB each week

12 Provide quarterly updates on local labor laws or other dynamics that can affect workflow, including list of statutory benefits for each country

COB first Monday of every quarter

13 Provide all contract close out requirements, including payout requirements.

Within 10 business days of request

14 Provide responses to employee questions and requests. Within 2 business days

15 Fully resolve issues flagged by Dexis or employee. Within 5 business days of request

16 Provide all mandated tax forms and other revenue forms (e.g., proof of end of year tax payments, pension payments, social security payments, etc.)

As required per country

17 Serve as employer of record for employees to be employed in every country requested by Dexis

Ongoing

18 Review and monitoring of compensation data, including payroll reconciliation

Ongoing

19 Calculate gross-to-net or net-to-gross pay as required, to include non-taxable deductions and pension-deductible calculations as required

Ongoing

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Description Deadline 20 Provide payroll reports tailored to employer specifications (gross-

to-net or net-to-gross as required) Monthly

21 Provision of annual employee forms Ongoing 22 Provide assistance with any legal issues regarding HR matters Ongoing 23 Work in conjunction with Dexis to apply disciplinary procedures to

hired staff Ongoing

24 Provide management and implementation of voluntary benefits Ongoing 25 Process visa and work permit for expatriate staff so they can legally

live and work at post. As needed

26 Process visa and residency permit for economic dependents accompanying expatriate staff to post.

As needed

Payroll processing needs for expatriate staff will be determined at the task order level as these employees may not be required to contribute to local tax authorities and/or social security institutions.

4.2 CASE STUDIES

Offerors must respond to one illustrative case study in each region that the Offeror proposes to provide services. In addition to a response addressing the details requested for each region-specific case study, each illustrative case study must include the following information at a minimum:

Table 2: Minimum Items Required for Responses to Each Illustrative Case Study

Item Description

Timeline

Provide an estimated timeline to fully onboard a candidate identified by Dexis, including all mandated registrations and enrollments with relevant local authorities. Assume Dexis notified the offeror on December 15, 2019.

Knowledge of Local Labor Laws

Provide a complete breakdown of fringe benefits (distinguish between legally mandated and customary benefits) which are paid by the employer. Provide a complete breakdown of employee deductions (income tax, social security contributions, etc.). Provide accurate estimate for all fringe benefits and employee deductions (e.g. social security – employer contributes 10% while employee contributes 5% of the employee’s gross income)

Anticipated Issues Does the offeror anticipate any issues with onboarding or offboarding the

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employee? How does the offeror propose mitigating anticipated issues (if any)?

Sample Case Study A – Tegucigalpa, Honduras (or another country in Latin America and the Caribbean)

Dexis prefers the offeror uses Tegucigalpa, Honduras for this sample case study; however, the offeror may propose a different country in the same region if it does not offer services in the preferred country. Please respond with at least the information listed in Table 2.

Sample Case Study for Latin America and the Caribbean

Employee Name Maria A. Employee’s Home of Record City where services are required Gross Salary $45,000 Duration of assignment 1 year

Specific Circumstance

The hired employee has consistently underperformed for a period of 6 months. The employee’s supervisor did not report any non-performance issues to Dexis’ staff at headquarters so Dexis was unaware of the precarious situation. Dexis’ client, which funds the salary of the employee in question, is furious and demands immediate termination.

Sample Case Study B – Kiev, Ukraine (or another country in Eastern Europe)

Dexis prefers the offeror uses Kiev, Ukraine for this sample case study; however, the offeror may propose a different country in the same region if it does not offer services in the preferred country. Please respond with at least the information listed in Table 2.

Sample Case Study for Eastern Europe

Employee Name Ivan Petrov Employee’s Home of Record France Gross Salary $65,000 Duration of assignment 2 years, with a possibility of extension


The employee requests an increase of 20% after 6 months of employment and claims that he has been underpaid for a while. The employee consistently receives stellar reviews. Dexis is unable to determine what the fair pay is for that position in that country. How would the offeror assist Dexis with this issue?

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Sample Case Study C – Manila, Philippines (or another country in Asia)

Dexis prefers the offeror uses Manila, Philippines for this sample case study; however, the offeror may propose a different country in the same region if it does not offer services in the preferred country. Please respond with at least the items listed in Table 2.

Sample Case Study for Asia

Employee Name Divina Bernardo Employee’s Home of Record Philippines Gross Salary $40,000 Duration of an assignment Unknown/as needed



Sample Case Study D – Niamey, Niger (or another country in Africa)

Dexis prefers the offeror uses Niamey, Niger for this sample case study; however, the offeror may propose a different country in the same region if it does not offer services in the preferred country. Please respond with at least the information listed in Table 2.

Sample Case Study for Africa

Employee Name Adamou Kientega Employee’s Home of Record city where services are required Gross Salary $56,800 Duration of an assignment 15 months


The employee requests an increase of 20% after 6 months of employment and claims that he has been underpaid for a while. The employee consistently receives stellar reviews. Dexis is unable to determine what the fair pay is for that position in that country. How would the offeror assist Dexis with this issue?

Sample Case Study E – Beirut, Lebanon (or another country in the Middle East)

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Dexis prefers the offeror uses Beirut, Lebanon for this sample case study; however, the offeror may propose a different country in the same region if it does not offer services in the preferred country. Please respond with at least the information listed in Table 2.

Sample Case Study for the Middle East

Employee Name John Doe Employee’s Home of Record Washington, DC Gross Salary $125,000 Duration of an assignment 5 years



4.3 PRICING

Offerors must submit to Dexis their proposed prices for the services offered. Offered prices will be fixed and valid for the duration of the BPA. Offerors may propose an annual escalation to prices but must keep in mind that the competitiveness of prices will be part of the evaluation criteria. Offerors may propose prices per country or per region if that is their pricing structure.

Table 3: Illustrative Price List

Service (revise as applicable) Frequency (revise as applicable) Rate (USD)

Setup Fee (per country) One time

Processing Fee (per employee or per country) Monthly

Fixed Administration Rate (per employee) Monthly

Onboarding Fee One time

Off boarding Fee One time

Visa Processing / Work Permit Fee One time

Currency Exchange Fees Per payslip

Fees on Allowances Per payslip

Off-cycle Fees (e.g. one time bonus) Per payment

Fees on reimbursement of local expenses (e.g. parking, travel expenses, etc.)

Per payslip

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Wire Fees Per payment

Other (please specify)

• Please disclose any discounts offered based on the number of covered employees. • Offeror must disclose any and all applicable taxes (e.g. value added tax)

4.4 PERIOD OF PERFORMANCE

The estimated period of performance of the Agreement is 4 (four) years. Dexis may break the Agreement down to one (1) base year and three (3) option years at Dexis’ discretion.

4.5 CONTENT OF THE OFFER AND SUBMISSION REQUIREMENTS

An offer must:

• Be in the English language. • Include a detailed technical proposal in accordance with the technical proposal requirements listed

below. • A price proposal in accordance with the price proposal requirements listed below. Pricing must be in

US Dollars. The Offeror must agree to keep these prices valid for a minimum of 90 calendar days. • Be complete and submitted on company letterhead. • Include proof of providing services in the region for which the offeror is proposing prices. • Names, addresses, and telephone numbers of five business references, and approval to contact those

references. Dexis reserves the right to request and check additional references. • A contact name, email address, and telephone number for an authorized negotiator of the Offeror. • A completed cover letter, provided in Annex 1, Evidence of Responsibility, and Size Self-Certification,

provided in Annex 2. • If an Offeror anticipates issuing an Agreement for any part of this Statement of Work, they must

disclose who is the anticipated recipient and the dollar value. Failure to disclose this in the proposal may result in either exclusion from competition or termination after award.

• Offerors must provide proof of legal registration under the laws of the country in which they operate.

Each offer must consist of two (2) sections, as follows: Technical Proposal Requirements. The technical proposal must address each of the evaluation criteria listed in Section 3.6. Specifically, each proposal must provide a detailed response and supporting documents, where requested, to each of the following areas:

I. Company Information, Capabilities/Services and Service Country Presence. Please provide a summary of your firm to include the following:

a. Please specify what is included in the offeror’s PEO services b. How many clients are currently using the offeror’s services in each country?

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c. How many employees does the offeror currently administer payroll services for in eachcountry? Please distinguish between local staff and international staff.

d. In which countries does the offeror have a physical presence from where it will be or havebeen providing services? Do not include countries where your company subcontracts outpayroll services to local vendors. Please provide proof of in-country presence andregistration in an annex.

e. How many employees work for the offeror in each country? Please include only direct hires,not employees of third-party vendors/providers.

f. How long has the offeror operated in each country? Only include number of years that theofferor directly provided services and not through third-party vendors.

g. Will the offeror need to subcontract any part of the work to third-party vendors? If yes,please specify for which countries and the names and responsibilities of the vendor(s).

h. Please provide a description of key staff that will be assigned to Dexis’ account in eachcountry/region and how Dexis’ account would be managed.

II. Relevant Past Experience. Please provide specific examples of similar services as those listed inSection 4 that were provided within the past three years. Please include one client for whom theOfferor transitioned staff from an incumbent PEO.

III. References. Provide references with contact information from a minimum of five client referencesthat currently use the offeror’s PEO services. Please include at least one client that can speak to theofferor’s performance on US Government-funded programs, and at least one client that for whom the offeror provides PEO services for locally hired staff. The same client may provide more than onereference if the work occurred in different countries. Offerors must submit at least 3 differentclients for the five references requested. Contact information should include:

a. Name of companyb. Name of point of contactc. Email addressd. Phone numbere. Confirm languages spoken by the point of contactf. Short description of services rendered, countries where the services were/are performed

Offerors may submit three written client testimonials in lieu of contact information for current clients. Testimonials must address the following topics related to the offeror:

a. Customer Serviceb. Responsivenessc. Capacityd. Value on fee for service

IV. Case Studies. Please respond to at least one of the case studies by addressing all the items listed inTable 2.

Section I and II may not exceed twenty (20) pages, size 11, Times New Roman font. Written client testimonials in Section III should not exceed two pages each. Response to each case study in Section IV may not exceed 2 pages.

Price Proposal Requirements. All price proposals must fully respond to the technical specification in the

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Statement of Work, and must include quotes in the format provided in Section 4.3 - Table 3. Offerors must also provide quotes, inclusive of all applicable fees, for the case studies selected. Prices must be expressed in U.S. Dollars. There is no page limit for the price proposal.

ORGANIZATIONAL REQUIREMENTS

5.1 GEOGRAPHIC CODE

Dexis’ projects may be funded by the US Government, including United States Agency for International Development (USAID,) and are therefore may be subject to Source and Nationality Geographic Codes 935, 937 and 110. Please see ADS Chapter 310 for additional information. Offerors who are not within the code must be aware that a waiver may be required for specific Task Orders, which may or may not be secured, and the award of any Agreement to an Offeror is subject to client approval or grant of a waiver, if applicable.

5.2 LICENSE, CLEARANCE, AND APPROVALS

The Offeror must already possess all legally required licenses, clearances, and/or approvals to provide the goods or services requested by the Scope of Work. If the Offeror is lacking any of those items, time to secure them should be included and specified in the proposed project timeline.

5.3 SMALL BUSINESS REQUIREMENT

Small business Offerors are encouraged to apply, but Dexis will consider offers from all types of businesses for this opportunity. Offerors are encouraged to partner with small businesses.

ADDITIONAL TERMS & CONDITIONS

6.1 NON-DISCLOSURE AGREEMENT

Any Agreement issued by Dexis will contain either a Non-Disclosure Agreement or provisions covering the disclosure of information in the course of completing the Scope of Work.

6.2 INTELLECTUAL PROPERTY

The Respondent should not use any intellectual property of Dexis including, but not limited to, all logos, registered trademarks, or trade names of Dexis, at any time without the prior written approval of Dexis, as appropriate.

6.3 OFFERORS’ RESPONSES

All accepted Responses shall become the property of Dexis and will not be returned.

https://www.usaid.gov/sites/default/files/documents/1876/310.pdf

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6.4. PARTIAL AWARD

Dexis reserves the right to accept all or part of the Offer when making the award.

6.5 LIABILITY

Dexis reserves the right to accept or reject any quotation or stop the procurement process at any time, without assigning any reason or liability. Dexis shall not be liable to any Offeror, person, or entity for any losses, expenses, costs, claims, or damages of any kind:

• Arising out of, by reason of, or attributable to, the Offeror responding to this RFP; or• As a result of the use of any information, error, or omission contained in this RFP document or

provided during the RFP process.

6.6 NO COLLUSION

Collusion is strictly prohibited. Collusion is defined as an agreement or compact, written or oral, between two or more parties with the goal of limiting fair and open competition by deceiving, misleading, or defrauding a third party.

6.7 GENERAL TERMS

Dexis will only consider responsive Offers from responsible offerors for award. Prices quoted must be valid for entire length of contract. All procurement will be subject to Dexis contractual terms and conditions.

6.8 ENTIRE RFP

This RFP, any addenda to it, and any attached schedules, constitute the entire RFP.

Dexis has zero tolerance for fraud. Fraud is any act or omission that intentionally misleads, or attempts to mislead, to obtain a benefit or to avoid an obligation. If you have concerns about potential fraud in any way related to Dexis projects, contracts, or activities, please visit https://www.lighthouse-services.com/index.html.

https://www.lighthouse-services.com/index.html

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ANNEXES

ANNEX 1: COVER LETTER

[Offeror: Insert date]

NAME

TITLE

Dexis Consulting Group

1412 Eye St. NW

Washington, DC 20005

Reference: Request for Proposal #18-BPA-16:

Subject: [Offeror: Insert name of your organization] technical and cost proposals

Dear NAME:

[Offeror: Insert name of your organization] is pleased to submit its proposal in regard to the above-referenced request for proposals. For this purpose, we are pleased to provide the information below:

Name of Organization’s Representative:

Name of Offeror:

Type of Organization:

Taxpayer Identification Number:

Address:

Address:

Telephone:

Fax:

E-mail:

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We are further pleased to provide the following annexes containing the information requested in the RFP:

[Offerors: Each offeror must read and understand the requirements of this RFP, and include all required information and annexes.]]

Sincerely yours,

______________________

Signature

[Offeror: Insert name of your organization’s representative]

[Offeror: Insert name of your organization]

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ANNEX 2: CERTIFICATIONS

Evidence of Responsibility

Company Name

Company Name makes the following statements with respect to Contractor Responsibility:

1) Company Name has adequate financial resources to perform the contract, or the ability to obtain them;

2) Company Name is able to comply with the required or proposed delivery or performance schedule, taking into consideration all existing commercial and governmental commitments;

3) Company Name has a satisfactory performance record; 4) Company Name has a satisfactory record of integrity and business ethics; 5) Company Name has the necessary organization, experience, accounting and operational

controls, and technical skills, or the ability to obtain them (including, as appropriate, such elements as production control procedures, property control systems, quality assurance measures, and safety programs applicable to materials to be produced or services to be performed by the prospective contractor and vendors).;

6) Company Name has the necessary production, construction, and technical equipment and facilities, or the ability to obtain them; and

7) Company Name is qualified and eligible to receive an award under applicable laws and regulations (e.g., Equal Opportunity, Clean Air and Water, Small Business Subcontracting, etc.)

I declare under penalty of perjury that the foregoing is true and correct.

Name

Title, Company Name

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Vendor Size Self-Certification Form

Reference Number: Funding agency's solicitation or contract number

Project Name: Enter full name of project

Company Name: Full legal name

Address: Street address

City, State, Zip: City, State Zip

DUNS Number: 123456789

Primary NAICS Code: Primary NAICS code

Other NAICS Codes: NAICS code(s) under this project

Contact Person: Name, Title

Contact Phone Number: (555) 555-5555

Type of Entity: If you have difficulty ascertaining the business size status, please refer to SBA’s website (www.sba.gov/size) or contact your local SBA office.

☐ Large Business ☐Small Business ☐Nonprofit ☐Educational ☐Government If “Small Business” is checked above, and if applicable, please identify any additional small business designations under which the company qualifies. You may wish to review the definitions for the below categories in the Federal Acquisition Regulation 19.7 or 52.219-8 (www.acquisition.gov/far/) to determine applicability.

☐ Small Disadvantage Business ☐ VOSB

☐ 8(a) ☐ SDVOSB

☐ HUBZone ☐ Alaskan Native Corporation

☐ WOSB ☐ Indian Tribe

By signature below, I hereby certify that the business type and designation indicated above is true and accurate as of the date of execution of this document, and I further understand that under 15 U.S.C. 645(d), any person who misrepresents a business’ size status shall (1) be punished by a fine, imprisonment, or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act.

________________________________ ___________________

Signature and Title Date

http://www.sba.gov/size

http://www.acquisition.gov/far/

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