71 
APPENDIX C: 
BIDDERS SIGNATURE FORM 
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72 
DELAWARE HEALTH AND SOCIAL SERVICES 
REQUEST FOR PROPOSAL 
BIDDERS SIGNATURE FORM 
NAME OF BIDDER: 
SIGNATURE OF AUTHORIZED PERSON:   
TYPE IN NAME OF AUTHORIZED PERSON: 
TITLE OF AUTHORIZED PERSON:  
STREET NAME AND NUMBER:   
CITY, STATE, & ZIP CODE: 
CONTACT PERSON:   
TELEPHONE NUMBER:   
FAX NUMBER:   
DATE:   
BIDDER’S FEDERAL EMPLOYERS IDENTIFICATION NUMBER: 
THE FOLLOWING MUST BE COMPLETED BY THE VENDOR: 
AS  CONSIDERATION FOR  THE AWARD AND  EXECUTION BY THE DEPARTMENT OF  HEALTH AND 
SOCIAL SERVICES OF THIS CONTRACT, THE (COMPANY NAME) 
HEREBY GRANTS, CONVEYS, SELLS, ASSIGNS, AND TRANSFERS TO THE STATE OF DELAWARE ALL OF 
ITS RIGHTS, TITLE AND INTEREST IN AND TO ALL KNOWN OR UNKNOWN CAUSES OF ACTION IT 
PRESENTLY HAS OR MAY NOW HEREAFTER ACQUIRE UNDER THE ANTITRUST LAWS OF THE UNITED 
STATES  AND  THE  STATE  OF  DELAWARE,  RELATING  THE  PARTICULAR  GOODS  OR  SERVICES 
PURCHASED  OR  ACQUIRED  BY  THE  DELAWARE  HEALTH  AND  SOCIAL  SERVICES  DEPARTMENT, 
PURSUANT TO THIS CONTRACT. 
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73 
APPENDIX D: 
CERTIFICATION SHEET 
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74 
DELAWARE HEALTH AND SOCIAL SERVICES 
REQUEST FOR PROPOSAL 
CERTIFICATION SHEET 
As the official representative for the proposer, I certify on behalf of the agency 
that: 
a.  They are a regular dealer in the services being procured. 
b.  They have the ability to fulfill all requirements specified for development 
within this RFP. 
c.  They have independently determined their prices. 
d.  They are accurately representing their type of business and affiliations. 
e.
They will secure a Delaware Business License. 
f.
They have acknowledged that no contingency fees have been paid                            
to obtain award of this contract. 
g.
The Prices in this offer have been arrived at independently, without 
consultation, communication, or agreement, for the purpose of restricting 
competition, as to any matter relating to such prices with any other 
contractor or with any competitor; 
h.
Unless otherwise required by Law, the prices which have been quoted in this 
offer have not been knowingly disclosed by the contractor and prior to the 
award in the case of a negotiated procurement, directly or indirectly to any 
other contractor or to any competitor; and 
i.
No attempt has been made or will be made by the contractor in part to 
other persons or firm to submit or not to submit an offer for the purpose of 
restricting competition. 
j.
They have not employed or retained any company or person (other than a 
full-time bona fide employee working solely for the contractor) to solicit or 
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75 
secure this contract, and they have not paid or agreed to pay any company 
or person (other than a full-time bona fide employee working solely for the 
contractor) any fee, commission percentage or brokerage fee contingent 
upon or resulting from the award of this contract. 
k.
They (check one) operate ___an individual; _____a Partnership ____a non-
profit (501 C-3) organization; _____a not-for-profit organization; or _____for 
profit corporation, incorporated under the laws of the State of 
____________________. 
l.
The referenced offerer has neither directly or indirectly entered into any 
agreement, participated in any collusion or otherwise taken any action in 
restraint of free competitive bidding in connection with this bid submitted this 
date to Delaware Health and Social Services. 
m.
The referenced bidder agrees that the signed delivery of this bid represents 
the bidder’s acceptance of the terms and conditions of this invitation to bid 
including all Specifications and special provisions. 
n.
They (check one): _______are; ______are not owned or controlled by a 
parent company.  If owned or controlled by a parent company, enter name 
and address of parent company: 
__________________________________________ 
__________________________________________ 
__________________________________________ 
__________________________________________ 
Violations and Penalties: 
Each contract entered into by an agency for professional services shall contain 
a prohibition against contingency fees as follows: 
1.
The firm offering professional services swears that it has not employed or 
retained any company or person working primarily for the firm offering 
professional services, to solicit or secure this agreement by improperly 
influencing the agency or any of its employees in the professional service 
procurement process. 
2.
The firm offering the professional services has not paid or agreed to pay any 
person, company, corporation, individual or firm other than a bona fide 
employee working primarily for the firm offering professional services, any 
fee, commission, percentage, gift, or any other consideration contingent 
upon or resulting from the award or making of this agreement; and 
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3.
For the violation of this provision, the agency shall have the right to terminate 
the agreement without liability and at its discretion, to deduct from the 
contract price, or otherwise recover the full amount of such fee, commission, 
percentage, gift or consideration. 
The following conditions are understood and agreed to: 
a.  No charges, other than those specified in the cost proposal, are to be levied 
upon the State as a result of a contract. 
b.  The State will have exclusive ownership of all products of this contract unless 
mutually agreed to in writing at the time a binding contract is executed. 
Date   
Signature & Title of Official Representative 
Type Name of Official Representative 
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77 
APPENDIX E 
STATEMENTS OF COMPLIANCE FORM
78 
DELAWARE HEALTH AND SOCIAL SERVICES 
REQUEST FOR PROPOSAL 
STATEMENTS OF COMPLIANCE FORM 
As the official representative for the contractor, I certify on behalf of the agency 
that   
(Company Name)  will  comply with all Federal 
and  Delaware  laws  and  regulations  pertaining  to  equal  employment 
opportunity and affirmative action.  In addition, compliance will be assured in 
regard to Federal and Delaware laws and regulations relating to confidentiality 
and individual and family privacy in the collection and reporting of data. 
Authorized Signature:   
Title:   
Date:  
79 
APPENDIX F 
Contract Boilerplate 
80 
DELAWARE  HEALTH  
AND SOCIAL SERVICES
DPH CONTRACT # _______ 
BETWEEN 
THE DIVISION OF PUBLIC HEALTH, 
DELAWARE DEPARTMENT OF HEALTH & SOCIAL SERVICES, 
AND 
[Contractor] 
FOR 
[TYPE OF SERVICE] 
A.   Introduction 
1. 
This contract is entered into between the Delaware Department of Health and Social 
Services (the Department), Division of Public Health, Division of Aging and Adults With 
Physical Disabilities and _______________________ (the Contractor). 
2
The Contract shall commence on __________________ and terminate on _____________ 
unless specifically extended by an amendment, signed by all parties to the Contract. Time is 
of the essence. (Effective contract start date is subject to the provisions of Paragraph C. 1. of 
this Agreement.) 
B.   Administrative Requirements 
1. 
Contractor recognizes that it is operating as an independent Contractor and that it is liable 
for any and all losses, penalties, damages, expenses, attorney's fees, judgments, and/or 
settlements incurred by reason of injury to or death of any and all persons, or injury to any 
and all property, of any nature, arising out of the Contractor's negligent performance under 
this Contract, and particularly without limiting the foregoing, caused by, resulting from, or 
arising out of any act of omission on the part of the Contractor in their negligent 
performance under this Contract.   
2. 
The Contractor shall maintain such insurance as will protect against claims under Worker’s 
Compensation Act and from any other claims for damages for personal injury, including 
death,  which  may  arise  from  operations  under  this  Contract.  The  Contractor  is  an 
independent contractor and is not an employee of the State. 
3. 
During the term of this Contract, the Contractor shall, at its own expense, carry insurance 
with minimum coverage limits as follows: 
a) Comprehensive General Liability   
$1,000,000 
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