D.1 Required Compliance Checklist

D.1 COMPLIANCE CHECKLIST – REQUIRED FOR CONTRACTORS TO COMPLETE

All sections below must be completed with accurate information. If an item is not applicable “N/A.”

Contractor Information
Name of Prime Contractor

DBA - Doing Business As (If applicable)

SAM UEI

Cage Code

Street Address of Prime Contractor

City, State & Zip

Primary POC – Prime Contractor

Phone Number

Years of V226 or 485910 Experience

SBA Certifications (Social-Economic Statuses) and active expiration date(s) of the PRIME ONLY. Certification
Mark (x) if held
SBA Certification
Active Expiration Date
Service Disabled Veteran Owned SB (SDVOSB)
Veteran Owned SB (VOSB)
Economically Disadvantaged Woman Owned SB (EDWOSB)
Woman Owned SB (WOSB)
8(a) Small Business (8(a))
HUBZone (HUB)
Small Disadvantaged Business (SDB)

The following are required based on the requirement document or submittals found on section E.1 FAR 52.212-1 located on page 88 of the RFQ. Each required document shall be submitted under the PDF with the title show as below.

Vendor Name – Technical I - 36C25027R5412
☐ SF 1449, Most updated. Must filled out and be signed
☐ SF 30, Amendment(s) must be signed. Each must be acknowledged on Table B.1 of RFQ. ☐ Statement of FAR 52.229-11 section E.5 page 95 of RFP. Completed in its entirety and signed. ☐ Statement of FAR 52.209-7 section E.4 page 94 of RFP. Completed in its entirety and signed.

Vendor Name – Technical II - 36C25027R5412
☐ D.3 Statement of FAR 52.222-41 Statement of DoL WD Compliance. Completed in its entirety and signed. ☐ D.4 Statement of FAR 52.219-14 Statement of Limitation of Subcontracting Compliance. Completed in its entirety to include occupational code(s) and occupational title. It must be signed. ☐ D.6 Start Date Confirmation. Completed and signed.
☐ A printout of an Active Emergency, Medical, Fire, and Transportation Service License in the Prime contractor’s name ☐ Proof of insurance. Meets limitations set in section C.6 of RFQ. Vendor Name – Technical III - 36C25027R5412
☐ Management, Staffing and Training Plan
☐ Fleet Plan
☐ Contingency Plan
☐ Quality Control Plan

Vendor Name – Past Performance -36C25027R5412
☐ Past performance (References, Questionnaires, or CPARS)

I understand that the above lists must be completed and checked off. Any items not completed or checked off will render the package non-compliant and exclude it from consideration in the competition for award of the contract for NEMT service at Cleveland VAMC.