Attachment 1Denver Human Services

2017 Housing and Supportive ServicesProposal Certification Form

(Please Print or Type)

Agency/Name: _________________________________________________________

Type (LLC/Sole Prop/etc.): __________________________________________________

Address: ______________________________________________________________

City: ________________________State: ___________________Zip: __________

Telephone Number: ___________________Fax Number: _______________________

Website: __________________________ Email Address: _______________________

Contact Person for this Application: ___________________________________________

Title: ________________________________ Phone: _______________________

Email Address: _______________________

Executive Director, CEO, or Owner: ________________________________________

Title: _______________________________ Phone: _______________________

Email Address: _______________________

Federal Identification Number or Social Security Number: _______________________

Total Proposal Request $____________

1

Attachment 2Denver Human Services

2017 Housing and Supportive ServicesProposal Checklist

Your Proposal will not be considered complete unless all of the documents are included. Please make certain that you include all of the following:

____Completed Proposer Certification Form (Attachment 1)____Completed Proposal Checklist (Attachment 2)____ Proposal Narrative (Scope of Work) not to exceed Ten (10)

pages (Attachment 3) ____Proposal Budget with narrative (Attachment 5) –Cost

Reimbursement or Fee for Service____IRS 501(c ) (3), Certification of Good Standing with Colorado ____Secretary, or State Corporation Papers____Current Agency Annual Budget____Current Independent Audit, Financial Review or IRS Tax Form____List of Board of Directors with occupations and affiliations____Organizational chart with staff names for Primary Agency ____Key Staff Resumes for Primary Agency ____Key Staff Job Descriptions for Primary Agency ____Non-discrimination Statement and Policy for Primary Agency ____Client Grievance Policy and Procedures for Primary Agency ____Certification Regarding Debarment, Suspension (Attachment 9)____Diversity And Inclusiveness in City Solicitations Information Request Executive Order 101 Diversity and Inclusiveness in City Solicitations Information Request has been completed per Part I, #15 on page six (6) of this RFP____CERTIFICATE OF INSURANCE per Attachment 7 ____Compliance with Insurance Statement and Contract Certification Form

(Attachment 11)____One (1) original, and six (6) copies (total seven) of the full proposal and attachments, plus one full electronic copy.

Please place an X next to the items above to indicate that it is included in your submission. This sheet must accompany your proposal. You are advised to review your materials to ensure it is comprehensive before you submit it.

I have reviewed this Proposal and have included all the required information:

_________________________________________Print Name of Person completing Proposal

________________________________ _______________ ____________Signature of Person completing Proposal Title Date

____________________________________________Print Name of Agency or Corporation Executive

______________________________ ________________ ____________Signature of Executive Title Date

1

Attachment 32017 Housing and Supportive Services Narrative

This RFP is designed to provide sufficient information for providers to prepare and submit a Request for Proposal. All responses should provide a straightforward, concise description of qualifications, and include any details of interest in the specifics you will be providing services for. The following information should be fully explained in your proposal and be presented as follows:

A. Agency Capacity and Experience 1. Provide an overview of your agency or organization including mission, history,

years in operation, total staff size, and program staff including number of staff, role in program, education or licensure requirements, and training provided.

2. Describe your agency’s experience providing housing and/or other human services to homeless populations and capacity to successfully manage the scope of work and other requirements described in the RFP.

3. Detail previous contracts with the City and County of Denver and/or other government agencies in the last five years and describe your agency’s experience managing/capacity and accounting for public funding.

4. Briefly describe your agency’s participation, active partnerships or collaborations in local homeless initiatives and planning efforts. Describe how they are enhanced by or will be supported by the program you are proposing for funding.

B. Programs/Services /Goals and Objectives to be provided in the context of this RFPProvide a summary of the proposed service design.

1. Include a description of the proposed services.2. How many unique households will you serve in 2017:

a. Capacity in program at one time: b. Estimated number of exiting participants:

i. Estimated number of successful exits: ii. Define your criteria for “successful”

iii. Estimated number of unsuccessful exits: iv. Define your criteria for “unsuccessful”

c. Estimated number of new participants brought on in 2017.d. Physical location itself, how services/operations will be organized,

and staffing levels. 3. Describe your referral and intake procedures. 4. Access to public transportation.5. Any fees that program participants are required to pay, if there are required

fees include a description of how the program serves clients with no income.

C. Experience and Qualifications1. What experience does your organization have in using HMIS?

a. Responses should include the number of employees trained in HMIS use and your agencies Data Quality results for each HMIS program.

b. The source of the Data Quality results should be based on the latest report issued by the Colorado Coalition for the Homeless.

2. Describe your agency’s experience with the following: a. Providing the supportive services for a Permanent Supportive

Housing Program, with specific attention to ACT and/or HIT models

b. Applying a Housing First model to your proposed programc. Providing case management and supportive services towards

housing retention, attainment, income attainment, benefits applications, and medical benefits attainment.

d. Providing mental health and/or substance abuse treatment services across a range of interventions

3. Describe your agency’s technical and administrative capacity to track program participants.

D. Emergency SituationsWhat is your ability to scale staff and capital resources in an emergency situation?

E. Cultural Competency and Diversity1. Describe the process your agency uses to identify specific culturally based

needs of populations other than the majority population, and how it uses that information to modify engagement, access and service delivery in order to meet unique needs. Give examples, if possible, from prior agency projects.

2. Explain your agency’s philosophy of cultural competency and specific efforts to ensure equity and social justice.

3. Specifically describe your agency’s client grievance process especially as it pertains to the proposed project. Include information about how and when clients are informed about it, the time frame in which a client’s grievance is heard and how decisions are rendered.

a. Does your grievance process require clients to be dismissed from your facility/program before the grievance procedure is completed?

b. Please explain how your organization ensures that clients filing a grievance are provided with due process? (DDHS requests a copy of your client grievance policy and procedures to be submitted with this RFP).

4. If your agency or the proposed project is associated with or supported by the faith community or religious organization(s), please describe the relationship and how it benefits the individuals served.

a. Are clients required to participate in religious programming?

F. Budget and Narrative 1. Provide a summary of your budget request, including personnel,

facility/operating, the basis for administrative costs, and any other information that helps clarify project costs.

2. Please find and complete Attachment 5 Budget Form and follow the instructions included. Provide any and all needed narrative related to the budget and be as detailed as possible.

G. Program Evaluation – Using the Outcome Tracker Template (Attachment 4), please demonstrate the following

1. Describe how your organization will monitor and evaluate the quality of the services provided.

2. Describe the methodology you will use to track each outcome.3. Please specify the methods and assessment tools used to measure your

program effectiveness

H. Reporting and Accounting Requirements

2

1. Describe your methodology and ability to track data and provide periodic reports on program progress.

2. Please describe your accounting systems.

I. Sustainability1. Describe how you would continue to support this program or services to

serve clients in the community if there was a reduction in funding in the future?

2. Please explain how this programming could be planned for and sustained in your organization in the future?

3. Is the program in alignment with your organizational vision and goals?

3

Attachment 4

Outcome Tracker – Denver’s Road Home Housing and Supportive Services Contracts 2017Program:

Current # _____Exited

# Successful _____ # Unsuccessful _____

Outcomes Benchmark Q1 Actual

Successful Exiter Benchmark

Q1 Actual Successful Exiter

Unsuccessful Exiter Benchmark

Q2 Actual Unsuccessful Exiter

obtained mainstream financial benefits (i.e. SSI, SSDI, TANF, AND), employment, or a steady source of income

50% 80% 50%

increased access to treatment services (as demonstrated by both referrals made and actual services provided as part of proposed program)

60% 90% 60%

program participants will be enrolled in healthcare benefits (i.e. Medicaid, Medicare, VA healthcare, etc)

60% 90% 60%

will demonstrate symptom improvement (Proposer will define what these improvements are & specifically how the proposed program will measure them – common improvements include sobriety, management of psychiatric symptoms, etc)

50% 80% 50%

Program Narrative: Successes This Quarter : Please describe the factors that have contributed to your

success in achieving your objectives this quarter. This can include anything from adequate funding (e.g., awarded a grant), staffing, program implementation (e.g., added an evidence-based program or procedure, changed a program or procedure), etc.

Challenges This Quarter and Plan to Overcome: Please describe the factors that have restricted your success in achieving your objectives this quarter. This can include anything from inadequate funding, to staff changes, to inconsistently an evidence-based implementing a program (i.e., didn’t achieve program “fidelity”)

Attachment 5 Cost Reimbursement

BUDGET (Cost Reimbursement )

Contractor Name:

Contract Term:

Program Name: 2017 Housing and Supportive Services

ITEM BUDGET BUDGET NARRATIVE JUSTIFICATION

INDIRECT COSTS

Staffing/Administration

Sub-Total (Staffing)

Other Administrative Costs

Sub-Total (Other Admin Costs)

FACILITIES

Operating and Overhead Costs

Sub-Total (Facilities)

SUM OF INDIRECT COSTS:

Accredited by Child Welfare League of America Since 1949Partnering with our community to protect those in harm’s way and

help all people in need.

Contracting Services - Business Management Division1200 Federal Boulevard, Fourth Floor

Denver, Colorado 80204-3221Phone: 720-944-2233 FAX Phone: 720-944-2224

Email: DHS_Contracting_Services@denvergov.org

DIRECT COSTS

Staffing

Sub-Total (Staffing)

Client Services

Sub-Total (Client Services)SUM OF DIRECT COSTS:

TOTAL COSTS):The Narrative must outline and clearly describe all items associated with each line item, the rationale and methodology used to establish the fees, cost allocations, and calculations associated with the funded program. The Budget Narrative should be outlined to the line items and is to be attached to the Budget Form page.

Attachment 5 Fee for Service

BUDGET (Fee for Service )

Contractor Name:Contract Term:Program Name: 2017 Housing and Supportive Services

Unit of Service Unit Price Number of Units Total

- - - - - - - - - - -

2

Accredited by Child Welfare League of America Since 1949Partnering with our community to protect those in harm’s way and

help all people in need.

Contracting Services - Business Management Division1200 Federal Boulevard, Fourth Floor

Denver, Colorado 80204-3221Phone: 720-944-2233 FAX Phone: 720-944-2224

Email: DHS_Contracting_Services@denvergov.org

- - -

- - - - - -

TOTAL BUDGET $0.00 $0.00A Budget Narrative must accompany this Budget Form. The Budget Narrative must outline and clearly describe all items associated with each item listed in the Budget with the rationale and methodology used to establish the fees, cost allocations, and calculations associated with the program. The Budget and Budget Narrative should be outlined identically on a line-by-line basis.

3

Attachment 6DHS Financial Services Required Documentation

Billings submitted for reimbursement must be accompanied by adequate documentation as described below.

1. Salaries & fringe Complete Expense Breakdown for Salary and Fringe form Payroll Register (employee information) Activity report (if applicable) Time Sheets signed by employee 100% time certification Supervisory approval

2. Supplies, capital Equipment (<$5,000), Facility expense Invoice Proof of payment ( receipts) Sales Tax NOT reimbursed

3. Gift Card, Bus Passes, and client foods and Incentives Complete Items Provided To Clients form Client signature or confirmation of client receipt for anything given to

clients Receipts Sales Tax NOT reimbursed Copy of gift card back, proof of payment Serial numbers for bus passes and tickets, proof of payment

4. Administrative / Indirect Costs Administrative 10 percent or lower

o Documentation to substantiate submitted charges Administrative over 10 percent

o Documentation to substantiate submitted charges Indirect 10 percent or lower

o No documentation required Indirect over 10 percent

o Federally Approved Indirect Cost letter*Indirect Cost Rate depends on contract funding source. Non-federal funding sources will be negotiated during contract creation

5. Rental Assistance Lease or Rental Agreement

o First page showing all rental and deposit amountso Last Page showing signatures of all partieso Must show the size of the unit (1 bedroom, 2 bedroom etc.)o A Rent Reasonableness Test should be submitted with any new

lease locationso Rent Reasonableness Test required if rental amount increases

(even if there is no new lease agreement and rent is within FMR)

o If receiving eviction services, please send lease

TPP Calculation Sheet (Tenant Payment Portion)o Required with every new rentalo Required with all changes to rental amount or tenant portion

Proof of Paymentso Proof of Tenant Payment o Proof of payment to rental unit

Utilitieso If this is being reimburse an invoice and proof of payment

should be submitted with the invoice Other Charges

o If the contractor is invoicing for any other expenses, the invoice must be accompanied with a bill for these charges and proof of payment

6. Professional Services/Fee For service Detailed invoice from Service provider

o This must include the service providedo Client identifier if services were provided for a client

Proof of Payment or Attendanceo Canceled check or bank statement to prove paymento Sign in sheet, certificate of attendance, registration for proof of

attendance if needed7. Mileage/Travel Expense

Mileageo Must have mileage spreadsheet showing starting and ending

physical address for every tripo Purpose of trip

Non-Mileage Travel to include Parkingo Supporting documentation or proof of payment for all charges.

This could be an invoice, receipts, ACH forms, bank statements or credit card bill

o All documentation must be clear and identifiable amounts must match the requested reimbursement

8. Conference/Training (employee) Employee name and purpose Proof of Attendance (Certificate of Attendance, Agenda, Travel

documents) Itemized Receipts for Expenses

9. Training/Certification (client) Client name and purpose Proof of Attendance (Client registration, Certificate of Completion,

List of Attendees) Proof of Payment

** NOTE: All backup documentation must be legible. If multiple items have been purchased but a select few are reimbursable, please annotate applicable expenses on documentation

2

ITEMS PROVIDED TO CLIENT(S)

Report of items given to clients allowed by fund / program

Contractor Name*:

Contractor Address*:

Contract Number*

During the dates shown below, the following goods were received by the listed client(s)

Detailed Description of Item and Purpose*

Client Name/ID# (type or print)* Client Signature* Date* Qty* Total Value*

King Soopers gift card - emergency food for client

John Smith 5/5/2015 1

$ 25.00

Total Value: $ 25.00

By signing this report, I certify that I have firsthand knowledge that the client(s) listed above was given the items listed and that the client(s) is/are eligible to receive these items, in accordance with the rules and requirements of the program/fund associated

with this expense.

Employee Printed Name* Employee Signature* Date

***NOTE: You must attach legible supporting documentation to this sheet (copies of receipt, gift card, bus pass/ticket etc.). If Client ID # is mandatory, printed name/signature not applicable. Gift card and bus expenses will not be reimbursed prior to client issuance. If multiple items have been purchased please annotate which items on the amount being billed.

INSTRUCTIONS

1. All fields with an asterisk (*) must be completed and legible even if the value is zero (0)

2. The Contractor Name is the company name referenced on the contract with Denver

3. The Contractor Address is the company address referenced on the contract with Denver

4. If a client number is used in lieu of a name, the number must be a unique identifier associated to only one client

5. You must select the type of property given to client; "GIFT CARD", "BUS PASS/TICKET", or "OTHER"

6. Client signature required as proof of receipt of expense item(s).

7. Date is the month, day, and year that client physically received the item(s).

8. Qty is the quantity of items received, if more than one. If this field is left blank, Denver will assume that only one (1) item was received by the client.9. A worker must sign this form certifying distribution of items to client(s)

BACKUP DOCUMENTATION

1. All expenses given to client must be supported with legible proof of payment.

1a. This would be a copy of the receipt for items purchased

1b. All gift cards given out must include a legible copy of the gift card number

3

Attachment 9Certification Regarding Debarment, Suspension, and Other Responsibility Matters

Primary Covered Transactions

Instructions for Certification

1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below.

2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency’s determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction.

3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminated this transaction for cause or default.

4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason

of changed circumstances.5. The terms covered transaction, debarred, suspended , ineligible, lower

tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations.

CERTIFICATION (1) The prospective primary participant certifies to the best of knowledge and belief, that it and its principals:

(a)Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department;

(b)Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen

property;(c)Are not presently indicted for or otherwise criminally or civilly charged by a governmental

entity (Federally, State or local) with a commission of any of the offenses enumerated in paragraph (1) (b) or this certification; and

(d)Have not within a three-year period preceding this application proposal had one or more public transactions (Federal, State or local) terminated for cause or default.(2)Where the Prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

_________________________________________ _______________________________Signature Principal Officer Title

__________________________________________ ________________________________Name of Agency Date

__________________________________________ ________________________________Address City, State, Zip Code

Attachment 11COMPLIANCE WITH CONTRACT AND INSURANCE CERTIFICATION FORM

CITY AND COUNTY OF DENVER2017 Housing and Supportive Services Program

I, on behalf of the proposer identified below, hereby certifies that I have read a copy of the sample contract attached to the RFP and understand the terms and provisions contained in that contract. I further hereby certify that it is the proposer’s intent to comply with each and every term and provision contained in the sample contract and propose no modifications to the sample contract except as follows:

1)

2)

3)

I understand that the modification stated above, if any, are offered for discussion purposes only and that the City and County of Denver reserves the right to accept, reject or further negotiate any and all proposed modification to the sample contract. Check and Initial Here_________

I, on behalf of the applicant identified below, hereby certify that I have submitted and provided a Certificate of Insurance with this proposal that shows evidence of the insurance required as described in the Description of Required Insurance within this RFP and as stated in the Sample Certificate of Insurance (Attachment 7).

There will be NO modifications to insurance provisions except in regards to the waiver of Workers’ Compensation for sole proprietors and personal auto in place of business auto for those who use personal autos for business use):

Proposer Name:

Program Name (if applicable):

Authorized Signature: ________________________________________________________ Signature Date

Name (please print): Title: _________________