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Request for Application (RFA) AppendicesKentucky Governor’s Office of Early Childhood

Appendix A - Checklist for the 2019-2020 Community Early Childhood Council (CECC) Request for Application (RFA)

Applicants shall submit all the following components for the CECC funding opportunity. Applications missing any component will not be considered and the applicant will be asked to resubmit.

Contact information for the Fiscal Agent using the Fiscal Agent Contact Information Form. The Form can be accessed using the following link: https://kidsnow.ky.gov/communities/cecc/Pages/cecc-resources.aspx.

Application Cover Page with Notary Seal Project Summary Summary of Previous Activities (Not applicable for new CECCs.) Community Needs Narrative Strategic Plan Narrative Work Plan Communication Plan Budget Narrative and Budget Preliminary Members List is due with submission of the application. The Preliminary Members List shall include

a list of all partner agencies on the CECC. At least one representative from each of the following entities must be included on the CECC: o Local agency or organization from profit, nonprofit or family child care;o Head Start or Early Head Start;o Each school district in the CECC’s designated service area.The Final Members List is due to the GOEC May 1, 2019, in Word document format via email to [email protected].

Letters of Commitment from three required community partners Conflict of Interest Form for each Council member Commitment to Reporting Original copy mailed to the GOEC as well as an electronic copy submitted to the GOEC via email to

[email protected] W-9 (if required) Affidavit (if required)

CECC Funding ApplicationApplication Deadline: March 8, 2019

Applications postmarked or hand delivered after this date will not be considered.

CECCs shall submit the completed application and documentation in both hard copy and electronic forms. Applications must be submitted to GOEC via email to [email protected] no later than March 8, 2019. Please keep each email with application documents under 8MB to assist the GOEC with receiving documents. All documents must be in PDF format; no images are allowed. Multiple emails can be sent with application documents, if needed. With each email, please identify the name of your CECC in the email’s Subject line.

Mailed copies must be received no later than March 8, 2019. CECCs shall mail the original application and documentation to: Kentucky Governor’s Office of Early Childhood, c/o Holly LaFavers, 125 Holmes Street, Third Floor, Frankfort, KY 40601.

mailto:[email protected]


https://kidsnow.ky.gov/communities/cecc/Pages/cecc-resources.aspx


Appendix B – Cover Page

Council Name: ______________________________________ Total Pages: _______________

Counties Served: ____________________________________ Total Membership: _________

Chair Information

Chair Name: _________________________________________________________________________

Address: ____________________________________________________________________________

Phone Number: ______________________________________________________________________

Email: ______________________________________________________________________________

Fiscal Agent

Fiscal Agent Name: ___________________________________________________________________

Organization: __________________________________ Org Type _____________________________

Tax ID (Federal): ___________________________ Tax ID (State): ______________________________

Address: ____________________________________________________________________________

Phone: _____________________________________________________________________________

Email: ______________________________________________________________________________

Is your Council a 501c3 Yes________ No________

The undersigned agree to ensure the funds awarded by this grant will be used to complete the plans outlined in this application and achieve School Readiness for children in the service area.

___________________________________________ Date: ___________________Community Early Childhood Council Chair

___________________________________________ Date: ___________________Community Early Childhood Council Fiscal Agent

Notary Public __________________________________________

My commission expires on: _____________________ Notary SealAppendix C – Conflict of Interest Statement


I, the undersigned, acknowledge and confirm that in carrying out my duties as a director, officer or member of The Governor’s Office of Early Childhood Community Early Childhood Council (CECC), a non-profit organization, I am charged with a duty of loyalty and fiduciary accountability to the CECC. To this end, I acknowledge my responsibilities to act in the course of my duties solely in the best interest of the CECC, without consideration of the interests of any other person or organization and to refrain from taking part in any transaction where I do not believe in good faith that I can with undivided loyalty to the CECC.

I shall disclose to the Council any potential conflict of interest I may have from time to time, including the identification of any material, financial or other beneficial interest held by me or by my immediate family in organizations engaged in the same business or services as the CECC or engaged in the delivery of products or services to the CECC. I shall also disclose any transaction with the CECC which would result in any benefit to me, my immediate family, or any organization in which I have a material financial or other beneficial interest or involvement, and I shall refrain from participation in any action on such matters, except to the extent permitted by the Conflict of Interest Policy.

I shall not disclose or exploit for any personal advantage, or for the advantage of any other organization in which I have an interest or involvement, any confidential information acquired by me regarding CECC business activities or plans. Further, I will abstain from CECC votes impacting organizations in which I have interest or involvement.

Pursuant to the above, I hereby report that I have an interest or involvement as an owner, partner, director, trustee, officer, employee, or agent of, or that I or my spouse, parents, children, or spouses of children, brothers or sister, or spouses of brothers or sister or any combination of them, have a material financial interest (greater than 5% ownership) or any other beneficial interest in:

1. The following organizations engaged in the same or substantially similar businesses or services as the Community Early Childhood Council.

a. Name:

Interest or Involvement

b. Name:


2. The following organizations engaged in the delivery of products or services to the corporation:

c. Name:


d. Name:


I assume the duty of notifying the Community Early Childhood Council, in writing, of any changes in or additions to the information disclosed in this Disclosure Statement.

Signature:

Printed Name: ______________________________________ Date:


Appendix D – Commitment to Reporting

I, the undersigned, acknowledge and confirm that in carrying out my duties as a director, officer or member of The Governor’s Office of Early Childhood Community Early Childhood Council (CECC), a non-profit organization, I am charged with submitting quarterly, mid-year, and year-end reports to the Kentucky Governor’s Office of Early Childhood. To this end, I acknowledge my responsibilities to act in the course of my duties and submit the required reports in the format and the timeframe outlined by the Office of Early Childhood.

Signature:

Printed Name: ______________________________________ Date:


Appendix E – Evaluation of ApplicationIndependent and trained reviewers with content expertise will review and score applications. Reviewers may include Child Care Resource and Referral staff, early childhood specialists, higher education faculty, and other qualified individuals. Reviewers will score and provide comments to the Early Childhood Advisory Council, which will be used to determine award recipients. Applications will be evaluated according to the extent that they meet the following criteria.

Disqualification FactorsThe following checklist documents those items that must be included in the application in order for the evaluation of the application to proceed. If any item in the checklist is not included, the application will be disqualified.

DISQUALIFICATION FACTORS CHECK LISTApplicants must include and/or meet ALL of the following to be considered; if any boxes are not checked, the application is disqualified from evaluation Typed, signed and notarized Cover Page Preliminary Members List with a list of all partnering agencies (that participate in

CECC meetings/activities). At least one representative from each of the following entities must be included on the CECC: Local agency or organization from profit, nonprofit or family child care, Head Start or Early Head Start and each school district in the CECC’s designated service area.

Letters of Commitment from the following required participating groups: child care, all Head Start(s) and/or Early Head Start(s) grantees in the service area, and all local school district(s) within the service area. School districts must have a Letter of Commitment signed by the Superintendent or School Board Chair.

Application stays within page limit Multiple applications were not submitted for overlapping regions Signed reporting commitment form (Appendix D) Budget request does not exceed maximum award amount for each county included in

the CECC Budget request does not include any prohibited expenditures Project Summary, Summary of Previous Activities, & Communication Plan submitted

Application Scoring Rubric

Criteria Maximum Points

Points Awarded

Community Needs NarrativeApplicants shall clearly (for each county if a multi-county council): Describe existing resources for children and families within the community; incorporating data

on availability and quality of services and documenting service area needs, gaps, and strengths. Describe how the CECC will achieve the School Readiness Goals based on community challenges

and strengths Document how the CECC plans to maintain existing and promote new community partnerships.

10

10

1030

Strategic Plan NarrativeApplicant shall clearly (for each county if a multi-county council): Utilize the Early Childhood Profiles to identify community needs, goals, strategies, and

achievable outcomes based on data review and analysis Explain how proposed outcome(s) are measureable and will increase school readiness rates Describe how proposed activity(ies) will lead to successful outcomes Demonstrate clear collaboration between CECC and community partners

10

10

10


Criteria Maximum Points

Points Awarded

Create a detailed Work Plan using the Work Plan Template with all required information provided to ensure proposed activities are successful

101050

Budget Narrative and WorksheetApplicants must: Provide templates with categories on GOEC website (Appendix F) Support implementation of the plan via documentation of reasonable fiscal resources and costs

of proposed activities Leverage community resources, either through monetary or in-kind contributions, to further

outcomes Document local or private funding commitments and in-kind match commitments of a

minimum of 10% of total grant award

55

5

5

20TOTAL POINTS 100

Bonus Points

Bonus Components Bonus Points Points Awarded Application includes new merger of two or more CECCs or a new

configuration of counties resulting in a larger CECC Applicant submitted 2018-19 quarterly and mid-year reports in a

timely manner

5

5

Total Bonus Points 10

TOTAL APPLICATION POINTS (out of a possible 110): ___________


Appendix F – RFA Budget Template

Please complete the CECC grant budget using the Budget Template below. Please refer to Appendix I for a list of Maximum Award Amounts by County.

Expense AmountTravel Click here to enter text.

Supplies, Materials, Equipment- Estimated number and cost of items Click here to enter text.

Administrative-Limited to 5% of requested amount. Click here to enter text.

Other Click here to enter text.

Total 0

In Kind Contributions Minimum 10% of grant total Click here to enter text.

Total Requested Amount $ Click here to enter text.


Appendix G - RFA Work Plan Template

Please complete each category in the Work Plan Template on the following page. Each of the School Readiness Goals shall be chosen using the dropdown box in the Goals column below. A School Readiness Strategy(ies), Identified Need, Performance Indicator, Activities, Person/Partner Responsible, Timeline and Outcomes shall be included for each School Readiness Goal. One or more School Readiness Strategies can be chosen for each School Readiness Goal using the dropdown box provided.

NOTE:

The Completion Date column on the Work Plan Template is for the use of CECCs during the grant cycle. It shall not be completed with the submission of the RFA.

School Readiness Goals

CECCs are asked to focus on the following School Readiness Goals:

1. Increasing awareness and participation in Kentucky ALL STARS;2. Increasing family engagement and support opportunities;3. Increasing awareness of school readiness;4. Increasing the number of children, particularly those at risk, participating in high quality early care and education programs.

School Readiness Strategies

To achieve the listed School Readiness Goals, four main strategies have been identified which are the focus of system efforts:

1. Improving the quality of all early care and education programs;2. Engaging families as their child’s first and most important teachers;3. Engaging the community to promote school readiness;4. Enhancing the ability to measure the impact of the work by improved data collection and integration.


Please complete the Work Plan using the Work Plan Template below.

Work Plan Template

School Readiness

Goal

Identified Need

School Readiness Strategy

Performance Indicators Activities Person/Partner

Responsible Timeline Completion Date

Measureable Outcomes

Example: Increasing awareness and participation in Kentucky ALL STARS

Example: Early Childhood Profile indicates only 2 of 10 child care programs participate in ALL STARS

Example: Improving the quality of all early care and education programs

Example: Increase number of child care programs participating in ALL STARS

Example: Outreach to non-participating child care centers; Developing of mentoring relationships

Example: John and Sue

Example: Aug. 2019-Dec. 2019

Example: December 19, 2019

Example: Participation in ALL STARS will increase from two child care programs in the service area to five child care programs in the service area.

Choose a School Readiness Goal.

Choose a School Readiness Strategy.






Choose a School Readiness Strategy. Choose a School Readiness Strategy. Choose a School Readiness Strategy. Choose a School Readiness


Strategy.







Choose a School Readiness Strategy. Choose a School Readiness


Strategy. Choose a School Readiness Strategy. Choose a School Readiness Strategy.


Appendix H - RFA Preliminary Members List

The Preliminary Members List is due with the submission of the application.

Per KRS 200.707, “A council shall be composed of no fewer than seven (7) and no more than twenty-seven (27) members. Each council shall be composed of at least one (1) member representing local agencies or organizations from profit, nonprofit or family child care, Head Start or Early Head Start and each school district in its designated service area. Other members may be appointed who represent local agencies and organizations, including, but not limited to, the organizations or agencies listed: Early childhood advocate; Faith community; Family resource center; Military establishment; Child-care resource and referral agency or child-care subsidy agent; Child-care consumer or parent; County cooperative extension service; Department for public health; University, college, or technical school; United Way; Kentucky Early Intervention System; Agency administering services to children with disabilities; Home visitation agency; Family literacy agency; Civic organization; Public library; Regional training center; Community action agency; Government; Business community; Home schooling association; Health care professional; Foster care parent; or Adoptive parent.”

In accordance with KRS 200.707(2), “Members shall serve on a community early childhood council on a voluntary basis and receive no compensation or expense reimbursement for their service.”

Using the table below, please provide the type of partnering agency as well as the name of the specific agency, organization or school district represented by each CECC member.

Type of Partnering Agency Name of Specific Agency, Organization or School District

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Appendix I - Final Members List

*The Final Members List is due May 1, 2019. To give CECCs additional time to complete the Final Members List, the Final Members List shall not be submitted with the CECC grant application. The Final Members List shall be submitted to the GOEC via email to [email protected] no later than May 1, 2019.

Per KRS 200.707, “A council shall be composed of no fewer than seven (7) and no more than twenty-seven (27) members. Each council shall be composed of at least one (1) member representing local agencies or organizations from profit, nonprofit or family child care, Head Start or Early Head Start and each school district in its designated service area. Other members may be appointed who represent local agencies and organizations, including, but not limited to, the organizations or agencies listed: Early childhood advocate; Faith community; Family resource center; Military establishment; Child-care resource and referral agency or child-care subsidy agent; Child-care consumer or parent; County cooperative extension service; Department for public health; University, college, or technical school; United Way; Kentucky Early Intervention System; Agency administering services to children with disabilities; Home visitation agency; Family literacy agency; Civic organization; Public library; Regional training center; Community action agency; Government; Business community; Home schooling association; Health care professional; Foster care parent; or Adoptive parent.”

In accordance with KRS 200.707(2), “Members shall serve on a community early childhood council on a voluntary basis and receive no compensation or expense reimbursement for their service.”

The Final Members List shall also include the following additional information: the county or counties each member represents and the date of appointment for each CECC member as well as their length of term.

Please submit the Final Members List using the template below. The Final Members List is due to the GOEC via email to [email protected] no later than May 1, 2019.




Final Members List Template

First Name Last Name

Place of Employment Agency

Is this member a required

representative from Child Care, Head Start/Early

Head Start or School

District?

Phone Email Member Role

County/Counties Represented


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(502) 555-5555

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Appendix J - Maximum Grant Award Amount by CountyFor reference, each county is listed with their Education and Work Force Development Area.

Amounts subject to change according to availability of funds.

A new funding formula has been adopted based on child population and poverty with a cap of $50,000 per county. The formula is: 35% based on under age 5 population, 45% based on under age 5 population living in poverty, and 20% split equally across counties (Data from 2016 was utilized for these calculations).* Maximum grant award amounts are listed below by county for 2019-20.

To determine a maximum CECC grant award, maximum award amounts for each county within the CECC should be totaled.

CountyUnder Age 5 Population

2016Under Age 5 in Poverty

2019-20 Maximum Award Amount

Adair County 1020 303 $ 6,500.00Allen County 1296 427 $ 8,100.00Anderson County 1311 239 $ 6,500.00Ballard County 407 110 $ 3,700.00Barren County 2889 900 $ 15,300.00Bath County 860 312 $ 6,300.00Bell County 1648 922 $ 13,100.00Boone County 8784 1315 $ 30,200.00Bourbon County 1212 290 $ 6,800.00Boyd County 2946 909 $ 15,500.00Boyle County 1640 354 $ 8,200.00Bracken County 546 98 $ 3,800.00Breathitt County 821 369 $ 6,700.00Breckinridge County 1142 258 $ 6,400.00Bullitt County 4189 707 $ 16,100.00Butler County 762 329 $ 6,300.00Caldwell County 750 142 $ 4,600.00Calloway County 1962 696 $ 11,700.00Campbell County 5454 1239 $ 23,200.00Carlisle County 327 102 $ 3,400.00Carroll County 806 451 $ 7,400.00Carter County 1732 523 $ 9,800.00Casey County 1017 313 $ 6,600.00Christian County 6930 1624 $ 29,400.00Clark County 2113 379 $ 9,300.00Clay County 1303 706 $ 10,600.00Clinton County 617 222 $ 5,000.00Crittenden County 563 134 $ 4,200.00Cumberland County 411 75 $ 3,400.00Daviess County 6762 1863 $ 31,100.00Edmonson County 569 161 $ 4,400.00Elliott County 352 120 $ 3,600.00Estill County 801 448 $ 7,400.00


Fayette County 19899 5393 $ 50,000.00Fleming County 962 464 $ 7,800.00Floyd County 2279 1214 $ 16,900.00Franklin County 2893 998 $ 16,200.00Fulton County 374 217 $ 4,500.00Gallatin County 512 126 $ 4,000.00Garrard County 954 298 $ 6,400.00Grant County 1839 275 $ 7,900.00Graves County 2457 609 $ 12,000.00Grayson County 1695 602 $ 10,400.00Green County 573 164 $ 4,500.00Greenup County 1954 465 $ 9,700.00Hancock County 606 129 $ 4,200.00Hardin County 7200 1977 $ 32,900.00Harlan County 1773 803 $ 12,300.00Harrison County 1087 254 $ 6,200.00Hart County 1250 434 $ 8,100.00Henderson County 2827 1198 $ 17,800.00Henry County 879 226 $ 5,600.00Hickman County 228 63 $ 2,900.00Hopkins County 2791 783 $ 14,100.00Jackson County 800 280 $ 5,900.00Jefferson County 48616 12463 $ 50,000.00Jessamine County 3517 905 $ 16,500.00Johnson County 1409 462 $ 8,600.00Kenton County 11096 2758 $ 47,200.00Knott County 898 426 $ 7,400.00Knox County 2054 1090 $ 15,300.00Larue County 779 144 $ 4,700.00Laurel County 3652 1181 $ 19,200.00Lawrence County 1066 413 $ 7,600.00Lee County 360 220 $ 4,500.00Leslie County 639 207 $ 5,000.00Letcher County 1389 717 $ 10,800.00Lewis County 757 271 $ 5,700.00Lincoln County 1507 592 $ 10,000.00Livingston County 517 87 $ 3,700.00Logan County 1688 273 $ 7,500.00Lyon County 258 75 $ 3,100.00Madison County 5109 1347 $ 23,400.00Magoffin County 761 328 $ 6,200.00Marion County 1252 286 $ 6,800.00Marshall County 1695 305 $ 7,800.00


Martin County 591 203 $ 4,800.00Mason County 1040 462 $ 7,900.00McCracken County 3853 1135 $ 19,200.00McCreary County 1043 644 $ 9,500.00McLean County 557 126 $ 4,100.00Meade County 1419 405 $ 8,200.00Menifee County 338 115 $ 3,600.00Mercer County 1258 381 $ 7,700.00Metcalfe County 631 213 $ 5,000.00Monroe County 667 300 $ 5,800.00Montgomery County 1845 578 $ 10,500.00Morgan County 672 286 $ 5,700.00Muhlenberg County 1658 327 $ 8,000.00Nelson County 2937 759 $ 14,200.00Nicholas County 435 217 $ 4,700.00Ohio County 1406 572 $ 9,600.00Oldham County 3314 155 $ 9,600.00Owen County 537 88 $ 3,700.00Owsley County 267 152 $ 3,800.00Pendleton County 868 173 $ 5,100.00Perry County 1827 544 $ 10,200.00Pike County 3323 1423 $ 20,700.00Powell County 821 171 $ 5,000.00Pulaski County 3649 1435 $ 21,400.00Robertson County 115 53 $ 2,600.00Rockcastle County 917 344 $ 6,700.00Rowan County 1325 565 $ 9,400.00Russell County 1103 520 $ 8,600.00Scott County 3483 558 $ 13,500.00Shelby County 3088 595 $ 13,000.00Simpson County 1137 463 $ 8,100.00Spencer County 1045 94 $ 4,800.00Taylor County 1593 617 $ 10,300.00Todd County 857 221 $ 5,500.00Trigg County 741 206 $ 5,100.00Trimble County 487 118 $ 3,900.00Union County 803 46 $ 3,900.00Warren County 8033 593 $ 22,500.00Washington County 751 191 $ 5,000.00Wayne County 1133 468 $ 8,200.00Webster County 848 259 $ 5,800.00Whitley County 2692 989 $ 15,700.00Wolfe County 413 267 $ 5,000.00


Woodford County 1478 261 $ 7,000.00

Source: U.S. Census. (2017). Annual estimates of resident population by selected age groups 2010-2016. * Calculations were run based on the formula with all counties. Two counties exceeded the $50,000 cap, and once identified, the formula was run again with these two counties removed to distribute the remaining funds per the formula.

Appendix K - W-9 (Due after award of contract)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

orNote. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Under penalties of perjury, I certify that:1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Prin

t or t

ype

See

Spe

cific

Inst

ruct

ions

on

page

2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate single-member LLCLimited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

6 City, state, and ZIP code

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Social security number

– –

Employer identification number

–

Part II Certification


3. I am a U.S. citizen or other U.S. person (defined below); and4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Date ▶

Signature ofU.S. person ▶

Sign Here


Appendix L - Affidavit (Due after award of contract)Affidavit Effective Date: _______________

Affidavit Expiration Date:_______________ Maximum Length One-Year

REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS PAGE 1 OF 2FOR BIDS AND CONTRACTS IN GENERAL: I. Each bidder or offeror swears and affirms under penalty of perjury, that:

a. In accordance with KRS 45A.110 and KRS 45A.115, neither the bidder or offeror as defined in KRS 45A.070(6), nor the entity which he/she represents, has knowingly violated any provisions of the campaign finance laws of the Commonwealth of Kentucky; and the award of a contract to the bidder or offeror or the entity which he/she represents will not violate any provisions of the campaign finance laws of the Commonwealth.

b. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and all subcontractors therein, are aware of the requirements and penalties outlined in KRS 45A.485; have properly disclosed all information required by this statute; and will continue to comply with such requirements for the duration of any contract awarded.

c. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and its affiliates, are duly registered with the Kentucky Department of Revenue to collect and remit the sales and use tax imposed by KRS Chapter 139, and will remain registered for the duration of any contract awarded.

d. The bidder or offeror swears and affirms under penalty of perjury that the entity bidding is not delinquent on any state taxes or fees owed to the Commonwealth of Kentucky and will remain in good standing for the duration of any contract awarded.

FOR “NON-BID” CONTRACTS (I.E. SOLE-SOURCE; NOT-PRACTICAL OR FEASIBLE TO BID; OR EMERGENCY CONTRACTS, ETC):

II. Each contractor further swears and affirms under penalty of perjury, that:

a. In accordance with KRS 121.056, and if this is a non-bid contract, neither the contractor, nor any member of his/her immediate family having an interest of 10% or more in any business entity involved in the performance of any contract awarded, have contributed more than the amount specified in KRS 121.150 to the campaign of the gubernatorial slate elected in the election last preceding the date of contract award. b. In accordance with KRS 121.330(1) and (2), and if this is a non-bid contract, neither the contractor, nor officers or employees of the contractor or any entity affiliated with the contractor, nor the spouses of officers or employees of the contractor or any entity affiliated with the contractor, have knowingly contributed more than $5,000 in aggregate to the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract award.


REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS

a. In accordance with KRS 121.330(3) and (4), and if this is a non-bid contract, to the best of his/her knowledge, neither the contractor, nor any member of his/her immediate family, his/her employer, or his/her employees, or any entity affiliated with any of these entities or individuals, have directly solicited contributions in excess of $30,000 in the aggregate for the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract.

As a duly authorized representative for the bidder, offeror, or contractor, I have fully informed myself regarding the accuracy of all statements made in this affidavit, and acknowledge that the Commonwealth is reasonably relying upon these statements, in making a decision for contract award and any failure to accurately disclose such information may result in contract termination, repayment of funds and other available remedies under law. If the bidder, offeror, or contractor becomes non-compliant with any statements during the affidavit effective period, I will notify the Finance and Administration Cabinet, Office of Procurement Services immediately. I understand that the Commonwealth retains the right to request an updated affidavit at any time.

Signature Printed Name

Title Date

Company Name

Address

Subscribed and sworn to before me by(Affiant) (Title)

of this _____day of ____________,20___.(Company Name)

Notary Public

[seal of notary] My commission expires:


Appendix M – Invoice Template

Name, Address and Contact Information of Fiscal Agent:

CECC Name:Contract #: Contract Start Date:Total Amount Request:

Remit Payment:Contact Name

Fiscal agent address

_______________________________ ______________________________Fiscal Agent Signature Governor’s Office of Early Childhood

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