Form 4732, Nongovernmental Contractor Certification

Effective Date: 3/2010

Availability

Word: 4732.doc

PDF: 4732.pdf

Instructions

Updated: 3/2010

Purpose

The Department of Aging and Disability Services (DADS) has adopted rules pertaining to contracting with nongovernmental organizations in which former employees, board members or their relatives have ownership or control. This certification provides a means for collecting and distributing information required to determine compliance with the rules. Incorrect or incomplete information may cause an application to be denied, payment for delivered services to be withheld or a contract to be terminated. Governmental entities are not required to submit this certification.

CONTRACTOR’S INSTRUCTIONS FOR COMPLETING AND SUBMITTING FORM 4732

This certification must be prepared and submitted to the DADS area responsible for approving the contract application or contract before consummating a new contract, contract assignment or a contract renewal. It must be submitted early enough (usually 60 days before the contract's effective date) so that the contracting area can provide it to DADS Office of the General Counsel 45 days before the contract's effective day if a Yes is answered to any question in the certification.

For competitively procured goods and services, if the contract is a new procurement, rather than a renewal, the certification is submitted according to instructions in the request for proposal.

Detailed Instructions

Does the potential contractor...—

    1. Check Yes or No as applicable.
    2. Check Yes or No as applicable.
    3. Check Yes or No as applicable.
    4. Check Yes or No as applicable.

Certification — The certification at the bottom of Page 1 applies to all information provided on the certification form.

Name of Potential Nongovernmental Contractor — Enter the entity's full legal name, exactly as it was chartered, filed, registered or otherwise legally declared.

Tax Payer Identification Number – Enter the nine-digit federal employer identification number (EIN) assigned to the legal entity by the Internal Revenue Service. If the legal entity is an individual or sole proprietorship that does not have to obtain an EIN, enter the individual’s Social Security number.

National Provider Identifier (NPI) – If applicable, enter the 10-digit NPI number issued to the legal entity by the National Plan and Provider Enumeration System.

Contract No. — If the certification is prepared as part of a procurement package or application package to obtain a new contract with DADS, leave this space blank. If the certification is prepared for an assignment or renewal of an existing contract, enter the DADS contract number.

Signature of Authorized Representative/Date — The owner or authorized representative of the legal entity must sign this certification. If an authorized representative provides this certification, that person must be named on a current Form 2031, Governing Authority Resolution. The person who signs the contract must also sign the certification.

Print or Type Name — Print or type the name of the signatory.

Submittal of Certification – For open enrollment client services contracts, submit the certification to the DADS area responsible for approving the contract application or assignment. The certification is submitted as part of the application package to become a DADS service provider.

For competitive procurements, submit the form to the procurement officer (for new contracts) or contract manager (for contract renewals). The certification is submitted as part of the offerer’s procurement package or as indicated in the instructions to the procurement package. In cases of contract renewals, the certification is submitted to the contract manager approximately 60 days before the effective date of any proposed renewal.

INSTRUCTIONS FOR DADS STAFF

Obtain a completed and signed Form 4732 for:

  • a new contract;
  • an assignment of contract (from the contractor being assigned the contract); and
  • a contract renewal.

For open enrollment client services contracts, retain Form 4732 in accordance with record retention requirements in DADS Contract Administration Handbook.

For competitive procurements, retain Form 4732 in accordance with DADS Records Retention Schedule. Unsuccessful offerers' certification documents must be kept a minimum of six months after the effective date of the contract or until the resolution of any appeal or litigation resulting from the procurement, whichever is longer.

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