DEPARTMENT OF HUMAN SERVICES

Transcription

1 DEPARTMENT OF HUMAN SERVICES LISA-MICHELE CHURCH Executive Director State of Utah GARY R. HERBERT Governor GREG BELL Lieutenant Governor OFFICE OF FISCAL OPERATIONS JENNIFER C. EVANS Director BUREAU OF CONTRACT MANAGEMENT STEPHANIE M. CASTRO Director ADDENDUM #1 RFP#: DHS90538 Agency: Division of Child and Family Services and Division of Juvenile Justice Services DESCRIPTION: Residential Treatment Services 1. PART III GENERAL INFORMATION, D. ELIGIBILITY: Add the following: Offerors submitting proposals for facilities located outside of the State of Utah will only be eligible to submit proposals for non-guaranteed beds. 2. PART IV SCOPE OF WORK, SECTION I RESIDENTIAL TREATMENT PROGRAMS, D. REQUIREMENTS SPECIFIC TO DIVISION PLACEMENT MODELS, 3. CHILD AND FAMILY SERVICES PLACEMENT MODEL, Table 2: Replace with the attached table: The updated table reflects a change in the low intensity DPB to allow two to three youth. 3. PART IV SCOPE OF WORK, SECTION I. RESIDENTIAL TREATMENT SERVICES, F. FACILITY ELIGIBILITY FOR MEDICAID, 3. k.(2) iii. Replace with the following: Clients from each of the Contractor's facilities attend an educational program operated by the Contractor and the educational program operates as a school for the broader community, children from outside of the Contractor's residential facilities also attend. The teacher may be employed by either the Contractor or the school district. 4. PART IV SCOPE OF WORK, SECTION VII. SERVICE REQUIREMENTS FOR OUTPATIENT MENTAL HEALTH SERVICES. Correct this section number to Section VI. Page 1 of North 1950 West, Salt Lake City, Utah telephone (801) facsimile (801)

2 5. PART IV SCOPE OF WORK, SECTION VIII. REQUIREMENTS FOR WRAP SERVICES (Non-Mental Health/Non-Medicaid). Correct this section number to Section VII. 6. PART IV SCOPE OF WORK, SECTION VIII. Insert a new section, Section VIII. RATE TABLES and add the following to Table 3: Rates Pertaining to DHS/DCFS and DHS/DJJS Care and Supervision Program Enhancement The daily rate includes this allocation for program activities that enhance the effectiveness of residential treatment. Applies to all residential treatment program service codes: DSF/YSF, DSF-Y/YSF-Y, DSE/YSE, DSD/YSD, DMF/YMF, DME/YME, DMD/YMD, DDE/YDE, DDD/YDD, DBF/YBF, DBE/YBE, and DBD/YBD Service Code Unit of Service Rate NA Day $ PART VI PROPOSAL REQUIREMENTS COMPANY QUALIFICATIONS, B. Add the following clarification: A printout from the State of Utah Department of Commerce, Business Entity Search website showing the status as active is sufficient documentation. 8. PART VI PROPOSAL REQUIREMENTS COMPANY QUALIFICATIONS, G. Add the following clarification: A printout from the State of Utah Division of Occupation and Professional Licensing s Verify a License website showing the detailed license information including the license number, license type, name of licensed individual, original issue date and expiration date, etc. is sufficient documentation. 9. PART VIII PROPOSAL REQUIREMENTS FACILITY QUALIFICATIONS (ALTERNATE POPULATION): Correct the reference to PART VII in the first paragraph with PART VIII. 10. PART VIII PROPOSAL REQUIREMENTS FACILITY QUALIFICATIONS (ALTERNATE POPULATION), B.: Correct the reference to PART VI in the first paragraph with PART VII. 11. PART IX COST PROPOSAL REQUIREMENTS B. Guaranteed and Non-Guaranteed Beds, 1., b.: Add the following statement: Residential treatment facilities located outside the State of Utah will not be considered for an award of guaranteed beds. However, out-of-state residential treatment facilities will be considered for an award of non-guaranteed beds. Page 2 of 14

3 12. PART XI ATTACHMENTS TO THE RFP: Replace the following with the attached corrected attachments. ATTACHMENT E: Facility Information Coversheet: Corrected to add populations. ATTACHMENT G-1: FORM 1: RESIDENTIAL FACILITY BID FOR GUARANTEED BEDS: #7 corrected to add missing populations. ATTACHMENT G-2: FORM 2: RESIDENTIAL FACILITY BID FOR NON- GUARANTEED BEDS ONLY: #6 corrected to add missing populations. #11 corrected title to read TOTAL BID NON-GUARANTEED BED REQUEST **********End of Addendum********** To acknowledge receipt of addendum, include a copy of this addendum with your Response or give written acknowledgement with your Response. It shall be the responsibility of the Offeror to appropriately disseminate this information to all concerned prior to assigned due date and time. Offeror Printed Name and Title Signature Date Page 3 of 14

4 TABLE 2 (This Contract only serves high and moderate need Clients. Gray areas below are informational only.) TREATMENT FOCUS Assessment Process Male Sex Offenders Female Sex Offenders Male or Female Mental Health Male or Female Substance Dependent Male or Female Behavioral High DSF/ DSF-Y NOJOS Level 6 DMF DBF I N T E N S I T Y Moderate With Awake Night Staff Moderate Certified Small Group Home No Awake Night Staff Low 1:4 DSE NOJOS 4 or 5 1:6 DSD NOJOS 4 or 5 1:6 DIB One youth DPB Two to three youth DSF NOJOS 4, 5, 6 1:4 DIB One youth DPB Two to three youth 1:4 DME 1:6 DMD 1:6 DIB One youth DPB Two to three youth DDE 1:6 DDD 1:6 DIB One youth DPB Two to three youth 1:4 DBE 1:6 DBD 1:6 DIB One youth DPB Two to three youth NOJOS Levels 1, 2, or 3 NOJOS Levels 1, 2, or 3 DAC Transition to Adult Living (Not category specific) PC2 Level II Contracted Foster Care (For sibling of Client in DPB placement) PC1 Level I Contracted Foster Care (For sibling of Client in DPB placement) BAB Supplemental Payment for Baby of Youth in Custody (For baby of Client in DPB placement) Permanency (Reunification, Adoption, Guardianship, Other Successful Lifelong Connections) Successful Termination Page 4 of 14

5 ATTACHMENT E FACILITY INFORMATION COVER SHEET (This form must be completed in its entirety for each facility) PART I PROPOSAL TYPE 1. Select ONLY ONE: Primary Proposal (The Offeror s first choice for population to be served) Alternate Proposal (Optional: The Offeror s second choice for population to be served) PART II OFFEROR AND FACILITY INFORMATION 2. Offeror: (Corp. Name/Address) 3. Facility: (Name/Address) 4. Date Facility is Available for DHS Clients July 1, Total Number of Licensed Beds in the facility PART III POPULATION TO BE SERVED 6. Client category and risk/need level to be served at the facility. (Select ONLY ONE) High Sex Offender Male Age 16+ High Sex Offender Male Age High/Moderate Sex Offender (Female) (combined level) Moderate Sex Offender Male Moderate Sex Offender Male Certified Model High Mental Health Moderate Mental Health Moderate Mental Health Certified Model High/Moderate Substance Dependent (combined level) Moderate Substance Dependent Certified Model High Behavioral Moderate Behavioral Moderate Behavioral Certified Model DSF/YSF DSF-Y/YSF-Y DSE/YSE DSE/YSE DSD/YSD DMF/YMF DME/YME DMD/YMD DDE/YDE DDD/YDD DBF/YBF DBE/YBE DBD/YBD 7. Client age range to be served at the Facility (Specify Range) Age to Page 5 of 14

6 Attachment E Continued Instructions for Facility Information Cover Sheet Part I. Line 1. Check the appropriate box to specify if cover sheet is for a Primary Proposal or Alternate Proposal for the facility. If the Offeror is submitting both a Primary Proposal and Alternate Proposal for a facility, a separate cover sheet must be completed for each proposal. Part II. Line 2. Enter Offeror corporate name and complete address. Part II. Line 3. Enter Facility Name and complete address. If Offeror is submitting proposals for more than one facility, ensure that Facility Names and addresses are distinct by facility so evaluators can correctly identify Primary and Alternate Proposals that pertain to specific facilities. Part II. Line 4. Facility must be available for service to DHS Clients by no later than July 1, 2010 to be considered for a Contract under this RFP. Part II. Line 5. Enter the total number of beds the facility is licensed for. This number cannot be greater than 16. If the facility is licensed for more than 16 beds, no bid shall be submitted. Part III. Line 6. Check the appropriate box to specify the population to be served at the facility according to Client Treatment Category and Need/Risk Level. Do not select more than one category per form. Part III. Line 7. Specify the age range for Clients to be served in the facility. Enter the youngest age to the oldest age. Page 6 of 14

7 ATTACHMENT G-1 FORM 1: RESIDENTIAL FACILITY BID FOR GUARANTEED BEDS (Facilities located outside of the State of Utah may not bid on guaranteed beds) (This form must be completed in its entirety for each bid for guaranteed beds submitted. Any deviation from this format may result in disqualification of proposal.) PART I BID STATUS 1. Select ONLY ONE: Primary Bid (The Offeror s first choice for population to be served) Alternate Bid (The Offeror has the option to submit one alternate bid per facility to serve a population other than the population specified in the Primary Bid. The Alternate Bid for guaranteed beds will be used if the Offeror is not awarded guaranteed beds for the population specified in the Primary Bid.) PART II OFFEROR AND FACILITY INFORMATION 2. Offeror: (Corp. Name/Address) 3. Facility: (Name/Address) 4. Total Number of Licensed Beds in the Facility 5. Number of DHS Guaranteed Beds Requested* *The number of DHS Guaranteed Beds requested cannot be higher than the facility total number of licensed beds minus one. If a Contract for Guaranteed Beds is awarded, DHS will pay for placement of Clients in any of the facility s non-guaranteed beds at the same rate as the guaranteed beds. PART III FACILITY COST INFORMATION 6. Facility Estimated Total Annual Cost Include only those costs associated with providing care and supervision, including Client personal needs and program enrichment costs. DO NOT include costs associated with providing mental health services, wrap services, or education. Labor Facility Other Direct Costs Administrative Costs Total Costs Total PART IV POPULATION TO BE SERVED 7. Client category and risk/need level to be served at the Facility. (Select ONLY ONE) High Sex Offender Male Age 16+ DSF/YSF High Sex Offender Male Age DSF-Y/YSF-Y High/Moderate Sex Offender (Female) (combined level) DSE/YSE Moderate Sex Offender Male DSE/YSE Moderate Sex Offender Male Certified Model DSD/YSD High Mental Health DMF/YMF Moderate Mental Health DME/YME Moderate Mental Health Certified Model DMD/YMD High/Moderate Substance Dependent (combined level) DDE/YDE Moderate Substance Dependent Certified Model DDD/YDD High Behavioral DBF/YBF Moderate Behavioral DBE/YBE Moderate Behavioral Certified Model DBD/YBD 8. Client age range to be served at the Facility (Specify Range) Age to Page 7 of 14

8 9. Facility Name/Address: Continuation of Form 1/ Guaranteed Beds Primary Bid Alternate Bid PART V OPTIONS FOR FACILITY The Offeror agrees to allow DHS to select from options specified by the Offeror below as needs by Division and gender are considered in awarding guaranteed bed contracts. 10. Division with which the Offeror wants to Contract for this Facility (Select ONLY ONE) DCFS ONLY DJJS ONLY EITHER, BUT MY PREFERENCE IS: 11. Gender of Clients to be served at this Facility (Select ONLY ONE) Male ONLY Female ONLY EITHER, BUT MY PREFERENCE IS: Male DCFS Female DJJS Will seek waiver to serve both genders in facility. (Attach description of how male and female clients will be separated in facility, such as separate floors with separate entrances, etc. This is NEVER allowed for sex offenders.) PART VI OFFEROR BID For Guaranteed Beds Daily rate includes the costs of and administrative costs associated with providing shelter, food, daily supervision, routine transportation, Client phone calls, Client s personal school supplies, Client s personal needs and clothing (DHS established amount), and program enrichment (DHS established amount). DO NOT include costs associated with providing mental health services, wrap services, or education. Facility Daily Care and Supervision Rate Cost Per Child Per Day 12. TOTAL BID GUARANTEED BED REQUEST Daily rate based on number of guaranteed beds requested in Part II Line 5. PART VII OFFEROR OPTION TO BID If Insufficient Number of Guaranteed Beds Are Available 13. Does Offeror want to bid for fewer guaranteed beds than originally requested in Part II Line 5, if fewer guaranteed beds are available than requested? YES Bid(s) provided below. Enter daily rate bid(s) based only on fewer beds than Offeror listed on Line 5. NO (STOP. Do NOT complete bid response below. Go to Line 18.) Facility Daily Care and Supervision Rate 14. TOTAL BID From 2-4 GUARANTEED BEDS 15. TOTAL BID From 5-7 GUARANTEED BEDS 16. TOTAL BID From 8-10 GUARANTEED BEDS 17. TOTAL BID From GUARANTEED BEDS Cost Per Child Per Day PART VIII OFFEROR OPTION TO BID If No Guaranteed Beds Awarded 18. Does Offeror want to bid for a Contract for non-guaranteed beds (ONLY) if no award is granted in response to the Offeror Primary Bid and, if applicable, Alternate Bid for guaranteed beds? YES Bid is provided below. NO (STOP. Do NOT complete bid response below.) Facility Daily Care and Supervision Rate 19. TOTAL BID NON-GUARANTEED BED REQUEST Cost Per Child Per Day Page 8 of 14

9 Attachment G-1 Continued Instructions for Form 1: Residential Facility Bid for Guaranteed Beds. Part I. Line 1. Check the appropriate box to specify if bid is the Primary Bid or Alternate Bid for the facility. A Primary Bid is required for each facility. An Alternate Bid is optional. If the Offeror is submitting both a Primary Bid and Alternate Bid for a Facility, a separate form must be completed for each bid. Part II. Line 2. Enter Offeror Corporate Name and complete address. Part II. Line 3. Enter Facility Name and complete address. Facilities located outside of the State of Utah may not bid on guaranteed beds. If Offeror is submitting bid forms for more than one facility, ensure that Facility Names and addresses are distinct by facility so evaluators can correctly identify Primary and Alternate Bids that pertain to specific facilities. Part II. Line 4. Enter the total number of beds the facility is licensed for. This number cannot be greater than 16. If the facility is licensed for more than 16 beds, no bid shall be submitted. Part II. Line 5. Enter the total number of beds the Offeror is requesting be guaranteed for payment. The number shall not exceed the total number of beds the facility is licensed for minus one. For example, if a facility is licensed for 16 beds, the maximum number of beds that may be requested for guarantee is 15. If a facility is licensed for 12 beds, the maximum number of beds that may be requested for guarantee is 11. The Offeror may request any number of guaranteed beds up to the maximum number allowed for the facility (total licensed beds minus one). For example, if a facility is licensed for 16 beds, the Offeror may request to guarantee any number of beds from one to 15. Part III. Line 6. Enter the estimated total annual cost to administer and provide care and supervision to Clients in the facility. Include the costs of providing and the administrative costs associated with providing: shelter food, daily supervision, routine transportation, Client phone calls, Client s personal school supplies, Client s personal needs and clothing, and program enrichment. Do not include costs associated with mental health services, wrap services, or education. Differentiate between Direct Costs and Administrative Costs in the three categories listed: (1) Labor, (2) Facility, and (3) Other. Direct Costs are those that pertain specifically to caring for the Client (i.e., any part of your work that touches the Client). Administrative Costs are those that do not pertain specifically to caring for the Client. Labor includes all costs associated with the people you pay to do the work including labor related expenses such as benefits, employer paid taxes, insurances, etc. Facility includes all costs associated with the facility, it s upkeep, improvement, depreciation, rent or mortgage payments, insurance, maintenance, repair, utilities, taxes, etc. Other refers to costs incurred for any other parts of your program not easily segregated into the above categories, but it does not include any costs associated with mental health services, wrap services, education, or costs that are not allowed under Federal, State, or DHS cost principles. Part IV. Line 7. Check the appropriate box to specify the population to be served in the facility according to Client Category and Need/Risk Level. Do not select more than one category per Bid Form. Part IV. Line 8. Specify the age range for Clients to be served in the facility. Enter the youngest age to the oldest age. Page 2. Top. Line 9. Enter facility name and address and check the appropriate box to specify if bid is Page 9 of 14

10 the Primary Bid or Alternate Bid for the facility to ensure page two of bid will correctly be linked to page one of the bid. Part V. Item 10. Check the box to specify the Division with which the Offeror wants to Contract for this Facility. Select only one box. If the Offeror specifies DCFS Only or DJJS Only, the Offeror will only be considered for guaranteed beds for the designated Division. If the Offeror wants to have the option to be considered for guaranteed beds with either Division, check the box to specify the Division of first preference. Part V. Item 11. Check the box to specify the gender the Offeror wants to serve in this facility. Select only one box. If the Offeror specifies Male Only or Female Only, the Offeror will only be considered for guaranteed beds for the designated gender. If the Offeror wants to have the option to be considered for either gender for guaranteed beds, check the box to specify the gender of first preference. If the Offeror wants to serve both genders in the facility, the Offeror shall attach to the bid a request to waive the requirement for a single gender in a facility and provide a description of how the two genders will be maintained separately in the facility, such as separate floors with separate entrances. No approval will be granted to combine genders in a facility serving sex offenders. The attached description shall also specify the number of beds available for each gender, not to exceed 16 beds in total for both genders. Part VI. Line 12. Enter the dollar amount for the total bid for a daily rate for one Client per day for the guaranteed bed request. This amount shall include the costs of and the administrative costs associated with providing shelter, food, daily supervision, routine transportation, Client phone calls, and Client personal school supplies, Client s personal needs and clothing (at DHS established amount), and the residential program enrichment (at DHS established amount). The Offeror s daily rate shall NOT include costs to provide mental health services, costs to provide wrap services, educational costs; and costs that are not allowed under Federal, State, or DHS cost principles. Part VII. Line 13. Check the box to specify if the Offeror wants to bid for a Contract for fewer guaranteed beds than were originally requested in Part II Line 5, if the number of beds requested are not available for guarantee. Part VII. Lines If the answer to Line 13 is No, do NOT complete Lines and go to Part VIII Line 17. If the answer to Line 13 is Yes, determine which of the ranges of guaranteed beds the Offeror would like to be considered for. Bids may be submitted for one or more of the specified guaranteed bed ranges. Do no enter a bid for any range in which the number of beds equals or exceeds the number of beds the Offeror requested for guarantee in Part II Line 5. If the Offeror wants to be considered for 2-4 guaranteed beds, enter the total bid for one Client per day on Line 14. If the Offeror wants to be considered for 5-7 guaranteed beds, enter the total bid for one Client per day on Line 15. If the Offeror wants to be considered for 8-10 guaranteed beds, enter the total bid for one Client per day on Line 16. If the Offeror wants to be considered for guaranteed beds, enter the total bid for one Client per day on Line 17 Base all rates for Lines on costs specified in instructions for Line 12. Part VIII Line 18. Check the box to specify if the Offeror wants to bid for a Contract for non-guaranteed beds ONLY if no award is granted in response to the Offeror s Primary Bid, or if applicable, Alternate Bid for this facility. Part VIII. Line 19. If the answer to Line 18 is Yes, complete this Item. Enter the dollar amount for the total bid for one Client per day for the non-guaranteed bed request, including costs specified in instructions for Line 12. If the answer to Line 18 was No, do NOT complete this Item. Page 10 of 14

11 ATTACHMENT G-2 FORM 2: RESIDENTIAL FACILITY BID FOR NON-GUARANTEED BEDS ONLY (The Offeror will use this form ONLY if NOT submitting a bid for Guaranteed Beds for this Facility. This form must be completed in its entirety for each bid for guaranteed beds submitted. Any deviation from this format may result in disqualification of proposal.) PART I BID STATUS 1. Select ONLY ONE: Primary Bid (The Offeror s first choice for population to be served) Alternate Bid (The Offeror has the option to submit one alternate bid per facility to serve a population other than the population specified in the Primary Bid. The Alternate Bid for non-guaranteed beds will be used if the Offeror is not awarded non-guaranteed beds for the population specified in the Primary Bid.) PART II OFFEROR AND FACILITY INFORMATION 2. Offeror: (Corp. Name/Address) 3. Facility: (Name/Address) 4. Total Number of Licensed Beds in the Facility PART III FACILITY COST INFORMATION 5. Facility Estimated Total Annual Cost Include only those costs associated with providing care and supervision, including Client personal needs and program enrichment costs. DO NOT include costs associated with providing mental health services, wrap services, or education. Labor Facility Other Direct Costs Administrative Costs Total Costs Total PART IV POPULATION TO BE SERVED 6. Client category and risk/need level to be served at the Facility. (Select ONLY ONE) High Sex Offender Male Age 16+ DSF/YSF High Sex Offender Male Age DSF-Y/YSF-Y High/Moderate Sex Offender (Female) (combined level) DSE/YSE Moderate Sex Offender Male DSE/YSE Moderate Sex Offender Male Certified Model DSD/YSD High Mental Health DMF/YMF Moderate Mental Health DME/YME Moderate Mental Health Certified Model DMD/YMD High/Moderate Substance Dependent (combined level) DDE/YDE Moderate Substance Dependent Certified Model DDD/YDD High Behavioral DBF/YBF Moderate Behavioral DBE/YBE Moderate Behavioral Certified Model DBD/YBD 7. Client age range to be served at the Facility (Specify Range) Age to Page 11 of 14

12 8. Facility Name/Address: Continuation of Form 2/Non-Guaranteed Beds Primary Bid Alternate Bid PART V OPTIONS FOR FACILITY The Offeror agrees to allow DHS to select from options specified by the Offeror below as needs by Division and gender are considered in awarding non-guaranteed bed contracts. 9. Division with which the Offeror wants to Contract for this Facility (Select ONLY ONE) DCFS ONLY DJJS ONLY EITHER, BUT MY PREFERENCE IS: DCFS DJJS 10. Gender of Clients to be served at this Facility (Select ONLY ONE) Male ONLY Female ONLY EITHER, BUT MY PREFERENCE IS: Male Female Will seek waiver to serve both genders in facility. (Attach description of how male and female clients will be separated in facility, such as separate floors with separate entrances, etc. This is NEVER allowed for sex offenders.) PART VI OFFEROR BID For Non-Guaranteed Beds Only Daily rate includes the costs of and administrative costs associated with providing shelter, food, daily supervision, routine transportation, Client phone calls, Client s personal school supplies, Client s personal needs and clothing (DHS established amount), and program enrichment (DHS established amount). DO NOT include costs associated with providing mental health services, wrap services, or education. Facility Daily Care and Supervision Rate 11. TOTAL BID NON-GUARANTEED BED REQUEST Cost Per Child Per Day Page 12 of 14

13 Attachment G-2 Continued Instructions for Form 2: Residential Facility Bid for Non-Guaranteed Beds. Part I. Line 1. Check the appropriate box to specify if bid is the Primary Bid or Alternate Bid for the facility. A Primary Bid is required for each facility. An Alternate Bid is optional. If both a Primary Bid and Alternate Bid will be provided for a facility, a separate form must be completed for each bid. Part II. Line 2. Enter Offeror Corporate Name and complete address. Part II. Line 3. Enter Facility Name and complete address. If Offeror is submitting Bid Forms for more than one facility, ensure that Facility Names and addresses are distinct by facility so evaluators can correctly identify Primary and Alternate Bids that pertain to specific facilities. Part II. Line 4. Enter the total number of beds the facility is licensed for. This number cannot be greater than 16. If the facility is licensed for more than 16 beds, no bid shall be submitted. Part III. Line 5. Enter the estimated total annual cost to administer and provide care and supervision to Clients in the facility. Include the costs of providing and the administrative costs associated with providing: shelter food, daily supervision, routine transportation, Client phone calls, Client s personal school supplies, Client s personal needs and clothing, and program enrichment. Do not include costs associated with mental health services, wrap services, or education. Differentiate between Direct Costs and Administrative Costs in the three categories listed: (1) Labor, (2) Facility, and (3) Other. Direct Costs are those that pertain specifically to caring for the Client (i.e., any part of your work that touches the Client). Administrative Costs are those that do not pertain specifically to caring for the Client. Labor includes all costs associated with the people you pay to do the work including labor related expenses such as benefits, employer paid taxes, insurances, etc. Facility includes all costs associated with the facility, it s upkeep, improvement, depreciation, rent or mortgage payments, insurance, maintenance, repair, utilities, taxes, etc. Other refers to costs incurred for any other parts of your program not easily segregated into the above categories, but it does not include any costs associated with mental health services, wrap services, education, or costs that are not allowed under Federal, State, or DHS cost principles. Part IV. Line 6. Check the appropriate box to specify the population to be served at the Facility according to Client Category and Need/Risk Level. Do not select more than one category per Bid Form Part IV. Line 7. Specify the age range for Clients to be served in the facility. Enter the youngest age to the oldest age. Page 2. Top. Line 8. Enter facility name and address and check the appropriate box to specify if bid is the Primary Bid or Alternate Bid for the facility to ensure page two of bid will correctly be linked to page one of the bid. Part V. Item 9. Check the box to specify the Division with which the Offeror wants to Contract for this facility. Select only one box. If the Offeror specifies DCFS Only or DJJS Only, the Offeror will only be considered for guaranteed beds for the designated Division. If the Offeror wants to have the option to be considered for guaranteed beds with either Division, check the box to specify the Division of first preference. Part V. Item 10. Check the box to specify the gender the Offeror wants to serve in this Facility. Select Page 13 of 14

14 only one box. If the Offeror specifies Male Only or Female Only, the Offeror will only be considered for guaranteed beds for the designated gender. If the Offeror wants to have the option to be considered for either gender for non-guaranteed beds, check the box to specify the gender of first preference. If the Offeror wants to serve both genders in the Facility, the Offeror shall attach to the bid a request to waive the requirement for a single gender in a facility and provide a description of how the two genders will be maintained separately in the facility, such as separate floors with separate entrances. No approval will be granted to combine genders in a facility serving sex offender. The attached description shall also specify the number of beds available for each gender, not to exceed 16 beds in total for both genders. Part VI. Line 11. Enter the dollar amount for the total bid for a daily rate for one Client per day for the non-guaranteed bed request. This amount shall include the costs of and the administrative costs associated with providing shelter, food, daily supervision, routine transportation, Client phone calls, and Client personal school supplies, Client s personal needs and clothing (at DHS established amount), and the residential program enrichment (at DHS established amount). The Offeror s daily rate shall NOT include costs to provide mental health services, costs to provide wrap services, educational costs; and costs that are not allowed under Federal, State, or DHS cost principles. Page 14 of 14