Request for Proposals. Community Needs Assessment Primary Data Collection: Surveys Focus Groups Photovoice RFP

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Page: 1 of 20 Request for Proposals Community Needs Assessment 2015-16 Primary Data Collection: Surveys Focus Groups Photovoice RFP 15-017 Deadline for Response: 12/15/2015 Children s Services Council of Palm Beach County 2300 High Ridge Road Boynton Beach, Florida 33426 561-740-7000 www.cscpbc.org 1 P a g e

Page: 2 of 20 Table of Contents SECTION 1: PROPOSED SCHEDULE...3 SECTION 2: INTRODUCTION...4 2.1 WHAT WE ARE SEEKING... 4 2.2 THE COUNCIL... 4 2.3 OVERVIEW OF THE CHILDREN S SERVICES COUNCIL... 4 SECTION 3: REQUEST FOR PROPOSAL...5 3.1 BACKGROUND... 5 3.2 PROJECT GOALS... 5 3.3 SCOPE OF SERVICES... 5 SECTION 4: CSC REVIEW AND SELECTION PROCESS...7 4.1 MINIMUM ADMINISTRATIVE REQUIREMENTS... 7 4.2 EVALUATION OF QUALIFICATIONS... 7 4.3 SELECTION CRITERIA... 7 4.4 COMPLIANCE WITH SECTION 287.133, FLORIDA STATUTES... 8 4.5 NOTICE OF SELECTED PROPOSER(S) FOR INTERVIEW(S)... 8 4.6 PROCEDURE FOR CONDUCTING INTERVIEWS... 8 4.7 NOTICE OF SELECTED PROPOSER(S) FOR CONTRACT(S) DISCUSSIONS... 8 SECTION 5: RFP PROCESS...9 5.1 LIMITATIONS ON CONTACTING CSC PERSONNEL... 9 5.2 PROPOSER DISQUALIFICATION... 9 5.3 INQUIRIES... 9 5.4 ACCEPTANCE OF PROPOSALS... 10 5.5 FINAL STEPS... 10 5.6 IMPORTANT REMINDERS... 10 5.7 FREQUENTLY ASKED QUESTIONS... 11 5.8 REFERENCES... 11 SECTION 6: RFP SUBMISSION INSTRUCTIONS AND FORMS... 12 6.1 INSTRUCTIONS FOR SUBMITTING RESPONSE TO RFP... 12 6.2 INCOMPLETE RESPONSE... 12 6.3 RESPONSE FORMAT... 12 RFP FORMS... 13 PROPOSAL CHECKLIST... 14 COVER PAGE... 15 QUESTIONNAIRE... 16 REFERENCES... 18 FEE SCHEDULE... 19 CONFLICT OF INTEREST DISCLOSURE... 20 2 P a g e

Page: 3 of 20 SECTION 1: PROPOSED SCHEDULE 11/16/2015 RFP packets are available on CSC website: (www.cscpbc.org/openprop) 11/23/2015 Deadline for submission of questions regarding clarification of RFP 12/4/2015 Final posting of questions and answers and/or clarification or addenda to RFP (if any) on CSC website (www.cscpbc.org/openprop) 12/15/2015 Deadline for Email Submission of Proposals is 2:00 PM at: BIDS@cscpbc.org Subject: RFP # 15-017 12/16/2015-1/6/2016 Evaluation of responses Proposals are opened publicly beginning at 2 PM Note: CSC email server date and time stamps all email 1/7/2015 Notification by email to proposers selected for interviews and list of the selected for interview posted on CSC website, if needed. (www.cscpbc.org/openprop) 1/11/2016-1/13/2016 Interviews at CSC offices, if needed 1/14/2016-1/27/2016 Contract finalized 1/28/2016 Recommendations submitted to the Council for approval 1/28/2016 Notice of Intent to award contracts posted on CSC website at: http://www.cscpbc.org/proposal-outcomes 2/1/2016 Contract Period Begins Notification by email of proposers not selected for further contract discussions. Note: CSC reserves the right to adjust the timetable and any adjustments will be made available on the CSC website. 3 P a g e

Page: 4 of 20 SECTION 2: INTRODUCTION 2.1 WHAT WE ARE SEEKING The Children s Services Council of Palm Beach County is seeking one or more qualified individuals, firms, organizations, colleges or universities to conduct primary data collection. This information will be included in a larger community needs assessment and help CSC learn more about the current needs facing mothers, families and children especially those who experience health disparities. The data collected will assist in the identification of community strengths and resources, both formal and informal, which are helping communities to thrive. The respondent must possess an understanding of research methodology, needs assessments and qualitative data analysis in order to design and conduct surveys, focus groups and/or photovoice sessions. 2.2 THE COUNCIL Children s Services Council of Palm Beach County ( Council or CSC ), a special district created by Palm Beach County voters in 1986, and reauthorized in 2014, provides leadership, funding, services and research on behalf of the county s children so they grow up healthy, safe and strong. 2.3 OVERVIEW OF THE CHILDREN S SERVICES COUNCIL The Council invests resources in programs and services that support the physical, social-emotional and psychological development of children. In order to have an impact in those areas, the Council has four goals: babies are born healthy and children are free from abuse and neglect, are ready to enter kindergarten, and have access to quality afterschool and summer programming. Supported by a blend of federal, state and local funding, our programs and systems are designed to achieve our goals by providing seamless, efficient, and accountable prevention and early intervention services to Palm Beach County s children and families. These systems include: Healthy Beginnings, which provides comprehensive, integrated direct services to pregnant women, infants, and young children (ages 0-5 years). Strong Minds, which provides services to increase the quality of child care and afterschool providers. Bridges, which is a neighborhood-based strategy to achieve CSC s goals at a population level. Bridges address such issues as adult literacy, father involvement, maternal depression, teen pregnancy prevention, cyclical poverty and child development. The Council believes that by offering families the right approach and combinations of programs and services at the right time, in the right place, we will achieve our goals. By strengthening the system of care, which is built upon sound research and strong data, we can achieve our child outcomes. For additional information regarding CSC, please visit www.cscpbc.org. 4 P a g e

Page: 5 of 20 SECTION 3: REQUEST FOR PROPOSAL 3.1 BACKGROUND CSC funds programs and services to support pregnant moms and parents in raising children. CSC is conducting a community needs assessment to help identify gaps in services and health priorities for pregnant women, infants and young children (0 to 5 years old) in Palm Beach County. This information will help to inform CSC s Strategic Review process and aid in writing a new five year Healthy Start Plan. The comprehensive community needs assessment will be completed in September 2016. 3.2 PROJECT GOALS The goal of the RFP is to select an organization/s to assist with primary data collection for a larger community needs assessment. The organization will develop a planned approach and corresponding timeline to conduct a survey, focus groups and/or photovoice sessions in order to help identify gaps in services and health priorities for the Healthy Beginnings System. Final reports must be submitted to CSC by July 1, 2016. 3.3 SCOPE OF SERVICES The selected organization/s will plan and conduct the following: 1. A survey to examine the needs of parents with children aged 0 to 5 years old in Palm Beach County 2. Focus group sessions (approximately 12) in targeted areas and specific population groups in the county 3. Photovoice sessions (approximately 3) to visually capture the environment and experiences in underrepresented populations Proposals should be submitted in response to one of the following categories. A. Photovoice ONLY B. Survey and focus groups ONLY C. Survey, focus groups and photovoice CSC may negotiate with a proposer submitting under category C to include the survey or focus groups or photovoice only. CSC may negotiate with a proposer submitting under category B to include the survey or focus groups only. The information gathered through the processes outlined should help CSC answer the following questions: What are the needs/opportunities/gaps in services within the communities for families, children and women of childbearing age? What are the opportunities and services families want most? What are the barriers that keep families from finding or using the services available? What opportunities/needs exist to improve the health of women before, during and after pregnancy? 5 P a g e

Page: 6 of 20 What opportunities/needs exist to improve preconception and pregnancy related maternal health, birth and health outcomes for newborns? What opportunities/needs do children aged 0 5 years have to ensure they are healthy, safe and ready for kindergarten? What are the opportunities/needs for youth and teenagers? The focus groups will be conducted with the following three (3) groups identified as: Women of childbearing age (preconception/interconception) Pregnant women Parents with children from 0 to 5 years The survey results should reflect a representative sample of parents in Palm Beach County with children aged 0 to 5 years old. Both the focus groups and photovoice sessions will be conducted in zip codes identified as areas of highest need, outlined by CSC. Groups may require translation services in Spanish and/or Creole. CSC may be able to assist with the recruitment of individuals from established community providers, the BRIDGES neighborhood initiative and other community groups; however, recruitment may be needed for groups outside CSC System. The photovoice sessions may be conducted with a different target population; however, the sessions must still identify answers to the questions outlined above. The project will include the following: Discovery Session with Children s Services Council of Palm Beach County representatives Qualifications for participants Screener, if necessary for outlined methodology Survey/Focus Group/Photovoice Design and administration summary Participant recruitment plan (CSC may be able to provide assistance in gaining participation from CSC service providers, Bridges locations and other community groups; however, recruitment may be needed for groups outside CSC System). Review process with CSC representatives Budget Timeline Final Report with Executive Summary Slide Show Presentation Meeting and presentation of findings to CSC The final reports and project deliverables must be completed by July 1, 2016. 6 P a g e

Page: 7 of 20 SECTION 4: CSC REVIEW AND SELECTION PROCESS 4.1 MINIMUM ADMINISTRATIVE REQUIREMENTS In order to ensure proposers possess the minimum qualifications and/or experience needed to support Children s Services Council s needs, applicants must meet the following requirements: Demonstrate experience and ability in designing and conducting survey, focus groups and/or photovoice sessions Complete all required submission documents and sign, as required Submit a current resume or vitae for each individual who will be working with Children s Services Council Provide information on current projects (timeline/budget) Provide a sample of recent work similar to this project Participate in an interview process, upon request Provide three professional references specifically relating to assignments completed within the past five years Abide by Florida Government in the Sunshine Laws pertaining to open records and open meetings 4.2 EVALUATION OF QUALIFICATIONS A Review Committee will convene, review, and discuss all proposals submitted. The Review Committee will assign points throughout the evaluation process in accordance with the selection criteria outlined below. The Review Committee reserves the right to interview any or all Proposers and/or require a formal presentation with key people who will administer the contract and who will be assigned to work on the contract. This interview is to be based upon the written proposal received from the Proposer. The Review Committee will make a recommendation to the Council for approval and award of contract(s) to the successful Proposer(s). 4.3 SELECTION CRITERIA A Review Committee will utilize the following evaluation criteria in selecting a proposer to perform the service/s requested by the RFP. Each aspect of the proposal will be evaluated separately. For example, if an organization submits a proposal to do all three projects, survey, focus groups and photovoice, (category C) all three components will be evaluated separately using the following criteria. Criteria Total Points Proposer s previous experience and references 40 Proposed timeline/cost 30 Availability to perform requested services 30 Total Possible Points 100 After completion of the scoring process based on the review criteria, CSC will determine which, if any, proposers meet the minimum requirements deemed necessary by CSC for interviews. Assuming that such 7 P a g e

Page: 8 of 20 minimum requirements have been met, CSC may conduct face-to-face interviews from one or more proposers. 4.4 COMPLIANCE WITH SECTION 287.133, FLORIDA STATUTES In accordance with 287.133, Florida Statutes, persons and affiliates who have been placed on the convicted vendor list may not submit responses, contract with, or perform work (as a contractor, supplier, subcontractor or consultant) with CSC in excess of the threshold amount provided in 287.017, Florida Statute, for Category Two for a period of thirty-six (36) months from the date of being placed on the convicted vendor list. Any response received from a person, entity or affiliate who has been placed on the convicted vendor list shall be rejected by CSC as unresponsive and shall not be further evaluated. 4.5 NOTICE OF SELECTED PROPOSER(S) FOR INTERVIEW(S) CSC will post a list of selected proposer(s) for interview(s) (if needed) after 1/7/2016 on the CSC website. 4.6 PROCEDURE FOR CONDUCTING INTERVIEWS After completion of the scoring process based on the review criteria, CSC will determine which, if any, proposers meet the minimum requirements deemed necessary by CSC for interviews. Assuming that such minimum requirements have been met, CSC will require face-to-face interviews with one or more proposers. 4.7 NOTICE OF SELECTED PROPOSER(S) FOR CONTRACT(S) DISCUSSIONS CSC will email selected proposer(s) for contract(s) discussion(s) after 1/13/2016. Proposers who were interviewed, but not selected for negations, will be notified by email. THE CHILDREN S SERVICES COUNCIL RESERVES THE RIGHT TO REJECT ANY AND ALL PROPOSALS OR INFORMALLY NEGOTIATE CERTAIN PROVISIONS OF THE FINAL AGREEMENT WITH A QUALIFIED PROPOSER. 8 P a g e

Page: 9 of 20 SECTION 5: RFP PROCESS All proposals are to be signed by an official/individual who is legally authorized to bind the proposer to the proposed activity. 5.1 LIMITATIONS ON CONTACTING CSC PERSONNEL This Request for Proposals is issued by the Children s Services Council of Palm Beach County. The contact person listed below is the sole point of contact for this RFP: Jennifer Hardy, Administrative Assistant IV Jennifer.Hardy@cscpbc.org All contact shall be by email only and all replies will be posted and available to the public on CSC s website at: www.cscpbc.org/openprop. 5.2 PROPOSER DISQUALIFICATION Proposers are prohibited from contacting CSC personnel or board members regarding this solicitation other than the person identified above. Any occurrence of a violation may result in the disqualification of the proposer. Failure to have performed any contractual obligations with CSC in a manner satisfactory to CSC will be sufficient cause for disqualification. To be disqualified as a proposer under this provision, the proposer must have: Previously failed to satisfactorily perform in a contract with CSC, been notified by CSC of unsatisfactory performance, and failed to correct the unsatisfactory performance to the satisfaction of CSC; or Had a contract terminated by CSC, by any other county or state agency, or by any Children s Services Council for cause. 5.3 INQUIRIES All inquiries requesting clarification regarding this RFP must be made in writing and emailed to the identified contact person by 11/23/2015. During the RFP period, Proposer s must not submit any forms of marketing or promotional materials that would raise the Proposer s profile or give the Proposer an advantage or benefit not enjoyed by other prospective proposers. Copies of responses to all inquiries that require clarifications and/or addenda to the RFP will be made available no later than 5 PM, 12/4/2015 on CSC s website. 9 P a g e

Page: 10 of 20 5.4 ACCEPTANCE OF PROPOSALS All responses must be received by CSC, via email, no later than 12/15/2015 by 2:00 PM. Sign, scan and all attach required document(s) in PDF format to email and send to: BIDS@cscpbc.org Subject: RFP 15-017 No changes, modifications or additions to the responses submitted will be accepted by, or binding on CSC after the deadline for submissions has passed. ALL EMAIL COMMUNICATIONS ARE DATE AND TIME STAMPED BY CSC S EMAIL SERVER. BIDS RECEIVED AFTER THE DEADLINE DATE AND/OR TIME WILL BE REJECTED AND WILL NOT BE OPENED BY CSC. CSC reserves the right to reject any and all responses or to waive minor irregularities when doing so would be in the best interest of CSC. A minor irregularity is defined as a variation from the RFP terms and conditions that do not affect the price of the application, or do not give the proposer an advantage or benefit not enjoyed by other prospective proposers, or do not adversely impact the interest of CSC. 5.5 FINAL STEPS Be sure to follow the instructions in this RFP. Complete the checklist provided with this packet to ensure that you have completed and included all the required information. Make sure you obtain signatures, package and submit your proposal by the deadline. 5.6 IMPORTANT REMINDERS All contact with CSC beginning with the effective date of publication of the RFP and ending on the date agreements are approved by the Council, shall be in writing and submitted to the CSC Contact listed in this document. Failure to respond to any item is considered a fatal flaw and will result in the disqualification of the Proposal for further consideration. All responses must be received via email no later than 12/15/2015 at 2 PM per the deadline in the RFP. Proposers will receive an auto-generated confirmation email acknowledging receipt of the proposal. Do not respond to this email. This receipt does not verify that CSC has received a complete proposal that will be determined after opening all proposals at the time set forth in this RFP. 10 P a g e

Page: 11 of 20 5.7 FREQUENTLY ASKED QUESTIONS Q: During the application process, if someone has a question, will that question be posted? A: Yes, all questions and answers will be posted on the CSC website up after the date specified in Section 1. Q: If someone submits their proposal and CSC recognizes that forms are missing; will CSC request the agency submit the missing forms? A: Proposers have until the deadline date and time to submit any forms that they recognize have been omitted. CSC will not accept any forms after the deadline. Q: Once an agency submits a proposal, does CSC ask for additional information or explanations? A: CSC may need to obtain clarification as part of the proposal review process. 5.8 REFERENCES Proposers who are not currently funded by CSC may be asked to supply contact information, including email addresses and telephone numbers, for current and past funders. Reference checks will be conducted in an effort to assert that the proposer has the capacity and consistency in meeting performance objectives, timely data submission, fiscal and administrative stability, and capacity for system work and teamwork. Submission of a reply to the RFP indicates the Proposer understands that funders may share information. Past funding relationships with CSC may be taken into consideration when reviewing this RFP. 11 P a g e

Page: 12 of 20 SECTION 6: RFP SUBMISSION INSTRUCTIONS AND FORMS 6.1 INSTRUCTIONS FOR SUBMITTING RESPONSE TO RFP All responses must be submitted on the forms included in this package - forms available on CSC s website (www.cscpbc.org/openprop) for download. All responses are to be typewritten and signed by an official who is legally authorized to bind the Proposer to the proposed activity. IMPORTANT: All responses must be received via email no later than 2 PM per the deadline provided in the RFP. Proposers will receive an auto-generated confirmation email acknowledging receipt of the proposal. Do not respond to this email. This receipt does not verify that CSC has received a complete proposal that will be determined after opening all proposals at the time set forth in this RFQ. CSC is not responsible for the email reputation of the Proposer s email account which may cause delays or undeliverable messages if your server has been blacklisted. To check your sender score, please utilize an email reputation service or use a service like http://www.senderbase.org/ to confirm that you have a good email reputation. CSC s email server has the capacity to accept large files but in some cases the Proposer s email server may delay sending email based on the size of attachments. Please ensure you allow ample time for transmission of files. CSC will not be responsible for emails received after the deadline. Proposals received after the deadline will not be considered. 6.2 INCOMPLETE RESPONSE Failure to respond to any item, including providing any requested information, or failure to follow these instructions shall be considered submission of an incomplete response will result in disqualification from further consideration. 6.3 RESPONSE FORMAT The typewritten portion of your response is to be submitted on the RFP forms included in Section 6. The forms are available for download on CSC s website: www.cscpbc.org/openprop 12 P a g e

Page: 13 of 20 RFP FORMS REMINDER DEADLINE FOR SUBMISSION IS 12/15/2015 BIDS@cscpbc.org Subject: RFP # 15-017 REPLIES ARRIVING AFTER 2:00 PM ON 12/15/2015 WILL NOT BE CONSIDERED 13 P a g e

Page: 14 of 20 PROPOSAL CHECKLIST The following checklist outlines all required documents AND supplemental materials to be submitted with your Proposal. The omission of any one of these documents constitutes a fatal omission and disqualifies your Proposal from further review and consideration. The following documents can be downloaded from CSC s website at: www.cscpbc.org/openprop Reference file name: RFP 15-017 Forms PROPOSAL CHECKLIST Responses must include the following information and/or documents and should be assembled in the following manner: Cover Page PROPOSAL DOCUMENTS Questionnaire Resume(s) or curriculum vitae as described in Section 4.1 (Minimum Requirements) Professional References INSTRUCTIONS Complete entire document, sign and scan and attach to email submission. This document must include a signature All questions are answered and included Complete, scan and attach to email submission List three professional references, other than Children s Services Council of Palm Beach County s staff, associated with similar work previously performed by the proposer preferably within the past 5 years. For each reference, please specify: Name, address, telephone number Project start date and duration Scope and cost of project Role in project Outcome of project Fixed Fee Conflict of Interest Disclosure Form Sample of recent work similar to the project as described in Section 4.1 (Minimum Requirements) Complete this document, scan and attach to email submission Complete this document, sign, scan and include with the response. This document must include a signature Complete, scan and attach to email submission. 14 P a g e

Page: 15 of 20 Submit this RFP response to: COVER PAGE BIDS@cscpbc.org Subject: RFP #15-017 RFP Title: Community Needs Assessment, 2015-16 Primary Data Collection RFP #: 15-017 NAME OF FIRM, ENTITY, ORGANIZATION: NAME OF CONTACT PERSON: TITLE: PHONE NUMBER: FAX NUMBER: EMAIL: MAILING ADDRESS: CITY: STATE: ZIP CODE: HEADQUARTERS ADDRESS (If different than mailing address): FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN): STATE OF FLORIDA BUSINESS LICENSE NUMBER (If Applicable): DO NOT include Social Security number with this application; CSC will obtain if/when contracted. ORGANIZATION STRUCTURE (Please check one): Corporation Partnership Proprietorship Joint Venture Other If Corporation, please provide the following: (A) Date of incorporation (B) State or Country of incorporation: I certify that this Proposal is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a proposal for the same materials, supplies, or equipment, and is in all respects fair and without collusion or fraud. I agree to abide by all terms and conditions of this RFP and certify that I am authorized to sign this Proposal and that this Proposal is in compliance with all requirements of the Request for Proposals, including but not limited to, certification requirements. Authorized Signature (Manual) (Authorized Signature (Print or Type) Title (Print or Type) COMPLETE & PRINT FORMS; SIGN THE COVER PAGE; SCAN INTO PDF FORMAT AND EMAIL TO CSC BY 2 PM ON DUE DATE 15 P a g e

Page: 16 of 20 The following Questionnaire shall be completed and submitted with the Request for Proposals. Proposer guarantees the truth and accuracy of all statements and answers herein contained. 1. Describe the services you would provide to CSC. QUESTIONNAIRE 2. How many years have you/your organization/company been in business? 3. Describe the most recent project of this nature that you have completed. 4. Have you ever failed to complete work awarded to you? NO YES If so, where and why? 5. Availability to Perform the Requested Services Indicate current and anticipated workload. Provide information concerning all contracts in progress as of the date of submission of this Proposal. Name of Project Client Total Contract Value Contracted Date of Completion % of Completion to Date 6. Explain how, with the proposer s current schedule as noted in question #5, the proposer will meet any agreed upon project deadlines, which may, at times, require expedited timelines. 7. How will you determine methodology? 8. How will you ensure achieving sampling numbers/participation? 9. Do you recommend any other additional deliverables not mentioned in this RFP that would support the needs assessment? 16 P a g e

Page: 17 of 20 10. How did you determine your budget? 17 P a g e

Page: 18 of 20 List three clients, current or past, who can serve as a reference on the development of similar work performed by the Proposer in the past five years. For each reference, please specify: a. Name, address, telephone number b. Project start date and duration c. Scope and cost of project d. Role in project e. Outcome of project REFERENCES Reference #1: Reference #2: Reference #3: 18 P a g e

Page: 19 of 20 FEE SCHEDULE PURPOSE: The purpose and intent of this RFP is to secure a fixed and firm fee and establish a term-contract for professional services. CSC intends to award contract(s) to the lowest, responsive, responsible, qualified Proposer in response to this RFP, taking into consideration experience, staffing, equipment, materials, references, and past performance. In the case of disputes in the award of contract(s), the decision by CSC shall be final and binding on both parties. PRICES SHALL BE FIXED AND FIRM FOR TERM OF CONTRACT: If the Proposer is awarded a contract under this solicitation, the price quoted by the Proposer shall remain fixed and firm during the term of the contract. WORK AUTHORIZATION: Statements of Work will be authorized by the CSC Chief Executive Officer or designee. No work shall commence without written authorization. INVOICES AND PAYMENT: Detailed reports will be required with submittal of invoices. Payment will be made within 30 days of receipt of invoice and acceptance of the complete unit(s). No down or partial payments will be made. FIXED FEE: 19 P a g e

Page: 20 of 20 CONFLICT OF INTEREST DISCLOSURE The Proposer certifies that this price is made independently and free from collusion. Proposer shall disclose below, to the best of its knowledge, any CSC Council member, employee, or any spouse, son, daughter, stepson, stepdaughter, or parent of any such officer or employee, who is an officer or director of, or has a material interest in, the Proposer s business. For purposes hereof, a person has a material interest if he or she directly or indirectly owns more than five percent (5%) of the total assets or capital stock of any business entity, or if he or she otherwise stands to personally gain if the contract is awarded to this vendor. Failure of a vendor to disclose any relationship described herein shall be reason for debarment. LIST NAME(S) AND RELATIONSHIPS (IF APPLICABLE) NAME RELATIONSHIPS (Print Name) (Print Name) REQUIRED SIGNATURE (Proposer s Signature) 20 P a g e