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					                                      Houston-Galveston Area Council-Area Agency on Aging
                                                   Direct Purchase of Services
                                             Fiscal Year 2010 Vendor Application

                                          Proposed Service Delivery and Bid Sheet
             Please fill out the complete bid sheet. Complete for each service your organization proposes to perform
 Vendor Name:
 Service Name:                      Congregate Meals
 Define a Unit of Service:          1 USDA Eligible Meal

 Define service delivery area(s):

 Service Delivery Capacity:
 Enter the total number of clients your organization plans to serve this year:
 Enter the total budget expenses for the contract year:
 Enter the total number of units your organization plans to serve for this year:
 Does your organization have the ability to serve 260 meals a year:
 Does your organization have the ability to serve 1 meal a day for 5 days:
 Does your organization have the following to provide this service:
            Facilities, Office Space & Storage:
            Necessary Equipment (Ex: Computers, Internet Access, Freezer, Carriers, & etc.):
            Necessary Vehicles: (Delivery Vehicles in good working condition)
            Qualified staff to perform this service: (Enough staff to perform task)

                                       Enter the proposed number of units per service type:

                                                                                                                          Proposed
                   Service                 Type of Unit
                                                                                                                            Units
      Congregate Meals                      Hot Meals
                                            Frozen Meals
                                            Shelf Stable Meals
                                            Liquid Meals
                                            Special Meals (Kosher, Ethnic, etc.)
                                            Special Diet Meals (Low Sodium, Diabetic, etc.)
                  Other Describe:
                                            Total: Should equal to the total number of Units in your budget.                      -

 Average Cost per Unit:                                     #DIV/0!
 Enter the Negotiated Unit Rate:
 Average Cost per Client:                                   #DIV/0!

 Percentage of Cash Match Contributing to this Service:
 What amount of In-Kind Match do you plan to contribute to this Service:

 I certify that the information contained in this application is true and fairly represents the organization and its proposed cost for the
 specified service. I acknowledge that I have read and understand the requirements and provisions with this bid proposal and the
 organization is prepared to implement the program as specified in this application.



 Name of Authorized Official                                              Signature of Authorized Official


 Signature and Date




Vendor Application
Service Delivery Bid Sheet                                          Page 1 of 4                                                  FFY 2008
                                      Houston-Galveston Area Council-Area Agency on Aging
                                                   Direct Purchase of Services
                                             Fiscal Year 2010 Vendor Application

                                          Proposed Service Delivery and Bid Sheet
             Please fill out the complete bid sheet. Complete for each service your organization proposes to perform
 Vendor Name:
 Service Name:                      Home Delivered Meals
 Define a Unit of Service:          1 USDA Eligible Meal

 Define service delivery area(s):

 Service Delivery Capacity:
 Enter the total number of clients your organization plans to serve this year:
 Enter the total budget expenses for the contract year:
 Enter the total number of units your organization plans to serve for this year:
 Does your organization have the ability to serve 260 meals a year:
 Does your organization have the ability to serve 1 meal a day for 5 days:
 Does your organization have the following to provide this service:
            Facilities, Office Space & Storage:
            Necessary Equipment (Ex: Computers, Internet Access, Freezer, Carriers, & etc.):
            Necessary Vehicles: (Delivery Vehicles in good working condition)
            Qualified staff to perform this service: (Enough staff to perform task)

                                       Enter the proposed number of units per service type:

                                                                                                                          Proposed
                   Service                 Type of Unit
                                                                                                                            Units
   Home Delivered Meals                     Hot Meals
                                            Frozen Meals
                                            Shelf Stable Meals
                                            Liquid Meals
                                            Special Meals (Kosher, Ethnic, etc.)
                                            Special Diet Meals (Low Sodium, Diabetic, etc.)
                  Other Describe:
                                            Total: Should equal to the total number of Units in your budget.                      -

 Average Cost per Unit:                                     #DIV/0!
 Enter the Negotiated Unit Rate:
 Average Cost per Client:                                   #DIV/0!

 Percentage of Cash Match Contributing to this Service:
 What amount of In-Kind Match do you plan to contribute to this Service:

 I certify that the information contained in this application is true and fairly represents the organization and its proposed cost for the
 specified service. I acknowledge that I have read and understand the requirements and provisions with this bid proposal and the
 organization is prepared to implement the program as specified in this application.



 Name of Authorized Official                                              Signature of Authorized Official


 Signature and Date




Vendor Application
Service Delivery Bid Sheet                                          Page 1 of 4                                                  FFY 2008
                                      Houston-Galveston Area Council-Area Agency on Aging
                                                   Direct Purchase of Services
                                             Fiscal Year 2010 Vendor Application

                                          Proposed Service Delivery and Bid Sheet
             Please fill out the complete bid sheet. Complete for each service your organization proposes to perform
 Vendor Name:
 Service Name:                      Transportation
 Define a Unit of Service:          1 One-Way Passenger Trip

 Define service delivery area(s):

 Service Delivery Capacity:
 Enter the total number of clients your organization plans to serve this year:
 Enter the total budget expenses for the contract year:
 Enter the total number of units your organization plans to serve for this year:
 Does your organization have the following to provide this service:
            Facilities, Office Space & Storage:
            Necessary Equipment (Ex: Computers, Internet Access, & etc.):
            Necessary Vehicles: (Delivery Vehicles in good working condition)
            Qualified staff to perform this service: (Enough staff to perform task)


                                       Enter the proposed number of units per service type:

                                                                                                                          Proposed
                   Service                Type of Unit
                                                                                                                            Units
        Transportation                      Senior Center Trips
                                            Shopping/Errand Trips
                                            Doctor's Visit Trips
                                            Medical Treatment Trips
                                            Trips Home
                  Other Describe:
                  Other Describe:
                                            Total: Should equal to the total number of Units in your budget.                      -

 Average Cost per Unit:                                     #DIV/0!
 Enter the Negotiated Unit Rate:
 Average Cost per Client:                                   #DIV/0!

 Percentage of Cash Match Contributing to this Service:
 What amount of In-Kind Match do you plan to contribute to this Service:

 I certify that the information contained in this application is true and fairly represents the organization and its proposed cost for the
 specified service. I acknowledge that I have read and understand the requirements and provisions with this bid proposal and the
 organization is prepared to implement the program as specified in this application.




 Name of Authorized Official                                              Signature of Authorized Official


 Signature and Date




Vendor Application
Service Delivery Bid Sheet                                          Page 1 of 4                                                  FFY 2008
                                      Houston-Galveston Area Council-Area Agency on Aging
                                                   Direct Purchase of Services
                                             Fiscal Year 2010 Vendor Application

                                          Proposed Service Delivery and Bid Sheet
             Please fill out the complete bid sheet. Complete for each service your organization proposes to perform

 Vendor Name:
 Service Name:                      Participant Assessment
 Define a Unit of Service:          One Complete Intake, Assessment, & Certifications

 Define service delivery area(s):

 Service Delivery Capacity:
 Enter the total number of clients your organization plans to serve this year:
 Enter the total budget expenses for the contract year:
 Enter the total number of units your organization plans to serve for this year:
 Does your organization have the following to provide this service:
            Facilities, Office Space & Storage:
            Necessary Equipment (Ex: Computers, Internet Access, & etc.):
            Necessary Vehicles: (Delivery Vehicles in good working condition)
            Qualified staff to perform this service: (Enough staff to perform task)

                                       Enter the proposed number of units per service type:

                                                                                                                          Proposed
                   Service                 Type of Unit
                                                                                                                            Units
  Participant Assessment                    Initial Assessment
                                            Reassessment                                                                          -
                  Other Describe:
                  Other Describe:




                                            Total: Should equal to the total number of Units in your budget.                      -

 Average Cost per Unit:                                     #DIV/0!
 Enter the Negotiated Unit Rate:
 Average Cost per Client:                                   #DIV/0!

 Percentage of Cash Match Contributing to this Service:
 What amount of In-Kind Match do you plan to contribute to this Service:

 I certify that the information contained in this application is true and fairly represents the organization and its proposed cost for the
 specified service. I acknowledge that I have read and understand the requirements and provisions with this bid proposal and the
 organization is prepared to implement the program as specified in this application.




 Name of Authorized Official                                              Signature of Authorized Official


 Signature and Date




Vendor Application
Service Delivery Bid Sheet                                          Page 1 of 4                                                  FFY 2008

				
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