Harris County Department of Education (HCDE) RFP Cover Sheet

Harris County Department
of Education (HCDE)
RFP Cover Sheet
Job No.:
08/030 DG
Due Date:
7/16/08
DUE NO LATER THAN 1:00 P.M.
LATE BIDS WILL NOT BE ACCEPTED
Request for Proposal (RFP) for: Work Flow System for Harris County
Department of Education.
PLEASE NOTE
Carefully read entire proposal document
and specifications. Complete all forms
Submit your bid with all appropriate
supplements.
Please submit your hard copy proposal in a
sealed envelope with job no., description,
and marked “SEALED PROPOSAL”.
RETURN PROPOSAL TO:
Attn: Derek Gillard – Purchasing
Harris County Department of Education
6300 Irvington Blvd., Room 223
Houston, TX 77022-5618
For additional information contact Derek Gillard at (713) 696-0786
You must sign below in INK; failure to sign WILL disqualify the offer. All prices and
responses must be typewritten or written in ink.
Total Amount of Proposal: $_________________
Company Name:
____________________________________________________
Company Address:
____________________________________________________
City, State, & Zip
____________________________________________________
Taxpayer I.D. #
____________________________________________________
Telephone # ______________ Fax # ___________ e-mail _______________________
Print Name
____________________________________________________
Signature
____________________________________________________
Your signature attests to your offer to provide the goods and/or services in this proposal
according to the published provisions of this Job. Contract is not valid until HCDE
Board has approved the award.
ACCEPTED BY: __________________________
HCDE Board Approval
Page 1 of 24
DATE: ________________
TABLE OF CONTENTS
Items below represent components which comprise this bid/proposal package. Offerors are
asked to review the package to be sure that all applicable parts are included. If any portion of
the package is missing, notify the Purchasing Department immediately.
It is the Offeror's responsibility to be thoroughly familiar with all Requirements and
Specifications. Be sure you understand the following before you return your bid packet.
1.
Cover Sheet (page 1)
Your company name, address, the total amount of the bid/proposal, and your signature (IN
INK) should appear on this page.
2. Table of Contents (page 2)
This page is the Table of Contents.
3. Terms and Conditions (pages 3-5)
You should be familiar with all of the requirements.
4. Specifications (pages 6-9)
This section contains the detailed description of the product/service sought by the HCDE.
5. Price Delivery Information (page 10)
6. Attachments (Submittals)
X
A. Proposal Submission Form (page 11)
X
B. Felony Conviction Notice (page 12)
X
C. Bid Certification Sheet (page 13)
X
D. No Response Form (page 14)
X
E. References (page 15)
X
F. Minimum Insurance Requirements (page 16)
X
G. Questionnaire (pages 17-18)
X
H. Conflict of Interest Questionnaire (pages 19-21)
X
I. HUB Certification Form (page 22)
X
J. IRS Form W-9 (pages 23-24)
Page 2 of 24
TERMS AND CONDITIONS
ASSIGNMENT - Any award made as a result of this solicitation, may not be transferred, assigned,
subcontracted, mortgaged, pledged, or otherwise disposed of or encumbered in any way by the
vendor.
CANCELLATION – HCDE reserves the right to cancel this solicitation. (See paragraph “Financial
Responsibility”).
CHANGES - Any changes to the requirements specified herein will be communicated to all
proposers by the issuance of an addendum. All proposers shall comply with the requirements
specified in any addendum issued by HCDE.
CUSTOMER REFERENCE LIST – The proposer shall be required to submit a customer reference
list.
CONTRACT TERM – The initial term of the contract will be for a period of one (1) year with HCDE
having the option to renew the contract four (4) additional years in one (1) year increments.
Consequently, the total term of the contract may be for a period of five (5) years. Both buyer and sell
will negotiate renewal prices at the time of renewal.
DISQUALIFICATION - A proposer may be disqualified before or after the proposals are opened,
upon evidence of collusion with the intent to defraud, or perform other illegal activities for the
purpose of obtaining an unfair competitive advantage.
EQUAL OPPORTUNITY – It is the policy of HCDE not to discriminate on the basis of race, color,
national origin, gender, limited English proficiency or handicapping conditions in its programs.
EXCEPTIONS – Proposers are responsible for identifying any exceptions to the requirements
specified herein. Any exceptions must be noted on the proposer’s letterhead and returned with the
proposal. Proposals, which are qualified with conditional clauses, items not called for, or
irregularities, may be considered non-responsive by HCDE.
FOB – All shipments shall be FOB destination full freight allowed.
FINANCIAL RESPONSIBILITY – HCDE assumes no financial responsibility for any costs
incurred in developing and submitting a proposal.
FORMAT –Proposals shall include one (1) original complete proposal. Proposers are responsible for
ensuring their proposal is received at the time and place specified on the cover page. HCDE is not
responsible for proposals that arrive late, or proposals that do not have all the required information.
INDEMNIFICATION - The vendor shall indemnify and hold harmless HCDE from all liabilities,
costs, expenses, attorney fees, fines, penalties or damages for any or claimed infringement of any
patents, trademarks, copyright or other corresponding right(s) which is related to any item the vendor
is required to deliver. The vendor’s obligation to this clause shall survive acceptance and payment by
HCDE.
INSURANCE – The successful proposer shall be required to provide HCDE with copies of
certificates of insurance, named as additional insured, Texas Workman’s Compensation and General
Liability Insurance.
Page 3 of 24
INTERPRETATION – This solicitation represents the basis for any award, and supersedes all prior
offers, negotiations, exceptions and understandings (whether orally or in writing). The information
submitted should be self-explanatory and not require any clarification or additional information.
INVOICES – HCDE will be invoiced directly; payment terms are net thirty (30) days.
PENALTIES- If a successful proposer is unable to provide the awarded items at the quoted prices,
after the proposal has been opened, HCDE may take the following action(s):
• Insist the successful proposer honor the quoted price(s) specified in their respective proposal;
• Have the successful proposer pay the difference between their price, and the price of the next
acceptable proposal (as determined by HCDE);
• Recommend to HCDE’s Board of Trustees the successful proposer no longer be given the
opportunity to submit a proposal to HCDE.
PERFORMANCE - The successful proposers will use best efforts to provide the services mutually
agreed upon.
POSTPONEMENT - The time and place established for the receipt of the proposals will not be
changed unless otherwise specified (in writing) by HCDE’s Director of Purchasing.
PRICES- All prices shall be firm for the contract.
QUESTIONS – Questions regarding the requirements specified in this solicitation must be faxed to
(713) 696-0732 attn: Derek Gillard no less than three (3) working days before the proposals are
due. Questions must be sent on the proposer’s letterhead, dated and signed by an authorized
representative of the proposer’s company. HCDE will not answer verbal questions. Any responses to
the proposer’s questions will be reduced in writing by HCDE and provided to all proposers.
QUALITY - Any order issued as a result of this solicitation will conform to the specification and
descriptions identified herein. Unless otherwise specified, the vendor will not deliver substitutes
without prior authorization.
RESPONSIBLE PROPOSER - A responsible proposer is a proposer who has adequate financial
resources (or the ability to obtain such resources), can comply with the delivery requirements (taking
into consideration existing business commitments), and is a qualified and established firm regularly
engaged in the type of business that provides the items listed herein.
RESPONSIVE PROPOSAL - Refers to a proposal that complies with all material and
administrative aspects of this solicitation.
RETURN OF PROPOSALS – Proposals once submitted will not be returned.
TAXES - HCDE is tax – exempt. Proposals prices should not include taxes.
TIE PROPOSALS - Should a tie occur (i.e., unit price is the same) between a non-resident proposer
and a Texas resident proposer, Purchasing will make an award to the Texas resident proposer, as
defined in Vernon’s Annotated Civil Statues Article 601g, Sections 1 and 2.
TITLE AND RISK OF LOSS - The title to any item shall pass upon acceptance or payment,
whichever is later.
Page 4 of 24
WARRANTY – All hardware, software, service, and/or parts must be warranted to be free from
defects in material and workmanship for a period of one (1) year.
Page 5 of 24
SPECIFICATIONS
Work Flow System for Harris County Department of Education.
BACKGROUND
The intention of this Request for Proposal (RFP) is to solicit proposals for a Work Flow System for
Harris County Department of Education.
HCDE is utilizing the Request for Proposal (RFP) method for the procurement of this service in
accordance with Section 44.031 Purchasing of Contracts, Item (3) Request for Proposals.
A pre-proposal conference is scheduled for July 2, 2008, at 9:00 a.m. at 6300 Irvington Blvd.,
Houston, Texas, 77022-5618. Attendance is not mandatory but all proposers are highly encouraged
to attend in order to have a better understanding of the requirements of this RFP. Persons with
disabilities requiring special accommodations should contact Derek Gillard at (713) 696-0786 at least
two (2) days prior to the conference.
For information regarding the proposal process, contact Derek Gillard of the Purchasing Division at
(713) 696-0786.
TIME TABLE
HCDE anticipates following the time table listed below for this job:
08/030DG Time Table
Item
1
2
3
4
5
Activity
Job Starts to Advertise (1st run)
Job Advertised (2nd run)
Pre-proposal Meeting
Bids Due
Award Date
Date
6/27/08
6/30/08
7/2/08
7/16/08
8/19/08
The table above is only an estimate and may vary.
SCOPE
Currently HCDE has a number of forms that are being manually processed and dispersed throughout
the organization. These forms are evaluated, authorized, and forwarded for additional authorizations
or evaluations. When the form reaches its final approval it is closed and remains on file.
HCDE is looking to implement a system that is able to automate and replace the current existing
manual process of generating forms into an electronic process. These “electronic forms” may or
may not need to incorporate an electronic approval flow in order to comply with local and legal
restrictions. All electronic forms, approvals, denials, and attachments should be archived for future
reference. HCDE currently uses Sungard Pentamation for business transactions and would require
compatibility with this software; including but not limited to extraction of data, importing of data,
and confirmation of available budget funds through ODBC (Open Database Connectivity) or similar
method. Electronic forms that would require some sort of import and/or export of data from
Page 6 of 24
Pentamation would be referred to as “Complex Forms”. “Simple Forms” would be forms that
require no import or export of data from Pentamation.
REQUIREMENTS
Please check Yes or No for each statement in the table below. If you answer requires further
explanation please include an additional attachment with your details.
PROCESS
ADMINISTRATION
There is a central module where all the forms are
managed and activated.
The system has a login interface which requires a
user name and a password.
The system has the ability to assign various levels
of authorization for each user created.
The system has the ability of allowing unlimited
levels of approval by administrators, directors,
clerks etc. for each form administered.
The system is capable of accepting, requiring or
denying attachments of any type.
The system is capable of forwarding to a list of
alternate users in the event of long term absence
by one of the participants.
The system is capable of linking via ODBC or
similar method to resident database in order to
obtain account information or other pertinent data
needed to determine approval or denial action.
The system complies with the Sarbanes-Oxley
Act.
The system has the ability to allow the
administrator to determine if a form must display
instructions prior to the initiation of any given
form.
The system has the capability of having the
administrator create the form’s instructions as
needed.
The system has the capability of maintaining an
editable table; listing the entities goals and
objectives to allow these to display on forms as
needed.
The system has the capabilities of maintaining
various editable tables of data for forms as
deemed necessary.
The system has the capability of importing data
to the editable tables from any data source.
The system has the capability of adding
additional forms HCDE may request from vendor
within reasonable time.
Page 7 of 24
YES
NO
OTHER
(EXPLAIN)
The system has the capability of generating
management reports from any of the forms.
The system has built in categorization of forms
for ease of search and initiation.
The system is web based.
The form has the capability of pre-populating
certain fields HCDE may request. These fields
will allow or disallow modification per HCDE’s
request.
USER INTERFACE
The system is capable of displaying the status of
each form in the approval process for the user’s
convenience.
The system is able to notify the next approver or
reviewer via e-mail of pending actions.
The system is able to provide a quick link in the
e-mail message for direct access to login screen.
The system allows the users to attach documents
of any type to a form if the form allows it or
requires it.
The system is capable of allowing users to cancel,
delete or modify the request before completion.
The system allows the user to save a draft of the
form in progress for later completion.
The system displays clearly a tracking number for
each form initiated.
The system notifies the user vie e-mail each time
the form has been further approved or verified.
The system allows any of the approvers or
reviewers to click on e-mail link of initiator or
previous approvers or reviewers in order to
communicate via e-mail.
The system allows users to view a list of current
requests at their level.
The system allows users to view a list of closed
requests.
The system allows users to view a list of pending
actions.
The system has built in help menu for the benefit
of the users.
The system has a built-in on-line support
interface for suggestions or assistance.
The system has a built in interface that allows
users to requests or suggest future forms to be
automated.
The system has a built in automatic timed log out
feature.
Page 8 of 24
YES
NO
OTHER
(EXPLAIN)
EVALUATION CRITERIA
Proposals will be evaluated based on the criteria listed below corresponding to requested scope of
services:
1. Price
.
2. Reputation of Vendor (References)
3. Quality of Vendor’s Service
4. Extent to which service meets HCDE’s needs
5. Vendor’s past relationship with the HCDE
6. Impact on historically underutilized businesses
7. Total long term cost to HCDE
Total
60 points
10 points
2.5 points
15 points
5 points
2.5 points
10 points
100pts.
Ideally, HCDE is looking to make an award to the highest evaluation score that meets HCDE
specifications. The proposal shall remain confidential information until an award decision has been
made. After the award has been made, all proposers will be allowed to view proposal results or
request bid tabulation results. If no proposals meet specifications then no award shall be made.
MAINTENANCE
All Maintenance Service shall be included for year one (1) and comply with guidelines list for year
two (2).. HCDE would like vendors to price maintenance/service agreements for Work Flow System
with the following guidelines for year two (2) and so on:
•
•
•
•
Agreements should start after initial one (1) year warranty expires.
Response time should be within 4-6 hours after service call via on-site or remote dial in.
All work performed should carry a minimum of one (1) year warranty.
Work should be performed by a trained certified application specialist.
Page 9 of 24
PRICE DELIVERY INFORMATION
I.
Proposers must complete the open boxes below.
Proposer:
Item
1
2
3
4
Description
Convert and
Implement one (1)
Simple electronic
form
Convert and
Implement one (1)
Complex
electronic forms
Special
Project/Consultant
Maintenance and
Updates year 2
and beyond
Unit of
Measure
Price
ea
ea
hourly
rate
Annual
Fee
II. Please include any price breaks below for converting and implementing a Simple electronic
form.
_____________________________________________________________________________
_____________________________________________________________________________
III. Please include any price breaks below for converting and implementing a Complex electronic
form.
_____________________________________________________________________________
_____________________________________________________________________________
Page 10 of 24
Attachment A
PROPOSAL SUBMISSION FORM
RFP NO. 08/030 DG Work Flow System for Harris County Department of Education.
Please Print
Whereas on the _____________ day of _________________________, 2008 (print name of
company)
______________________________________________________________________
reviewed
has
HCDE’s solicitation No. 08/030 DG and has responded in accordance with the terms and conditions
therein:
______________________________________
_____________________________________
Street Address
City, State, Zip Code
______________________________________
_____________________________________
Telephone Number
Fax Number
______________________________________
_____________________________________
_
Name of Authorized Individual
Signature of Authorized Individual
Page 11 of 24
Attachment B
FELONY CONVICTION NOTICE
State of Texas Legislative Senate Bill No. 1 Section 44.034, Notification of Criminal History,
Subsection (a), states “a person or business entity that enters into an agreement with a school district
must give advance notice to the district if the person or an owner or operator of the business entity
has been convicted of a felony. The notice must include a general description of the conduct resulting
in the conviction of a felony”
Subsection (b) states “a school district may terminate the agreement with a person or business entity
if the district determines that the person or business entity failed to give notice as required by
Subsection (a), or misrepresented the conduct resulting in the conviction. The district must
compensate the person or business entity for services performed before the termination of the
agreement”
Note: This notice is not required of a Publicly-Held Corporation
I, the undersigned agent for the firm named below, certify that the information concerning
notification of felony convictions has been reviewed by me and the following information furnished
is true to the best of my knowledge.
Vendor’s Name: ______________________________________________
Authorized Company Official’s Name (Printed or Typed): ________________________
A)
My firm is a publicly-held corporation; therefore the above reporting requirement does not
apply
Signature of Company Official: ______________________________________________
B)
My firm is not owned nor operated by anyone who has been convicted of a felony
Signature of Company Official: ______________________________________________
C)
My firm is owned or operated by the following individual(s) who has/have been convicted of
a felony:
Name of individuals: ______________________________________________________
Detail of Conviction(s):____________________________________________________
____________________________________________________
____________________________________________________
Page 12 of 24
Attachment C
BID CERTIFICATION SHEET
In order for a bid to be evaluated and considered, the following information must be provided.
As defined by Texas House Bill 602, a "nonresident bidder" means a bidder whose principal place of
business is not in Texas, but excludes a contractor whose ultimate parent company or majority owner
has its principal place of business in Texas.
I certify that my company is a "resident bidder":
Signature: ___________________________ Date: _____________________
-----------------------------------------------------------------------------------------------------------If you qualify as a "nonresident bidder," you must furnish the following information:
What is your resident state? (The state your principal place of business is located)
______________________________________________________________
Address (include City, State and Zip Code)
(A) Does your "residence state" require bidders whose principal place of business is in Texas to
underbid bidders whose residence state is the same as yours by a prescribed amount or percentage to
receive a comparable contract? "Residence State" means the state in which the principal place of
business is located. Yes______ No______
(B) What is the amount or percentage? __________%
I certify that the above information is correct:
_______________________________________ _________________________
Typed Name
Position
______________________________________
Company Name
Page 13 of 24
Attachment D
NO RESPONSE FORM
RFP NO. 08/030 DG Work Flow System for Harris County Department of Education.
Please Print
Whereas on the ___________ day of ____________________, 2008 (print name of
company)
__________________________________________________________________________
has reviewed HCDE’s solicitation No. 08/030 DG, and elects not to submit a proposal:
______________________________________________
Street Address
______________________________________________
City, State, Zip Code
______________________________________________
Telephone/Fax Number
______________________________________________
Name of Authorized Individual
___________________________________________
Signature of Authorized Individual
Page 14 of 24
Attachment E
References
Please provide at least three (3) references (co. name, address, telephone no. and contact) that have
used your communication system in the last 3-4 years.
1.
Company Name:
__________________________________
Address:
__________________________________
__________________________________
__________________________________
2.
Contact:
__________________________________
Phone Number:
__________________________________
E-mail:
__________________________________
Company Name:
__________________________________
Address:
__________________________________
__________________________________
__________________________________
3.
Contact:
__________________________________
Phone Number:
__________________________________
E-mail:
__________________________________
Company Name:
__________________________________
Address:
__________________________________
__________________________________
__________________________________
Contact:
__________________________________
Phone Number:
__________________________________
E-mail:
__________________________________
Page 15 of 24
Attachment F
Minimum Insurance Requirements
•
The contractor shall, at all times during the term of this contract, maintain insurance coverage with
not less than the type and requirements shown below. Such insurance is to be provided at the sole
cost of the contractor. These requirements do not establish limits of the contractor's liability.
•
All policies of insurance shall waive all rights of subrogation against HCDE, its officers, employees
and agents.
•
Upon request, certified copies of original insurance policies shall be furnished to HCDE.
•
HCDE reserves the right to require additional insurance should it be deemed necessary.
A. Workers' Compensation (with Waiver of subrogation to HCDE) Employer's Liability,
including all states, U.S. Longshoremen, Harbor Workers and other endorsements, if
applicable to the Project.
Statutory, and Bodily Injury by Accident: $100,000 each employee. Bodily Injury by
Disease: $500,000 policy limit $100,000 each employee. HCDE shall be named as
"additional insured" on workers’ compensation policy.
B. Commercial General Liability Occurrence Form including, but not limited to, Premises and
Operations, Products Liability Broad Form Property Damage, Contractual Liability, Personal
and Advertising Injury Liability and where the exposure exists, coverage for watercraft,
blasting collapse, and explosions, blowout, catering and underground damage.
o $300,000 each occurrence Limit Bodily Injury and Property Damage combined
o $300,000 Products-Completed Operations Aggregate Limit $500,000 per Job Aggregate
o $300,000 Personal and Advertising Injury Limit
HCDE shall be named as "additional insured" on commercial general liability policy.
C. Automobile Liability Coverage:
o $300,000 Combined Liability Limits Bodily Injury and Property Damage Combined.
HCDE shall be named as "additional insured" on automobile policy.
Page 16 of 24
Attachment G
Questionnaire
(add additional sheets if necessary)
1. How long has your company been in business providing work flow systems?
___________________________________________________________________________
___________________________________________________________________________
2. Explain in detail the system training that will be provided if any. The warranty support and
customer support that will be made available.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. What is standard lead time for implementation of a “simple form”? What is standard lead
time for implementation of a “complex form”?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4. What are your customer service hours of operation?
___________________________________________________________________________
___________________________________________________________________________
5. What makes your company different from your competitors?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Page 17 of 24
6. Will our account be assigned a dedicated sales representative from your company? If so, who
is the contact name?
___________________________________________________________________________
___________________________________________________________________________
7. Can your company deliver and/or service all locations within Texas? Please list your regional
offices.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Page 18 of 24
Attachment H
CONFLICT OF INTEREST DISCLOSURE STATEMENT
HCDE is required to comply with Texas Local Government, Code 176 and Disclosure of Certain
Relationships with Local Government Officers. This means any company that does business with
HCDE must fill out a Conflict of Interest Questionnaire (CIQ) if the following situation exists:
1. The person has employment or other business relationship with the local government officer or a
family member resulting in the officer or family member receiving taxable income.
2. Your company has given one of HCDE’s local government officers or family member one or
more gifts (excluding food, logging, transportation, and entertainment) that has an aggregate value of
more than $250 in the twelve month period preceding the date the officer becomes aware of an
executed contract or consideration of the person for a contract to do business with the District.
Statements must be filed within seven (7) business days after the officer becomes aware a conflict of
interest exists.
Below is a listing of current HCDE Board of Trustees (BOT):
Mr. Raymond T. Garcia, President
Ms. Angie Chesnut, Vice-President
Mr. Roy Morales
Mr. Louis Evans, III
Mr. Michael Wolfe
Dr. Robert Peterson
Mr. Carl Schwartz
Dr. John Sawyer
Below is a listing of current local government officers:
Jesus Amezcua
Janell Baker
Karl Boland
Curtis Davis
Angela Drake
Malcolm Greer
Celes Harris
Les Hooper
Deborah Johnson
Doug Kleiner
Tammy Lanier
Noemi Lopez
Pam Newman
Elaine Nichols
Linda Pitre
Jean Polichino
Joanie Rethlake
Alfonso Saldivar
Dean Zajicek
Natasha Truitt
Faye Wells
Jeannette Truxillo
Page 19 of 24
Shannon Bishop
Jim Davis
Richard Griffin
Sonny Janczak
Michele Kronke
Peggy McGrane
Venetia Peacock
Gayla Rawlinson
Jim Schul
John Weber
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
This questionnaire is being filed in accordance with chapter 176 of
the Local Government Code by a person doing business with the
governmental entity.
Form CIQ
OFFICE USE ONLY
Date Received
By law this questionnaire must be filed with the records
administrator of the local government not later than the 7th business
day after the date the person becomes aware of facts that require the
statement to be filed. See Section 176.006, Local Government Code.
A person commits an offense if the person violates Section 176.006,
Local Government Code. An offense under this section is a Class C
misdemeanor.
1. Name of person doing business with local governmental entity.
2.
Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later
than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is
pending and not later than the 7th business day after the date the originally filed questionnaire becomes
incomplete or inaccurate.)
3. Describe each affiliation or business relationship with an employee or contractor of the local
governmental entity who makes recommendations to a local government officer of the local
governmental entity with respect to expenditure of money.
4. Describe each affiliation or business relationship with a person who is a local government
officer and who appoints or employs a local government officer of the local governmental entity
that is the subject of this questionnaire.
Page 20 of 24
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
FORM CIQ
Page 2
5. Name of local government officer with whom filer has affiliation or business relationship.
(Complete this section only if the answer to A, B, or C is YES.)
This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the
filer has affiliation or business relationship. Attach additional pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income
from the filer of the questionnaire?
Yes
No
B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction
of the local government officer named in this section AND the taxable income is not from the local
governmental entity?
Yes
No
C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local
government officer serves as an officer or director, or holds an ownership of 10 percent or more?
Yes
No
D. Describe each affiliation or business relationship.
6. Describe any other affiliation or business relationship that might cause a conflict of interest.
___________________________________________
Signature of person doing business with the governmental entity
Page 21 of 24
_______________
Date
Attachment I
Historically Underutilized Business
(HUB) Certification Form
Bidding companies that have been certified by the State of Texas as Historically Underutilized
Business (HUB) entities are encouraged to indicate their HUB status when responding to this Bid
Invitation. The electronic catalogs will indicate HUB certifications for vendors that properly indicate
and document their HUB certification on this form.
_____ I certify that my company has been certified by the State of Texas as a Historically
Underutilized Business (HUB), and I have attached a copy of our HUB certification to this form.
(Required documentation for recognition as a HUB)
_____ My company has NOT been certified by the State of Texas as a Historically Underutilized
Business (HUB).
______________________________________
Signature of Authorized Representative
______________________________________
Name (Please Print)
______________________________________
Company Name (Please Print)
Page 22 of 24
_________________________
Title
Attachment J
Form W-9
Taxpayer Identification Number Request
Revised March 2005
This form may be used only by a U.S. person, including a resident alien. Foreign persons should furnish us with the appropriate Form W-8.
The IRS defines a U.S. person as: *a U.S. citizen; *an entity (company, corporation, trust, partnership, estate, etc.) created or organized in, or under the
laws of, the United States; *a U.S. resident (someone who has a “green card” or has passed the IRS “substantial-presence test.” For an explanation of
the substantial-presence test, please see IRS Pubs. 515 or 519.)
Please complete all three parts below.
Part 1 - Tax Identification:
1. Name: _________________________________________________________________________________
2. Enter your Taxpayer Identification Number in the appropriate box.
For individuals, this is your social security number (SSN). For other entities, it is your employer identification number (EIN).
Social Security Number
Employer Identification Number
_____ _____ _____ ⎯ _____ _____ ⎯ _____ _____ _____ _____
O
R
_____ _____ ⎯ _____ _____ _____ _____ _____ _____ _____
IF you are a SOLE PROPRIETOR or SINGLE-OWNER LLC – whether payment is made to a personal name or to a doing business name,
you must provide the following:
Required: Personal name of owner of the business: ________________________________________________________________________________
Optional: Business name if different from above:__________________________________________________________________________________
IF you assign payment to a third party – such as a factor – provide the following:
Required: Your name: _______________________________________________________________________________________________________
Optional: Name of third party: _________________________________________________________________________________________________
Part 2 - Exemption: If exempt from Form 1099 reporting, check your qualifying reason below:
†Corporation
Note that there is no
corporate exemption
for medical and
healthcare payments or
payments for legal
services.
†Tax Exempt Entity
under 501(a)
(includes 501(c)(3),
or IRA.
†The United
States or any of
its agencies or
instrumentalities
†A state, the District
† A foreign government
of Columbia, a
possession of the
United States, or any
of their political
subdivisions or
agencies.
or any of its political
subdivisions or an
international
organization in which
the United States
participates under a
treaty or Act of
Congress.
Part 3 - Certification/Signature: Under penalties of perjury my signature certifies that:
1. I am a U.S. person (including a U.S. resident alien).
2. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).
3. 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.
Certification Instructions - You must cross out item 3 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, number 3 above does not apply. For mortgage interest paid, acquisition or abandonment of secured
property, cancellation of debt, contributions to an individual
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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.
Person completing this form: ______________________________ Phone: (
) _________________
Signature: ___________________________ ___________Date: _______________________________
Address: ___________________________________________________________________________
City: ___________________________
State: _______ ZIP: _______________________________
Instructions We are about to pay you an amount that may be reported to the Internal Revenue Service (IRS). The IRS
will match this amount to your tax return. In order to avoid additional IRS scrutiny, we must provide the IRS with your
name and Taxpayer Identification Number. The name we need is the name that you use on the tax return that will
report this amount. We are required by law to obtain this information from you.
Exempt from backup withholding. On page 2 of this form is a chart showing who is exempt from backup withholding.
If you are exempt from backup withholding, indicate the reason why in part 2 of this form, and we will not send you a
Form 1099.
Penalties Your failure to provide a correct name and Taxpayer Identification Number may subject your payments to 28%
federal income tax backup withholding. If you do not provide us with this information, you may be subject to a $50
penalty imposed by IRS under section 6723. If you make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a $500 civil penalty. Willfully falsifying certifications or affirmations may subject
you to criminal penalties including fines and/or imprisonment.
Confidentiality If we disclose or use your Taxpayer Identification Number in violation of Federal law, we may be
subject to civil and criminal penalties.
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