Harris County Department of Education (HCDE) RFP Cover Sheet

Harris County Department
of Education (HCDE)
RFP Cover Sheet
Job No.:
08/012 DG
Due Date:
6/25/2008
DUE NO LATER THAN 1:00 P.M.
LATE BIDS WILL NOT BE ACCEPTED
Request for Proposal (RFP) for: Food Service Equipment, Parts/
Related Items, and Maintenance Service for Purchasing Cooperative.
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.
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 45
DATE: ________________
TABLE OF CONTENTS
Items checked 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, tax payer id, telephone, fax, email address, 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 6-7)
This section contains the detailed description of the product/service sought by the HCDE.
5. Price Delivery Information (pages 8-25)
6. Attachments (Submittals)
X
A. Proposal Submission Form (page 26)
X
B. Felony Conviction Notice (page 27)
X
C. Bid Certification Sheet (page 28)
X
D. No Response Form (page 29)
X
E. Certification Regarding Debarment, Suspension, etc (page 30)
X
F. Certification Regarding Lobbying and Instructions (pages 31-33)
X
G. Clean Air and Water Act (page 34)
X
H. References (page 35)
X
I.
Minimum Insurance Requirements (page 36)
X
J.
Questionnaire (pages 37-39)
X
K. Conflict of Interest Questionnaire (pages 40-42)
X
L. HUB Certification Form (page 43)
X
M. IRS Form W-9 (pages 44-45)
Page 2 of 45
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 may 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. Because all products will be provided on
an “as needed” basis, HCDE makes no representation either orally or in writing to the amount of trailer
equipment or related items HCDE will use during the term of the contract(s). 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 less than 50 lbs shall be made F.O.B. Destination full freight allowed. All
shipments over 50 lbs shall be made F.O.B. Origin prepay & add.
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.
Page 3 of 45
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.
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 and cooperative members will be invoiced directly; payment terms are net thirty
(30) days.
NEGOTIATIONS – Buyer has the right to negotiate deeper discounts if buying in larger quantities
than stated in this contract.
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. All prices quoted shall include a two (2%)
percent participation fee to be remitted to HCDE. HCDE will invoice contractor for this
participation fee on a quarterly basis of gross sales.
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.
Page 4 of 45
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.
WARRANTY – All equipment must be warranted to be free from defects in material and workmanship
for a period of one (1) year from manufacturer.
Page 5 of 45
SPECIFICATIONS
Food Service Equipment, Parts/Related Items and Maintenance Service for
Purchasing Cooperative.
BACKGROUND
The intention of this Request for Proposal (RFP) is to solicit proposals for Food Service Equipment,
Parts/Related Items, and Maintenance Service for Purchasing Cooperative.
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 June 12, 2008, at 9:00 a.m. at 6300 Irvington Blvd.,
Houston, TX 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:
08/012DG 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
6/6/08
6/9/08
6/12/08
6/25/08
7/15/08
The table above is only an estimate and may vary.
EQUIPMENT
The Purchasing Cooperative is looking for Food Service Equipment, Parts, Related Items, and
Maintenance Service. The equipment listed in this RFP will be used for food preparation, cooking,
storage, and/or cleaning in school cafeterias.
Although HCDE is referencing a manufacturer’s name we will accept other manufacturers that are
equivalent. Vendors may offer brand names that are equal to, or exceed, the quality of the requested
brand named product(s). Burden of equivalency rests solely with the vendor. HCDE shall decide if
substituted manufacturers are equal.
Page 6 of 45
PARTS/RELATED ITEMS
Parts will be defined as components used to repair equipment to include consumables such as oil,
gaskets, freon, and special tools. The Purchasing Cooperative will also have the option to purchase
these parts. Proposers shall provide a percentage discount off of parts catalog pricing in column 1 of
the supplied table. Discount can be by manufacturer, commodity, and entire catalog across the board,
or any combination.
Related Items is defined as all those pieces of equipment and accessories not listed. The Purchasing
Cooperative will also have the option to purchase related items not specifically listed. Proposers shall
provide a discount off related items by manufacturer, commodity, and entire catalog across the board,
or any combination in column 2 of the supplied table. During the course of the contract, contractor
shall be allowed to add new product lines and delete those that they no longer represent. This product
line update shall take place on a quarterly basis.
MAINTENANCE SERVICE
All Maintenance Service shall be for one (1) year and include all parts and labor. The Purchasing
Cooperative would like vendors to price maintenance/service agreements for food service equipment
with the following guidelines:
• Agreements should start after initial one (1) year warranty expires.
• Response time should be 4-6 hours on-site after service call.
• All service work performed should carry a minimum of one (1) year warranty on parts and ninety
(90) day warranty on labor.
• Work should be performed by a trained certified service technician
SHIPPING POINT
All shipments less than 50 lbs shall be made F.O.B. destination, full freight allowed. All shipments 50 lbs
and over shall be made F.O.B. origin, prepay & add.
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 Products and service
4. Extent to which service meets Cooperative’s needs
5. Vendor’s past relationship with the Cooperative
6. Impact on historically underutilized businesses
7. Total long term cost to Cooperative
8. Ability to service cooperative membership across the state of Texas
65 points
5 points
5 points
5 points
5 points
5 points
5 points
5 points
Total 100pts.
The Purchasing Cooperative is looking to make possible multiple awards to the highest evaluation
scores (70/pts or better) that meet HCDE evaluation criteria. The proposal(s) 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.
Page 7 of 45
PRICE DELIVERY INFORMATION
I.
Equipment.
No.
Description
Manufacturer
Model #
Qty
FOOD MIXER
GLOBE
SP60P
1-2
GARLAND
MCO-GS20-S
$
1
CONVECTION
OVEN
1-2
2
CONVECTION
STEAMER
ACCUTEMP
S64803D140
1-2
3
RANGE
GARLAND
SS686
4
SLICER
UNIVEX
9512
RATIONAL
SCC-102
ELECTRIC
BLODGETT
DFG-100
GAS
CLEVELAND
24-CGA-10
GAS
5
COMBI OVEN
3-5
3-5
1-2
6
CONVECTION
OVEN
1-2
7
CONVECTION
STEAMER
1-2
8
STEAM JACKETED
KETTLE
CLEVELAND
KGT-12-T
1-2
9
TILT BRAISING
PAN
GROEN
BPP-40G
1-2
10
WARMER FULL
PAN 12X20
ELECTRIC 120
VOLT
APW-WYOTT
W-3V
$
$
$
$
$
$
$
$
$
BUN PAN RACK
FOR 18 FULL SZ
18X26 PANS
ADVANCE
TABCO
PR18-3K
3-5
$
12
MICROWAVE
OVEN 1000 WATT
S/S W/TOUCH PAD
AMANA
ALD10T
3-5
$
13
MARK III
SANITECH
MARK III
14
MARK II
Page 8 of 45
$
3-5
11
15
Unit Price
SANITECH
MARK II
1-2
1-2
$
$
No.
Description
Manufacturer
CRESCOR
HEATED CABINET,
UNIVERSAL
ANGLE
CRES COR
Model or
Equivalent
Qty
H-137-UA12C
1-2
$
16
ICE MAKER AND
BIN W/ FILTER,
500LBS CAP
ICE O MATIC
ICE0500
3-5
$
17
II.
Unit Price
18
CONVECTION
OVEN
19
SLICER
GLOBE
GC12
3-5
20
MICROWAVE
OVEN
PANASONIC
NE-2157
3-5
21
ICE MAKER
MANITOWOC
SD-0852A
3-5
22
FOOD
PROCESSOR
MANHART
M2000
1-2
23
40QT FLOOR
MIXER
HOBART
D340
1-2
24
HEATED HOT
CABINET
CRES COR
H-339-214
1-2
25
MOBILE HOT
FOOD COUNTER
MOD-USERVE
MCT-HF5
3-5
MONTAGUE
3-5
EK8-N
$
$
$
$
$
$
$
$
Parts and Related Items. Please list your percentage off catalog. Please note items 299-310 have
been left blank for you to include other manufacturers not listed your company may represent. If
you need more space please attach separate sheet.
No.
Page 9 of 45
Mfg.
1
ABC Wunderbar
2
Accu-Temp
3
Adamation
4
Admiral Craft
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
No.
5
Advance/Tabco
6
Aero
7
Alston Quality Ind.
8
Alto Sham
9
Amana
10
American Panel
11
American Range
12
Anetsberger Bros
13
Ansul, Inc.
14
APW/Wyott
15
Arctic Air
16
Arctic Temp
17
Arctica
18
19
20
21
22
23
24
25
Page 10 of 45
Mfg.
Atlas Metal
ATS Seating
Automated
Merchandising Systems
(AMS)
Automatic Products
Avtec
Ayrking
Baker's Aid
Baker's Pride
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
Page 11 of 45
Mfg.
Barker
Baxter
Berkel
Berner
Best Value
Beverage Air
Bevless Corp
BKI
Blakeslee
Blodgett
Bloomfield
Brass Smith
Brewmatic
Brown Halco
Bunn
Cadco
Caddy Corp
Cal-Mil
Cambro
Carlisle
Carter-Hoffman
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
47
48
49
50
51
52
53
54
55
Mfg.
Cashmaster (Intelliscale)
Champion
Chicago Faucets
Chicago Metallic
Cleveland
CMA
Coinco
Cold Tech
Color Point
56
Cooler Guard
57
58
59
60
61
62
63
64
65
66
Page 12 of 45
Coolerking
Conlux
Continental Mfg.
Continental Refrigerator
Cook Tek
Cooper
Counter Craft
Craig
Cres cor
Crimsco
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
ATTACH LIST FOR FIRM
PRICING FOR VARIOUS #
OF FILTERS INSTALLED
AT ONE LOCATION
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
Mfg.
No.
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
Page 13 of 45
Cuno
Curtic
Curtron
Dean
Delfield
Detecto Scales
Dexter/Russell
Dispense Rite
Dito
Dixie Narco
Dormont Mfg.
Dough Pro
Doyon Equip
Duke
E-Control Refrigeration
Eagle-Metal Master
Edge Craft
Edlund
Eloma
Ember Glo
Erika
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
Page 14 of 45
Mfg.
Eurodib
Everpure Filters
Farberware
Federal Industries
Fisher
Food Warming
Equipment
Frigidaire
Frosty Factory
Frymaster
FEW/Food Warming
Equip
Galaxy
Galley
Garland-Welbilt
Gaylord
G.E.
G.E.T.
Gelberg Signs
Gemini Bakery Equip
Glenco
Globe
Goldstar
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
Page 15 of 45
Mfg.
Grainger
Grindmaster
Groen
Grosfillex
Hamilton Beach
Hardt Equipment
Harford
Hatco
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
Hobart Section
(cooking)
(food preparation)
(mixers)
(ware wash/waste)
Hodges
Holman Cooking Equip
Hood Depot
Hoshizaki
Hot Food Boxes
Howard McCray
Hubbel
Hussmann
No.
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
Page 16 of 45
Mfg.
IAF-Freshmarx
Ice-o-matic
Imperial
Impinger Ovens
Insinger
Insinkerator
Intedge
Intek Mfg
Inter-Metro Industries
International Cold
Storage System
International Tableware
ISS Shelving
Jackson
Jade Range
Jet-Tech Systems
Jordan
Kairak
Katchall parts of San
Jamar
Keating
Kelmax Corp
Kelvinator
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
Page 17 of 45
Mfg.
Kevry Corp
Kitchen Aid
Kloppenberg Ice Disp
Kolpak
Kool Star
Koolco
Krowne
Kruger
Kysor Panels
Lakeside Mfg.
Lancer
Lang
Leggett-Platt
Legion
Libertyware
Liftpak, L.C.
Lincoln/ Wearever
Lockwood Mfg
Low Temp Industries
Lowe Refrigeration
Magic Chef
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
Page 18 of 45
Mfg.
Mainstreet Menu
Manitowoc
Mannhart
Marc Refrigeration
Market Forge
Mars, Inc.
Mars Air Door
Mars Electronics
Master-Bilt
Master Disposers
McCall
McCary
Meal Time
Meico
Menu Mark
Menu Quick
Merco/Savory
Metal Masters F.S.
Metcraft
Metro
Middleby Marshall
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
Page 19 of 45
Mfg.
Migali Refrigeration
Miroil
Mod-U-Serve
Moffat Inc.
Montague
Moyer Diebel
Multiplex
Mundial
National Conveyors
Nemco
New Age Industrial
Nexel
Norlake
Nu-Vu
Oliver Products
Pacific Handy Cutter
Palmer Hamilton
Panasonic
Pest Control
Piper Products
Pitco
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
Page 20 of 45
Mfg.
Plastique
Plymold
Polar King (exterior
boxes)
Polarware
Powersoak/Metcraft
Precision Temp
Prince Castle
Prolon
Protech Mats Industries
Randell
Rankin-Delux
Rational
Raytek Food Safety
Thermometers
RDT
Redgoat
Regal - Pinnacle
Revent
R.F. Hunter
Robot Coup
Roper
Royal Fixtures
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
Page 21 of 45
Mfg.
Royalton
Rubbermaid/ Pelouze
Salvajor
Sani Serv
Sanitech (Steam
Cleaners)
Schematics Graphic
Scotsman
Seco
Select Stainless
Sentry9000 (HAACP
system)
Server
Servenal
Servolift/Eastern
Seymour
Silver King
Somat
Somerset
Southbend
Spokane Stainless
Star Food (reimburseable
vending machines)
Star Mfg
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
Page 22 of 45
Mfg.
Stellar Steam
Stero
Sterno
St. Louis Stainless
Stove Parts
Sunkist
Sur-Step
T & S Brass & Bronze
Tablecraft
Taylor Precision
Teknor Apex
Thermo-kool
Toastmaster
Toastwell
Traex
Traulsen
True Refrigeration
Tucker Burnguard
Turbo-Air
U.S. Range
Ultrafryer Systems
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
Page 23 of 45
Mfg.
Unimac
Universal Stainless
Univex
U-Select-IT (USI)
Varimixer
Ventmaster
Victory
Visual Graphic
Vollrath
Vulcan
WA Brown
Waring
Wells
West Bend
Westinghouse
Whirlpool
Win-Holt
Winston Industries
Wittco
Wolf Range
WoodStone
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
No.
Mfg.
Percentage Off
Parts Catalog
Percentage Off
Catalog
%
%
299
%
%
300
%
%
301
%
%
302
%
%
303
%
%
304
%
%
305
%
%
306
%
%
307
%
%
308
%
%
309
%
%
310
%
%
298
Zesto
III. Maintenance Service
Page 24 of 45
No.
Description
Qty
Value
1
Annual maintenance
1/year
Equipment Valued
$1 - $999
$
2
Annual maintenance
1/year
Equipment Valued
$1000 - $4999
$
3
Annual maintenance
1/year
Equipment Valued
$5000 - $9999
$
4
Annual maintenance
1/year
5
Annual maintenance
1/year
6
Annual maintenance
1/year
Equipment Valued
$10,000 - $19,999
Equipment Valued
$20,000 - $39,999
Equipment Valued
$40,000 +
Annual Fee
$
$
$
IV. Payment Terms: Payment Terms are net thirty (30) days. If applicable, please provide your discount
for early payment (i.e. 1% net 5) in the space below:
_______________________________________________________________________
_______________________________________________________________________
V.
Discount Catalog: Please include your discount catalog and/or price list.
___________________________________________________________________________________
Page 25 of 45
Attachment A
PROPOSAL SUBMISSION FORM
RFP NO. 08/012 DG Food Service Equipment, Parts, Related Items, and Maintenance Service for
Purchasing Cooperative
Please Print
Whereas on the ___________ day of ________________________, 2008 (print name of company)
_____________________________________________________________________has reviewed
RFP No. 08/012 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 26 of 45
Attachment B
FELONY CONVICTION NOTICE
Section 44.034, Texas Education Code, Notification of Criminal History of Contractor, Subsection
(a): “A person or business entity that enters into a contract 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): “A school district may terminate a contract 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 contract.”
Subsection (c): This section does not apply to a publicly held corporation.
You must check A, B or C, and sign below:
A)
Firm is a publicly held corporation; therefore the above reporting requirement does not
apply per Section 44.034, Texas Education Code, Subsection (c).
Contractor/Firm is not owned nor operated by anyone who has been convicted of a felony.
B)
C)
Contractor/Firm is operated or owned by the following individual(s) who has/have been
convicted of a felony:
Name of Individuals: _____________________________________________________
Detail of Conviction(s): ___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Attach additional pages labeled Attachment C2 if required.
I, the undersigned or agent for the firm named below, certify that the information concerning
notification of felony convictions has been reviewed by me and the information furnished is true to the best
of my knowledge:
Contractor’s Name/Company Name:
Authorized Official’s Name (Printed or Typed): _______________________________________
Signature:
Page 27 of 45
Date: _________________________
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 28 of 45
Attachment D
NO RESPONSE FORM
RFP NO. 08/012 DG Food Service Equipment, Parts, Related Items, and Maintenance Service for
Purchasing Cooperative
Please Print
Whereas on the __________ day of ____________________, 2008 (print name of company)
__________________________________________________________________________
has reviewed HCDE’s solicitation No. 08/012 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 29 of 45
Attachment E
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNTARY EXCLUSION
Instructions
1.
2.
3.
4.
5.
6.
7.
8.
9.
By signing and submitting this form, the prospective lower tier participant is providing the certification set out on the form in
accordance with these instructions.
The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered
into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification in addition to
other remedies available to the federal government, the department or agency with which this transaction originated may pursue
available remedies, including suspension and/or debarment.
The prospective lower tier participant shall provide immediate written notice to the person to whom this proposal is submitted if at
any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.
The terms “covered transaction,” “debarred,” “suspended,” “lower tier covered transaction,” “participant,” “person,” “primary
covered transaction,” “principal,” “proposal” and “voluntarily excluded,” as used in this clause, have the meanings set out in the
Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this
proposal is submitted for assistance in obtaining a copy of those regulations.
The prospective lower tier participant agrees by submitting this form that, should the proposed covered transaction be entered into, it
shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible or
voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this
transaction originated.
The prospective lower tier participant further agrees by submitting this form that it will include this clause titled “Certification
Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction” without modification in
all lower tier covered transactions and in all solicitations for lower tier covered transactions.
A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction
that it is not debarred, suspended, ineligible or voluntarily excluded from the covered transaction; unless it knows that the
certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals.
Each participant may, but is not required to, check the Non-procurement List.
Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith
the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of business dealings.
Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters
into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation
in this transaction, in addition to other remedies available to the federal government, the department or agency with which this
transaction originated may pursue available remedies, including suspension and/or debarment.
U. S. DEPARTMENT OF AGRICULTURE
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion—Lower Tier
Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and
Suspension, 7 CFR Part 3017, Section 3017.510, Participants’ responsibilities. The regulations were
published as Part IV of the January 30, 1989, Federal Register (pages 4722-4733). Copies of the
regulations may be obtained by contacting the Department of Agriculture agency with which this
transaction originated.
(Before completing certification, read attached instructions.)
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor
its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal.
Organization Name
Name and Title of Authorized Representative
Signature
Page 30 of 45
Date
Attachment F
CERTIFICATION REGARDING LOBBYING
Applicable to grants, Sub-grants, Cooperative Agreements, and Contracts Exceeding $100,000 in Federal
Funds.
Submission of this certifications a prerequisite for making or entering into this transaction and is imposed by
section 1352, Title 31, U.S. Code. This certification is a material representation of fact upon which reliance
was placed when this transaction was made or entered into. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each
such failure.
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress,
an officer or employee of congress, or an employee of a Member of Congress in connection with the awarding
of a Federal contract, the making of a Federal grant, the making of a Federal loan, the entering into a
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of a Federal
contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer
or employee of congress, or an employee of a Member of Congress in connection with this Federal grant or
cooperative agreement the undersigned shall complete and submit Standard Form-LLL, SF-LLL “Disclosure
of Lobbying Activities” Form in accordance with its instructions (see following page).
16. The undersigned shall required that the language of this certification be included in the award documents for
all covered sub awards exceeding $100,000 in Federal funds at all appropriate tiers and that all sub recipients
shall certify and disclose accordingly.
Name/Address of Organization
Name/Title of Submitting Official
Signature
Page 31 of 45
Date
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the Initiation
or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. Section 1352. The
filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting
to influence an officer or employees of any agency, a Member of Congress, an officer or employee of Congress, or an employee
of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional
information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change
report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is a/or has been secured to influence the
outcome of a covered Federal Action.
2. Identify the status of the covered Federal Action.
3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity for this covered Federal Action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known.
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or sub award
recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Sub awards include
but are not limited to subcontracts, sub grants, and contract awards under grants.
5. If the organization filing the report in item 4 checks “Sub awardee,” then enter the full name, address, city, state and zip
code of the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal Agency making the award or loan commitment. Include at least one organizational level
below agency name, if known. For example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog
of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g.,
Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant,
or loan award number; the application proposal control number assigned by the Federal agency). Include prefixes, e.g.,
“RFP-DE-90-001.”
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the
Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified
in item 4 to influence the covered Federal action.(b) Enter the full names of the individual(s) performing services, and
include full address if different from 10 (a). Enter Last Name, First Name, and Middle Initial (MI).
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the
lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all
boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be
made.
12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution, specify
the nature and value of the in-kind payment.
13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to
perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in
actual contact with Federal officials. Identify the Federal official(s) or employee(s) contact or the officer(s),
employee(s), or Member(s) of Congress that were contacted.
15. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.
16. The certifying official shall sign and date the form; print his/her name, title, and telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork
Reduction Project (0348-0046), Washington, D.C 20503.
Page 32 of 45
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Approved by OMB 0348-0046
1. Types of Federal Action:
2. Status of Federal Action:
3. Report Type:
A. contract
A. bid / offer / application
A. initial filing
B. grant
B. initial award
B. material change
C. cooperative agreement
C. post-award
For Material Change Only:
D. loan
year_____ quarter______
E. loan guarantee
date of last report_______
F. loan insurance
5. If Reporting Entity in No. 4 is Sub awardee, Enter Name and
4. Name and Address of Reporting Entity
Address of Prime:
Prime
Sub awardee
Tier______, if known
Congressional District, if known:
6. Federal Department/Agency:
8. Federal Action Number, if known:
10. A. Name and Address of Lobbying Entity(if
individual, last name, first name, MI):
Congressional District, if known:
7. Federal Program Name/Description:
CFDA Number, if applicable:___________
9. Award Amount, if known:
$
B. Individuals Performing Services(including address if
different from No. 10a) (last name, first name, MI):
(attach Continuation Sheet(s) SF-LLL-A, if necessary)
11. Amount of Payment (check all that apply):
13. Type of Payment (check all that apply):
□ A. retainer
$ ___________ □ actual
□ planned
□ B. one-time fee
□ C. commission
12. Form of payment (check all that apply):
□ D. contingent fee
□ A. cash
□ E. deferred
□ B. in-kind; specify: nature
□ F. other; specify:__________________
14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), or Member(s)
contacted, for Payment Indicated in Item 11:
(attach Continuation Sheet(s) SF-LLL-A, if necessary)
15. Continuation Sheet(s) SF-LLL-A:
□ Yes
□ No
16. Information requested through this form is
authorized by article 31 U.S.C. section 1352. This
Signature: _________________________________
disclosure of lobbying activities is a material
representation of fact upon which reliance was placed by
the tier above when this transaction was make or entered Print Name:________________________________
into. This disclosure is required pursuant to 31 U.S.C.
Title: _____________________________________
1352. This information will be reported to the Congress
semi-annually and will be available for public
Telephone No.: _____________________________
inspection. Any person who fails to file the required
disclosure shall be subject to a civil penalty of not less
Date: ______________________________________
than $10,000 and not more than $100,000 for each such
failure.
Federal Use Only:
Authorized for Local Reproduction Standard Form – LLL
Page 33 of 45
Attachment G
CLEAN AIR AND WATER ACT
CLEAN AIR AND WATER ACT CERTIFICATION
I certify that my company is in compliance with all applicable standards, orders or regulations issued
pursuant to the Clean Air Act of 1970, as amended (42 U.S.C. 1857(h). Section 508 of the Clean Water
Act, as amended (33 U.S.C. 1368), Executive Order 117389 and Environmental Protection Agency
Regulation, 40 CFR Part 15 as required under OMS Circular A-102, Attachment 0, Paragraph 14 (1)
regarding reporting violations to the grantor agency and to the United States Environmental Protection
Agency Assistant Administrator for the Enforcement.
I (We) the undersigned, agent for the firm, named below certify that the above information is true to
the best of my knowledge.
Organization Name
Name and Title of Authorized Representative
Original Signature
Date
Page 34 of 45
Attachment H
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 35 of 45
Attachment I
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 36 of 45
Attachment J
Questionnaire
(add additional sheets if necessary)
1. How long has your company been in business providing food equipment?
_____________________________________________________________________________
_____________________________________________________________________________
2. Explain in detail the equipment training that will be provided if any.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. Explain the standard warranty on new equipment items.
_____________________________________________________________________________
_____________________________________________________________________________
4. Explain the standard warranty on replacement parts.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. What is standard lead time for delivery of new equipment items?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Page 37 of 45
6. Are your service technicians uniformed with badges?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
7. What are your customer service hours of operation?
_____________________________________________________________________________
_____________________________________________________________________________
8. Does your company do onsite warranty or out of warranty work?
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________
9. What makes your company different from your competitors?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
10. Will our account be assigned a dedicated sales representative from your company? If so, who is
the contact name?
_____________________________________________________________________________
_____________________________________________________________________________
11. Can your company deliver and/or service all locations within Texas? Please list your regional
service/sales centers.
_____________________________________________________________________________
_____________________________________________________________________________
Page 38 of 45
12. DELIVERY SERVICE: Please list if you provide delivery on Food Service Equipment, which
could include:
1.
Inside delivery
______ YES _____ NO
2.
Uncrating, set in place, removal of packaging
______ YES _____ NO
3.
Installation
______ YES _____ NO
4.
Hauling away of existing equipment
______ YES _____ NO
5.
Any other special delivery requirements
______ YES _____ NO
13. Does your company provide on-site repair?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
14. Please explain the various ways our Cooperative members can order from your company.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
15. What is your company’s restocking/return policy?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
16. What is your company’s procedure for order acknowledgement and confirmation?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
17. Did you provide a copy of your maintenance service agreement with your proposal?
__________________________________________________________________________________
Page 39 of 45
Attachment K
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
Nathan Jones
Michele Kronke
Tammy Lanier
Peggy McGrane
Pam Newman
Venetia Peacock
Linda Pitre
Joanie Rethlake
Alfonso Saldivar
Dean Zajicek
Natasha Truitt
Faye Wells
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Shannon Bishop
Jim Davis
Richard Griffin
Sonny Janczak
Doug Kleiner
Noemi Lopez
Elaine Nichols
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
Local Government Code by a person doing business with the
governmental entity.
Form CIQ
OFFICE USE ONLY
the
Date Received
By law this questionnaire must be filed with the records
administrator of the local government not later than the 7th business
after the date the person becomes aware of facts that require the
statement to be filed. See Section 176.006, Local Government Code.
day
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.
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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
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_______________
Date
Attachment L
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)
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_________________________
Title
Attachment M
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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