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2. government
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Harris County Department
of Education (HCDE)
CSP Cover Sheet
Job No.:
09/009LB
Due Date:
January 5, 2009
DUE NO LATER THAN 1:00 P.M.
LATE BIDS WILL NOT BE ACCEPTED
Request for Proposal (RFP): Phone System for Harris County Department of Education
and Purchasing Cooperative.
PLEASE NOTE
Carefully read entire bid 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: Lytrina Bob– Purchasing
Harris County Department of Education
6300 Irvington Blvd., Room 223
Houston, TX 77022-5618
For additional information contact Lytrina Bob (713) 696-2112
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 #
E-mail
Print Name
Signature
Total Amount of Bid: $_________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
_________________________ Fax # ____________________
____________________________________________________
____________________________________________________
____________________________________________________
Your signature attests to your offer to provide the goods and/or services in this bid
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 27
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)
A.
Proposal Submission Form (page 11)
B.
Felony Conviction Notice (page 12)
C.
Bid Certification Sheet (page 13)
D.
No Response Form (page 14)
E.
References (page 15)
F.
Minimum Insurance Requirements (page 16)
G.
Questionnaire (pages 17)
H.
Conflict of Interest Questionnaire (pages 18- 19)
I.
HUB Certification Form (page 20)
J.
IRS Form W-9 (page 21-22)
K.
Antitrust Certification (page 23)
L.
Debarment Certification (page 24)
M.
Sole Source Affidavit (pages 25- 26)
Page 2 of 27
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.
THE BUY AMERICA ACT - HCDE and cooperative members have a preference
for domestic end products for supplies acquired for use in the United States when
spending federal funds. Purchases that are made with non-federal funds or grants are
excluded from the Buy America Act.
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 nonresponsive 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.
Page 3 of 27
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.
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.
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.
Page 4 of 27
QUESTIONS – Questions regarding the requirements specified in this solicitation
must be faxed to (713) 696-0732 attn: _Lytrina Bob 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 nonresident 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 products and or service must be warranted to be free from
defects in material and workmanship for a period of one (1) year.
Page 5 of 27
BACKGROUND
Request for Proposal (RFP): Phone System for Harris County Department of
Education and the Purchasing Cooperative
The intention of this Request for Proposal (RFP) is to solicit proposals for a
Phone System for Harris County Department of Education (HCDE) and its 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.
For information regarding the proposal process, contact Lytrina Bob of the Purchasing
Division at (713) 696-2112.
A pre-proposal conference is scheduled for December 19, 2008 at 9:00 a.m. at 6300
Irvington Blvd., Houston, TX 77022-5618. Attendance is not mandatory but is
encouraged to have a better understanding of the requirements of this RFP. Persons
with disabilities requiring special accommodations should contact Lytrina Bob at (713)
696-2112 at least two (2) days prior to the conference.
For information regarding the proposal process, contact Lytrina Bob of the Purchasing
Division at 713-696-2112 and for technical questions contact Arthur Vu at 713-696-8278
or Nathaniel Jones at 713-696-8274.
TIME TABLE
HCDE anticipates following the time table listed below for this job:
09/009LB 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
The table above is only an estimate and may vary.
Page 6 of 27
Date
12/9/08
12/16/08
12/19/08
1/05/09
2/24/09
SPECIFICATIONS
Harris County Department of Education
IP Phone System RFP
Technical Specifications
Telephone functions:
•
Integrated Ethernet switch port for dual connection to Phone and PC.
•
•
•
Support for separate VLAN for phone and attached PC.
Power over Ethernet (802.3af) support.
Support for Automatic: VLAN configuration (preferred), QoS + phone
software image management
Message waiting indicator
LCD Display
Full duplex speaker phone with intercom capability
Programmable buttons (soft keys) for display-based access to features and to
make call queue login easy
Speed dial buttons, programmable from the telephone
Compatible with common headsets and lifters
Distinguished ring tones, allowing staff working in close quarters to
differentiate between their telephone ringing and a co-worker’s telephone
A small number of telephones may need a visual indicator of incoming calls
instead an audible tone. If the telephone has both an audible and visual
indicator of incoming calls, there must be an ability to disable or inactivate the
audible tone. Any other audible indicators, such as tones when buttons are
pressed, must also have the ability to be disabled or inactivated.
•
•
•
•
•
•
•
•
System Functions:
•
•
•
•
Page 7 of 27
Audible dial tone - User must hear a dial tone when requesting a line to place
a call, prior to dialing the destination telephone number.
Background Music - Provide background music while callers are on hold.
Include a selection of music free of ongoing licensing fees and\ or the ability
to play a local radio station while the caller is on hold.
Call Relay - If the system has the ability to transfer a call received from the
outside to another outside line, the feature needs to be enabled on a per-user or
per-group basis. The default access for this feature must be “off’.
Call Accounting and Reporting - Keep track of calls placed, type of call,
originating extension, destination, and duration of call. Log and report on
inbound and outbound call traffic, port usage, call queue traffic, user log
•
•
•
•
•
•
•
•
•
•
•
•
Page 8 of 27
in/log out, average wait times and peak periods. Output reports on paper and
in common file formats such as CSV and XLS.
System administration should be accessible through web browser interface
Call Blocking - The system should have the ability to block collect calls
and/or toll calls on a per-telephone and/or per-user basis. Also give the ability
to make 900 calls and restrict 900 calls were applicable.
E-mail Alert - Send messages when call processing thresholds have been
reached or exceeded, or if the system otherwise needs an administrator’s or
call queue supervisor’s attention
911 - System must support the ability for users to dial 911 in the event of an
emergency. Send an alert to specified extensions and via e-mail in the event
911 is dialed. Allow both “911” and the outside line access code + “911” to be
dialed to reach the 911 operator.
Call Handling – System must be able to handle multiple call handling modes
for out of office, vacation, holidays etc.
Business Hours Schedule - At least two different schedules can be defined by
the system administrator in terms of day of week and time of day to designate
when calls are routed to call queues and when other messages are played to
callers, without the need for manual intervention.
Least-Cost Routing - System must route calls based on number dialed,
allowing calls to be placed using the least expensive route.
Automated Attendants - Use automated attendants to receive and route calls to
extensions and call queues. Time of day and a system-wide Holiday schedule
should be used to determine whether callers can be routed to call queues or
should receive informational messages.
Caller Response to Prompts - Automated Attendant menu options and other
prompts should be selected by a single key press. Should the system have the
ability to recognize spoken words as a response to a prompt (IVR), responses
should be limited to the equivalent of a single key press (e.g., “Press or say
three”). System should optionally, on a message by message basis, prevent a
prompt from being recognized while a message is being played. This will
ensure that an entire message is heard by the caller, such as a disclaimer, or to
allow a user who is familiar with the prompts to select options before they
have been played.
Supervisory Monitoring - A message must be played stating that their call
may be monitored for training and quality control purposes. Supervisors
should have the ability to listen in on calls in progress, and have the ability to
record a call they are listening in on.
Call Bridging - Allow a minimum of 8-10 people to dial into the system to
participate in a conference call. Allow designated users to establish meet-me
conference arrangements so conferees can dial a predetermined
number/extension, input an access code and join the conference call.
Soft phone - software that turns a PC into a phone that can be used to place
calls over the Internet
•
Computer Telephony Integration (CTI) - linking a computer to a telephone
system in order to deliver business benefits through the automation of call
handling.
EVALUATION CRITERIA
Proposal will be evaluated based on the criteria listed below. Please ensure that your
proposal addresses the following evaluation criteria areas completely:
1. Price
.
40 points
2. Reputation of Vendor (References)
10 points
3. Quality of Vendor’s Service
10 points
4. Extent to which service meets Cooperative’s needs
10 points
5. Vendor’s past relationship with the Cooperative
5 points
6. Impact on historically underutilized businesses
5 points
7. Total long term cost to Cooperative
10 points
8. Ability to service cooperative membership across the state of Texas
10 points
Total 100 pts
The proposal that receives the highest evaluation score and meets HCDE specifications
will be the party receiving the award recommendation. HCDE reserves the right to make
a single award, split, multiple or none. The proposal shall remain confidential
information until an award decision has been made. After the award has been made, all
bidders will be allowed to view bid results or request bid tabulation results.
Page 9 of 27
PRICE DELIVERY INFORMATION
I. Submitter must complete the request for information supplied in the
Description section listed below. Attach price sheet to satisfy requested information.
Item
Description
Qty.
1.
2.
3.
4.
Equipment Cost – Hardware
Software & License Cost
Installation & Configuration Cost
Learning Credits for System
Administration Training
Training for System Administrators
Training for end users
Yearly Maintenance Costs up to 5 yrs
1/lot
1/lot
1/lot
1/lot
5.
6.
7.
Price
1/lot
1/lot
1/lot
II. Payment Terms: Please provide your payment terms in the space below:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
_____________________________________________
Page 10 of 27
Attachment A
PROPOSAL SUBMISSION FORM
RFP NO. 09/009LB Phone System
Please Print
Whereas on the _____________ day of ___________________, 2009 (print name of company)
______________________________________________________________________ has
reviewed
HCDE’s solicitation No. 09/009LB 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 27
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 27
Attachment C.
PROPOSAL CERTIFICATION SHEET
In order for a proposal 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 proposers whose principal place of business is in
Texas to underbid proposers 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 27
Attachment D.
NO RESPONSE FORM
RFP NO. 09/009LB
Phone System for Harris County Department of Education (HCDE)
Please Print
Whereas on the ___________ day of ____________________, 2009 (print name of company)
__________________________________________________________________________
has reviewed HCDE’s solicitation RFP No. 09/009LB, 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 27
Attachment E.
References
Please provide at least three (3) references (co. name, address, telephone no. and contact)
that have used your company for the same goods or services HCDE is requesting in this
proposal. List those companies that have used your goods or services in the last 3-4
years.
A. ______________________________
______________________________
______________________________
______________________________
B. _______________________________
_______________________________
_______________________________
_______________________________
C. ________________________________
________________________________
________________________________
________________________________
Page 15 of 27
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.
$300,000 each occurrence Limit Bodily Injury and Property Damage Combined
$300,000 Products-Completed Operations Aggregate Limit $500,000 Per Job Aggregate
$300,000 Personal and Advertising Injury Limit. HCDE shall be named as "additional
insured" on commercial general liability policy.
C. Automobile Liability Coverage:
$300,000 Combined Liability Limits. Bodily Injury and Property Damage Combined.
HCDE shall be named as "additional insured" on automobile policy.
Page 16 of 27
Attachment G.
Questionnaire
(add additional sheets if necessary)
1. How long has your company been in business providing Phone Systems?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. What implementing methodology will your company provide in setting up our
account and how seamless of a transition will it be?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. Explain in detail the user training that will be provided. The technical support
and customer support that will be made available.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Is there a charge for additional on site user training or on site technical support?
__________________________________________________________________
__________________________________________________________________
5. Please provide last year’s certified financial statement of your company’s:
Balance Sheet and Income Statement
6. What is the lead time for delivery and complete installation of the system?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7. Do you have 24/hr., 7/day customer service support?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
8. Can system be installed after hours, weekends to avoid work disruptions?
__________________________________________________________________
Page 17 of 27
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
Linda Pitre
Dean Zajicek
Page 18 of 27
Celes Harris
Joanie Rethlake
Natasha Truitt
Les Hooper
Jim Schul
FORM CIQ
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
OFFICE USE ONLY
This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code by a
person who has a business relationship as defined by Section 176.001(1-a) with a local governmental
entity and the person meets requirements under Section 176.006(a).
Date Received
By law this questionnaire must be filed with the records administrator of the local governmental entity 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 knowingly violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
1
2
Name of person who has a business relationship with local governmental entity.
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 the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)
3
Name of local government officer with whom filer has employment or business relationship.
Name of Officer
This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an employment or other
business relationship as defined by Section 176.001(1-a), Local Government Code. 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, other than investment
income, from the filer of the questionnaire?
Yes
No
B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the
direction of the local government officer named in this section AND the taxable income is not received from the local
governmental entity?
Yes
No
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local
government officer serves as an officer or director, or holds an ownership of 10 percent or more?
Yes
No
D. Describe each employment or business relationship with the local government officer named in this section.
4
Signature of person doing business with the governmental entity
Page 19 of 27
Date
Adopted 06/29/2007
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 20 of 27
_________________________
Title
Page 21 of 27
Substitute
Form
W9
(Rev. February 2005)
Request for Taxpayer
Identification Number and Certification
Give form to the
requester. Do not send
to the IRS.
Please print or type
See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name, if different from above
Check
appropriate
box:
Individual/Sole Proprietor
Corporation
Partnership
LLC filing as Sole Proprietor
LLC filing as Corporation
LLC filing as Partnership
Address (number, street, and apt. or suite no.)
Other
Exempt from backup
withholding
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Social security number
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding.
For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity,
see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a
or
number, see How to get a TIN on page 3.
Employer identification number
Note: If the account is in more than one name, see the chart on page 3 for guidelines on whose number to enter.
Part II
Certification
Under penalties of perjury, I certify that:
1.
The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2.
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, and
3. I am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 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, item 2 does not apply. For mortgage interest paid, acquisition or
abandonment of secured property, cancellation of debt, contributions to an individual 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. (See the instructions on page 3.)
Sign Here
Signature of
U.S. person ►
Purpose of Form A person who is required to file an information return with the
IRS must obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest you paid,
acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
U.S. person. Use form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the requester) and,
when applicable, to:
1. Certify the TIN you are giving is correct (or you are waiting for a number to
be issued),
2.
Certify you are not subject to backup withholding, or
3.
Claim exemption from backup withholding if you are a U.S. exempt payee.
Note: If a requester gives you a form other than Form W-9 to request your TIN,
you must use the requester’s form if it is substantially similar to this Form W-9.
For federal tax purposes you are considered a person if you are:
•
An individual who is a citizen or resident of the United States,
•
A partnership, corporation, company, or association created or organized in
the United States or under the laws of the United States, or
•
Any estate (other than a foreign estate) or trust. See Regulations sections
301.7701-6(a) and 7(a) for additional information.
Foreign person. If you are a foreign person, do not use For W-9. Instead use the
appropriate FormPage
W-8 22
(see
515, Withholding of Tax on Nonresident
ofPublication
27
Aliens and Foreign Entities).
Date ►
Nonresident alien who becomes a resident alien. Generally, only a nonresident
alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a provision known as a
“saving clause.” Exceptions specified in the saving clause may permit an
exemption from tax to continue for certain types of income even after the recipient
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on a exception contained in the
saving clause of a tax treaty to claim an exemption from U.S. tax on certain types
of income, you must attach a statement to Form W-9 that specifies the following
five items:
1. The treaty country. Generally, this must be the same treaty under which you
claimed exemption from tax as a nonresident alien.
2.
The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the saving
clause and its exceptions.
4.
The type and amount of income that qualifies for the exemption from tax.
5. Sufficient facts to justify the exemption from tax under the terms of the
treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an exemption from
tax for scholarship income received by a Chinese student temporarily present in the
United States. Under U.S. law, this student will become a resident alien for tax
purposes if his or her stay in the United States exceeds 5 calendar years. However,
paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984)
allows the provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
Substitute Form W-9 (Rev. 02-2005)
Attachment K.
Antitrust Certification Statement
(Tex. Government Code § 2155.005)
I affirm under penalty of perjury of the laws of the State of Texas that:
(1) I am duly authorized to execute this contract on my own behalf or on behalf of
the company, corporation, firm, partnership or individual (Company) listed below;
(2) In connection with this bid, neither I nor any representatives of the Company
have violated any provision of the Texas Free Enterprise and Antitrust Act, Tex. Bus. &
Comm. Code Chapter 15;
(3) In connection with this bid, neither I nor any representative of the Company
have violated any federal antitrust law; and
(4) Neither I nor any representatives of the Company have directly or indirectly
Page 23 of 27
communicated any of the contents of this bid to a competitor of the Company or any other
company, corporation, firm, partnership or individual engaged in the same line of business as
the Company.
Vendor
_______________________
Bidder
______________________
Signature
_______________________
______________________
Printed Name
Address
_______________________
______________________
Position with Company
_______________________
_______________________
Fax
_______________________
_______________________
Official
Authorizing Bid
_______________________
Signature
_______________________
Printed Name
_______________________
Position with Company
Attachment L.
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.
(1)
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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.
________________________________________________________________________
Organizations Name
PR/Award # or Project Name
________________________________________________________________________
Name and Title of Authorized Representative
________________________________________________________________________
Signature
Page 25 of 27
Attachment M.
Instructions for Sole Source Affidavit
! Applicable to: Vendors requesting to become a Sole Source Vendor
! Criteria: In order to become a Sole Source Vendor, you must meet the Texas
Education Code Statute Number 44.031 (j) Sole Source, as described below.
Selected purchases may be exempt from competitive procurement if they meet the
established criteria for a sole source purchase:
#
#
#
Identification and confirmation that competition in providing the
item or product to be purchased is precluded by the existence of
o a patent, copyright, secret process or monopoly
Identification and confirmation that the product is a
o film
o manuscript
o book
o utility service including electricity, gas, or water
o captive replacement part or component for equipment
Sole source does not apply to mainframe data-processing
equipment and peripheral attachments with a single item purchase
price in excess of $15,000.
It is incumbent upon the district to obtain and retain documents from the vendor which
clearly delineates the reasons that qualify the purchase to be made on a sole source
basis.
! Information must be mailed to: In order to do business with the Department as a Sole
Source Vendor, HCDE must receive a notarized Sole Source Affidavit along with
proof of your company being sole source. Please mail this information to:
HCDE
Attn: Purchasing Office
6300 Irvington
Houston, Texas 77022
! HCDE Business Office reserves the right to decide if your company is indeed a
qualified Sole Source Vendor for the Department.
Page 26 of 27
(On Vendors Letterhead)
SOLE SOURCE AFFIDAVIT
Before me, the undersigned official, on this day, personally appeared ____________________, a person
known to me to be the person whose signature appears below, whom after being duly sworn upon his oath
deposed and said:
1. My name is ______________________, I am over the age of 18, have never been convicted of a crime
and being competent to make the affidavit.
2. I am an authorized representative of the following company or firm:
_____________________________________________________________________________
3. The above named company or firm is the sole source of the following item(s), and no other company or
firm in the United States of America sales or distributes the product(s) listed below:
__________________________________________________________________________________
____________________________________________________________________________
4. Competition in providing the above named item(s) or product is precluded by the existence of a patent,
copyright, secret process, or monopoly.
5. The product is a film, manuscript, book, a utility service (including electricity, gas, or water), or a
captive replacement part or component for equipment.
6. There is/are no other like item(s) or product(s) available for purchase that would serve the same
purpose or function and there is only one price for the above named item(s) or product(s) because of
exclusive distribution or marketing rights.
Signature of Authorized Vendor Official
Title of Authorized Vendor Signature
Signature of Supervisor of Authorized Vendor Official
Title of Authorized Vendor Signature
Affidavit will be valid for two (2) years from date subscribed and sworn.
SUBSCRIBED AND SWORN to before me on this __________day of ___________, 20______.
(SEAL)
______________________________
Notary Public Signature
______________________________
Printed Name
______________________________
Date Commission Expires
Company: ________________________________ Contact Person: ____________________________
Address: __________________________________________________________________________
City, State, and Zip: __________________________________________________________________
Telephone Number: ___________________________ Fax: ___________________________________
Page 27 of 27