Harris County Department of Education (HCDE) ITB Cover Sheet
Harris County Department of Education (HCDE) ITB Cover Sheet Job No.: 09/015JC Due Date: 02/27/09 DUE NO LATER THAN 1:00 P.M. CST LATE BIDS WILL NOT BE ACCEPTED Invitation to Bid (ITB) for: Books for Harris County Department of Education (HCDE) Adult Education Division. PLEASE NOTE Carefully read entire bid document and specifications. Complete all forms submit your bid with all appropriate supplements. Please submit your hard copy bid in a sealed envelope with job no., description, and marked “SEALED BID”. RETURN ITB TO: Attn: Jack Cutting– Purchasing Harris County Department of Education 6300 Irvington Blvd., Room 226 Houston, TX 77022-5618 For additional information contact Jack Cutting at (713) 696-0744 You must sign below in INK; failure to sign WILL disqualify the offer. All prices and responses must be typewritten or written in ink. Total Amount of Bid: $_________________ 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 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 26 DATE: ________________ TABLE OF CONTENTS Items below represent components which comprise this bid 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, 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 3-4) You should be familiar with all of the requirements. 4. Specifications (page 5) This section contains the detailed description of the product/service sought by the HCDE. 5. Price Delivery Information (pages 6-10) 6. Attachments (Submittals) A. Bid 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 (page 17) H. Conflict of Interest Questionnaire (pages 18-19) I. HUB Certification Form (page 20) J. IRS Form W-9 (pages 21-22) K. Antitrust Certification (page 23) L. Debarment Certification (page 24) M. Sole Source Affidavit (pages 25-26) Page 2 of 26 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 proposer. 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. DISQUALIFICATION - A proposer may be disqualified before or after the bids 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 bid. Bids, which are qualified with conditional clauses, items not called for, or irregularities, may be considered non-responsive by HCDE. FOB – All shipments shall be FOB destination full freight allowed. FINANCIAL RESPONSIBILITY – HCDE assumes no financial responsibility for any costs incurred in developing and submitting a bid. FORMAT –Bids shall include one (1) original complete bid. Proposers are responsible for ensuring their bid is received at the time and place specified on the cover page. HCDE is not responsible for bids that arrive late, or bids that do not have all the required information. INDEMNIFICATION - The proposer 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 proposer is required to deliver. The proposer’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 will be invoiced directly by proposer; payment terms are net thirty (30) days. Page 3 of 26 PENALTIES- If a successful proposer is unable to provide the awarded items at the quoted prices, after the bid has been opened, HCDE may take the following action(s): • Insist the successful proposer honor the quoted price(s) specified in their respective bid; • Have the successful proposer pay the difference between their price, and the price of the next acceptable bid (as determined by HCDE); • Recommend to HCDE’s Board of Trustees the successful proposer no longer be given the opportunity to submit a bid 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 bids will not be changed unless otherwise specified (in writing) by HCDE’s Director of Purchasing. PRICES- All prices shall be firm for the term of the contract. QUALITY - Any order issued as a result of this solicitation will conform to the specification and descriptions identified herein. Unless otherwise specified, the proposer will not deliver substitutes without prior authorization. QUESTIONS – Questions regarding the requirements specified in this solicitation must be faxed to (713) 696-0732 attn: Jack Cutting no less than three (3) working days before the bids 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. 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 BID - Refers to a bid that complies with all material and administrative aspects of this solicitation. RETURN OF BIDS – Bids once submitted will not be returned. TAXES - HCDE is tax – exempt. Bid prices should not include taxes. TIE BIDS - 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 products must be warranted to be free from defects in material and workmanship. Page 4 of 26 SPECIFICATIONS Invitation to Bid (ITB) for: Books for Harris County Department of Education (HCDE) Adult Education Division. BACKGROUND The intention of this Invitation to Bid (ITB) is to solicit bids for books for HCDE’s Adult Education Division. The books shall be new, the latest edition in good condition and packaged and shipped properly to avoid damage. HCDE is utilizing the Invitation to Bid (ITB) method for the procurement of this service in accordance with Section 44.031 Purchasing of Contracts, Item (1) Competitive Bidding. For information regarding the bid process, contact Jack Cutting of the Purchasing Division at (713) 696-0744. TIME TABLE HCDE anticipates following the time table listed below for this job: 09/015JC Time Table Item 1 2 3 4 Activity Job Starts to Advertise (1st run) Job Advertised (2nd run) Bids Due Award Date Date 1/30/09 2/02/09 2/27/09 4/21/09 The table above is only an estimate and may vary. SCOPE The books listed in the price delivery information below should be priced with unit price and total amount on the bid. Vendor should indicate the complete delivery time from the receipt of a purchase order. Page 5 of 26 PRICE DELIVERY INFORMATION Bidders must complete the open boxes below. HCDE reserves the right to award bid as it sees most beneficial. Books will be shipped FOB Destination. I. Item Book Title 1 Civics and Lit. Student Book 2 3 Literacy Skills Workbook Ready for the Interview Student Book 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Teachers Guide (All Components) Citizenhip: Passing the Test (Student Pack) Stand Out Basic (Class Set) (25/set) Stand Out Basic, Lesson Planner, 2nd Edition Assesment CD-ROM with ExamView Stand Out 1, (Class Set) Stand Out 1, Lesson Planner Assesment CD-ROM with ExamView Stand Out 2, (Class Set) Stand Out 2, Lesson Planner Assesment CD-ROM with ExamView Stand Out 3, (Class Set) Stand Out 3, Lesson Planner Assesment CD-ROM with ExamView Stand Out 4, (Class Set) StandO Out 4, Lesson Planner Page 6 of 26 Publisher New Readers Press New Readers Press New Readers Press New Readers Press New Readers Press Heinle & Heinle Bidder: ISBN Qty Unit Price $ 2888-AES09 200 2890-AES09 200 2226-AES09 200 2889-AES09 9 CITPK-AES09 10 1424031656 4 set Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle 978-1-42401927-4 978-14240-09992 4 Heinle & Heinle 6 1424031664 978-1-42401929-8 978-1-42400974-9 4 set 1424031672 978-1-42401934-2 978-1-42400989-3 4 set 1424031680 978-1-42401935-9 978-1-42400994-7 4 set 1424031699 4 set 978-1-42401936-6 4 4 6 4 6 4 6 Total Amount $ Item Book Title 20 Assesment CDROM with ExamView Stand Out 5, (Class Set) Stand Out 5, Lesson Planner Assesment CDROM with ExamView Downtown Basic, Text/Workbook Pkg Downtown Basic Text/Workbook/Au dio CDs Pkg Downtown 1, text book/Workbook Pkg Downtown 1, Teacher's Edition Textbook/Workboo k/CDs Pkg Downtown 2, text book/Workbook Pkg Downtown 2, Teacher's Edition Textbook/Workboo k/CDs Pkg Downtown 3, text book/Workbook Pkg Downtown 3, Teacher's edition Textbook/Workboo k/CDs Pkg Downtown 4, text book/Workbook Pkg Downtown 4, Teacher's Edition Textbook/Workboo k/CDs Pkg 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Complete Pre-GED Complete GED Preparation Complete Pre-GED Preparation Side By Side Plus Level 1 Value Package Test Package 1 Side By Side Plus Level 2 Value Package Page 7 of 26 Publisher ISBN Qty Heinle & Heinle Heinle & Heinle Heinle & Heinle 978-1-42400997-8 6 Heinle & Heinle 978-1-42401783-6 6 Heinle & Heinle 978-1-42409840-8? 100 Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle Heinle & Heinle McGrawHill/Conte mporary 978-1-424098446 978-1-42409840-8? 978-0-83845047-5 978-1-42409844-6 978-1-42409851-4 978-0-83845165-6 978-1-42409841-5 978-1-42409849-1 978-0-83845328-5 978-1-42409842-2 978-1-42409850-7 978-0-83845620-0 978-1-42409847-7 978-0-07286356-7 SteckVaughn SteckVaughn 978-1-41905399-3 978-0-73988785-1 Pearson Longman Pearson Longman 0138140235 978-0-13026752-8 50 Pearson Longman 0138140243 50 1424031702 978-1-42401937-3 4 set 4 10 75 10 10 75 10 10 75 10 10 75 7 7 200 200 100 6 Unit Price Total Amount Item Book Title 44 45 46 Test Package 2 Side By Side Plus Level 3 Value Package Side by Side 3 Teacher's Guide 33rd Edition 47 48 49 Test Package 3 Side By Side Plus Level 4 Value Package Side by Side 4 Teacher's Guide3rd Edition 50 Test Package 4 51 52 53 54 55 56 57 58 59 60 61 62 63 64 Number Power 3: Algebra Number Power 4: Geometry Number Power 5: Graphs, Charts, Schedules, and Maps Number Power: Review English in Action, Teachers Guide 1 English in Action, Teacher's Guide 2 English in Action, Teacher's Guide 3 English in Action, Teacher's Guide 4 Basic English Grammar (Red) Fundamentals of English Grammar (Black) Achieving TABE Success in Reading, Level E WB Achieving TABE Success in Reading, Level E Reader Achieving TABE Success in Reading, Level M WB Achieving TABE Success in Reading, Level M Reader Page 8 of 26 Publisher ISBN Qty Pearson Longman 978-0-13026767-2 6 Pearson Longman 0138140251 50 Pearson Longman Pearson Longman 978-0-13512612-7 978-0-13026885-3 Pearson Longman 0138140227 Pearson Longman Pearson Longman 978-0-13512613-4 978-0-13026890-7 Contempo rary 0-8092-2388-0 100 Contempo rary 0-8092-2382-1 100 0-8092-2381-3 100 150 Heinle Pearson Longman 0-8092-2379-1 978-0-83845184-7 978-0-83845193-9 978-0-83845196.0 978-0-83845201-1 978-0-13184937-2 Pearson Longman 978-0-13049447-4 100 Contempo rary 978-0-07704459-6 250 Contempo rary 978-0-07704463-3 250 McGrawHill/Conte mporary 978-0-07704460-2 350 McGrawHill/Conte mporary 978-0-07704464-0 350 Contempo rary Contempo rary Heinle Heinle Heinle 7 6 50 10 6 2 5 4 6 100 Unit Price Total Amount Item 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 Book Title Achieving TABE Success in Reading, Level D WB Achieving TABE Success in Reading, Level D Reader Achieving TABE Success in Reading, Level A WB Achieving TABE Success in Reading, Level A Reader Achieving TABE Success in Mathematics, Level E Achieving TABE Success in Mathematics, Level M Achieving TABE Success in Mathematics, Level D Achieving TABE Success in Mathematics, Level A Achieving TABE Success in Language, Level E Achieving TABE Success in Language, Level M Achieving TABE Success in Language, Level D Achieving TABE Success in Language, Level A Ventures Basic Level Classroom Pack (25/pack) Ventures Level 1 (Classroom Pack) Ventures Level 2 (Classroom Pack) Ventures Level 3 (Classroom Pack) Ventures Level 4 (Classroom Pack) 82 American History 1 Student Book 83 American History 1 Resource Binder Page 9 of 26 Publisher ISBN Qty McGrawHill/Conte mporary 978-0-07704461-9 250 McGrawHill/Conte mporary 978-0-07704465-7 250 McGrawHill/Conte mporary 978-0-07704462-6 200 McGrawHill/Conte mporary 978-0-07704466-4 200 McGrawHill/Conte mporary 978-0-07704467-1 250 McGrawHill/Conte mporary 978-0-07704468-8 350 McGrawHill/Conte mporary 978-0-07704469-5 250 978-0-07704470-1 200 978-0-07704455-8 300 978-0-07704456-5 350 978-0-07704457-2 250 978-0-07704458-9 150 McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary Cambridg e Cambridg e Cambridg e Cambridg e Cambridg e McGrawHill/Conte mporary McGrawHill/Conte mporary 978-0-52172117-2 978-0-52172115-8 978-0-52172114-1 978-0-52172113-4 978-0-52172112-7 10 pk 8 pk 8 pk 6 pk 6 pk 978-0-07704435-0 30 978-0-07704436-7 1 Unit Price Total Amount Item Book Title 84 American History 2 Student Book 85 American History 2 Resource Binder 86 World History Student Book World History Teacher's Resource Binder 87 88 Biology Student Book. 89 Biology Workbook Earth and Space Science Student Book 90 91 Earth and Space Sciene Workbook Websters New College Dictionary Rogets II The New Thesaurus Key to GED Success: Social Studies Key to GED Success: Mathematics Keys to GED Success: Science Keys to GED Success: Language Arts, Reading Keys to GED Success: Language Arts, Writing 92 93 94 95 96 97 98 II. Publisher McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary McGrawHill/Conte mporary ISBN Qty 978-0-07704438-1 30 978-0-07074439-8 1 978-0-07704447-3 30 978--0-07704448-0 1 978-0-07704536-4 30 978-0-07704132-8 30 978-0-07704148-9 30 978-0-07704152-6 30 Butler 0-395-96214-5 30 Butler 0-618-25414-5 30 Stech Vaugh 978-1-41905351-1 30 Stech Vaugh Stech Vaugh 978-1-41905347-4 978-1-41905350-4 Stech Vaugh 978-1-41905349-8 Stech Vaugh 978-1-41905348-1 TOTAL Unit Price Total Amount 30 30 30 30 $ Payment Terms and Shipping Point: Please provide your payment terms and shipping point in the space below: _____________________________________________________________________ _____________________________________________________________________ III. Delivery: Indicate the delivery date on the books you are bidding after receipt of a purchase order. _________________________________________________________________________________ _________________________________________________________________________________ Page 10 of 26 Attachment A BID SUBMISSION FORM ITB NO. 09/015 JC, Books for Harris County Department of Education Please Print Whereas on the _____________ day of _________________________, 2009 (print name of company) ______________________________________________________________________ reviewed has HCDE’s solicitation No. 09/015JC 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 26 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. Proposer’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 26 Attachment C BID CERTIFICATION SHEET In order for a bid to be evaluated and considered, the following information must be provided. As defined by Texas House Bill 602, a "nonresident bidder" means a bidder whose principal place of business is not in Texas, but excludes a contractor whose ultimate parent company or majority owner has its principal place of business in Texas. I certify that my company is a "resident bidder": Signature: ___________________________ Date: _____________________ -----------------------------------------------------------------------------------------------------------If you qualify as a "nonresident bidder," you must furnish the following information: What is your resident state? (The state your principal place of business is located) ______________________________________________________________ Address (include City, State and Zip Code) (A) Does your "residence state" require bidders whose principal place of business is in Texas to underbid bidders whose residence state is the same as yours by a prescribed amount or percentage to receive a comparable contract? "Residence State" means the state in which the principal place of business is located. Yes______ No______ (B) What is the amount or percentage? __________% I certify that the above information is correct: _______________________________________ _________________________ Typed Name Position ______________________________________ Company Name Page 13 of 26 Attachment D NO RESPONSE FORM ITB NO. 09/015JC, Books for Harris County Department of Education Please Print Whereas on the ___________ day of ____________________, 2009 (print name of company) __________________________________________________________________________ has reviewed HCDE’s solicitation No. 09/015JC, and elects not to submit a bid: ______________________________________________ Street Address ______________________________________________ City, State, Zip Code ______________________________________________ Telephone/Fax Number ______________________________________________ Name of Authorized Individual ___________________________________________ Signature of Authorized Individual Page 14 of 26 Attachment E References Please provide at least three (3) references (co. name, address, telephone no. and contact) that have purchased products and/or related items from you in the last 3-4 years. 1. Company Name: __________________________________ Address: __________________________________ __________________________________ __________________________________ 2. Contact: __________________________________ Phone Number: __________________________________ E-mail: __________________________________ Company Name: __________________________________ Address: __________________________________ __________________________________ __________________________________ 3. Contact: __________________________________ Phone Number: __________________________________ E-mail: __________________________________ Company Name: __________________________________ Address: __________________________________ __________________________________ __________________________________ Contact: __________________________________ Phone Number: __________________________________ E-mail: __________________________________ Page 15 of 26 Attachment F Minimum Insurance Requirements • The contractor shall, at all times during the term of this contract, maintain insurance coverage with not less than the type and requirements shown below. Such insurance is to be provided at the sole cost of the contractor. These requirements do not establish limits of the contractor's liability. • All policies of insurance shall waive all rights of subrogation against HCDE, its officers, employees and agents. • Upon request, certified copies of original insurance policies shall be furnished to HCDE. • HCDE reserves the right to require additional insurance should it be deemed necessary. A. Workers' Compensation (with Waiver of subrogation to HCDE) Employer's Liability, including all states, U.S. Longshoremen, Harbor Workers and other endorsements, if applicable to the Project. Statutory, and Bodily Injury by Accident: $100,000 each employee. Bodily Injury by Disease: $500,000 policy limit $100,000 each employee. HCDE shall be named as "additional insured" on workers’ compensation policy. B. Commercial General Liability Occurrence Form including, but not limited to, Premises and Operations, Products Liability Broad Form Property Damage, Contractual Liability, Personal and Advertising Injury Liability and where the exposure exists, coverage for watercraft, blasting collapse, and explosions, blowout, catering and underground damage. o $300,000 each occurrence Limit Bodily Injury and Property Damage combined o $300,000 Products-Completed Operations Aggregate Limit $500,000 per Job Aggregate o $300,000 Personal and Advertising Injury Limit HCDE shall be named as "additional insured" on commercial general liability policy. C. Automobile Liability Coverage: o $300,000 Combined Liability Limits Bodily Injury and Property Damage Combined. HCDE shall be named as "additional insured" on automobile policy. Page 16 of 26 Attachment G Questionnaire Job No. 09/015JC, Books for Harris County Department of Education (add additional sheets if necessary) 1. How long has your company been in the book publishing business? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 2. How long has your company been in the book distribution business? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 3. How quickly can your company respond to HCDE book orders? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 4. What else would you like to tell us about your company that makes you qualified for this job? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Page 17 of 26 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): Ms. Angie Chesnut, President Mr. Louis Evans, III, Vice-President Mr. Roy Morales Mr. Jim Henley Mr. Michael Wolfe Ms. Debra Kerner Mr. Carl Schwartz Dr. John Sawyer Below is a listing of current local government officers: Jesus Amezcua Linda Pitre Dean Zajicek Page 18 of 26 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 Name of person who has a business relationship 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 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 26 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 proposers 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 26 _________________________ Title Attachment J Substitute Form W-9 Give form to the requester. Do not send to the IRS. Request for Taxpayer Identification Number and Certification (Rev. February 2005) 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 number, see How to get a TIN on page 3. 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 or Employer identification number 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 ► Page 21 of 26 Date ► Purpose of FormA 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 Form W-8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). 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) Page 22 of 26 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 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. Proposer _______________________ Bidder ______________________ Signature _______________________ ______________________ Printed Name Address _______________________ ______________________ Position with Company _______________________ _______________________ Fax _______________________ _______________________ Page 23 of 26 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) The prospective lower tier participant certifies, by submission of this bid, 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 bid. ________________________________________________________________________________ Organizations Name PR/Award # or Project Name ________________________________________________________________________________ Name and Title of Authorized Representative ________________________________________________________________________________ Signature Page 24 of 26 Attachment M Instructions for Sole Source Affidavit Applicable to: Proposers 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 25 of 26 (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______. ______________________________ Notary Public Signature (SEAL) ______________________________ Printed Name ______________________________ Date Commission Expires Company: ________________________________ Contact Person: ____________________________ Address: __________________________________________________________________________ City, State, and Zip: __________________________________________________________________ Telephone Number: ___________________________ Fax: ___________________________________ Page 26 of 26
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