1. law, govt and politics
2. government
3. legislative

Harris County Department
of Education (HCDE)
RFP Cover Sheet
Job No.:
09/005JC
Due Date:
11/10/08
DUE NO LATER THAN 1:00 P.M.
LATE BIDS WILL NOT BE ACCEPTED
Request for Proposal (RFP) for: Amplification Sound System for Harris County
Department of Education (HCDE) Choice Facility Partners Division.
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: 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
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 26
DATE: ________________
TABLE OF CONTENTS
Items checked below represent components which comprise this bid/proposal package. If the item IS NOT checked, it
is NOT APPLICABLE to this bid/proposal. 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.
__X__ 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.
__X__ 2.
Table of Contents (page 2)
This page is the Table of Contents.
__X__ 3.
Terms and Conditions (pages 3-5)
You should be familiar with all of the requirements.
__X__ 4.
Specifications (pages 6-10)
This section contains the detailed description of the product/service sought by the HCDE.
__X__ 5.
Price Delivery Information (page 11)
__X__ 6.
Attachments (Submittals)
Page 2 of 26
__X__ a.
Proposal Submission Form (page 12)
__X___ b.
Felony Conviction Notice (page 13)
__X__ c.
Bid Certification Sheet (page 14)
__X__ d.
No Response Form (page 15)
__X__ e.
References (page 16)
__X__ f.
Minimum Insurance Requirements (page 17)
__X__ g.
Amplification Sound System Questionnaire (page 18)
__X__ h.
Conflict of Interest Questionnaire (page 19-21)
__X__ i.
HUB Certification (page 22)
__X__ j.
W-9 Form (page 23-24)
__X__ k.
Antitrust Certification (page 25)
__X__ l.
Debarment Certification (page 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 vendor.
BUY AMERICAN 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 American 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 services will be provided on an “as needed” basis, HCDE
makes no representation either orally or in writing to the amount of temporary services
HCDE will use during the term of the contract(s).
DISQUALIFICATION - A proposer may be disqualified before or after the proposals
are opened, upon evidence of collusion with the intent to defraud, or perform other illegal
activities for the purpose of obtaining an unfair competitive advantage.
EQUAL OPPORTUNITY – It is the policy of HCDE not to discriminate on the basis of
race, color, national origin, gender, limited English proficiency or handicapping
conditions in its programs.
EXCEPTIONS – Proposers are responsible for identifying any exceptions to the
requirements specified herein. Any exceptions must be noted on the proposer’s letterhead
and returned with the proposal. Proposals, which are qualified with conditional clauses,
items not called for, or irregularities, may be considered non-responsive by HCDE.
FOB – All shipments shall be FOB destination full freight allowed in Houston, TX &
adjoining counties. Shipments outside of this area will be FOB Shipping Point pre-paid
and add.
Page 3 of 26
FINANCIAL RESPONSIBILITY – HCDE assumes no financial responsibility for any
costs incurred in developing and submitting a proposal.
FORMAT –Proposals shall include one (1) original complete proposal. Proposers are
responsible for ensuring their proposal is received at the time and place specified on the
cover page. HCDE is not responsible for proposals that arrive late, or proposals that do
not have all the required information.
INDEMNIFICATION - The vendor shall indemnify and hold harmless HCDE from all
liabilities, costs, expenses, attorney fees, fines, penalties or damages for any or claimed
infringement of any patents, trademarks, copyright or other corresponding right(s) which
is related to any item the vendor is required to deliver. The vendor’s obligation to this
clause shall survive acceptance and payment by HCDE.
INSURANCE – The successful proposer shall be required to provide HCDE with copies
of certificates of insurance, named as additional insured, Texas Workman’s
Compensation and General Liability Insurance.
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 CFP. CFP will invoice contractor
for this participation fee on a monthly basis of gross payments made by the Buyer.
Page 4 of 26
QUESTIONS – Questions regarding the requirements specified in this solicitation must
be faxed to (713) 694-0732 attn: Jack Cutting 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.
TERMS – Payment terms on all invoices are Net 30 days
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.
Page 5 of 26
SPECIFICATIONS
Request for Proposal (RFP) for: Amplification Sound System for Harris County
Department of Education (HCDE) Choice Facility Partners Division.
BACKGROUND
The intention of this Request for Proposal (RFP) is to solicit proposals for amplification
sound system for Harris County Department of Education (HCDE) Choice Facility
Partners Division and any federal, state or local agency authorized to enter into a MOU
for said services under the State of Texas Government Code Chapter 791. Interlocal
Cooperation Contracts.
HCDE is utilizing the Request for Proposal (RFP) method for the procurement of this
service in accordance with Texas Governmental Code Section 44.031 Purchasing of
Contracts, Item (3) Request for Proposals.
For information regarding the proposal process, contact Jack Cutting of the Purchasing
Division at (713) 696-0744.
TIME TABLE OF RFP:
Job advertised – 10/24/08 & 10/27/08
Proposals due – 11/10/08
Estimated award – 12/16/08
SCOPE
Functionality Requirements
The amplification sound system must be multi-functional with different types of media
components and compatible with other sound systems. It should be user friendly by the
operator and should be able to be effectively managed and maintained by in-house
technology staff. The system must be able to self balance within the room with minimal
fade out. The amplification sound system will be utilized in classrooms to provide
amplification of the teacher’s voice and also include a pass around student microphone.
A typical classroom shall contain four to six speakers ceiling or wall mounted. These
speakers should provide uniform sound distribution regardless of the arrangement of
teacher and students.
All miscellaneous equipment required for a complete, professional installation shall be
included in the base bid. No allowances for any additional equipment, hardware, cabling
or miscellaneous items will be considered unless specifically excluded from the base bid.
Page 6 of 26
The amplification sound system should be compatible with any existing electrical system
that a client member currently has installed.
Electrical Component Standard: Provide work complying with applicable requirements of
NFPA 70 “National Electrical Code” including, but not limited to:
1. Article 250, Grounding
2. Article 300, Part A. Wiring Method
3. Article 310, Conductors for General Wiring
4. Article 725, Remote Control, Signaling Circuits.
5. Article 800, Communication Systems.
In addition, all city, county and state codes must be met as applicable.
Upon completion of installation, the Manufacturer shall provide initial in-service training
with this system. These sessions shall be broken into segments that will facilitate the
training of individual users in the operation of this system as directed by client member.
System Features
There are features that are applicable to the over-all sound system. Please indicate
what the system you are proposing has to offer in the following areas.
Overall System
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Page 7 of 26
Standard Operating frequency
Operating range
Alternative Carrier Frequencies (IR)
Frequency Stability
Maximum Deviation
Dynamic Range
Frequency Response
Type of equalizer
Signal/Power interface
LED power indicator
Reception area
Wireless
Inside and outside use
Light weight hand held or lapel microphone
Ability to use with computer, audio and video systems, television, DVD and VCR
and LCDE projector, screen/white board
Wall and ceiling mount speakers
Receiver Specifications
• Transmission type
• Receiver Sensitivity
• Reception Selectivity
Amplifier Specifications
• Power Output
• Total Harmonic Distortion
• Speaker Load Impedance
• Frequency response:
• Minimum Dimensions (W x D x H)
• Power Supply
• Weight
• Mounting
• Speaker wire
Inputs/Outputs
• Infrared Sensor
• Input power jack
• Auxiliary audio with volume control
• Mic charge jack
• Jacks for external sensor connection
Microphone Specifications
• Transmission type
• Transmitting frequency
• Frequency response
• Operating range
• Distortion
• Batteries
• Battery life
• Weight (with batteries)
• Provide dimensions of microphone
• User controls
Hand Held Microphone/Transmitter
• Transmission type
• Transmitting frequency
Page 8 of 26
•
•
•
•
•
•
Microphone element type
Audio distortion
Battery Power
Battery Life
Weight with battery
Provide dimensions of microphone
Sensor
• Type
• Operating frequency
• Power
• Reception Coverage: provide range
• Cable
• Mounting
• Diodes
• Sensor wire
Please explain any unique features about you equipment.
In addition, indicate if your company is a member of any other purchasing
cooperative. If so, will you guarantee that Choice Facility Partners (CFP) will
receive equal or better pricing than any other purchasing cooperative.
Please provide a marketing plan and indicate how you propose to market your
products with Choice Facility Partners.
Page 9 of 26
EVALUATION CRITERIA
Proposals will be evaluated based on the criteria listed below corresponding to requested
scope of services:
1.
2.
3.
4.
5.
6.
7.
8.
Price
Reputation of Vendor
Quality of Vendor’s Service
Extent to which service meets HCDE needs
Vendor’s past relationship with the HCDE
Impact on historically underutilized businesses
Total long term cost to HCDE
Previous work with governmental agencies
Total
25%
15%
10%
15%
5%
5%
10%
15%
100%
The proposal that receives the highest evaluation score and meets HCDE specifications
will be the party receiving the award recommendation. The proposal shall remain
confidential information until an award decision has been made. After the award has
been made, all proposers will be allowed to view proposal results or request bid
tabulation results.
Page 10 of 26
PRICE DELIVERY INFORMATION
Offeror must complete the open boxes using information supplied in the
Description section listed above. Multiply “Qty.” X “Unit Price” for
“Extension.”
I.
Proposer:
Item
Description
I.
Typical amplification
system for a standard
classroom/computer lab,
35’ x 26’ (910 net sq. ft.)
Typical amplification
system for a standard
classroom/science lab for
elementary school, 36’ x
27’ (972 net sq. ft.)
Typical amplification
system for a standard
classroom/science lab for
middle school, 36’ x 40.5’
(1458 net sq. ft.)
Typical amplification
system for a standard
classroom/science lab for
high school, 36’ x 54’
(1944 net sq. ft.)
II.
III.
IV.
Unit of
Measure
Qty.
Lot
1
Lot
1
Lot
1
Lot
1
Unit Price
Percentage
off
Catalog/Shop
Rate
V.
VI.
II.
Related Items and
Accessories
Maintenance Service
%
$
hr rate
Payment Terms: Please provide your payment terms in the space below:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Page 11 of 26
Attachment a.
PROPOSAL SUBMISSION FORM
RFP NO. 09/005JC
Amplification Sound System_for Harris County Department of Education
Please Print
Whereas on the _____________ day of _____________________________, 2008 (print name of company)
___________________________________________________________________________ has reviewed
RFP 09/005JC 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 12 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.
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 13 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 14 of 26
Attachment d.
NO RESPONSE FORM
RFP NO. 09/005JC
Amplification Sound System County Department of Education (HCDE)
Please Print
Whereas on the ___________ day of ____________________, 2008 (print name of company)
__________________________________________________________________________
has reviewed HCDE’s solicitation No. 09/005JC, 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 15 of 26
Attachment e.
References
Please provide at least three (3) references (co. name, address, telephone no. and contact)
that have used your _________________ in the last 3-4 years.
A. ______________________________
______________________________
______________________________
______________________________
B. _______________________________
_______________________________
_______________________________
_______________________________
C. ________________________________
________________________________
________________________________
________________________________
Page 16 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.
$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 17 of 26
Attachment g.
Amplification Sound System Questionnaire
(add additional sheets if necessary)
1. How long has your company been in business providing amplification sound
systems?
__________________________________________________________________
__________________________________________________________________
2. How many clients do you currently serve?
__________________________________________________________________
__________________________________________________________________
3. What areas of the state of Texas have you worked in over the last five years?
__________________________________________________________________
__________________________________________________________________
4. Please provide last certified financial statement of your company’s:
Balance Sheet and Income Statement
5. What is your firms experience in working with educational and governmental
entities?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
6. Do you have 24/hr., 7/day customer service support?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7. Can the system be installed after hours, weekends to avoid work disruptions?
__________________________________________________________________
__________________________________________________________________
8. What else would you like us to know about your company?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Page 18 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, lodging, 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
Jim Schul
Page 19 of 26
Celes Harris
Joanie Rethlake
Dean Zajicek
Les Hooper
Alfonso Saldivar
Natasha Truitt
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
This questionnaire is being filed in accordance with chapter 176 of the Local
Government Code by a person doing business with the governmental entity.
By law this questionnaire must be filed with the records administrator of the
local government not later than the 7th business day after the date the person
becomes aware of facts that require the statement to be filed. See Section
176.006, Local Government Code.
Form CIQ
OFFICE USE ONLY
Date Received
A person commits an offense if the person violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
1. Name of person doing business with local governmental entity.
2.
Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority
not later than September 1 of the year for which an activity described in Section 176.006(a), Local
Government Code, is pending and not later than the 7th business day after the date the originally filed
questionnaire becomes incomplete or inaccurate.)
3. Describe each affiliation or business relationship with an employee or contractor of the
local governmental entity who makes recommendations to a local government officer of the
local governmental entity with respect to expenditure of money.
4. Describe each affiliation or business relationship with a person who is a local
government officer and who appoints or employs a local government officer of the local
governmental entity that is the subject of this questionnaire.
Page 20 of 26
CONFLICT OF INTEREST QUESTIONNAIRE
FORM CIQ
For vendor or other person doing business with local governmental entity
Page 2
5. Name of local government officer with whom filer has affiliation or business relationship.
(Complete this section only if the answer to A, B, or C is YES.)
This section, item 5 including subparts A, B, C & D, must be completed for each officer with
whom the filer has affiliation or business relationship. Attach additional pages to this Form CIQ
as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable
income from the filer of the questionnaire?
Yes
No
B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the
direction of the local government officer named in this section AND the taxable income is not
from the local governmental entity?
Yes
No
C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the
local government officer serves as an officer or director, or holds an ownership of 10 percent or
more?
Yes
No
D. Describe each affiliation or business relationship.
6. Describe any other affiliation or business relationship that might cause a conflict of
interest.
___________________________________________
Signature of person doing business with the governmental entity
Page 21 of 26
_______________
Date
Attachment i.
Historically Underutilized Business
(HUB) Certification Form
Bidding companies that have been certified by the State of Texas as Historically
Underutilized Business (HUB) entities are encouraged to indicate their HUB status when
responding to this Bid Invitation. The electronic catalogs will indicate HUB
certifications for vendors that properly indicate and document their HUB certification on
this form.

I certify that my company has been certified by the State of Texas as a
Historically Underutilized Business (HUB), and I have attached a copy of our HUB
certification to this form. (Required documentation for recognition as a HUB)

My company has NOT been certified by the State of Texas as a Historically
Underutilized Business (HUB).
______________________________________
Signature of Authorized Representative
______________________________________
Name (Please Print)
______________________________________
Company Name (Please Print)
Page 22 of 26
_________________________
Title
Attachment j.
Form W-9 page 1 of 2
•
Revised March 2005
Taxpayer Identification Number Request
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
OR
__ __ __ ⎯ __ __ ⎯ __ __ __ __
__ __ ⎯ __ __ __ __ __ __ __
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.
Page 23 of 26
†Tax Exempt Entity †The United States †A state, the District of
under 501(a) (includes
501(c)(3), or IRA.
or any of its agencies
or instrumentalities.
Columbia, a possession of
the United States, or any of
their political subdivisions or
agencies.
† A foreign government 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 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. Instructions continued on Page 2
Page 24 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 representative 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 representative 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.
_________________________
Signature
Address __________________________
_________________________
__________________________
Printed Name
__________________________
_________________________
Position with Company
Phone __________________________ Official
_________________________
Authorizing Signature
Fax
__________________________ Bid
_________________________
Printed Name
Email
__________________________
_________________________
Position with Company
Vendor
Page 25 of 26
__________________________ Bidder
Attachment l.
Certification Regarding Debarment Suspension, Ineligibility and Voluntary
Exclusion-Lower Tier Covered Transactions
This certificate is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 7CFR Part 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 the
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 of this proposal.
_________________________________________________________________________
Organizations Name
PR/Award # or Project Name
_________________________________________________________________________
Name and Title of Authorized Representative
_________________________________________________________________________
Signature
Page 26 of 26