PART III: Attachments Please include all original completed forms … · 2020. 11. 13. · FORM O:...

PART III: New Project Attachments

Please include all original completed forms with the original version of your

submission and one electronic copy on the required USB Drive.

Forms/Attachments:

FORM A: Supplier Information FORM B: Attachment B - M/WBE Instructions and Participation Report

FORM C: ACORD FORM and Certification by Insurance Broker or AgentFORM D: Reference Survey Instructions

FORM E: Reference Survey

FORM F: Price Schedule (if applicable)

FORM G: General Certifications

FORM H: EDGAR Certifications

FORM I: Conflict of Interest Instructions and Questionnaire (Form CIQ)

FORM J: Instructions for Completion of Disclosure of Interested Persons Certification (HB 1295)

FORM K: IRS Form W‐9 (updated October 2018)FORM L: Exceptions

FORM M: Criminal History Background Check Certification

FORM N: Acknowledgment FormFORM O: Nutrition Services Only - Certification Regarding Federal Lobbying (TDA Form H2049)FORM P: Nutrition Services Only - Compliance with Buy American Provision

Category Specialist: _____________________________________________________________________________________

Proposal Due Date: _____________________________________________________________________________________

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FORM A: SUPPLIER INFORMATION

This Form A is required. See HISD Policy CHE (Local).

LEGAL NAME OF SUPPLIER:

DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER:

TYPE OF BUSINESS/DESCRIPTION OF PRODUCTS AND/OR SERVICES PROVIDED:

SUPPLIER MAILING ADDRESS:

CITY: STATE: ZIP CODE:

SUPPLIER STREET ADDRESS:

CITY: STATE: ZIP CODE:

TELEPHONE: FAX:

CONTACT PERSON’S NAME:

CONTACT PERSON’S TELEPHONE NUMBER: FAX:

CONTACT PERSON’S E-MAIL ADDRESS:

1. TYPE OF BUSINESS ENTITY: ☐ PUBLICLY TRADED CORPORATION ☐ PRIVATE CORPORATION

☐ LIMITED PARTNERSHIP ☐ PARTNERSHIP

☐ SOLE PROPRIETORSHIP ☐ NOT FOR PROFIT ENTITY

2. NUMBER OF FULL TIME EMPLOYEES: NUMBER OF PART TIME EMPLOYEES:

3. IS SUPPLIER IS A RESIDENT BIDDER? ☐ YES ☐ NO

A RESIDENT BIDDER REFERS TO A PERSON WHOSE PRINCIPAL PLACE OF BUSINESS IN THE STATE OF TEXAS,

INCLUDING A SUPPLIER WHOSE ULTIMATE PARENT COMPANY OR MAJORITY OWNER HAS ITS PRINCIPAL PLACE OF

BUSINESS IN THIS STATE.

4. CITY AND STATE OF SUPPLIER'S PRINCIPAL PLACE OF BUSINESS:

IF NOT TEXAS, DOES THE STATE HAVE PREFERENTIAL TREATMENT ON BIDS? ☐ YES ☐ NO

IF YES, WHAT PERCENTAGE: ____________%

5. NUMBER OF YEARS SUPPLIER HAS BEEN IN CONTINUOUS OPERATION:

6. NUMBER OF YEARS SUPPLIER HAS BEEN IN BUSINESS UNDER ITS PRESENT BUSINESS NAME:

7. HAS SUPPLIER CONDUCTED BUSINESS WITH THE DISTRICT UNDER ANOTHER NAME? ☐ YES ☐ NO

IF YES, PROVIDE OTHER NAME(S):

8. NUMBER OF YEARS DOING BUSINESS WITH HISD: ____________________________________________________

9. DOES SUPPLIER HAVE A PARENT COMPANY OR SUBSIDIARY THAT CURRENTLY CONDUCTS OR THAT HAS

PREVIOUSLY CONDUCTED BUSINESS WITH THE DISTRICT? ☐ YES ☐ NO

IF YES, NAME PARENT COMPANY AND/OR SUBSIDIARY:

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10. DO YOU HAVE EXPERIENCE WITH OTHER SCHOOL DISTRICTS? ☐ YES ☐ NO

IF YES, NAMES OF SCHOOL DISTRICTS:

11. DOES SUPPLIER HAVE ANY OWNERS, PRINCIPAL SHAREHOLDERS OR STOCKHOLDERS, OFFICERS, AGENTS,

SALESPEOPLE OR KEY EMPLOYEES WHO HAVE BEEN MEMBERS OF THE HISD BOARD OF EDUCATION DURING THE

LAST 5 YEARS? ☐ YES ☐ NO

IF YES, NAME(S) AND TITLE(S):

12. DOES ANY OFFICER, PARTNER, OWNER, SALES REPRESENTATIVE AND/OR SPOUSE WORK FOR HISD? ☐ YES ☐ NO


13. DOES SUPPLIER HAVE ANY OWNERS, PRINCIPAL SHAREHOLDERS OR STOCKHOLDERS, OFFICERS, AGENTS,

SALESPEOPLE OR KEY EMPLOYEES WHO ARE DISTRICT EMPLOYEES OR WHO ARE MEMBERS OF A DISTRICT

EMPLOYEE’S IMMEDIATE FAMILY WHO EITHER WORK OR WHO MAY POTENTIALLY WORK ON THIS CONTRACT WITH

THE DISTRICT? ☐ YES ☐ NO


14. NAMES OF AUTHORIZED AGENTS, INCLUDING ANY PERSON OR ENTITY AUTHORIZED TO ‘ACT WITH’ OR ‘ACT ON

YOUR BEHALF,’ SUCH AS CONSULTANTS, SUB-CONTRACTORS, RE-SELLERS, LOBBYISTS, CONFIDANTS, ETC.,

WHETHER COMPENSATED OR NOT COMPENSATED:

15. DOES SUPPLIER HAVE RELATIONSHIP(S) WITH ANY POLITICAL ACTION COMMITTEES? ☐ YES ☐ NO

IF YES, NAME(S) AND PAC(S):

16. HAS SUPPLIER (INCLUDING ANY OWNER, PRINCIPAL SHAREHOLDER OR STOCKHOLDER, OFFICER, AGENT,

SALESPERSON, OR EMPLOYEE) BEEN INVOLVED IN PAST, PENDING, OR PRESENT LITIGATION INVOLVING THE

DISTRICT? ☐ YES ☐ NO

IF YES, PLEASE PROVIDE THE STYLE AND STATUS OF THE CASE AS WELL AS THE TYPE OF LITIGATION:

17. FINANCIAL AND BUSINESS REFERENCES, INCLUDING BANK WITH WHICH SUPPLIER CONDUCTS BUSINESS:

Name of bank with which supplier conducts business: ______________________________________________ ____

Bank officer: Officer’s phone number:

Name of other banking/financial institution(s):

18. NAME OF INSURANCE COMPANIES:

INSURANCE COMPANIES INSURANCE COMPANIES

19. HISD ENCOURAGES THE PARTICIPATION OF MINORITY AND WOMEN OWNED BUSINESS. IS SUPPLIER A MINORITY

AND/OR WOMAN OWNED COMPANY? ☐ YES ☐ NO

IF YES, WHAT PERCENTAGE OF OWNERSHIP IS MINORITY OR WOMAN OWNED _____________%

v 06.18.2020 Page 3 of 24

20. CHECK ONE OF THE FOLLOWING:

☐ SUPPLIER WILL PROVIDE GOODS AND SERVICES WITH OWN WORK FORCE

☐ SUPPLIER WILL PURCHASE GOODS DIRECTLY FROM THE MANUFACTURER OR OTHER SUPPLIER

21. HISD CAN ONLY DO BUSINESS WITH EQUAL OPPORTUNITY EMPLOYERS.

DO YOU ADVERTISE AS AN EQUAL OPPORTUNITY EMPLOYER? ☐ YES ☐ NO

DO YOU HAVE A WRITTEN NON-DISCRIMINATORY POLICY OF EMPLOYMENT? ☐ YES ☐ NO

HAS THIS POLICY BEEN CIRCULATED THROUGHOUT YOUR ORGANIZATION? ☐ YES ☐ NO

PERSON TO CONTACT REGARDING EQUAL OPPORTUNITY INFORMATION ISSUES:

NAME: TITLE:

I ATTEST THAT I HAVE ANSWERED THE QUESTIONS REGARDING SUPPLIER INFORMATION TRUTHFULLY AND TO THE

BEST OF MY KNOWLEDGE.

Vendor’s Name

Printed Name and Title of Authorized Representative

Email Address

Signature of Authorized Representative Date

FORM B: M/WBE INSTRUCTIONS (Part II of Download)

Please refer to Attachment B – M/WBE Participation Report that is located on the Houston I.S.D.

Purchasing Department website.

FORM C: ACORD FORM and CERTIFICATE OF INSURANCE BROKER OR AGENT

Certificate of Insurance (Acord Form) or a Letter from vendor's insurance provider stating that proposercan provide the levels of insurance specified in this project is required, along with Form C.

v 06.18.2020 Page 4 of 24

Project:

Insured Name (Vendor):

Check the applicable box:

The undersigned insurance broker or agent represents to the Houston Independent School District (HISD) that the accompanying Certificate of Insurance Acord Form is accurate in all material respects. Acord form must be submitted with this documentation. (See sample Acord form)

The undersigned insurance broker or agent represents to the Houston Independent School District (HISD) that the accompanying Letter from Insurance Carrier is accurate in all material respects. Letter must be submitted with this documentation. (See sample letter)

Name of Broker or Agent

Address of Broker or Agent

Email Address of Broker or Agent Phone Number of Broker or Agent

Name and Title of Broker or Agent

Signature of Authorized Broker or Agent Date

Signature of Proposer Date

FORM C: INSURANCE VERIFICATION

CERTIFICATION BY INSURANCE BROKER OR AGENT

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CERTIFICATE OF LIABILITY INSURANCEDATE (MM/DD/YYYY)

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES

BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the

terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the

certificate holder in lieu of such endorsement(s). PRODUCER CONTACT

NAME:

PHONE (A/C, No, Ext):

FAX (A/C, No):

E-MAIL ADDRESS:

PRODUCER CUSTOMER ID #:

INSURER(S) AFFORDING COVERAGE NAIC #INSURED

INSURER A:

INSURER B:

INSURER C:

INSURER D:

INSURER F:

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD

INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,

EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.INSR LTR TYPE OF INSURANCE

ADDL INSR

SUBR WVD POLICY NUMBER

POLICY EFF (MM/DD/YYYY)

POLICY EXP (MM/DD/YYYY) LIMITS

GENERAL LIABILITY

X X XXXXX XX/XX/XX XX/XX/XX

EACH OCCURRENCE $1,000,000COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED

PREMISES (Ea occurrence) $

CLAIMS-MADE X OCCUR MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $1,000,000GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS/COMP/OP AGG $

POLICY PROJECT LOC $AUTOMOBILE LIABILITY

X X XXXXX XX/XX/XX XX/XX/XX

COMBINED SINGLE LIMIT(Ea accident) $1,000,000

X ANY AUTO BODILY INJURY (Per person) $ALL OWNED AUTOS BODILY INJURY (Per

accident) $SCHEDULED AUTOS PROPERTY DAMAGE (Per

accident) $

X HIRED AUTOS $

X NON-OWNED AUTOS $

$UMBRELLA LIAB

OCCUR EACH OCCURRENCE $EXCESS LIAB CLAIMS-MADE AGGREGATE $DEDUCTIBLE $ $RETENTION $ $

WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N

X XXXXX XX/XX/XX XX/XX/XX

X WC STATU-TORY LIMITS

OTH-ER

ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?

N E.L. EACH ACCIDENT $100,000

(Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $100,000

If yes, describe underDESCRIPTION OF OPERATIONS below

E.L. DISEASE - POLICY LIMIT $100,000

PER INCIDENT $AGGREGATE $

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

Certificate Holder Houston Independent School District is named as Additional Insured on the Automobile and Commercial General Liability policy. HoustonIndependent School District is named as an Alternate Employer on the Workers’ Compensation policy. A Waiver of Subrogation shall apply in favor ofHouston Independent School District on the Workers Compensation, Automobile and General Liability policies.

Enter the name of the bid and assigned bid project number as well.

CERTIFICATE HOLDER CANCELLATION

Houston Independent School DistrictHattie Mae White Educational Support Center4400 West 18th StreetHouston, TX 77092-8501

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE GENERAL TERMS AND CONDITIONS IN THE PROJECT SOLICITATION. AUTHORIZED REPRESENTATIVE

© 1988-2010 ACORD CORPORATION. All rights reserved.

v 06.18.2020 Page 6 of 24

SAMP

LE

SAMPLE INSURANCE AGENCY

123 Main Street

Anytown, Texas 77777

Telephone: 888-555-1111

Fax: 888-555-2222

Date

Houston Independent School District

RE: Houston ISD Project Name and NumberSupplier’s Name

The undersigned certifies Supplier will be able to provide an Acord certificate of insurance (COI) confirming to coverage

indicated below within three (3) business days from intent to award from HISD Risk Management. All coverages would

be placed with carriers rated -A VII or better and licensed to do business in the State of Texas. I have marked the

applicable box for each section.

X COVERAGES LIMITS

WORKERS’ COMPENSATION SECTION

Workers’ Compensation

Employers’ Liability

Waiver of Subrogation and Alternate Employer provisions in favor of HISD

Statutory

$100,000 per

Accident

Supplier has employees, but none in the State of Texas

Worker’s Compensation

Employer’s Liability

Waiver of Subrogation in favor of HISD

Statutory

$100,000 per

Accident

Supplier has no Employees

Workers’ Compensation does not apply

Not Applicable

AUTOMOBILE LIABLITY SECTION

Automobile Liability covering All Owned, Hired & Non-Owned Autos,

Including Additional Insured and Waiver of Subrogation in favor of HISD.

$1,000,000 CSL

Supplier owns no vehicles in the company name—

Automobile Liability covering Hired & Non-Owned Autos,

Including Additional Insured and Waiver of Subrogation in favor of HISD.

$100,000 CSL

COMMERICAL GENERAL LIABLITY SECTION

Commercial General Liability, including Additional Insured and Waiver of

Subrogation in favor of HISD.

$1,000,000 per

Occurrence

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FORM D: REFERENCE SURVEY INSTRUCTIONS

Proposer must complete and return Form D as part of this project.

The Evaluation Committee considers Proposer’s reputation and quality of Proposer’s goods or services in the

evaluation of this Proposal. To aid in this process, the District requests that Proposer send the attached Form

D, Performance Evaluation Survey (Survey) to three (3) valid references.

Proposer must fill out the top portion of Form D, “Supplier Name” on each Survey. No other portion of the

Survey may be completed by Proposer. It is Proposer’s sole responsibility to ensure that Surveys are sent to

Proposer’s desired references. Recipients must return the completed survey to HISD by one of the methods

outlined on the Survey. The District will not accept a Survey returned by Proposer or a Survey returned

after the assigned deadline.

While Proposer may choose its recipients, more weight is given to the following references:

• Clients who are governmental entities, and school districts; and

• Clients provided with similar goods and/or services as called for by this project;

Please provide the name and contact information of all references to whom Proposer intends to send the

Survey.

(1) ________________________________________ ________________________________________

Name of Entity or Business Contact Name

________________________________________ ________________________________________

Email Address Mailing Address

________________________________________ ________________________________________

Phone Number Goods and/or services provided

(2) ________________________________________ ________________________________________


________________________________________ ________________________________________


________________________________________ ________________________________________


(3) ________________________________________ ________________________________________


________________________________________ ________________________________________


________________________________________ ________________________________________


v 06.18.2020 Page 8 of 24

FORM E: REFERENCE SURVEY

(To be completed by third party and emailed directly to Houston ISD Purchasing Services)

To Whom It May Concern:

The Houston Independent School District (HISD) has implemented a process to collect Supplier performance

evaluations. HISD may use the information provided in its assessment of the above Supplier to determine a

responsive and responsible procurement. The Supplier listed above has chosen to participate in this process

and listed you as a past or present client for whom it has provided goods and/or services. HISD would greatly

appreciate your completion of the survey below.

(I) Please evaluate the performance of the Supplier on a scale of one (1) through ten (10), with 10 being the

highest. If you do not have sufficient knowledge of Supplier’s past and/or current performance in a

particular area, please leave it blank.

TOTAL POINTS (out of 90): ____________

(II) How long have you done business with the Supplier?

(III) Please provide a brief description of the goods and/or services provided to you by the Supplier and

include any additional information you believe might assist HISD in its evaluation (attach additional

sheets if necessary):

NO. CRITERIA UNIT SCORE

1 Ability to Manage Cost (1-10)

2 Quality of Product(s) and/or Services (1-10)

3 Quality of Customer Service (1-10)

4 Quick Response Time (1-10)

5 Ability to Maintain Confidentiality (1-10)

6 Close Out Process (invoicing, no unexpected fees) (1-10)

7 Communication (1-10)

8 Ability to Follow Rules, Regulations, and Requirements (1-10)

9 Overall Customer Satisfaction Based on Performance (comfort level

using company again)

(1-10)

Vendor Name (10 pts):

Thank you for your time and effort, it is greatly appreciated!

This survey must be received before:

Please sign below and return this completed survey directly to Houston I.S.D. via email to:

Houston I.S.D. Purchasing Services:

Completed by:

District / Company Name Printed Name of Evaluator

Signature of Evaluator Date

v 06.18.2020 Page 9 of 24

FORM G: GENERAL CERTIFICATION FORMS

CERTIFICATION OF CODE OF SILENCE

The Board of Education (Board) has adopted a “Code of Silence” policy (Board Policy CAA (Local)) attached

by URL link hereto and incorporated by reference.

The “Code of Silence" prohibits any communication regarding any project, bid, or other competitivesolicitation between:

• Any person who seeks an award from the District or its affiliated entities (including, but not limited to,

the HISD Foundation and the HISD Public Facility Corporation), including a potential vendor or

vendor's representative, and

• Board members, the Superintendent of Schools, senior staff members, principals, department heads,

directors, managers, or other District representatives who have influence in the evaluation or selection

process.

The “Code of Silence” period shall begin when the project is issued and ends upon the execution of theContract. During the “Code of Silence,” campaign contributions, gifts, donations, loans, and any other items

of value are prohibited between these parties, including candidates who have filed for election to the Board.

I hereby certify that I have reviewed Board Policy CAA (Local) pertaining to the “Code of Silence,” I and

agree and understand that non-compliance with the “Code of Silence” policy may result in

disqualification.

________ Initials of Authorized Representative of Vendor

CERTIFICATION OF COMPLIANCE WITH TEXAS FAMILY CODE PROVISION

As per Section 14.52 of the Texas Family Code, added by S.B. 84, Acts, 73rd Legislature, R.S. (1993), all

bidders must complete and submit with the bid the following: I, the undersigned Vendor, do hereby

acknowledge that NO sole proprietor, partner, majority shareholder of a corporation, or an owner of 10% or

more of another business entity is 30 days or more delinquent in paying child support under a court order

or a written repayment agreement. I understand that under this provision, a sole proprietorship,

partnership, corporation or other entity in which a sole proprietor, partner, majority shareholder or a

corporation, or an owner of 10% or more of another entity is 30 days or more delinquent in paying child

support under a court order or a written repayment agreement is NOT eligible to bid or receive a state

contract.


CERTIFICATION OF AUTHORIZATION, PERMITS, AND BUSINESS CERTIFICATES

REQUIREMENT

For the duration of the Contract, Vendor must have and maintain current licenses, permits, fees, business

certificates and similar authorizations required by the City of Houston, Harris Country, and the State of Texas

to conduct business and provide awarded goods and/or services to the District. Upon the request of the

District, Vendor shall provide copies of all licenses, business certificates permit and fees as being paid and

current that are required to do business by the city, county and State for the type of business Vendor provides,

or seeks to provide, to the District.

Vendor understands and agrees to abide by the Authorization, Permits, and Business Certificates

Requirement above. Vendor certifies that it has all current licenses, certificates, similar authorizations

required by the City of Houston, Harris County, and the State of Texas to conduct business and/or provide

awarded goods and/or services to the District.


v 06.18.2020 Page 10 of 24

https://pol.tasb.org/Policy/Download/592?filename=CAA(LOCAL).pdf

CERTIFICATION OF ANTITRUST CERTIFICATION STATEMENT

Texas Government Code Section 2155.005

My initials below affirm under penalty of perjury of the laws of the State of Texas that:

1. I am duly authorized to execute this Proposal/Contract on my own behalf or on behalf of the company,

corporation, firm, partnership or individual (Vendor) listed below;

2. In connection with this proposal, neither I nor any representative of Vendor 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 Vendor have violated any federal

antitrust law; and

4. Neither I nor any representative of Vendor have directly or indirectly communicated any of the

contents of this proposal to a competitor of Vendor or any other company, corporation, firm,

partnership or individual engaged in the same line of business as Vendor.


CERTIFICATION REGARDING HAZARD ANALYSIS AND CRITICAL CONTROL POINTS (HACCP)

All products purchased by HISD must be manufactured in compliance with HACCP regulations.

Vendor certifies that: all products on this proposal are processed and packaged in a HACCP compliant

plant. Vendor agrees Vendor further understands that HISD requires processors to maintain records and

monitoring logs pertaining to HACCP compliance, at a minimum, in the following Key Areas of HACCP

compliance:

• Hazard Analysis

• Critical Control Points established and limits set

• Planned procedures in place to correct processes

when deviation may occur

• Detailed and accurate record keeping

• Verification procedures

• Equipment installation and maintenance

• Master cleaning and sanitation schedule

• Orientation for all employees

• Ongoing training on food safety and HACCP

procedures

• Separation of food and chemical products

• Refrigerated dock receiving and loading

• Master cleaning and sanitation schedule

• Time/Temperature monitoring

• Pest Control

Vendor further understands and agrees that documentation and monitoring logs must be verified by an

acceptable third-party auditing firm or government agency and provided to HISD upon request. Vendor also

understands and agrees that if a processor loses inspection/processing rights or has a recall involving product

sold to HISD, Vendor must notify HISD within 24-48 hours.


CERTIFICATION OF VENDOR (AND IF APPLICABLE, SUBCONTRACTOR)

NATIONWIDE CRIMINAL BACKGROUND CHECKS

Pursuant to sections 22.085 and 22.0834 of the Texas Education Code Sections 22.085 and 22.0834 and HISD

Policy CJA (Legal), Vendor hereby certifies that all of Vendor’s employees, subcontractors and volunteers

(including those hired before January 1, 2008) who have, or will have, continuing duties related to the

contracted services, and who have, or will have, direct contact with students, have passed a national criminal

history background record information review as required by those sections and by HISD Policy CJA (Legal).

Vendor understands that if an employee subcontractor, or volunteer has a Disqualifying Criminal History,

the District may elect not to enter into this Contract or may elect to cancel the Contract.

v 06.18.2020 Page 11 of 24

“Disqualifying Criminal History” means: (1) a conviction or other criminal history information

designated by HISD; (2) a felony or misdemeanor offense that would prevent a person from being

employed under Texas Education Code § 22.085(a), that is: if at the time of the offense, the victim was

under 18 or was enrolled in a public school: (a) a felony offense under Title 5, Texas Penal Code; (b) an

offense on conviction for which a defendant is required to register as a sex offender under Chapter 62,

Texas Code of Criminal Procedure; or (c) an offense under federal law or the laws of another state that

is equivalent to (a) or (b).

Vendor further certifies that:

(1) Vendor will immediately remove an employee, subcontractor, or volunteer from contract duties and notify

HISD in writing within 3 business days if:

a. Vendor receives information that an employee, subcontractor, or volunteer has a reported criminal

history, or

b. HISD objects to the assignment of an employee, subcontractor, or volunteer based on the

individual(s) criminal history review information (CHRI).

(2) Upon request, Vendor will provide HISD with the name and any other requested information of an

employee, subcontractor, or volunteer so that HISD may obtain the CHRI on the individual(s).


CERTIFICATION OF FELONY CONVICTION NOTIFICATION

Pursuant to section 44.034 of the Texas Education Code, a person or business entity entering into a contract

and/or agreement with HISD must give advance notice to HISD if the person or an owner or operator of the

business entity has been convicted of a felony. The disclosure should include a general description of the

conduction resulting in the conviction of a felony. HISD may terminate a contract with a person of business

entity if HISD determines that the person or the business entity failed to give notice as required by section

44.034 or misrepresented the conduct resulting in the conviction. In such a case, HISD will compensate the

person or business entity for services performed before the termination of the contract. ---THIS NOTICE IS NOT REQUIRED OF A PUBLICLY HELD-CORPORATION ---

Please check the following as applicable:

☐ Vendor is a publicly held corporation; therefore, the above reporting requirement does not apply.

☐ Vendor is not owned nor operated by anyone who has been convicted of a felony.

☐ Vendor is operated or owned by the following individual(s) who has/have been convicted of a felony:

Name of Individual(s): _________________________________________________________________

Detail of conviction(s), attach additional pages if necessary: _____________________________________________


CERTIFICATION OF INSURANCE REQUIREMENT

I, the undersigned Vendor, do hereby certify that I shall maintain all insurance policies required by and in

accordance with Section 1.25 of this project. I further understand and agree that I must make the certificates of insurance and insurance policies available to HISD upon request.


v 06.18.2020 Page 12 of 24

CERTIFICATION OF NON-COLLUSION STATEMENT

I, the undersigned Vendor, do hereby certify that:

a) All statements of fact in such proposal are true.

b) Such Proposal was not made in the interest of or on behalf of any undisclosed person, partnership,

company, association, organization or corporation.

c) Such Proposal is genuine and not collusive or sham.

d) Vendor has not, directly or indirectly by agreement, communication or conference with anyone, attempted

to induce action prejudicial to the interest of the District or of any other bidder or anyone else interested

in the proposed procurement.

e) Vendor did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder

or anyone else would submit a false or sham bid or proposal, or that anyone should refrain from bidding

or withdraw his bid or proposal.

f) Vendor did not, in any manner, directly or indirectly seek by agreement, communication or conference

with anyone to raise or fix the bid or proposal price of said bidder or of anyone else, or to raise or fix any

overhead, profit or cost element of his bid or proposal price, or that of anyone else.

g) Vendor did not, directly or indirectly, submit his bid or proposal price or any breakdown thereof, or the

contents thereof, or divulge information on data relative thereto, to any corporation, partnership,

company, association, organization, bid depository, or to any member or agent thereof, or to any

individual or group of individuals, except to the District, or to any person or persons who have a

partnership or other financial interest with said Proposer in his business.

h) Vendor did not provide, directly or indirectly to any officer or employee of the District any gratuity,

entertainment, meals, or anything of value, whatsoever, which could be construed as intending to invoke

any form of reciprocation or favorable treatment.

i) No officer or principal of the undersigned Vendor is related to any officer or employee of the District by

blood or marriage within the third degree or is employed, either full or part time, by the District either

currently or within the last two (2) years.

j) No officer or principal of the undersigned Vendor nor any subcontractor to be engaged by the principal

has been convicted by a court of competent jurisdiction of any charge of fraud, bribery, collusion,

conspiracy or any other act in violation of any state or federal anti-trust law in connection with the bidding,

award of, or performance of any public work contract and/or agreement with any public entity.

k) I have answered the questions regarding non-collusion truthfully and to the best of my knowledge.


RE: FORM G: GENERAL CERTIFICATIONS

Vendor’s Name


Email Address


v 06.18.2020 Page 13 of 24

FORM H: EDGAR CERTIFICATIONS

The following certifications and provisions are required and apply when HISD expends federal funds for any

contract resulting from this procurement process. Accordingly, the parties agree that the following terms

and conditions apply to the Contract between the District and _______________________________

(“Vendor”) in all situations where Vendor has been paid or will be paid with federal funds:

REQUIRED CONTRACT PROVISIONS FOR NON-FEDERAL ENTITY CONTRACTS UNDER FEDERAL

AWARDS - APPENDIX II TO 2 CFR PART 200

(A) Contracts for more than the simplified acquisition threshold currently set at $150,000, which is the

inflation adjusted amount determined by the Civilian Agency Acquisition Council and the Defense

Acquisition Regulations Council (Councils) as authorized by 41 U.S.C. 1908, must address administrative,

contractual, or legal remedies in instances where contractors violate or breach contract terms, and provide

for such sanctions and penalties as appropriate.

Pursuant to Federal Rule (A) above, when HISD expends federal funds, HISD reserves all rights and

privileges under the applicable laws and regulations with respect to this procurement in the event of

breach of contract by either party.

Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor

(B) Termination for cause and for convenience by the grantee or sub-grantee including how it will be

affected and the basis for settlement. (All contracts in excess of $10,000)

Pursuant to Federal Rule (B) above, when HISD expends federal funds, HISD reserves the right to

immediately terminate any agreement in excess of $10,000 resulting from this procurement process in the

event of a breach or default of the agreement by Vendor in the event Vendor fails to: (1) meet schedules,

deadlines, and/or delivery dates within the time specified in the procurement solicitation, contract, and/or

a purchase order; (2) make any payments owed; or (3) otherwise perform in accordance with the contract

and/or the procurement solicitation. HISD also reserves the right to terminate the contract immediately,

with written notice to vendor, for convenience, if HISD believes, in its sole discretion that it is in the best

interest of HISD to do so. Vendor will be compensated for work performed and accepted and goods

accepted by HISD as of the termination date if the contract is terminated for convenience of HISD. Any

award under this procurement process is not exclusive and HISD reserves the right to purchase goods

and services from other vendors when it is in HISD’s best interest.


(C) Equal Employment Opportunity. Except as otherwise provided under 41 CFR Part 60, all contracts that

meet the definition of “federally assisted construction contract” in 41 CFR Part 60-1.3 must include the equal

opportunity clause provided under 41 CFR 60-1.4(b), in accordance with Executive Order 11246, “Equal

Employment Opportunity” (30 FR 12319, 12935, 3 CFR Part, 1964-1965 Comp., p. 339), as amended by

Executive Order 11375, “Amending Executive Order 11246 Relating to Equal Employment Opportunity,”

and implementing regulations at 41 CFR part 60, “Office of Federal Contract Compliance Programs, Equal

Employment Opportunity, Department of Labor.”

Pursuant to Federal Rule (C) above, when HISD expends federal funds on any federally assisted

construction contract, the equal opportunity clause is incorporated by reference herein.

Does Vendor agree to abide by the above? YES ________ Initials of Authorized Representative of Vendor

(D) Davis-Bacon Act, as amended (40 U.S.C. 3141-3148). When required by Federal program legislation, all

prime construction contracts in excess of $2,000 awarded by non-Federal entities must include a provision

for compliance with the Davis-Bacon Act (40 U.S.C. 3141-3144, and 3146-3148) as supplemented by

Department of Labor regulations (29 CFR Part 5, “Labor Standards Provisions Applicable to Contracts

v 06.18.2020 Page 14 of 24

Covering Federally Financed and Assisted Construction”). In accordance with the statute, contractors must

be required to pay wages to laborers and mechanics at a rate not less than the prevailing wages specified in

a wage determination made by the Secretary of Labor. In addition, contractors must be required to pay

wages not less than once a week. The non-Federal entity must place a copy of the current prevailing wage

determination issued by the Department of Labor in each solicitation. The decision to award a contract or

subcontract must be conditioned upon the acceptance of the wage determination. The non-Federal entity

must report all suspected or reported violations to the Federal awarding agency. The contracts must also

include a provision for compliance with the Copeland “Anti-Kickback” Act (40 U.S.C. 3145), as

supplemented by Department of Labor regulations (29 CFR Part 3, “Contractors and Subcontractors on

Public Building or Public Work Financed in Whole or in Part by Loans or Grants from the United States”).

The Act provides that each contractor or sub-recipient must be prohibited from inducing, by any means,

any person employed in the construction, completion, or repair of public work, to give up any part of the

compensation to which he or she is otherwise entitled. The non-Federal entity must report all suspected or

reported violations to the Federal awarding agency.

Pursuant to Federal Rule (D) above, when HISD expends federal funds during the term of an award for

all contracts and sub-grants for construction or repair, Vendor will be in compliance with all applicable

Davis-Bacon Act provisions.


(E) Contract Work Hours and Safety Standards Act (40 U.S.C. 3701-3708). Where applicable, all contracts

awarded by the non-Federal entity in excess of $100,000 that involve the employment of mechanics or

laborers must include a provision for compliance with 40 U.S.C. 3702 and 3704, as supplemented by

Department of Labor regulations (29 CFR Part 5). Under 40 U.S.C. 3702 of the Act, each contractor must be

required to compute the wages of every mechanic and laborer based on a standard work week of 40 hours.

Work in excess of the standard work week is permissible provided that the worker is compensated at a rate

of not less than one and a half times the basic rate of pay for all hours worked in excess of 40 hours in the

work week. The requirements of 40 U.S.C. 3704 are applicable to construction work and provide that no

laborer or mechanic must be required to work in surroundings or under working conditions which are

unsanitary, hazardous or dangerous. These requirements do not apply to the purchases of supplies or

materials or articles ordinarily available on the open market, or contracts for transportation or transmission

of intelligence.

Pursuant to Federal Rule (E) above, when HISD expends federal funds, Vendor certifies that Vendor will

be in compliance with all applicable provisions of the Contract Work Hours and Safety Standards Act

during the term of an award for all contracts by HISD resulting from this procurement process.


(F) Rights to Inventions Made Under a Contract or Agreement. If the Federal award meets the definition of

“funding agreement” under 37 CFR §401.2 (a) and the recipient or sub-recipient wishes to enter into a

contract with a small business firm or nonprofit organization regarding the substitution of parties,

assignment or performance of experimental, developmental, or research work under that “funding

agreement,” the recipient or sub-recipient must comply with the requirements of 37 CFR Part 401, “Rights

to Inventions Made by Nonprofit Organizations and Small Business Firms Under Government Grants,

Contracts and Cooperative Agreements,” and any implementing regulations issued by the awarding agency.

Pursuant to Federal Rule (F) above, when federal funds are expended by HISD, Vendor certifies that

during the term of an award for all contracts by HISD resulting from this procurement process, Vendor

agrees to comply with all applicable requirements as referenced in Federal Rule (F) above.


v 06.18.2020 Page 15 of 24

(G) Clean Air Act (42 U.S.C. 7401-7671q.) and the Federal Water Pollution Control Act (33 U.S.C. 1251-1387),

as amended—Contracts and sub-grants of amounts in excess of $150,000 must contain a provision that

requires the non-Federal award to agree to comply with all applicable standards, orders or regulations

issued pursuant to the Clean Air Act (42 U.S.C. 7401-7671q) and the Federal Water Pollution Control Act as

amended (33 U.S.C. 1251- 1387). Violations must be reported to the Federal awarding agency and the

Regional Office of the Environmental Protection Agency (EPA).

Pursuant to Federal Rule (G) above, when federal funds are expended by HISD, Vendor certifies that


agrees to comply with all applicable requirements as referenced in Federal Rule (G) above.


(H) Debarment and Suspension (Executive Orders 12549 and 12689)—A contract award (see 2 CFR 180.220)

must not be made to parties listed on the government wide exclusions in the System for Award Management

(SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR

part 1986 Comp., p. 189) and 12689 (3 CFR part 1989 Comp., p. 235), “Debarment and Suspension.” SAM

Exclusions contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well

as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549.

Pursuant to Federal Rule (H) above, when federal funds are expended by HISD, Vendor certifies that


certifies that neither it nor its principals are presently debarred, suspended, proposed for debarment,

declared ineligible, or voluntarily excluded from participation by any federal department or agency.


(I) Byrd Anti-Lobbying Amendment (31 U.S.C. 1352)—Contractors that apply or bid for an award exceeding

$100,000 must file the required certification. Each tier certifies to the tier above that it will not and has not

used Federal appropriated funds to pay any person or organization for influencing or attempting to

influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or

an employee of a member of Congress in connection with obtaining any Federal contract, grant or any other

award covered by 31 U.S.C. 1352. Each tier must also disclose any lobbying with non-Federal funds that

takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier

up to the non-Federal award.

Pursuant to Federal Rule (I) above, when federal funds are expended by HISD, Vendor certifies that

during the term and after the awarded term of an award for all contracts by HISD resulting from this

procurement process, the vendor certifies that it is in compliance with all applicable provisions of the Byrd

Anti-Lobbying Amendment (31 U.S.C. 1352). The undersigned further certifies that:

(1) No Federal appropriated funds have been paid or will be paid for on behalf of the undersigned, to any

person for influencing or attempting to influence an officer or employee of any agency, a Member of

Congress, an officer or employee of congress, or an employee of a Member of Congress in connection

with the awarding of a Federal contract, the making of a Federal grant, the making of a Federal loan,

the entering into a cooperative agreement, and the extension, continuation, renewal, amendment, or

modification of a Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for

influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an

officer or employee of congress, or an employee of a Member of Congress in connection with this

Federal grant or cooperative agreement, the undersigned shall complete and submit Standard Form-

LLL, “Disclosure Form to Report Lobbying”, in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award

documents for all covered sub-awards exceeding $100,000 in Federal funds at all appropriate tiers and

that all sub-recipients shall certify and disclose accordingly.


v 06.18.2020 Page 16 of 24

RECORD RETENTION REQUIREMENTS FOR CONTRACTS INVOLVING FEDERAL FUNDS

When federal funds are expended by HISD for any contract resulting from this procurement process, Vendor

certifies that it will comply with the record retention requirements detailed in 2 CFR § 200.333. Vendor further

certifies that it will retain all records as required by 2 CFR § 200.333 for a period of three years after grantees or

sub-grantees submit final expenditure reports or quarterly or annual financial reports, as applicable, and all

other pending matters are closed.


CERTIFICATION OF COMPLIANCE WITH THE ENERGY POLICY AND CONSERVATION ACT

When HISD expends federal funds for any contract resulting from this procurement process, Vendor certifies

that it will comply with the mandatory standards and policies relating to energy efficiency which are contained

in the state energy conservation plan issued in compliance with the Energy Policy and Conservation Act (42

U.S.C. 6321 et seq.; 49 C.F.R. Part 18).


CERTIFICATION OF EQUAL EMPLOYMENT STATEMENT

It is the policy of HISD not to discriminate on the basis of race, color, national origin, gender, limited English

proficiency or handicapping conditions in its programs. Vendor agrees not to discriminate against any

employee or applicant for employment to be employed in the performance of this Contract, with respect to

hire, tenure, terms, conditions and privileges of employment, or a matter directly or indirectly related to

employment, because of age (except where based on a bona fide occupational qualification), sex (except where

based on a bona fide occupational qualification) or race, color, religion, national origin, or ancestry. Vendor

further agrees that every subcontract entered into for the performance of this Contract shall contain a provision

requiring non-discrimination in employment herein specified, binding upon each subcontractor. Breach of this

covenant may be regarded as a material breach of the Contract.


CERTIFICATION OF ACCESS TO RECORDS – 2 C.F.R. § 200.336

Vendor agrees that the District’s Inspector General or any of their duly authorized representatives shall have

access to any books, documents, papers and records of Vendor that are directly pertinent to Vendor’s discharge

of its obligations under the Contract for the purpose of making audits, examinations, excerpts, and

transcriptions. The right also includes timely and reasonable access to Vendor’s personnel for the purpose of

interview and discussion relating to such documents.


CERTIFICATION OF APPLICABILITY TO SUBCONTRACTRS

Vendor agrees that all contracts it awards pursuant to the Contract shall be bound by the foregoing terms and

conditions.


v 06.18.2020 Page 17 of 24

VENDOR AGREES TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS,

RULES, REGULATIONS, AND ORDINANCES. IT IS FURTHER ACKNOWLEDGED THAT VENDOR

CERTIFIES COMPLIANCE WITH ALL PROVISIONS, LAWS, ACTS, REGULATIONS, ETC. AS

SPECIFICALLY NOTED ABOVE.

RE: FORM H: EDGAR CERTIFICATIONS

Vendor’s Name


Email Address


v 06.18.2020 Page 18 of 24

FORM I: CONFLICT OF INTEREST CERTIFICATION, INSTRUCTIONS, AND QUESTIONNAIRE (CIQ)

I. CONFLICT OF INTEREST CERTIFICATION

The Board of Education (Board) has adopted a “Conflict of Interest Disclosures” policy (Board Policy BBFA (Local)) attached

by URL link hereto and incorporated by reference.

HISD is required to comply with Texas Local Government Code Chapter 176, Disclosure of Certain Relationships with Local

Government Officers as well as the conflict of interest standards set forth in EDGAR, 2 C.F.R. § 200.318 when HISD expends

federal funds. No employee, officer, or agent may participate in the selection, award, or administration of a contract if he or

she has a real or apparent conflict of interest. HISD local government officers must disclose conflicts of interest by completing

Form CIS, Local Government Officer Conflicts Disclosure Statement.

I hereby certify that I have read Board Policy BBFA (Local) pertaining to “Conflict of Interest Disclosures,” and I agree and

understand that the failure of a Board member to disclose a conflict of interest may result in the debarment of a Supplier

for 24 months.

________ Initials of Authorized Representative of Supplier

II. CONFLICT OF INTEREST QUESTIONNAIRE (CIQ) INSTRUCTIONS

HISD is required to comply with Texas Local Government Code Chapter 176, Disclosure of Certain Relationships with Local

Government Officers. H.B. 23 significantly changed the laws relating to Conflict of Interest Disclosures as well as the

corresponding forms and required disclosures. As of September 1, 2015, Supplier must sign and complete the new Conflict of

Interest Questionnaire (CIQ) and submit the CIQ with its proposal.

In accordance with Chapter 176 of the Texas Local Government Code, any Supplier who does business with HISD or who

seeks to do business with HISD must fill out the new Conflict of Interest Questionnaire (CIQ) whether or not a conflict of

interest exists. A conflict of interest exists in the following situations:

1) If the Supplier has an employment or other business relationship with a local government officer of HISD or a family

member of the officer, as described by section 176.003(a)(2)(A) of the Texas Local Government Code; or

2) If the Supplier given a local government officer of HISD, or a family member of the officer, one or more gifts with the

aggregate value of $100, excluding any gift accepted by the officer or a family member of the officer if the gift is: (a) a

political contribution as defined by Title 15 of the Election Code; or (b) a gift of food accepted as a guest; or

3) If the Supplier a family relationship with a local government officer of HISD.“Supplier” means a person who enters or seeks to enter into a contract with a local governmental entity. The term includes an agent of a

Supplier. The term includes an officer or employee of a state agency when that individual is acting in a private capacity to enter into a

contract. The term does not include a state agency except for Texas Correctional Industries. Texas Local Government Code 176.001(7).

“Business relationship” means a connection between two or more parties based on commercial activity of one of the parties. The term does

not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity

or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the

public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to

regular examination by, and reporting to, that agency. Texas Local Government Code 176.001(3).

“Local government officer” means: (A) a member of the governing body of a local governmental entity; (B) a director, superintendent,

administrator, president, or other person designated as the executive officer of a local governmental entity; or (C) an agent of a local

governmental entity who exercises discretion in the planning, recommending, selecting, or contracting of a Supplier. Texas Local

Government Code 176.001(4).

“Family relationship” means a relationship between a person and another person within the third degree by consanguinity or the second

degree by affinity, as those terms are defined by Subchapter B, Chapter 573, Government Code. Texas Local Government Code 176.001(2-a).

SUPPLIER MUST SIGN AND SUBMIT FORM CIQ EVEN IF NO CONFLICT EXISTS.

If no conflict exists, Supplier must fill out Box 1 and write N/A in Box 3.

I hereby certify that I have read Form I, Conflict of Interest Questionnaire (CIQ) Instructions, and I agree and understand

that the failure to disclose a conflict of interest and/or the failure to sign and submit Form CIQ, even if no conflict exists,

with this proposal may result in disqualification.

Name of Authorized Representative


v 06.18.2020 Page 19 of 24

http://www.houstonisd.org/HISDConnectEnglish/Images/PDF/BBFA_Local.pdf

Signature of vendor doing business with the governmental entity Date

CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ

For vendor doing business with local governmental entity

Name of Officer

This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a).

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 vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code.

A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor.

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 on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)

Name of vendor who has a business relationship with local governmental entity.

Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIQ as necessary.

Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more.

B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at thedirection of the local government officer or a family member of the officer AND the taxable income is notreceived from the local governmental entity?

Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).

Yes

Yes No

No

OFFICE USE ONLY

Date Received

6

1

4

3

2

5

7

Name of local government officer about whom the information is being disclosed.

A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,

other than investment income, from the vendor?

v 06.18.2020 Page 20 of 24

Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015

FORM J: HISD CERTIFICATE OF INTERESTED PARTIES – FORM 1295

Certificate of Interested Parties (Form 1295 – must be filled out electronically with the Texas Ethics Commission’s online

filing application, printed, sign (unsworn declaration), and attached to Supplier’s response to this solicitation.

Houston ISD (“HISD”) is required to comply with House Bill 1295, which amended the Texas Government Code by adding

Section 2252.908, Disclosure of Interested Parties. Section 2252.908 prohibits HISD from entering into a contract resulting

from this project with a business entity unless the business entity submits a Disclosure of Interested Parties (Form 1295) toHISD at the time business entity submits the signed contract. The Texas Ethics Commission has adopted rules requiring

the business entity to file Form 1295 electronically with the Texas Ethics Commission.

“Interested Party” means a person:

a) who has a controlling interest in a business entity with whom HISD contracts; or

b) who actively participates in facilitating the contract or negotiating the terms of the contract, including a broker,

intermediary, adviser, or attorney for the business entity.

“Business Entity” means an entity recognized by law through which business is conducted, including a sole proprietorship,

partnership, or corporation.

As a “business entity,” all Supplier s must electronically complete, print, sign, and submit Form 1295 with their proposals

even if no “interested parties” exist.

Proposers must file Form 1295 electronically with the Texas Ethics Commission using the online filing application, which can

be found at https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm. Proposers must use the filing application on the

Texas Ethics Commission’s website to enter the required information on Form 1295. Proposers must print a copy of the

completed form, which will include a certification of filing containing a unique certification number. The Form 1295 must be

signed by an authorized agent of the business entity, and the form must be notarized.

The completed Form 1295 with the certification of filing must be filed with HISD by attaching the completed form to the

Supplier’s solicitation response.

HISD must acknowledge the receipt of the filed Form 1295 by notifying the Texas Ethics Commission of the receipt of the filed

Form 1295 no later than the 30th day after the date the contract binds all parties to the contract. After HISD acknowledges the

Form 1295, the Texas Ethics Commission will post the completed Form 1295 to its website with seven business days after

receiving notice from HISD. The acknowledgement of your 1295 form does not guarantee that you will be selected as an

approved Supplier. An evaluation committee will select the Supplier (s) for the project and the Board of Education will

approve it during the next available board meeting. An award or regret letter will be sent once the selection and approval

process is complete. In the event that your proposal is not selected, we will request you to withdraw your 1295 form from the

Texas Ethics Commission website.

FORM K: IRS FORM W-9 (Rev Oct. 2018)

Please include an IRS Form W-9, only the newest form (Revised October 2018) will be accepted. For more instructions orto download the form please visit: HTTPS://WWW.IRS.GOV/PUB/IRS-PDF/FW9.PDF

v 06.18.2020 Page 21 of 24

http://www.ethics.state.tx.us/https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htmhttps://www.irs.gov/pub/irs-pdf/fw9.pdf

FORM L: EXCEPTION FORM

All deviations and exceptions to the project must be expressly stated in this Exception Form (additionalpages to this form may be added if necessary). In the absence of any entry on this Exception Form, Supplier

assures HISD of its full agreement and compliance with all specifications, terms and conditions,

requirements and obligations of the project. All exceptions must detail the section number, paragraphnumber, page number, and the specific language excepted.

YOU MUST SIGN AND SUBMIT THIS FORM WITH YOUR PROPOSAL REGARDLESS OF WHETHER

THERE ARE EXCEPTIONS LISTED OR NOT.

Vendor’s Name


Email Address


v 06.18.2020 Page 22 of 24

FORM M: CRIMINAL HISTORY BACKGROUND CHECK CERTIFICATION

TO: Office of Ethics and Compliance

Houston Independent School District

Vendors - Check ONE of the two options below:

NO direct contact with students - sign belowAs required by the Houston Independent School District contract, I hereby certify that NO employee and/or

subcontractor will have direct contact with any student at HISD as defined under 19 Texas Administrative Code

153.1101. SKIP ‘Section II’ and complete ‘Section III’ below.

WITH direct contact with students - enter employee names, then sign belowAs required by the Houston Independent School District contract, I hereby certify that the list of employees and/or

subcontractors below MAY/WILL have direct contact with students at HISD as defined under 19 Texas

Administrative Code 153.1101. COMPLETE ‘Section II’ and ‘Section III’ below.

Texas Administrative Code 153.1101. (7) Direct contact with students--The contact that results from activities that

provide substantial opportunity for verbal or physical interaction with students that is not supervised by a certified

educator or other professional district employee. Contact with students that results from services that do not provide

substantial opportunity for unsupervised interaction with a student or students, such as addressing an assembly,

officiating a sports contest, or judging an extracurricular event, is not, by itself, direct contact with students. However,

direct contact with students does result from any activity that provides substantial opportunity for unsupervised contact

with students, which might include, without limitation, the provision of coaching, tutoring, or other services to students.

Name* Date of Birth

1

2

3

4

5

6

7

8

9

10

11

12

*Attach additional pages as necessary

Vendor Name Name & Title of Authorized Representative

Signature of Authorized Representative Date Taxpayer Identification Number

FOR INTERNAL USE ONLY

NO STUDENT CONTACT DIRECT STUDENT CONTACT

Name of person receiving document Date Received by OEC

Signature of person receiving document

v 06.18.2020 Page 23 of 24

FORM N: ACKNOWLEDGMENT FORM

Project Due Date / Bid Opening:

THIS ACKNOWLEDGEMENT FORM MUST BE SIGNED AND RETURNED WITH YOUR PROPOSAL RESPONSE

TO ACKNOWLEDGE AND AFFIRM AGREEMENT TO ALL OF THE STATEMENTS AND TERMS & CONDITIONS

CONTAINED IN THIS REQUEST FOR PROPOSAL/QUALIFICATION. THE AUTHORIZED SUPPLIER

REPRESENTATIVE MANUALLY SIGNING THIS ACKNOWLEDGEMENT FORM WARRANTS THAT THEY ARE

IN RECEIPT OF THE FULL REQUEST FOR PROPOSAL AND ARE DULY AUTHORIZED TO COMMIT ON BEHALF

OF THEIR COMPANY TO CONTRACTUAL OBLIGATIONS AND PRICING.

I hereby acknowledge that I have received and read the following parts of the proposal in its entirety:

Document Initials

Part I: General Terms and Conditions

Part II: Request for Proposals

Attachment B: M/WBE Instructions & Participation Report

Part III: Project Attachments

Part IV: Bid Tabulation (Excel Format Only)

Part V: Nutrition Packet OR Vendor Questionnaire

VENDOR AGREES TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS, RULES,

REGULATIONS, AND ORDINANCES. IT IS FURTHER ACKNOWLEDGED THAT VENDOR CERTIFIES

COMPLIANCE WITH ALL PROVISIONS, LAWS, ACTS, REGULATIONS, ETC. AS SPECIFICALLY NOTED ABOVE.

Vendor’s Name

Address, City, State, and Zip Code

Contact Phone Number Contact Fax Number


Email Address


v 06.18.2020 Page 24 of 24

XX-XX-XX Part III RFP AttachmentsXX-XX-XX Part III RFP AttachmentsRFP Part 3 Attachments 1XX-XX-XX Part III RFx Attachments 1PART III RFx Project Name Attachments Template December 13 2017RFP Part 3 Attachments 1.28.19 NS Non-Food

Certficate of Insurance- Verfication FormXX-XX-XX Part III RFP AttachmentsXX-XX-XX Part III RFP AttachmentsRFP Part 3 Attachments 1XX-XX-XX Part III RFx Attachments 2 16

Pages from RFP Part 3 Attachments 2

RFP Attachments Ack. Page

TYPE OF BUSINESSDESCRIPTION OF PRODUCTS ANDOR SERVICES PROVIDED: PUBLICLY TRADED CORPORATION: OffLIMITED PARTNERSHIP: OffSOLE PROPRIETORSHIP: OffPRIVATE CORPORATION: OffPARTNERSHIP: OffNOT FOR PROFIT ENTITY: OffNUMBER OF PART TIME EMPLOYEES: undefined: IS SUPPLIER IS A RESIDENT BIDDER: OffIF NOT TEXAS DOES THE STATE HAVE PREFERENTIAL TREATMENT ON BIDS: undefined_2: OffHAS SUPPLIER CONDUCTED BUSINESS WITH THE DISTRICT UNDER ANOTHER NAME: OffPREVIOUSLY CONDUCTED BUSINESS WITH THE DISTRICT: OffText11: Text12: Text13: Text14: Text15: Text16: Text17: Text18: Text19: Text20: Text21: Text22: 10 DO YOU HAVE EXPERIENCE WITH OTHER SCHOOL DISTRICTS: OffLAST 5 YEARS: Off12 DOES ANY OFFICER PARTNER OWNER SALES REPRESENTATIVE ANDOR SPOUSE WORK FOR HISD: OffTHE DISTRICT: OffWHETHER COMPENSATED OR NOT COMPENSATED 1: WHETHER COMPENSATED OR NOT COMPENSATED 2: WHETHER COMPENSATED OR NOT COMPENSATED 3: undefined_3: OffDISTRICT: OffIF YES PLEASE PROVIDE THE STYLE AND STATUS OF THE CASE AS WELL AS THE TYPE OF LITIGATION: INSURANCE COMPANIESRow1: INSURANCE COMPANIESRow1_2: INSURANCE COMPANIESRow2: INSURANCE COMPANIESRow2_2: INSURANCE COMPANIESRow3: INSURANCE COMPANIESRow3_2: INSURANCE COMPANIESRow4: INSURANCE COMPANIESRow4_2: ANDOR WOMAN OWNED COMPANY: Offundefined_4: Text23: Text24: Text25: Text26: Text27: Text28: Text29: Text30: Text31: SUPPLIER WILL PROVIDE GOODS AND SERVICES WITH OWN WORK FORCE: OffSUPPLIER WILL PURCHASE GOODS DIRECTLY FROM THE MANUFACTURER OR OTHER SUPPLIER: Offfill_1: Text32: Text33: Name of Entity or Business: Survey will be requested if neededEmail Address_2: Phone Number: Name of Entity or Business_2: Email Address_3: Phone Number_2: Name of Entity or Business_3: Email Address_4: Phone Number_3: Contact Name: Survey will be requested if neededMailing Address: Goods andor services provided: Contact Name_2: Mailing Address_2: Goods andor services provided_2: Contact Name_3: Mailing Address_3: Goods andor services provided_3: SCORE110: SCORE110_2: SCORE110_3: SCORE110_4: SCORE110_5: SCORE110_6: SCORE110_7: SCORE110_8: SCORE110_9: TOTAL POINTS out of 90: District Company Name: Printed Name of Evaluator: Date_2: Text34: Survey will be requested if neededText41: Jennifer M. Williams [email protected]: January 6, 2021 10:00AMInitials of Authorized Representative of Vendor: Initials of Authorized Representative of Vendor_2: Initials of Authorized Representative of Vendor_3: Initials of Authorized Representative of Vendor_4: Initials of Authorized Representative of Vendor_5: employee subcontractor or volunteer so that HISD may obtain the CHRI on the individuals: Vendor is a publicly held corporation therefore the above reporting requirement does not apply: OffVendor is not owned nor operated by anyone who has been convicted of a felony: OffVendor is operated or owned by the following individuals who hashave been convicted of a felony: OffName of Individuals: undefined_6: Detail of convictions attach additional pages if necessary: insurance and insurance policies available to HISD upon request: Initials of Authorized Representative of Vendor_8: Printed Name and Title of Authorized Representative_2: Email Address_5: Date_3: and conditions apply to the Contract between the District and: Does Vendor agree YES: YES_15: YES_16: Does Vendor agree YES_2: Does Vendor agree YES_3: Does Vendor agree YES_4: Does Vendor agree YES_5: Does Vendor agree YES_6: Does Vendor agree YES_7: Does Vendor agree YES_8: Does Vendor agree YES_9: Does Vendor agree YES_10: Does Vendor agree YES_11: Does Vendor agree YES_12: fill_1_2: Printed Name and Title of Authorized Representative_4: Email Address_7: Date_5: CONFLICT OF INTEREST QUESTIONNAIRE CIQ INSTRUCTIONS: Name of Authorized Representative: Date_7: Name of local government officer about whom the information is being disclosed: Date_8: Check Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffText40: Check Box41: OffTHERE ARE EXCEPTIONS LISTED OR NOT 1: THERE ARE EXCEPTIONS LISTED OR NOT 2: THERE ARE EXCEPTIONS LISTED OR NOT 3: THERE ARE EXCEPTIONS LISTED OR NOT 4: THERE ARE EXCEPTIONS LISTED OR NOT 5: THERE ARE EXCEPTIONS LISTED OR NOT 6: THERE ARE EXCEPTIONS LISTED OR NOT 7: THERE ARE EXCEPTIONS LISTED OR NOT 8: THERE ARE EXCEPTIONS LISTED OR NOT 9: THERE ARE EXCEPTIONS LISTED OR NOT 10: THERE ARE EXCEPTIONS LISTED OR NOT 11: THERE ARE EXCEPTIONS LISTED OR NOT 12: THERE ARE EXCEPTIONS LISTED OR NOT 13: THERE ARE EXCEPTIONS LISTED OR NOT 14: THERE ARE EXCEPTIONS LISTED OR NOT 15: THERE ARE EXCEPTIONS LISTED OR NOT 16: THERE ARE EXCEPTIONS LISTED OR NOT 17: THERE ARE EXCEPTIONS LISTED OR NOT 18: THERE ARE EXCEPTIONS LISTED OR NOT 19: THERE ARE EXCEPTIONS LISTED OR NOT 20: fill_21: Printed Name and Title of Authorized Representative_5: Email Address_8: Date_6: WITH direct contact with students: OffName1: Date of Birth1: Name2: Date of Birth2: Name3: Date of Birth3: Name4: Date of Birth4: Name5: Date of Birth5: Name6: Date of Birth6: Name7: Date of Birth7: Name8: Date of Birth8: Name9: Date of Birth9: Name10: Date of Birth10: Name11: Date of Birth11: Name12: Date of Birth12: Vendor Name: Name Title of Authorized Representative: Date_9: Taxpayer Identification Number: NO STUDENT CONTACT: OffDIRECT STUDENT CONTACT: OffName of person receiving document: Date Received by OEC: InitialsPart I General Terms and Conditions: InitialsPart II Request for Proposals: InitialsAttachment B MWBE Instructions Participation Report: InitialsPart III Attachments: InitialsPart IV Bid Tabulation Excel Format Only: InitialsPart V Nutrition Packet OR Vendor Questionnaire: Vendors Name: Address City State and Zip Code: Contact Phone Number: Contact Fax Number: Printed Name and Title of Authorized Representative: Email Address: Date: Text50: 16-10-48-E RFP/Teacher and Staff Development Text1: Text2: Text3: Text4: Text5: Text6: Text7: Text8: Text9: Group11: Choice1fill_3: Text10: NO direct contact with students: OffText35: Check Box40: OffCheck Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffText48: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffText36: Text37: Text38:

PART III: Attachments Please include all original completed forms … · 2020. 11. 13. · FORM O:...

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