VALLEY VIEW INDEPENDENT SCHOOL DISTRICT

Transcription

1 Valley View Independent School District 9701 S. Jackson Rd., Pharr, TX Phone (956) Fax (956) Valley View Independent School District is accepting proposals for: Sealed proposals are to be mailed or hand delivered to the attention of Laura Harris, Purchasing Coordinator, Valley View Independent School District, 9701 S. Jackson Rd., Pharr, Texas Please mark your envelope plainly: Proposal for, due date: Monday, July 11, 9:00 a.m. Sealed proposals will be accepted until 9:00 a.m. on Monday, July 11, 2016 and will be opened at 2:00 p.m. in the District Conference Room in the Business Office Building, 9701 S. Jackson Rd., Pharr, Texas Any proposals received late will be returned unopened. Valley View ISD is not responsible for proposals misplaced or mailed incorrectly. Please reply using the enclosed forms. Please submit one original and one copy of your proposal. Any questions on this Request for Proposals should be submitted in writing to Laura Harris, Purchasing Coordinator, via fax (956) or at lharris@vviewisd.net, or mailed to 9701 S. Jackson Rd., Pharr, Texas The awarding of the proposal will take place at a public school board meeting. The Board of Education reserves the right to accept, reject any and /or all proposals, waive minor technicalities, or to award the proposal to the most responsible offeror which best serves the interest of the District. We look forward to hearing from you. Sincerely, - Original Signed - Laura Harris Purchasing Coordinator ***Summer schedule is as follows: Mon-Thurs. 9am-12pm, and 2pm-5pm. 1

2 PROPOSAL PACKAGE CHECKLIST REMINDER IN ORDER FOR YOUR PROPOSAL TO BE CONSIDERED IN THE PROPOSAL PROCESS, THE FOLLOWING ITEMS ARE REQUIRED TO BE INCLUDED IN THE PROPOSAL PACKAGE: DESCRIPTION OF ITEM YES NO N/A 1. STANDARD TERMS & CONDITIONS, GENERAL PROPOSAL & ASSUMPTIONS BACKGROUND (Pages 3 & 4). 2. FELONY CONVICTION NOTIFICATION (Fill in one of the appropriate sections A, B, Or C, Page 5). 3. PROPOSAL SPECIFICATION REQUIREMENT FORM (Page 6) 4. NON-COLLUSION STATEMENT & SIGNATURE SHEET (Page 8). 5. PROPOSAL FORMS pertaining to this proposal Should have all lines filled in as needed (Pages 12-19). 6. CONFLICT OF INTEREST QUESTIONNAIRE (Page 21 & 22) 7. PLEASE SUBMIT THE WHOLE PACKAGE EVEN IF NOT SUBMITTING A PROPOSAL ON ALL ITEMS. **(FAILURE TO MANUALLY SIGN THE PROPOSAL WILL DISQUALIFY IT.)** 2

3 STANDARD TERMS AND CONDITIONS NOTICE TO OFFERORS ITEMS BELOW APPLY TO AND BECOME A PART OF TERMS AND CONDITIONS OF PROPOSALS UNLESS SUPERSEDED BY ANY ATTACHED TERMS AND SUPPLEMENTAL CONDITIONS OR SPECIFICATIONS IN WHICH CASE ATTACHED CONDITIONS WILL PREVAIL ANY EXCEPTIONS MUST BE IN WRITING 1. Proposals should be submitted on this form. Each proposal shall be placed in a separate envelope, sealed and properly identified with the proposal title, proposal number, date. 2. Proposal shall follow the plan as specified. Answer all the yes/no questions and completely fill in all the blanks. RFP must be complete or it will be rejected. 3. Proposals must be received in the District s Business Office before the hour and date specified. Late proposals will not be considered under any circumstances. 4. Proposals must have original signatures. 5. Proposal prices must be firm for acceptance for ninety (90) days from proposal opening date. No proposals may be withdrawn without written approval after a contract has been signed or partial performance of the proposal agreement has begun. 7. Failure to manually sign proposal will disqualify it. Person signing proposal should show title or authority to bind their firm to a contract. 8. The District reserves the right to accept or reject all or any part of any proposal, waive minor technicalities and award the proposal to the Offeror that best serves the interest of the District. 9. No Proposal: All proposal forms should be signed & marked No Bid, as needed, and returned even if Offeror is unable to submit a proposal at this time, but wishes to remain on offeror s list. 10. Term of Contract: The contract will be effective as per Insurance Policy, or after Board approval whichever occurs later. The District would prefer a one-year contract with the option to renew for two (2) additional (separate) one (1) year terms, if there are no changes in terms and conditions, insurance agent or underwriting company, and the insurance rates do not increase more than 10% per year. 11. Venue: In the event of legal disputes related to this contract, the venue shall be Hidalgo County in the State of Texas. Date Company Name 3

4 GENERAL PROPOSAL REQUIREMENTS & ASSUMPTION BACKGROUND Sealed proposals will be accepted until 9:00 a.m. on Monday, July 11, 2016 and will be opened at 2:00 p.m., in the District Conference Room in the Business Office Building, 9701 S. Jackson Rd., Pharr, Texas. Any proposals received late will be returned unopened. Valley View ISD is not responsible for proposals misplaced or mailed incorrectly. All inquiries regarding this request for proposals should be submitted in writing to Laura Harris, Purchasing Coordinator, via fax (956) , or mailed to 9701 S. Jackson Rd., Pharr, Texas The original plus one copy of sealed proposals are to be mailed or hand delivered to the attention of: Laura Harris Purchasing Coordinator Valley View ISD 9701 S. Jackson Rd. Pharr, Texas Proposed effective date as per insurance policy inception date, or after approval by the School Board, whichever occurs later. 3. Valley View ISD would like to enter into a one-year contract with the option to renew for two (2) additional (separate) one (1) year terms, if there are no changes in terms and conditions, insurance agent or underwriting company, and the insurance rates do not increase more than 10% per year. 4. A minimum of 90 days advance notice must be provided to the District concerning any subsequent adjustment to premium rates or fees. 5. Please return the original proposal forms in the same ordered received with the yes or no questions answered and the blanks filled in. This will make it a lot easier to analyze the proposal. This is to the benefit of both parties. 4

5 FELONY CONVICTION NOTIFICATION State of Texas Legislative Senate Bill No. 1, Section , Notification of Criminal History, Subsection (a), states a person or business entity that enters into a contract with a school district must give advance notice to the district if the person, 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 a contract with a person or business entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or misrepresented the conduct resulting in the conviction. The district must compensate the person or business entity for services performed before the termination of the contract. THIS NOTICE IS NOT REQUIRED OF A PUBLICLY-HELD CORPORATION, BUT THE COMPANY REPRESENTATIVE MUST CHECK OFF A SELECTION BELOW (A, B, OR C) 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 NAME: AUTHORIZED COMPANY OFFICIAL S NAME (PRINTED) AND SIGNATURE: DATE: ***** PLEASE CHECK OFF A SELECTION BELOW***** ( ) A. My firm is a publicly-held corporation, therefore, this reporting requirement is not applicable. ( ) B. My firm is not owned and/or operated by anyone who has been convicted of a felony. ( ) C. My firm is owned or operated by the following individual(s) who has/have been convicted of a felony: Name of Felon: Details of Convictions(s): 5

6 PROPOSAL SPECIFICATIONS REQUIREMENTS (TO BE FILLED IN BY OFFEROR AND SUBMITTED WITH PROPOSAL) Is this proposal in conformance with the enclosed specifications? Yes No If the answer is no, offeror must identify and explain each exception taken, with reference to each page and paragraph to which the exception will apply. It should be understood that if no exception is taken the vendor should supply all items as specified at the time of sale. Failure to indicate any difference in products offered proposed in this proposal may be deemed sufficient grounds of a vendor proposal. Comments: Date Company Name 6

7 It is the intent of these specifications to secure proposals for: For further information, please submit questions in writing to: Laura Harris Purchasing Coordinator Phone (956) , Fax , Valley View Independent School District 9701 S. Jackson Rd. Pharr, Texas According to the Texas Education Code, Subchapter B, Section (b), in determining to whom to award a contract, the district will consider the following: (1) the purchase price; (2) the reputation of the vendor and of the vendor s goods or services; (3) the quality of the vendor s goods or services; (4) the extent to which the goods or services meet the district needs; (5) the vendor s past relationship with the district; (6) the impact on the ability of the District to comply with laws and rules relating to historically underutilized business; (7) the total long-term cost to the District to acquire the vendor s goods or services; and (8) any other relevant factor specifically listed in the request for bids or proposals. 7

8 Evaluation Criteria Maximum Points Purchase Price 25 Reputation of Vendor's goods and services 15 Quality of Vendor's goods and services 15 Extent to which goods or services meet District needs 35 Vendor's past relationship with the District 0 Impact on the ability of the District to comply with laws and rules to historically underutilized business 5 Long-term cost to the District to acquire the Vendor's goods or services; and 5 Any other relevant factor specifically listed in the request for bids or proposals 0 Total 100 8

9 NON-COLLUSION STATEMENT & SIGNATURE SHEET The undersigned affirms that he/she is duly authorized to execute this contract, that this company, corporation, firm, partnership, or individual has not prepared this proposal in collusion with any other offeror, and that the contents of this proposal as to prices, terms or condition of said proposal have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or any individual affiliated with Valley View ISD, prior to the official opening of this proposal. Further, I affirm that after the opening of this proposal, I (or any representative of my company) will not discuss the contents of this proposal with any person affiliated with Valley View ISD, other than the District s Finance Director, or his designee, prior to the awarding of this proposal. I understand that failure to observe this procedure may cause my proposal to be rejected. I,, have read the standard terms and conditions (page 3), (Print/Type Name of Company Officer), general proposal requirements and assumptions background (page 4), proposal specifications requirements (page 6), I fully understand them, and will fully execute them if I am awarded this proposal. I have represented the truth concerning the felony conviction notification. I have checked off one of the three statements, and have signed the form on page 5. I have read the criteria that the District may consider to award this contract, as per Texas Education Code, Subchapter B, Section (b), (Page 7). I fully understand the proposal s specifications (pages 12-22). COMPANY ADDRESS CITY, STATE, ZIP CODE AREA CODE/TELEPHONE/FAX SIGNATURE TITLE DATE 9

10 ATHLETIC, UIL, JROTC, VOCATIONAL EDUCATION, SPECIAL EDUCATION & STUDENT VOLUNTARY Effective Date: August 1, 2016 July 31, 2017 Valley View I.S.D. is requesting proposals for Athletic/UIL/JROTC/Vocational Education/ Special Education Vocational/Occupational Training Programs and Voluntary. The RFP quotation should duplicate our specifications as near as possible. All items on the attached specifications must be answered. DO NOT ANSWER ANY QUESTIONS BY SAYING SEE BROCHURES. ONLY ANSWERS ON THE SPECIFICATIONS SHEETS WILL BE CONSIDERED. The policy issued by the selected company will provide coverage that duplicates the answers in the specifications. In the event of any variation, the company or completing agent warrants the policy will be amended to comply with specifications or they will be responsible for providing benefits as described in the ANSWERS TO SPECIFICATIONS. DESIRED PLAN Valley View ISD desires to secure the most comprehensive insurance coverage available at the most competitive price. The District desires to obtain quotes for Reasonable & Customary with Catastrophic Coverage. We are requesting the same plan. Every consideration will be given to deviations from these specifications where the offeror is proposing a better plan than the current plan. Price alone is by no means the sole criterion for selection. We are very much interested in services to be provided. Please complete the proposal forms, then make additional proposals you feel may benefit the District. In completing the questionnaires, the format must be followed. If additional space is required to answer a question, please attach a separate sheet with your comments and reference the question being addressed. 10

11 ATHLETIC, UIL, JROTC, VOCATIONAL EDUCATION, SPECIAL EDUCATION & STUDENT VOLUNTARY DEFINITIONS COVERAGE is a student covered while practicing for, competing in, or traveling to and from as a representative of a member school and under the direct supervision of a full-time school employee, all athletic and activity events under the regulation and jurisdiction of the School. Coverage for girls and boys in such approved inter-school athletics includes: Senior and Junior High School Tackle Football, Basketball, Volleyball, Track, Cross Country, Golf, Tennis, Soccer, Baseball, Softball, Swimming, Wrestling, Gymnastics, Cheerleaders, Team Managers and all other inter-school participants. COMPULSORY COVERAGE - means student accident insurance coverage that student is covered under when he or she is playing a covered sport. BLANKET COVERAGE is another name for COMPULSORY COVERAGE. VOLUNTARY COVERAGE - means student accident insurance coverage, which the student s parents/guardians or person having responsibilities for the student may purchase. Voluntary Coverage can be divided into two (2) coverage/classifications, they are SCHOOL TIME COVERAGE and 24 HOUR COVERAGE. SCHOOL TIME COVERAGE - means coverage for accidental injuries occurring while at school, when school is in session and while participating in any non-athletic school sponsored and supervised activities. 24 HOUR COVERAGE means coverage for accidental injuries occurring around-the-clock, at home, at school, on weekends and during the summer. Coverage is effective from the policy effective date until the first day of the school the following year or for 12 months, whichever is sooner, if the initial enrollment deadline is met. CATASTROPHIC COVERAGE means the coverage that takes over when the Voluntary Coverage limits are exceeded. SPECIAL EDUCATION refers to Special Education Vocational/Occupational Training Programs and includes coverage for accidents occurring while On-Job-Training Programs (OJT) and On-Site-Training (OST). VOCATIONAL EDUCATION refers to Senior High School Vocational Education Classes and Vocational Education off Campus. This includes JROTC and any non-sport extracurricular activities. 11

12 REFERENCE SHEET LIST FIVE SCHOOL DISTRICTS IN THE STATE OF TEXAS WHERE YOU NOW HAVE A STUDENT ATHLETIC INSURANCE PLAN IN EFFECT. Company Name: Contact Name: Address: City: State: Zip Code: Phone Number: Fax Number: Company Name: Contact Name: Address: City: State: Zip Code: Phone Number: Fax Number: Company Name: Contact Name: Address: City: State: Zip Code: Phone Number: Fax Number: Company Name: Contact Name: Address: City: State: Zip Code: Phone Number: Fax Number: Company Name: Contact Name: Address: City: State: Zip Code: Phone Number: Fax Number: 12

13 ESTIMATES OF PARTICIPATION (For use in totals on proposals) (Valley View Independent School District pays all Student Athletic Insurance) Activity Participation Estimates Football (Jr. High & High School) 138 Basketball (Jr. High & High School) 85 Baseball 40 Soccer (Jr. High & High School) 139 Volleyball (Jr. High & High School) 62 Softball 48 Other Sports 275 ROTC 125 Cheerleaders (Jr. High & High School) 40 Band (Jr. High & High School) 160 Other Activities 400 Special Education 30 REQUESTED PLAN BASE PLAN COVERAGE REQUIREMENTS 1. Maximum Benefits per occurrence at least $25,000 ( ) $25,000 ( ) $10,000 ( ) Other $ 2. Deductible Information ( ) No Deductible Required a. Sports, Cheerleaders, Band, UIL ( )$ Deductible Required b. Vocational Students ( ) No Deductible Required ( )$ Deductible Required 3. Maximum number of days between injury & first ( ) 30 Days ( ) 60 Days report of injury ( ) 90 Days ( ) Other 4. Standard benefit period should be at least 52 weeks ( ) 52 Weeks ( ) No ( ) Two years Is a Two Year Benefit Period available as an Option? ( ) Yes ( ) No 5. Excess provisions should provide for coverage on ( ) Excess of Group Policy Only a Secondary Basis to Group & Individual Policies. ( ) Excess of Group Policy & Individual Policies 13

14 BASE PLAN SCHEDULE OF BENEFITS For each benefit listed, please answer YES if provided by your proposed policy. NO if not provided by your proposed policy. The benefits listed are Usual and Customary; based on the Dallas & Houston areas. (Please explain any NO answers or qualifying remarks in the space for limitations) MEDICAL PAYMENTS ($ $25,000.00) LIMITATIONS Hospital in-patient expenses $3,000 per day surgery: ( ) Yes ( ) No $400 per day thereafter ( ) Yes ( ) No Hospital outpatient emergency care expenses (within 72 hours of injury) $300 per day thereafter ( ) Yes ( ) No Hospital outpatient expenses $3,000 per day surgery: ( ) Yes Emergency Room (out-patient) $300 per day surgery: ( ) Yes ( ) No ( ) No Physician Emergency Room $300 per injury ( ) Yes ( ) No Physician expenses (non-surgical) $100 per visit, $80 each subsequent visit ( ) Yes ( ) No Physician expenses $500 per unit allowance under the (Surgical) California Relative Valley Studies ( ) Yes ( ) No Assistant Surgeon Expenses 25% of Surgeon s Allowance/$1,000 max ( ) Yes ( ) No Anesthesia Expense 25% of Surgeon s Allowance/$1,000 max ( ) Yes ( ) No Private Nurse Expense Reasonable & Customary ( ) Yes ( ) No Outpatient Physical Therapy Expenses $100 per visits up to 20 visits up to 3 per week ( ) Yes ( ) No Out-patient X-rays expenses $400 for fracture: $900 for non-fracture per injury ( ) Yes ( ) No 14

15 Out-patient Laboratory Reasonable & Customary Expenses ( ) Yes ( ) No MEDICAL PAYMENTS ($ $25,000.00) LIMITATIONS Dental expenses for treatment of sound and natural teeth: (repair or replacement) ( ) Yes ( ) No Ambulance expenses 100% of Usual & Customary One trip to nearest Hospital by ground transportation & air transportation: ( ) Yes ( ) No Injury cause by motor vehicle (expenses) $500 per injury: ( ) Yes ( ) No Diagnostic Surgery expense $750 per injury: ( ) Yes ( ) No Diagnostic Imaging expense (MRI) $750 per injury: ( ) Yes ( ) No Extended Dental Coverage expense $25,000 maximum: ( ) Yes ( ) No Flouroscan Imaging expense $250 per injury: ( ) Yes ( ) No Miscellaneous Hospital $500 per injury: ( ) Yes ( ) No Services while confined or surgery performed Intensive Care for up to $500 per injury: ( ) Yes ( ) No Seven (7) days Consultant, second opinions $125 per injury: ( ) Yes ( ) No Prescribed Orthopedic Appliances: Maximum in Hospital $400 ( ) Yes ( ) No Out of Hospital $400 ( ) Yes ( ) No Prescribed Drugs/Medicine 100% of Usual & Customary ( ) Yes ( ) No Replacement, when broken as a result of injury: (Eyeglasses, contacts, hearing aides) 100% of Usual & Customary ( ) Yes ( ) No 15

16 1. Indicate if any of the following are excluded from coverage, or limited in any way: Heat Exhaustions or Heat Stroke ( ) Covered ( ) Excluded Dehydration ( ) Covered ( ) Excluded Hernias ( ) Covered ( ) Excluded Blisters ( ) Covered ( ) Excluded Orthodontics (Due to covered injury) ( ) Covered ( ) Excluded 2. Indicated the definition of covered sports: Answer the following with (Yes or No) ( ) UIL Endorsed Activities only ( ) Including Off-Season Conditioning (No additional cost) ( ) Including Off-Season Conditioning (Additional cost) ( ) All school sponsored & supervised Interscholastic Sports ( ) Including Off-Season Conditioning (No additional cost) ( ) Including Off-Season Conditioning (Additional cost) ( ) Coverage included during Try-Outs, Practices, Games, Travel to Games ( ) Coverage includes: ( ) Senior High School Sports Coverage is limited to Grades: to ( ) Junior High School Sports Coverage is limited to Grades: to ( ) Senior High School Sports Coverage applies to all grades in a Senior High School ( ) Coverage applies to both Junior Varsity and Varsity ( ) Coverage is available for Intra-Mural Sports for Grades: ( ) No Name Lists are required ( ) Name Lists are required. ( ) Spring Training Coverage is available ( ) There is not set period of coverage for Spring Training Coverage ( ) Spring Training Coverage is applicable from: to ( ) Sports Coverage includes Cheerleaders & Band 3. Coverage for other activities ( ) Coverage available for UIL endorsed activities only ( ) Coverage is not available for other activities ( ) Coverage is available for other extra-curricular sponsored & supervised activities (UIL & Non-UIL) ( ) Coverage included travel to and from competition ( ) Coverage includes Practices & Meetings ( ) Coverage is available for FFA Activities ( ) Coverage is available for Cheerleaders & Band ( ) Coverage is available for Power Lifting Activities ( ) Spring Training Coverage is available 16

17 4. Special Provisions If your plan includes unusual coverages (such as broken eyeglasses), please explain those coverages below: CATASTROPHIC PLAN COVERAGE QUESTIONS 1. Catastrophic Deductible Amount: $ 2. Deductible Accumulation Period: ( ) Two Years ( ) Three Years ( ) Other 3. Catastrophic Deductible based on: ( ) Two Years ( ) Three Years ( ) Other 4. Benefit Period ( ) Two Years ( ) Three Years ( ) Other 5. Benefit Based on: ( ) Two Years ( ) Three Years ( ) Other 6. Catastrophic Coverage extends to: ( ) All activities covered under base plan ( ) Other 7. Catastrophic Provisions: A signed waiver is required: ( ) Yes ( ) No Is there provisions in the Policy Limiting benefits base on Statutory Liability Limits ( ) Yes ( ) No 8. Maximum Benefits for Medical Expenses for each Accident: $ 9. Is there any variation in benefits for different types of injuries? If yes, explain ( ) Yes ( ) No 17

18 ACCIDENTAL DEATH & DISMEMBERMENT COVERAGE Premiums for Coverage should be included in the Sports quotation 1. Losses included Benefits Death $ One Hand $ One Foot $ Sight or One Eye $ Thumb & Forefinger of same hand $ Other $ Any two of the above (except death) $ 2. Loss must occur within days of the accident. GENGERAL QUESTIONS Are Monthly Claim Reports furnished? ( ) Yes ( ) No Are Year End Loss Reports furnished? ( ) Yes ( ) No What is the location of Claim Payment Office: Phone #: What is claim turnaround time? Days Is there an 800 or 888 number for claim questions? ( ) Yes ( ) No Can claims be filed online? ( ) Yes ( ) No Do you required a claim form to be filed by each Doctor or hospital for the same claim/ ( ) Yes ( ) No Do you have someone who can periodically review claims on site? ( ) Yes ( ) No Do you assign local representatives to each School District? ( ) Yes ( ) No Will the School District be issued its own policy on a direct sites basis? ( ) Yes ( ) No Will all coverages be fully insured? ( ) Yes ( ) No 18

19 INSURANCE COMPANY INFORMATION Name of Proposing Company: Name of Underwrite Representing Company: Signature of Authorized Representative: Title of Representative: Home Office Address: Home Office Telephone#: Best Rating: Admitted Carrier in Texas? ( ) Yes ( ) No If there are not any special features or provisions in your plan that have not been listed above, that you would like considered, please describe below: Name of School District: Street Address: Valley View Independent School District 9701 S. Jackson Rd. City, State, and Zip Code: Pharr, TX Telephone Number: (956) Contact Person: Laura Harris, Purchasing Coordinator 19

20 STUDENT ATHLETIC INSURANCE All Athletics & Activities under UIL Competition $ Including Cheerleaders & Band CATASTROPHIC COVERAGE $25,000 deductible with excess coverage: OPTIONAL COVERAGE $5,000,000 $ $2,000,000 $ $1,000,000 $ Sub-Total $ Braces & Appliances (Usual & Customary) $ Vocational, FFA, Trade or Industrial (Usual & Customary) $ Total $ Cost: **PLEASE PROVIDE INFORMATION PACKETS TO LAURA HARRIS BY AUGUST 1, 2016 TO BE DISTRIBUTED TO STUDENTS. 20

21 ATHLETIC, UIL, JROTC, VOCATIONAL EDUCATION, SPECIAL EDUCATION & STUDENT VOLUNTARY Schedule showing Premiums & Losses: Year of Coverage Premium Losses Loss Ratio $113, $79, % $113, $25, % $98, $79, % $96, $94, % $96, $58, % *Claims paid as of June 1,

22 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local government 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 7 th business day after the date the person becomes aware of facts that require the statement to be filed. See Section , Local Government Code. FORM CIQ OFFICE USE ONLY Date received A person commits an offence if the person violates Section , 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 (a) Local Government Code, is pending and not later than the 7 th 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 governmental entity with respect to expenditures of money. 4) Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs local government officer of the governmental entity that is the subject of this questionnaire. 22

23 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity FORM CIQ 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. 7) Signature of person doing business with the governmental entity Date 23

24 CERTIFICATE OF INTERESTED PARTIES FORM 1295 Complete Nos. 1-4 and 6 if there are interested parties. Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties. OFFICE USE ONLY 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the goods or services to be provided under the contract. 4 Name of Interested Party 5 Check only if there is NO Interested Party. City, State, Country (place of business) Nature of Interest (check applicable) Controlling Must file online Intermediary 6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct. AFFIX NOTARY STAMP / SEAL ABOVE Signature of authorized agent of contracting business entity Sworn to and subscribed before me, by the said, this the day of, 20, to certify which, witness my hand and seal of office. Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath ADD ADDITIONAL PAGES AS NECESSARY Form provided by Texas Ethics Commission Adopted 10/5/2015