part iii: new project attachments please include all ... · owned autos, including additional...

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 Agent FORM D: Reference Survey Instructions FORM E: Reference Survey FORM F: Price Schedule - Excel Format Only FORM G: General Certifications FORM H: EDGAR Certifications FORM I: Conflict of Interest Instructions and Questionnaire (Form CIQ) FORM J: 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: Execution of Offer Form FORM O: Nutrition Kit FORM P: Certification Regarding Federal Lobbying (TDA Form H2049) FORM Q: Compliance with Buy American Provision FORM R: Confidentiality Declaration Form

Category Specialist:

Proposal Due Date:

Houston ISD NS RFP 1 of 37 Revised 10.01.2020

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:


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 _____________%


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 proposer

can provide the levels of insurance specified in this project is required, along with Form C.


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


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.


SAMPLE

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 Number

Supplier’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


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) ________________________________________ ________________________________________


________________________________________ ________________________________________


________________________________________ ________________________________________



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


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 competitive solicitation 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 orvendor'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 selectionprocess.

The “Code of Silence” period shall begin when the project is issued and ends upon the execution of the Contract. 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 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.



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

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; and4. 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 processeswhen 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 HACCPprocedures

• 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.


“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, orb. 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 44.34 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.



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 interestedin the proposed procurement.

e) Vendor did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidderor anyone else would submit a false or sham bid or proposal, or that anyone should refrain from biddingor withdraw his bid or proposal.

f) Vendor did not, in any manner, directly or indirectly seek by agreement, communication or conferencewith anyone to raise or fix the bid or proposal price of said bidder or of anyone else, or to raise or fix anyoverhead, 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 thecontents 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 anyindividual or group of individuals, except to the District, or to any person or persons who have apartnership 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 invokeany 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 byblood or marriage within the third degree or is employed, either full or part time, by the District eithercurrently or within the last two (2) years.

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


CERTIFICATION REGARDING TERRORIST ORGANIZATIONS Vendor hereby certifies that it is not a company identified on the Texas Comptroller’s list of companies known to have contracts with, or provide supplies or services to, a foreign organization designated as a Foreign Terrorist Organization by the U.S. Secretary of State.


CERTIFICATION REGARDING BOYCOTTING OF ISRAEL If (a) Vendor is not a sole proprietorship; (b) Vendor has ten (10) or more full-time employees; and (c) this Agreement has a value of $100,000 or more, the following certification shall apply; otherwise, this certification is not required. Pursuant to Chapter 2270 of the Texas Government Code, the Vendor hereby certifies and verifies that neither the Vendor, nor any affiliate, subsidiary, or parent company of the Vendor, if any (the “Vendor Companies”), boycotts Israel, and the Vendor agrees that the Vendor and Vendor Companies will not boycott Israel during the term of this Agreement. For purposes of this Agreement, the term “boycott” shall mean and include refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations with Israel, or with a person or entity doing business in Israel or in an Israeli-controlled territory, but does not include an action made for ordinary business purposes. NOTE: On April 25, 2019, the U.S. District Court for the Western District of Texas entered a


preliminary injunction enjoining the enforcement of the above-referenced law in any state contract. In compliance with the Court’s order, HISD will not seek enforcement of this law until further order of the court or a higher court having jurisdiction over the issue.


CERTIFICATION REGARDING CONTRACTING INFORMATION If Vendor is not a governmental body and (a) this Agreement has a stated expenditure of at least $1 million in public funds for the purchase of goods or services by HISD; or (b) this Agreement results in the expenditure of at least $1 million in public funds for the purchase of goods or services by HISD in a fiscal year of HISD, the following certification shall apply; otherwise, this certification is not required. As required by Tex. Gov’t Code § 552.374(b), the following statement is included in the RFP and the Agreement (unless the Agreement is (1) related to the purchase or underwriting of a public security; (2) is or may be used as collateral on a loan; or (3) proceeds from which are used to pay debt service of a public security of loan): “The requirements of Subchapter J, Chapter 552, Government Code, may apply to this RFP and Agreement and the contractor or vendor agrees that the contract can be terminated if the contractor or vendor knowingly or intentionally fails to comply with a requirement of that subchapter.” Pursuant to Subchapter J, Chapter 552, Texas Government Code, the Vendor hereby certifies and agrees to (1) preserve all contracting information related to this Agreement as provided by the records retention requirements applicable to HISD for the duration of the Agreement; (2) promptly provide to HISD any contracting information related to the Agreement that is in the custody or possession of the Vendor on request of HISD; and (3) on completion of the Agreement, either (a) provide at no cost to HISD all contracting information related to theAgreement that is in the custody or possession of Vendor, or (b) preserve the contracting information related to theAgreement as provided by the records retention requirements applicable to HISD.


RE: FORM G: GENERAL CERTIFICATIONS

Vendor’s Name


Email Address



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/Agreement 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

The following provisions are required and apply when federal funds are expended by HISD for any contract resulting from this procurement process. Accordingly, the parties agree that the following terms and conditions apply to this procurement solicitation and the Agreement, as applicable, in all situations in which Vendor will be paid with federal funds.

(A) Contracts for more than the simplified acquisition threshold currently set at $250,000, which is theinflation adjusted amount determined by the Civilian Agency Acquisition Council and the DefenseAcquisition Regulations Council (Councils) as authorized by 41 U.S.C. 1908, must addressadministrative, contractual, or legal remedies in instances where contractors violate or breach contractterms, and provide for such sanctions and penalties as appropriate.

Pursuant to Federal Rule (A) above, when federal funds are expended by HISD, 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 subgrantee including the manner bywhich it will be effected and the basis for settlement. (All contracts in excess of $10,000)

Pursuant to Federal Rule (B) above, when federal funds are expended by HISD, 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. The 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 the best interest of HISD.


(C) Equal Employment Opportunity. Except as otherwise provided under 41 CFR Part 60, all contracts thatmeet the definition of “federally assisted construction contract” in 41 CFR Part 60-1.3 must include the equalopportunity clause provided under 41 CFR 60-1.4(b), in accordance with Executive Order 11246, “EqualEmployment Opportunity” (30 FR 12319, 12935, 3 CFR Part, 1964-1965 Comp., p. 339), as amended by ExecutiveOrder 11375, “Amending Executive Order 11246 Relating to Equal Employment Opportunity,” andimplementing regulations at 41 CFR part 60, “Office of Federal Contract Compliance Programs, EqualEmployment Opportunity, Department of Labor.”


Pursuant to Federal Rule (C) above, when federal funds are expended by HISD 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, allprime construction contracts in excess of $2,000 awarded by non-Federal entities must include a provision forcompliance with the Davis-Bacon Act (40 U.S.C. 3141-3144, and 3146- 3148) as supplemented by Department ofLabor regulations (29 CFR Part 5, “Labor Standards Provisions Applicable to Contracts Covering FederallyFinanced and Assisted Construction”). In accordance with the statute, contractors must be required to paywages to laborers and mechanics at a rate not less than the prevailing wages specified in a wage determinationmade 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 theDepartment of Labor in each solicitation. The decision to award a contract or subcontract must be conditionedupon the acceptance of the wage determination. The non-Federal entity must report all suspected or reportedviolations to the Federal awarding agency. The contracts must also include a provision for compliance with theCopeland “Anti-Kickback” Act (40 U.S.C. 3145), as supplemented by Department of Labor regulations (29 CFRPart 3, “Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part byLoans or Grants from the United States”). The Act provides that each contractor or subrecipient must beprohibited from inducing, by any means, any person employed in the construction, completion, or repair ofpublic work, to give up any part of the compensation to which he or she is otherwise entitled. The non-Federalentity must report all suspected or reported violations to the Federal awarding agency.

Pursuant to Federal Rule (D) above, when federal funds are expended by HISD, during the term of an award for all contracts and subgrants for construction or repair, the 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 contractsawarded by the non-Federal entity in excess of $100,000 that involve the employment of mechanics or laborersmust include a provision for compliance with 40 U.S.C. 3702 and 3704, as supplemented by Department of Laborregulations (29 CFR Part 5). Under 40 U.S.C. 3702 of the Act, each contractor must be required to compute thewages of every mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of thestandard work week is permissible provided that the worker is compensated at a rate of not less than one anda half times the basic rate of pay for all hours worked in excess of 40 hours in the work week. The requirementsof 40 U.S.C. 3704 are applicable to construction work and provide that no laborer or mechanic must be requiredto work in surroundings or under working conditions which are unsanitary, hazardous or dangerous. Theserequirements do not apply to the purchases of supplies or materials or articles ordinarily available on the openmarket, or contracts for transportation or transmission of intelligence.

Pursuant to Federal Rule (E) above, when federal funds are expended by HISD, the vendor certifies that during the term of an award for all contracts by HISD resulting from this procurement process, the vendor will be in compliance with all applicable provisions of the Contract Work Hours and Safety Standards Act.


(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 subrecipient 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 subrecipient 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, the vendor certifies that during the term of an award for all contracts by HISD resulting from this procurement process, the vendor agrees to comply with all applicable requirements as referenced in Federal Rule (F) above.


(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 subgrants of amounts in excess of $150,000 must contain a provision that requiresthe non-Federal award to agree to comply with all applicable standards, orders or regulations issued pursuantto 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 theEnvironmental Protection Agency (EPA).

Pursuant to Federal Rule (G) above, when federal funds are expended by HISD, the vendor certifies that during the term of an award for all contracts by HISD resulting from this procurement process, the vendor 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 governmentwide 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 part1986 Comp., p. 189) and 12689 (3 CFR part 1989 Comp., p. 235), “Debarment and Suspension.” SAM Exclusionscontains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declaredineligible under statutory or regulatory authority other than Executive Order 12549.

Pursuant to Federal Rule (H) above, when federal funds are expended by HISD, the vendor certifies that during the term of an award for all contracts by HISD resulting from this procurement process, the vendor certifies that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation by any federal department or agency or by the State of Texas. Vendor shall immediately provide written notice to HISD if at any time the vendor learns that this certification was erroneous when submitted or has become erroneous by reason of changed circumstances. HISD may rely upon a certification of a vendor that the vendor is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract, unless HISD knows the certification is erroneous.

(I) Byrd Anti-Lobbying Amendment (31 U.S.C. 1352)—Contractors that apply or bid for an awardexceeding $100,000 must file the required certification. Each tier certifies to the tier above that it will notand has not used Federal appropriated funds to pay any person or organization for influencing orattempting to influence an officer or employee of any agency, a member of Congress, officer or employeeof 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 areforwarded from tier to tier up to the non- Federal award.


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

Pursuant to Federal Rule (I) above, when federal funds are expended by HISD, the 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 by or on behalf of the undersigned, toany 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 inconnection with the awarding of a Federal contract, the making of a Federal grant, the making of aFederal 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 forinfluencing 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 thisFederal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submitStandard 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 awarddocuments for all subawards at all tiers (including subcontracts, subgrants, and contracts undergrants, loans, and cooperative agreements) and that all subrecipients shall certify and discloseaccordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certificate is a prerequisite for making or entering into this transaction imposed by Section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

(J) Procurement of Recovered Materials – When federal funds are expended by HISD, HISD and itscontractors must comply with section 6002 of the Solid Waste Disposal Act, as amended by the ResourceConservation and Recovery Act. The requirements of Section 6002 include: (1) procuring only items designatedin guidelines of the Environmental Protection Agency (EPA) at 40 CFR part 247 that contain the highestpercentage of recovered materials practicable, consistent with maintaining a satisfactory level of competition,where the purchase price of the item exceeds $10,000 or the value of the quantity acquired during the precedingfiscal year exceeded $10,000; (2) procuring solid waste management services in a manner that maximizes energyand resource recovery; and (3) establishing an affirmative procurement program for procurement of recoveredmaterials identified in the EPA guidelines.

Pursuant to Federal Rule (J) above, when federal funds are expended HISD, as required by the Resource Conservation and Recovery Act of 1976 (42 U.S.C. § 6962(c)(3)(A)(i)), the vendor certifies, by signing this document, that the percentage of recovered materials content for EPA-designated items to be delivered or used in the performance of the contract will be at least the amount required by the applicable contract specifications or other contractual requirements.


(K) Required Affirmative Steps for Small, Minority, And Women-Owned Firms for Contracts Paid for withFederal Funds – 2 CFR § 200.321 – When federal funds are expended by HISD, Vendor is required to take allaffirmative steps set forth in 2 CFR 200.321 to solicit and reach out to small, minority and women owned firms



for any subcontracting opportunities on the project, including: 1) Placing qualified small and minority businesses and women's business enterprises on solicitation lists; 2) Assuring that small and minority businesses, and women's business enterprises are solicited whenever they are potential sources; 3) Dividing total requirements, when economically feasible, into smaller tasks or quantities to permit maximum participation by small and minority businesses, and women's business enterprises; 4) Establishing delivery schedules, where the requirement permits, which encourage participation by small and minority businesses, and women's business enterprises; and 5) Using the services and assistance, as appropriate, of such organizations as the Small Business Administration and the Minority Business Development Agency of the Department of Commerce.


RECORD RETENTION REQUIREMENTS FOR CONTRACTS PAID FOR WITH FEDERAL FUNDS (2 CFR § 200.333)

When federal funds are expended by HISD for any contract resulting from this procurement process, the vendor certifies that it will comply with the record retention requirements detailed in 2 CFR § 200.333. The vendor further certifies that vendor will retain all records as required by 2 CFR § 200.333 for a period of three years after grantees or subgrantees submit final expenditure reports or quarterly or annual financial reports, as applicable, and all other pending matters are closed.

CERTIFICATION OF COMPLIANCE WITH EPA REGULATIONS APPLICABLE TO GRANTS, SUBGRANTS, COOPERATIVE AGREEMENTS, AND CONTRACTS IN EXCESS OF $100,000

When federal funds are expended by HISD for any contract resulting from this procurement process in excess of $100,000, the vendor certifies that the vendor is in compliance with all applicable standards, orders, regulations, and/or requirements issued pursuant to the Clean Air Act of 1970, as amended (42 U.S.C. 1857(h)), Section 508 of the Clean Water Act, as amended (33 U.S.C. 1368), Executive Order 117389 and Environmental Protection Agency Regulation, 40 CFR Part 15.

CERTIFICATION OF COMPLIANCE WITH THE ENERGY POLICY AND CONSERVATION ACT

When federal funds are expended by HISD for any contract resulting from this procurement process, the vendor certifies that the vendor will be in compliance with 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 (Pub. L. 94-163, 89 Stat. 871).

CERTIFICATION OF COMPLIANCE WITH BUY AMERICA PROVISIONS

Vendor certifies that vendor is in compliance with all applicable provisions of the Buy America Act. Purchases made in accordance with the Buy America Act must still follow the applicable procurement rules calling for free and open competition.






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



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

I. CONFLICT OF INTEREST CERTIFICATIONThe 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. In accordance with HISD Policy CDC(Local), no gift, favor, loan, service, entertainment, or anything of more than token value shall be acceptedby a District employee from any District vendor or prospective vendor seeking to do business with theDistrict. Items of token value include trinkets of minimal value such as coffee mugs, key chains, caps, andthe like.

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 Vendor

II. EDGAR CONFLICT OF INTEREST

In accordance with federal EDGAR requirements, 2 CFR § 200.318(c)(1), no employee, officer, or agent may participate in the selection, award, or administration of a contract supported by a federal award if he or she has a real or apparent conflict of interest. Such a conflict of interest would arise when the employee, officer, or agent, any member of his or her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has a financial or other interest in or a tangible personal benefit from a firm considered for a contract. The officers, employees, and agents of HISD may neither solicit nor accept gratuities, favors, or anything of monetary value, other than items of token value, from contractors.

Violations of this standard by an employee will be reported to the Superintendent’s Office and addressed through HISD’s personnel policies. Violations of this standard by an officer or the Superintendent shall be addressed to the Board President and addressed through HISD Board policies.

III. CONFLICT OF INTEREST QUESTIONNAIRE (FORM CIQ)

HISD is required to comply with Texas Local Government Code Chapter 176, Disclosure of Certain Relationships with Local Government Officers. House Bill 23 significantly changed Chapter 176 as well as the required disclosures and the corresponding forms. As of September 1, 2015, any vendor 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 vendor has an employment or other business relationship with a local government officerof HISD or a family member of the officer, as described by section 176.003(a)(2)(A) of the TexasLocal Government Code; or

2) If the vendor has 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 ora family member of the officer if the gift is: (a) a political contribution as defined by Title 15 ofthe Election Code; or (b) a gift of food accepted as a guest; or

3) If the vendor has a family relationship with a local government officer of HISD.

“Vendor” means a person who enters or seeks to enter into a contract with a local governmental entity. The term includes an agent of a vendor. 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).


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

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

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

“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).

“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 vendor. Texas Local Government Code 176.001(4).

• HISD Board of Education members:Sue Deigaarrd Wanda Adams Judith Cruz Patricia K. Allen Daniela “Dani” Hernandez Elizabeth Santos Kathy Blueford-Daniels Holly Maria Flynn Vilaseca Anne Sung

• Current local government officers include, but are not limited to:Interim Superintendent Grenita LathanChief of Staff Silvia TrinhInterim Chief Academic Officer Yolanda RodríguezChief Communications Officer Rebecca SuárezChief Financial Officer Glenn ReedChief Human Resources Officer Julia DimmittInterim Chief Operating Officer Eugene SalazarInterim Chief Operating Officer Alishia JolivetteChief of Police Pedro Lopez Jr.Chief Strategy and Innovation Officer Rick CruzChief Technology Information Officer Scott GilhousenGeneral Counsel Elneita Hutchins-TaylorBusiness Logistics & Purchasing Officer Alexis LicataPurchasing Services General Manager Juan “Enrique” KladisPurchasing Services Senior Category Manager Cristina GiacamanPurchasing Services PersonnelNutrition Services Officer Betti WigginsNutrition Services General Manager Jennifer BoeschNutrition Services Senior Manager Amanda OcegueraNutrition Services Senior Manager Frank MiltonNutrition Services Manager William PavlasNutrition Services Manager Neill AscencioNutrition Services Personnel

If no conflict of interest exists, you must fill out Box 1 and type N/A on Box 3 of the CIQ form, sign and date it. In the event of changed circumstances, an updated CIQ must be filed within seven (7) business days after the vendor becomes aware that a conflict of interest exists. Vendor understands and agrees that this failure to disclosure a conflict of interest and/or failure to sign and submit Form CIQ, even if no conflict exists, with vendor’s proposal may result in disqualification.


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?


FORM J: HISD CERTIFICATE OF INTERESTED PARTIES – FORM 1295 HISD is required to comply with HB 1295, which amended the Texas Government Code by adding Section 2252.908, Disclosure of Interested Parties. Section 2252.908 applies to a contract of HISD that (1) requires an action or vote by the HISD Board of Education before the contract may be signed; (2) has a value of at least $1 million; or (3) is for services that would require a person to register as a lobbyist under Tex. Gov’t Code Chapter 305. If applicable, the business entity must submit a Disclosure of Interested Parties (Form 1295) to HISD at the time business entity submits the signed contract. The Form 1295 requirement does not apply to: (1) a contract with a publicly traded business entity or wholly owned subsidiary of the same; (2) an electric utility; or (3) a gas utility. The Texas Ethics Commission has adopted rules requiring the business entity to fileForm 1295 electronically with the Texas Ethics Commission. The following definitions apply:

(1) “Business Entity” means an entity recognized by law through which business is conducted, including a soleproprietorship, partnership, or corporation. TEX. GOV’T CODE § 2252.908(1).

(2) “Interested Party” means a person:a) who has a controlling interest in a business entity with whom HISD contracts; orb) 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. TEX. GOV’T CODE § 2252.908(3).(3) “Controlling interest” means:

a) an ownership interest or participating interest in a business entity by virtue of units, percentage, shares, stock, orotherwise that exceeds 10 percent;

b) membership on the board of directors or other governing body of a business entity of which the board or othergoverning body is composed of not more than 10 members; or

c) service as an officer of a business entity that has four or fewer officers, or service as one of the four officers mosthighly compensated by a business entity that has more than four officers. Subsection (c) does not apply to an officerof a publicly held business entity or its wholly owned subsidiaries. TEX. ETHICS COMM. RULE 46.3(c).

(4) “Intermediary” means a person who actively participates in the facilitation of the contract or negotiating the contract,including a broker, adviser, attorney, or representative of or agent for the business entity who:

a) receives compensation from the business entity for the person’s participation;b) communicates directly with the governmental entity or state agency on behalf of the business entity regarding

the contract; andc) is not an employee of the business entity. TEX. ETHICS COMM. RULE 46.3(e).

As a “business entity,” vendors must: (1) complete 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- All vendors must complete Form 1295, even if no interested parties exist- In Section 2, insert “Houston Independent School District”- In Section 3, insert the HISD procurement solicitation number (i.e., RFP #) for this proposal

(2) print a copy of the completed form (make sure that it has a computer-generated certification number in the “Office UseOnly” box)

(3) have an authorized agent of the business entity sign the form(4) submit the completed Form 1295 by including the form with your submitted proposal.

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 receipt. 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.

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 or to download the form please visit: HTTPS://WWW.IRS.GOV/PUB/IRS-PDF/FW9.PDF


https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm

https://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 (additional

pages 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, paragraph

number, 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



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

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*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


FORM N: EXECUTION OF OFFER FORM

The undersigned vendor has carefully examined all instructions, requirements, specifications, terms and conditions of this RFP and the Agreement and certifies:

1) It is a reputable company regularly engaged in providing goods and/or services necessary to meet therequirements, specifications, terms and conditions of the RFP and the Agreement.

2) It has the necessary experience, knowledge, abilities, skills, and resources to satisfactorily perform therequirements, specifications, terms and conditions of the RFP and the Agreement. Further, if awarded, the vendoragrees to perform the requirements, specifications, terms and conditions of the RFP and the Agreement.

3) All statements, information and representations prepared and submitted in response to this RFP are current,complete, true, and accurate. Vendor acknowledges that HISD will rely on such statements, information andrepresentations in selecting the successful vendor(s).

4) It is not currently barred or suspended from doing business with the Federal government, any of the membersrepresented, or any of their respective agencies.

5) It shall be bound by all statements, representations, warranties, and guarantees made in its proposal.6) Submission of a proposal indicates the vendor’s acceptance of the evaluation technique and the vendor’s

recognition that some subjective judgments may be made by HISD as part of the evaluation.7) That all of the requirements of this RFP and the Agreement have been read and understood. In addition,

compliance with all requirements, terms and conditions will be assumed by HISD if not otherwise noted invendor’s proposal.

8) The individual signing below has authority to enter into this execution of offer on behalf of vendor. Vendoracknowledges that the Agreement may be canceled if any conflict of interest or appearance of a conflict of interestis discovered by HISD.

9) Vendor acknowledges that a solicitation/proposal does not become a contract unless and until it is accepted byHISD after all necessary approvals, including any required approval by the HISD Board of Education (“Boardaward”). A contract is formed when an authorized HISD representative(s) signs this Execution of Offer form. Bysubmitting this Execution of Offer Form vendor acknowledges and agrees to be bound by the procurementsolicitation issued by HISD (including Parts I, II, and III), and Vendor’s proposal submitted in response to HISD’sprocurement solicitation, and the attached and incorporated addendum, or exhibits, and/or forms, includingHISD’s Vendor Packet (including all certifications therein).

10) The Agreement is subject to purchase/work orders duly authorized and executed by HISD.

VENDOR’S NAME:

AUTHORIZED SIGNATURE:

PRINT NAME:

TITLE:

DATE:

ADDRESS:

CITY, STATE, ZIP CODE:

PHONE: FAX:

EMAIL ADDRESS:


Houston ISD Contract Number: __________________________________________________________________

Date of Houston ISD Board Approval (Subject to Change):___________________________________________

Exception(s) to the solicitation and/or to the Agreement submitted by Vendor are accepted rejected by HISD, as reflected in the attached accepted exceptions (if any). (Attached exceptions accepted by HISD).

Approved by Houston Independent School District:

______________________________________Enrique KladisPurchasing Services General Manager

PROVIDER:

Vendor Name

Address

Representative Name

Representative Title

Signature

Date

Taxpayer Identification Number

HOUSTON INDEPENDENT SCHOOL DISTRICT

Date Sue Deigaard Board President

Date Patricia Allen Board Secretary

Date Grenita F. Lathan, Ph.D. Interim Superintendent of Schools

APROVED AS TO FUNDING/BUSINESS TERMS:

Date Glenn Reed Interim Chief Financial Officer

APPROVED AS TO FORM:

Date Elneita Hutchins-Taylor General Counsel

FORM N: Execution of Offer Form

PRODUCT VERIFICATION FORM

NOTE: As referenced in the original RFP scope, this form needs to be returned with the RFP in a separate envelope marked "Nutrition Kit". There should be a total of three (3) printed Nutrition Kits per vendor. A separate,

corresponding USB flash drive must also be included with submission documents, containing ONLY Nutrition Kits. Nutritional information must be listed in numerical order on USB for ALL items submitted in RFP.

Line #

Product Name

Bidder Packer /Brand

Manufacturer's Name

Product Code

Pack Size

For the product listed above, please fill out the following criteria placing an X in the YES or NO column. If yes, circle the applicable allergens:

YES NO Allergen Information

1. Does product contain peanuts,nuts or any peanut product?2. Does product contain any porkor pork by products?3. Does product contain anyallergen?

I certify that all information provided is accurate. I understand that the product may be checked by independent laboratory for selected composition and that if the product does not comply with the bid specifications or information provided, the product may be determined to be unacceptable as a bid item

Vendor Name

Vendor Contact Person Phone

Email Fax

Mailing Address City

State Zip Code

Printed Name and Title of peson completing form Signature of person completing form

Eggs Peanuts Fish Soy

Milk Tree Nuts Shellfish Wheat


Product Information Sheet with Nutrition Facts Label

THIS FORM MUST BE COMPLETED FOR EACH ITEM AND RETURNED IN THE NUTRITION KIT WITH RFP SUBMITTAL.

Product Name

Manufacturer Mfg. Code No.

Case Weight and Pack/Count


Nutrition Facts Label MUST Contain the Following: 1. Nutrition Facts Label listing the RFP name and number2. Ingredient List3. Trans Fatty Acid Amount that clearly designates Product is “zero grams trans-fat” as determined by FDA

standards.4. CN label (for meat/meat alternative and/or grain products) and/or USDA approved product analysis

(attached) signed by a high ranking official.THIS LABEL MUST BE SUBMITTED ON USB Flash Drive AS PART OF THE “NUTRITION KIT” SUBMITTED WITH THE RFP. PLEASE SAVE EACH LINE ITEM AS A SEPARATE FILE BY PRODUCT NAME AND PRODUCT CODE ON THE SAME USB. THERE NEEDS TO BE THREE NUTRITION KITS WITH HARD COPIES IN EACH.


Nutrition Facts Label MUST Contain the Following:

THIS IS A SAMPLE ONLY

Nutrition Facts Serving Slice 1 PIECE (78g)

Servings Per Container: About 120

Amount per Serving

Calories 240 Calories form Fat 70

-----------------------------------------------

% Dailey Value*

Total Fat 7g 11%

Saturated Fat 1g 5%

Trans Fat 0g

Polyunsaturated Fat 4g

Monounsaturated Fat 1.5 ---------------------------------------------------- Cholesterol 0mg 0% ---------------------------------------------------- Sodium 270mg 11% -------------------------------------- Total Carbohydrates 37g 12%

Dietary Fiber 2g 9%

Sugars 1g

Protein 7g 14% -------------------------------------- Vitamins A 0% * Vitamins C 0% ------------------------------------------------------- Calcium 0% Iron 4% ---------------------------------------------------- * Percent daily values based on 2,000 calorie

diet. Your daily values may be higher or lower

depending on calorie needs.


Texas Department of Agriculture Sample Statement| Product Analysis/Formulation | Grains July 27, 2012

Sample Statement (Place on company letterhead.)

Product Analysis Sheet/Product Formulation Statement to Provide for a GRAIN Product

Product Name

Manufacturer Mfg. Code No.

Case Weight and Pack/Count

Volume and weight of one serving of product

Grain ingredient(s) in product (NOTE: primary grain ingredient must be enriched or whole grain flour or meal.)

Weight of grain (gram weight) in one serving of product: (NOTE: It takes 16.0 grams of whole grain or enriched flour or meal, bran or germ, or an equivalent amount of cereal as provided in FNS Instruction 783‐1, Rev. 2, to equal 1 serving Grain. Grains may be credited in 1/4 serving increments.)

I certify that the above information is true and correct and that one serving of the above product (ready to eat) contains _______ serving(s) of Grains.

Printed Name Title

Signature Date


Sample Product Formulation Statement (Product Analysis) for Meat/Meat Alternate (M/MA) Products

Child Nutrition Program operators should include a copy of the label from the purchased product carton in addition to the following information on letterhead signed by an official company representative.

Product Name Code No.

Manufacturer Case/Pack/Count/Portion/Size

1. Meat/Meat Alternate - Please fill out the chart below to determine the creditable amount of Meat/Meat AlternateDescription of Creditable

Ingredients per Food Buying Guide (FBG)

Ounces per Raw Portion of Creditable Ingredient

Multiply FBG Yield/ Servings Per Unit

Creditable Amount *

X

X

X

A. Total Creditable M/MA Amount1

*Creditable Amount - Multiply ounces per raw portion of creditable ingredient by the FBG Yield Information.

2. Alternate Protein Product (APP) - If the product contains APP, please fill out the chart below to determine the creditable amount ofAPP. If APP is used, you must provide documentation as described in Attachment A for each APP used.

Description of APP, manufacture’s name, and code number

Ounces Dry APP Per Portion

Multiply % of Protein As-Is*

Divide by 18**

Creditable Amount APP***

X ÷ by 18

X ÷ by 18

X ÷ by 18

B. Total Creditable APP Amount1

C. TOTAL CREDITABLE AMOUNT (A + B rounded down to nearest ¼ oz)

*Percent of Protein as-is is provided on the attached APP documentation. **18 is the percent of protein when fully hydrated. ***Creditable amount of APP equals ounces of Dry APP multiplied by the percent of protein as-is divided by 18. 1Total Creditable

Amount must be rounded down to the nearest 0.25oz (1.49 would round down to 1.25 oz meat equivalent). Do not round up. If you are crediting M/MA and APP, do not round down in box A (Total Creditable M/MA Amount) until after you have added the Total Creditable APP Amount from box B to box C. Total weight (per portion) of product as purchased ____________________

Total creditable amount of product (per portion) (Reminder: Total creditable amount cannot count for more than the total weight of product.)

I certify that the above information is true and correct and that an ounce serving of the above product (ready for serving) contains ounces of equivalent meat/meat alternate when prepared according to directions.

I further certify that any APP used in the product conforms to the Food and Nutrition Service Regulations (7 CFR Parts 210, 220, 225, 226, Appendix A) as demonstrated by the attached supplier documentation.

Printed Name Title

Signature Date


Product Information Sheet for Shelf Life

THIS FORM MUST BE COMPLETED AND RETURNED IN THE NUTRITION KIT WITH RFP SUBMITTAL FOR EACH ITEM

Product Name

Manufacture Name

Product Code

Shelf Life

Manufacturer Lot Code Information (Ex: MM/DD/YY, Julian Code, etc.)


FORM P: CERTIFICATION REGARDING FEDERAL LOBBYING Texas Department of Form H2049 Agriculture July 2017

CERTIFICATION REGARDING FEDERAL LOBBYING (Certification for Contracts, Grants, Loans, and Cooperative Agreements)

Federal legislation generally prohibits entities from using federally appropriated funds to lobby the executive or legislative branches of the Federal government. Lobbying with respect to certain grants, contracts, cooperative agreements, and loans is governed by relevant statutes, including among others, the provisions of 31 U.S.C. 1352, as well as common rule, “New Restrictions on Lobbying” published at 55 Federal Register (FR) 6736 (February 26, 1990), including definitions, and the Office of Management and Budget “Government wide Guidance on New Restrictions on Lobbying” and notices published at 54 FR 52306 (December 20, 1989), 55 FR 24540 (June 15, 1990), 57 FR 1772 (January 15, 1992), and 61 FR 1412 (January 19, 1996).

Contracting entities or sponsored sites that contract for goods or services using Federal funds must obtain this certification for any award exceeding $100,000 and if necessary must obtain the Standard Form-LLL, “Disclosure Form to Report Lobbying.”

CERTIFICATION: The undersigned certifies, to the best of his or her knowledge and belief, that:

1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to anyperson for influencing or attempting to influence an officer or employee of an agency, a Member ofCongress, an officer or employee of Congress, or an employee of a Member of Congress in connection withthe awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, theentering into of any cooperative agreement, and the extension, continuation, renewal, amendment, ormodification of any 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 forinfluencing or attempting to influence an officer or employee of an agency, a Member of Congress, anofficer or employee of Congress, or an employee of a Member of Congress in connection with this Federalcontract, grant, loan, 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 forall subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, andcooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Name of Organization submitting certification

Name of Organization Representative Title

Signature of Organization Representative Date


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FORM Q: COMPLIANCE WITH BUY AMERICAN PROVISION Houston Independent School District (“HISD” or the “District”) participates in the National School Lunch Program and School Breakfast Program and is required under the Buy American provision (7 C.F.R. § 210.21(d)) to use the nonprofit food service funds, to the maximum extent practical, to buy domestic commodities or products. 7 C.F.R. § 210.21(d)) defines a “domestic commodity or product” as one that is either produced in the U.S. or is processed in the U.S. substantially using agricultural commodities that are produced in the U.S. “Substantially” means that over 51 percent of the final processed product consists of agricultural commodities that were grown domestically. When USDA Foods items are manufactured into processed end products, 51% of resulting food products must be of United States origin.

Vendor certifies that, in compliance with the Buy American provision, all products listed as 51% or more U.S. Domestic submitted for award with this contract are domestic commodities or products as defined by 7 C.F.R. § 210.21(d).

YES Initials of Authorized Representative of Vendor If “NO”, complete the bottom portion of this document for EACH item not in compliance.

REQUEST FOR EXCEPTION FROM THE BUY AMERICAN PROVISION Exceptions to the Buy American provision are utilized by HISD as a last resort; however, an exception may be approved upon request. If Vendor did not certify compliance with the Buy American provision above, it may request an exception by checking one or both of the following grounds for an exception:

The product is not produced or manufactured in the U.S. in sufficient and reasonable available quantities of a satisfactory quality. Product country of origin: ________________

The costs of a U.S. product are significantly higher than the non-domestic product.

Vendor certifies that it submits this request for an exception from the Buy American provision in good faith and with the reasonable belief that: (a) the product is not produced or manufactured in the U.S. in sufficient and reasonable available quantities of a satisfactory quality; and/or (b) the costs of a U.S. product are significantly higher than the non-domestic product.

YES Initials of Authorized Representative of Vendor

Vendor further agrees that, if HISD determines that it does not qualify for one of the exceptions to the Buy American provision listed above, Vendor is ineligible for this Contract.

YES Initials of Authorized Representative of Vendor

Bidder Name: Line Item #:

Mfg. Item # Pack Size:

Mfg. Item Name/Description:

Authorized Vendor Representative Name: Authorized Vendor Representative Signature:

For Houston ISD Use Only

Purchasing Manager: Date: Approve

Signature: Reject


FORM R: CONFIDENTIALITY DECLARATION FORM

INFORMATION SUBMITTED TO HISD IN CONNECTION WITH THIS PROCUREMENT SOLICITATION OR THE AGREEMENT IS GOVERNED BY TEXAS GOVERNMENT CODE, CHAPTER 552

As a governmental body, HISD is subject to the Texas Public Information Act found in Chapter 552, Texas Government Code. Proposals and other information submitted to HISD in connection with this procurement solicitation or the Agreement may be subject to release as public information. If a Vendor believes that part(s) of its proposal or any other information submitted by Vendor to HISD in connection with this procurement solicitation or the Agreement contain confidential, proprietary, and/or trade secret information or otherwise may be excepted from disclosure under Texas law, the Vendor must clearly and conspicuously mark the applicable information as “CONFIDENTIAL.”

Marking information as “CONFIDENTIAL” does not guarantee that the information will be withheld from disclosure. If HISD receives a request for public information involving information that Vendor has clearly and conspicuously marked as “CONFIDENTIAL,” HISD will respond pursuant to Chapter 552, Texas Government Code, which may or may not require that HISD provide notice of the request to Vendor. Vendor understands and agrees that it is solely responsible for submitting to the Attorney General of Texas each reason why the requested information should be withheld and a letter, memorandum, or brief in support of that reason. Pursuant to Tex. Gov’t Code § 552.02222, “contracting information”1 is public and must be released unless excepted from disclosure under Chapter 552. The exceptions provided by Chapter 552 for disclosure for proprietary information (552.1101), commercial or financial information that would cause substantial competitive harm if released (552.110(c)), or trade secrets (552.110(b)) may not be asserted for the following types of contracting information:

(1) the following contract or offer terms or their functional equivalent: (A) any term describing the overall ortotal price the governmental body will or could potentially pay, including overall or total value, maximumliability, and final price; (B) a description of the items or services to be delivered with the total price for eachif a total price is identified for the item or service in the contract; (C) the delivery and service deadlines;(D) the remedies for breach of contract; (E) the identity of all parties to the contract; (F) the identity of allsubcontractors in a contract; (G) the affiliate overall or total pricing for a vendor, contractor, potentialvendor, or potential contractor; (H) the execution dates; (I) the effective dates; and (J) the contract durationterms, including any extension options; or

(2) information indicating whether a vendor, contractor, potential vendor, or potential contractor performedits duties under a contract, including information regarding: (A) a breach of contract; (B) a contract variance or exception; (C) a remedial action; (D) an amendment to a contract; (E) any assessed or paid liquidateddamages; (F) a key measures report; (G) a progress report; and (H) a final payment checklist.

HISD assumes no obligation or responsibility relating to the disclosure or nondisclosure of information submitted by Vendors, and Vendor hereby waives any claim against and releases from liability HISD, its respective officers, employees, agents, and attorneys with respect to disclosure of information provided under or in connection with this procurement solicitation or the Agreement or otherwise created, assembled, maintained, or held by Vendor or HISD and determined by HISD, the Attorney General of Texas, or a court of law to be subject to disclosure under the Texas Public Information Act. Further, even if Vendor marks information as “CONFIDENTIAL,” Vendor expressly agrees that HISD may disclose Vendor’s proposal, including, but not

1 “Contracting information” is defined by Tex. Gov’t Code § 552.003(7) as “the following information maintained following information maintained by a governmental body or sent between a governmental body and a vendor, contractor, potential vendor, or potential contractor: (A) information in a voucher or contract relating to the receipt or expenditure of public funds by a governmental body; (B) solicitation or bid documents relating to a contract with a governmental body; (C) communications sent between a governmental body and a vendor, contractor, potential vendor, or potential contractor during the solicitation, evaluation, or negotiation of a contract; (D) documents, including bid tabulations, showing the criteria by which a governmental body evaluates each vendor, contractor, potential vendor, or potential contractor responding to a solicitation and, if applicable, an explanation of why the vendor or contractor was selected; and (E) communications and other information sent between a governmental body and a vendor or contractor related to the performance of a final contract with the governmental body or work performed on behalf of the governmental body.”


limited to, pricing information, to other governmental entities and/or members of HISD’s cooperative purchasing program, Choice Partners.

Please check ONLY ONE of the following options:

Declaration of Confidentiality – Vendor HAS clearly and conspicuously marked information contained in its proposal and/or other information submitted by Vendor to HISD in connection with this procurement solicitation or the Agreement as “CONFIDENTIAL.” Vendor declares that the information marked by Vendor as “CONFIDENTIAL” contains confidential, proprietary, and/or trade secret information and is excepted from disclosure under Chapter 552, Texas Government Code.

Waiver of Confidentiality – Vendor HAS NOT marked any information contained in its proposal and/or other information submitted by Vendor to HISD in connection with this procurement solicitation or the Agreement as “CONFIDENTIAL.” Vendor certifies that it has not submitted any confidential, proprietary, and/or trade secret information to HISD and that its proposal and all other information—including any pricing information—submitted by Vendor to HISD in connection with this procurement solicitation or the Agreement is subject to disclosure under Chapter 552, Texas Government Code. Vendor hereby expressly waives any claim of confidentiality with respect to its proposal and/or any other information submitted by Vendor to HISD in connection with this procurement solicitation or the Agreement.

Vendor Name

Printed Name of Authorized Officer Title

Signature Date


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