1-Supplemental Information.pdf

NON-RESIDENT BIDDERS

As defined in Texas Government Code Section 2252.002, a governmental entity may not award a governmental contract to a nonresident bidder unless the nonresident underbids the lowest bid submitted by a responsible resident bidder by an amount that is not less than the amount by which a resident bidder would be required to underbid the nonresident bidder to obtain a comparable contract in the state in which the nonresident’s principal place of business is located.

In order to make this determination, please answer the following questions:

1. Address and phone number of your principal place of business:

2. Name and address of principal place of business, and phone number of your company's majority owner:

3. Name and address of principal place of business, and phone number of your company's ultimate parent company:

MINORITY/WOMAN-OWNED BUSINESS PARTICIPATION

It is the policy of the City of Frisco to involve small businesses and qualified minority/women-owned businesses to the greatest extent possible in the procurement of goods, equipment, services and construction projects. To assist us in our record keeping, please list below the names of the minority or woman-owned firms you would be utilizing in this bid, and note the monetary involvement:

NAME OF FIRM TELEPHONE # $ INVOLVEMENT

FIRM INFORMATION

Please provide the following information for contract development.

Is your firm?

1. Sole Proprietorship YES NO

2. Partnership YES NO

3. Corporation YES NO

If company is a sole proprietorship, list the owner's full legal name:

If company is a partnership, list the partner's full legal name(s):

If company is a corporation, list the full legal name as listed on the corporate charter:

Is this firm a minority, or woman-owned business enterprise?

NO YES If yes, specify ( ) MBE ( ) WBE

Has this firm been certified as a minority/woman-owned business enterprise by any governmental agency? NO YES

If yes, specify governmental agency:

Date of certification:

Authorized Signatory (Officer or representative vested with the powers to commit the organization to a binding agreement):

Name: ____________________________ Title: ____________________________

AFFIDAVIT OF NO PROHIBITED INTEREST

THE STATE OF _____________ §

THE COUNTY OF ___________ §

I, __________________, a member of the Contractor team, make this affidavit and hereby under oath state the following:

I, and/or a person or persons related to me, have the following interest in a business entity that would be affected by the work or decision on the Project (Check all that apply):

Ownership of ten percent (10%) or more of the voting shares of the business entity.

Ownership of Twenty-Five Thousand and 00/100 Dollars ($25,000) or more of the fair market value of the business entity.

Funds received from the business entity exceed ten percent (10%) of my income for the previous year.

Real property is involved, and I have an equitable or legal ownership with a fair market value of at least Twenty-Five Thousand and 00/100 Dollars

($25,000).

A relative of mine has a substantial interest in the business entity or property that would be affected by my business decision of the public body which I am a member.

Other:

None of the Above.

Upon filing this affidavit with the City of Frisco, Texas, I further affirm that no relative of mine, in the first degree by consanguinity or affinity, as defined in Chapter 573, TEX. GOV’T CODE, as amended, is a member of a public body which took action on the agreement.

Signed this _____ day of ______________, 20______.

Signature of Official/Title

BEFORE ME, the undersigned authority, this day personally appeared _____________________, and on oath stated that the facts hereinabove stated are true to the best of his/her knowledge or belief.

Sworn to and subscribed before me on this day of ______________, 20______.

Notary Public in and for the State of _____________ My commission expires: ______________________

CONFLICT OF INTEREST QUESTIONNAIRE

Contract Risk Assessment Questionnaire

1. Has your business/company/organization filed for bankruptcy within the last five (5) years? Yes No If so, please enclose details.

2. Has your business/company/organization ever had a contract for the general type of services/product sought by the City terminated for non-compliance or inadequate performance? Yes No If yes, please enclose details.

3. Has your business/company/organization ever defaulted on a contract for the general type of services/product being sought by the City? Yes No If yes, please enclose details.

4. In the last five (5) years has there been or is there now pending any litigation, arbitration, governmental proceeding or regulatory proceeding involving claims in excess of $100,000 with respect to the performance of any services or the provision of any product by your business/company/organization? Yes No If yes, please enclose details.

5. Has your business/company/organization fulfilled all of its obligations relating to the payment of City taxes, fees, or other obligations if applicable? Yes No If no, please enclose details.

6. In the last five (5) years, has your business/company/organization, been or currently involved in any action, audit or investigation brought by any federal government agency or authority or by any state or local governmental agency? Yes No If yes, please enclose details.

7. In the last five (5) years, has your business/company/organization been debarred or suspended for any reason by any federal, state or local government or has refrained from bidding on a project due to an agreement with such governmental agency?

Yes No If yes, please attach a full explanation.

8. In the past five (5) years, has your business/company/organization had its surety called upon to complete any contract, whether government or private sector?

Yes No If yes, please enclose details.

9. In the past five (5) years, has your business/company/organization had a revocation, suspension or disbarment of any business or professional permit and/or license? Yes No If yes, please enclose details.

10. Has your firm or any of its owners, officers or partners ever been convicted of a federal or state crime of fraud, theft, or any other act of dishonesty? Yes No if “yes,” identify on a separate signed page the person or persons convicted, the court (the City if a state court, the district or location of the federal court), the year and the criminal conduct.

11. In accordance with Chapter 2270 of the Texas Government Code, do you certify that your business/company/organization (a) does not boycott Israel; and (b) will not boycott Israel during the term of any contract with City? Yes No

Signature

A. THE UNDERSIGNED HEREBY CERTIFIES THAT THE RESPONSES PROVIDED ARE

CORRECT AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE AND FOR THOSE

RESPONSES GIVEN WHICH ARE BASED ON INFORMATION AND BELIEF, THOSE

RESPONSES ARE TRUE AND CORRECT BASED ON MY PRESENT BELIEF AND

INFORMATION.

B. Dated this ______ day of __________________ in the year _________

Name of organization: _____________________________________________

Signature: _______________________________________________________

Printed name and title: _____________________________________________

SIGNATURE FORM

The undersigned certifies that the prices contained in this solicitation have been carefully reviewed and are submitted as correct and final. The undersigned further certifies and agrees to furnish any and/or all product/service upon which prices are extended at the price offered, and upon the conditions in the specifications of the solicitation.

“I hereby certify that the foregoing bid has not been prepared in collusion with any other bidder or other person or persons engaged in the same line of business prior to the official opening of this bid. Further, I certify that the bidder is not now, nor has been for the past six (6) months, directly or indirectly concerned in any pool or agreement or combination to control the price of product/service bid on, or to influence any person or persons to bid or not to bid thereon."

Name of Bidder: _______________________

Address of Bidder: _______________________

City: ______________________ State: _______________ Zip Code: _______________

Telephone Number: Fax:

E-mail address:

By (print name) _______ Title:_______________________________

Federal ID #/SSN #: ______________________

Signature:

Acknowledgement of Addenda: #1 #2 #3 #4 #5_____