10-Form 4 - Respondents Statement of Organization.pdf

FY26 – Version 2 Procurement Department October 2025

Form 4 – Respondent’s Statement of Organization

Purpose

This form identifies the Respondent’s legal structure, registration, ownership, and standing to do business with the City of Brownsville. Submission of this form is required for all formal solicitations and cooperative contract purchases requiring City Commission approval

Entity Information

Legal Business Name: _________________________________________________

Assumed Name (DBA), if applicable: ______________________________________

Federal Employer Identification Number (FEIN): ____________________________

Texas Taxpayer ID or SOS File Number: ____________________________

SAM.gov Unique Entity ID (if applicable): ____________________________

Business Address: _________________________________________________

City/State/ZIP: __________________________________________

Telephone: __________________________ Email: __________________________

Website: __________________________________________

Type of Organization (check one):

☐ Corporation ☐ Limited Liability Company (LLC) ☐ Partnership ☐ Sole Proprietorship ☐ Joint Venture ☐ Non-Profit ☐ Other: _____________

State of Incorporation or Formation: ____________________________

Date Established: ____________________________

Is the firm registered to do business in Texas? ☐ Yes ☐ No

Ownership Disclosure

List all officers, partners, or principal owners with an equity interest of ten percent (10%) or more in the firm:

Name Title/Position Ownership

City Employee, Officer, or Board Member? (Y/N)

FY26 – Version 2 Procurement Department October 2025

Name Title/Position Ownership

City Employee, Officer, or Board Member? (Y/N)

Attach additional pages if necessary.

Debarment and Suspension Certification

By signing below, the Respondent certifies and acknowledges that:

1. The Respondent and its principals are not presently debarred, suspended, or proposed for debarment by any federal, state, or local government entity.

2. The Respondent has not, within the past five (5) years, been convicted of or had a civil judgment rendered against it for fraud, criminal offense, violation of antitrust laws, or any other offense indicating a lack of business integrity.

3. The Respondent agrees to notify the City of Brownsville immediately if any such debarment, suspension, or investigation occurs prior to award or during performance of a contract.

This certification applies to all City procurements. References to federal regulations (2 CFR Part 180 – Debarment and Suspension) apply only when the procurement is federally funded. In such cases, Respondents must also complete an additional Form that will be provided by the City of Brownsville.

(Required by Texas Gov’t Code § 2155.077 and, when applicable, 2 CFR § 180.335 for federally funded projects.)

Certification and Authorization

By signing below, the undersigned certifies that they are an authorized representative of the Respondent and that all information provided herein is true, complete, and accurate. The Respondent understands that the City may verify any information provided, and that false or misleading statements may result in disqualification, termination of award, or prosecution under Texas Penal Code §37.10 (Tampering with Governmental Record).

Signature: ____________________________________________

Printed Name: _________________________________________

Title: _________________________________________________

Date: ______________________

Company Name: ________________________________________

Phone: ______________________