2-3. Required Forms (26-019V).pdf

Schertz-Cibolo-Universal City ISD Solicitation No. 26-019V Medical Plan Brokerage Services

SECTION 5 – ATTACHMENTS

REQUIRED FORMS

FORMS INCLUDED IN THIS SOLICITATION DOCUMENT

(1) Attachment A – Proposal Form

(2) Attachment B – Exceptions to this Solicitation

(3) Attachment C – Felony Conviction Notice

(4) Attachment D – Conflict of Interest Form CIQ

*Download solicitations, addenda and other forms at: https://scucisd.procureware.com

ATTACHMENT A

PROPOSAL FORM

NOTE: Failure to complete this form shall result in your Proposal being deemed non-responsive and rejected without further evaluation.

We, , (Company Name) of, , (Business Address) (Zip Code)

The undersigned, having fully and carefully read and examined the Request for Proposal (RFQ) Documents, Enclosures and Addenda, hereby offers to Schertz-Cibolo-Universal City Independent School District a Proposal for 26-019V Medical Plan Brokerage Services in accordance with the solicitation documents, and addenda at the place, price and in a manner set out therein and certifies the following;

a. Represents that to the best of its knowledge it is not indebted to the Schertz Cibolo Universal City Independent School District. Indebtedness to the District shall be basis for the non-award and/or cancellation of any award.

b. Certifies that no suspension or debarment is in place that would preclude receiving a federally funded contract.

c. The undersigned affirms that they are duly authorized to execute this contract, to fully comply with the terms and conditions of this Request for Proposal, including all forms and attachments included herein, that this company, corporation, firm, partnership or individual has not prepared this Proposal in collusion with any other Bidder, and that the contents of this Proposal as to prices, terms or conditions of said Proposal have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business prior to the official opening of this solicitation.

ADDENDA ACKNOWLEDGEMENT

Acknowledgement is hereby made of receipt of the following addenda to this PROPOSAL document:

Addendum No. dated , pages

Addendum No. dated , pages Addendum No. dated , pages

Signatures: Signed and submitted by:

(Signature of person authorized to sign) (Print name of person authorized to sign)

Name of person to contact regarding this Proposal:

Title: Telephone #:

FAX: E-Mail:

ATTACHMENT B

EXCEPTIONS TO THIS SOLICITATION

Does the Prospective Bidder have any deviations to any conditions and/or specifications/scope of services listed in this document?

No

Yes

If yes, noted in writing herein.

(Attach additional Pages if necessary)

Note: Each exception must be clearly defined and referenced to the proper section and paragraph in this Solicitation.

ATTACHMENT C

FELONY CONVICTION NOTICE

I, the undersigned agent for the firm named below, certify that the information concerning notification of felony convictions has been reviewed by me and the following information furnished is true to the best of my knowledge.

VENDOR’S NAME:

AUTHORIZED COMPANY OFFICIAL’S NAME:

A. My firm is a publicly-held corporation; therefore, this reporting requirement is not applicable.

Signature of Company Official:

B. My firm is not owned nor operated by anyone who has been convicted of a felony.

Signature of Company Official:

C. My firm is owned or operated by the following individual(s) who has/have been convicted of a felony.

Name of Felon(s):

(Attach additional sheet if necessary.)

Details of Conviction(s):

(Attach additional sheet if necessary.)

Signature of Company Official:

State of Texas Legislative Senate Bill No. 1, Section 44.034, Notification of Criminal History, Subsection (a), states “a person or business entity that enters into a contract with a school District must give advance notice to the District if the person or an owner or operator of the business entity has been convicted of a felony. The notice must include a general description of the conduct resulting in the conviction of a felony”.

Subsection (b) states “a school District may terminate a contract with a person or business entity if the District determines that the person or business entity failed to give notice as required by Subsection (a) or misrepresented the conduct resulting in the conviction. The District must compensate the person or business entity for services performed before the termination of the contract”.

THIS NOTICE IS NOT REQUIRED OF A PUBLICLY-HELD CORPORATION (Sign under ITEM A)

ATTACHMENT D

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

FORM CIQ

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.

OFFICE USE ONLY

Date Received

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

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.)

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

Name of Officer

4 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.

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?

Yes No

B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity?

Yes No

5 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.

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).

Signature of vendor doing business with the governmental entity Date