2-RFB2026-05 SIGNATURE DOCUMENTS.pdf

RFB2026-05 HOT MIX-COLD LAY ASPHALT

CHECK LIST

ATTENTION VENDORS: All documents noted below must be completed and returned with the proposal or bid.

Check list for Hood County Bid/Proposal/Qualification packets:

❑ Cover Sheet

❑ Request for Bids / Proposals / Qualifications

❑ General Terms & Conditions

❑ Insurance Requirements

❑ Unsworn Vendor Affidavit

❑ Residence Certification

❑ Vendor References

❑ Debarment Policy

❑ Conflict of Interest Questionnaire

❑ Form W-9

❑ Online submissions must include upload of completed and signed Signature Documents, any requested Responses, and completion of online entries.

❑ Hard copy submissions must include the original and three (3) copies of all documents at https://hoodcounty.texas.gov/departments/purchasing/bids.php plus a thumb drive with a digital copy.

Any proposal that does not include the above items is subject to disqualification of bid/proposal. Form HB1295 will be required of the awarded vendor.

HOOD COUNTY

REQUEST FOR BIDS / PROPOSALS / QUALIFICATIONS

COVER SHEET

RFB2026-05

HOT MIX COLD LAY (HMCL)

OFFERORS NOTE!

1. Carefully read all instructions, requirements and specifications.

2. Fill out all forms properly and completely.

3. Submit bid with all appropriate supplements and/or samples.

For all questions pertaining to this RFB, RFP or RFQ, please contact Glenn Tilleman, Hood County Purchasing Agent at gtilleman@hoodcounty.texas.gov .

Vendor must sign below in INK; failure to sign will Disqualify the offer.

Company Name: ____________________________________________________________________

Company Address: __________________________________________________________________

City, State and Zip Code: _____________________________________________________________

Taxpayer Identification Number (T.I.N.): __________________________________________________

Telephone No.: __________________________ FAX No.: __________________________________

E-Mail Address: _____________________________________________________________________

Print Name: ________________________________________________________________________

Signature: _________________________________________________________________________ (Vendor’s signature attests to the vendor’s offer to provide the goods and/or services in this request according to the published provisions of the RFB/RFP/RFQ, as well as the General Terms, Conditions & Requirements and other documents included.)

APPROVED ________________________________________

Commissioners’ Court Date

REJECTED

Purchasing Agent

DUE DATE: April 7, 2026 NO LATER THAN 10:00 AM. RESPONSES RECEIVED

AFTER THE DATE AND TIME SHOWN WILL NOT BE CONSIDERED.

mailto:gtilleman@hoodcounty.texas.gov

INSURANCE REQUIREMENTS

1. The awarded Vendor shall instruct his insurance agent or carrier to furnish at his/her own expense, to the County, a Certificate of Liability Insurance listing the County as “Additional Insured”.

2. Unless otherwise agreed, the awarded Vendor shall furnish and keep in full force the following insurance during the term of this contract:

a. Statutory workers comp in accordance with State of Texas requirements.

b. Commercial General Liability at minimum combined single limits of

($1,000,000 per occurrence and $2,000,000 general aggregate) for bodily injury and for property damages, which coverage shall include products/completed operations at $2,000,000 per occurrence. Coverage must be written on an occurrence form.

c. Commercial Automobile Liability at minimum combined single limits of $500,000 per occurrence for Bodily Injury and Property Damage, including owned, non-owned, and hired vehicle coverage. All insurance must be written on forms filed with and approved by the Texas Board of Insurance.

Certificates of Insurance shall be prepared and executed by the insurance company or its authorized agent.

3. All of the aforementioned policies shall be issued immediately after the Vendor receives notification of award. Receipt of the Certificates of Insurance is required before any funds will be released for payment.

4. Neither acceptance of proof of insurance supplied by the successful Vendor, nor failure to disapprove the insurance shall relieve the successful Vendor of full responsibility of liability, damages, and accidents as set forth herein.

5. No additional payments shall be made for any insurance that the successful Vendor may be required to carry.

It is the responsibility of the successful Vendor to provide renewals of their insurance at expiration during the contract term. Payments will be withheld until current certificates of Insurance are received.

Acknowledged by:____________________________Title:_______________________

Typed/Printed Name_____________________________________________________

Company Name_____________________________Date_______________________

Attachment A Affidavit

UNSWORN VENDOR AFFIDAVIT

RFB2026-05 HOT MIX COLD LAY ASPHALT

The undersigned certifies that the bid prices contained in this bid/proposal have been carefully checked and are submitted as correct and final and if bid is accepted (within 90 days unless otherwise noted by Vendor), agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications.

___________________________________________________________________ hereinafter called “Vendor” is the duly authorized agent of said company and that the person signing said proposal has been duly authorized to execute the same. Vendor affirms that they are duly authorized to execute this contract, that this company, corporation, firm, partnership, or individual has not prepared this bid in collusion with any other Vendor, and that the contents of this bid as to prices, terms or conditions of said bid 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 bid.

NAME AND ADDRESS OF VENDOR:

PHONE NUMBER: ________________________

EMAIL ADDRESS: ________________________

SIGNATURE

PRINT NAME

TITLE

RESIDENCE CERTIFICATION

Pursuant to Texas Government Code §2252.001 et seq., as amended, Hood County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contracts; pertinent provisions of §2252.001 are stated below:

(3) "Nonresident bidder" refers to a person who is not a resident.

(4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state.

I certify that ______________________________________ is a Resident Bidder [Company Name] of Texas as defined in Government Code §2252.001.

I certify that ______________________________________ is a Nonresident [Company Name]

Bidder as defined in Government Code §2252.001 and our principal place of business in _______________________________________.

[City & State]

Attachment C Vendor References

VENDOR REFERENCES

Please list three (3) references of current customers who can verify the quality of service your company provides. The County prefers customers of similar size and scope of work to this proposal or bid. THIS FORM MUST BE RETURNED WITH THE

PROPOSAL OR BID.

REFERENCE ONE

Government/Company Name:

Address:

Contact Person and Title:

Phone: Email:

Contract Period: - Scope of Work:

REFERENCE TWO

REFERENCE THREE

THESE QUESTIONS MUST BE ANSWERED!

LOCAL & STATE CONTRACT/BIDS

DEBARMENT

By submitting a BID, the Vendor certifies that it is not currently debarred from receiving contracts from any political subdivision or agency of the State of Texas and that it is not an agent of a person or entity that is currently debarred from receiving contracts from any political subdivision or agency of the State of Texas.

FEDERAL GRANTS:

Debarment and Debarred Vendors:

No products and/or services utilizing Federal funds may be procured from vendors that are listed on the (EPLS) Excluded Parties List System (now known as SAM). Hood County reserves the right to reject from award consideration and/or terminate any contract with any vendor found to be suspended, ineligible and/or debarred as noted on the EPLS (SAM) list.

If making a purchase from other than a cooperative purchasing contract, and using Federal Grant Funds, the Purchasing Office shall first check the GSA EPLS website www.sam.gov to verify that the vendor to be used by the County is not on the excluded parties list. It shall be documented and saved in the file that the subject vendor either is or is not on the list. If the vendor is on the EPLS (SAM) list a contract between that vendor and the County cannot be executed.

PLEASE PLACE YOUR ANSWER DIRECTLY AFTER THE QUESTION BELOW. IF

NEEDED, YOU MAY ADD ANOTHER SHEET OF PAPER.

1. Address any performance related litigation that your firm may be, or has been, involved in over the last five (5) years.

2. Identify if your firm has had any contracts terminated due to non-performance over the last five (5) years.

3. Identify adverse actions sanctioned by any regulatory authorities over the last five (5) years.

NOTICE FOR CONFLICT OF INTEREST QUESTIONNAIRE

[Form CIQ]

Chapter 176 of the Texas Local Government Code requires vendors who wish to conduct business or be considered for business with a County to file a “conflict of interest ques�onnaire.” The Texas Ethics Commission (TEC) created the Conflict of Interest ques�onnaire (Form CIQ).

Who must complete and filed CIQ form?

Every vendor doing business with Hood County or seeking to do business with Hood County must complete Box 1 and sign and date in Box 7. Whether or not a conflict exists determines the other informa�on to include on the form.

Who is a vendor?

The term “vendor” includes a partnership, corpora�on or other legal en��es, including those performing professional services. Partnerships or corpora�ons act through individuals, but it is the partnership or corpora�on that is doing business with or seeking to do business with the County. If the vendor seeking to do business with the County is a sole proprietorship, then just the name of the person who is the vendor is needed.

What triggers the requirement to file the Form CIQ?

When a vendor (or an agent of the vendor) begins (1) contract discussions or nego�a�ons with the County or (2) submits an applica�on, quote, response to request for proposals or bids, or anything else that could result in an agreement (contract or purchase order) with the County, Form CIQ must be completed. Whether the vendor ini�ates the discussion, or the County ini�ates the discussions, Form CIQ must be completed. The monetary amount or value of the contract/purchase does not ma�er. The contract or purchase may involve the sale or purchase of property, goods, or services with the County.

When does a conflict requiring disclosure exist? What has to be revealed?

• A vendor shall file a completed conflict of interest ques�onnaire if the vendor has a business rela�onship with Hood County and the vendor:

(1) has an employment or other business rela�onship with an officer of Hood County, or a family member of an officer, that results in taxable income exceeding $2,500 during the 12-month period preceding the date a contract/purchase is executed or a contract/purchase is being considered; or

(2) has given an officer of Hood County, or a family member of an officer, one or more gi�s with the aggregate value of more than $100 in the 12-month period preceding the date a contract/purchase is executed or a contract/purchase is being considered

(3) has a family rela�onship with an officer of Hood County.

What family rela�onships create a conflict?

A “family member" is a person related to another person within the first degree by consanguinity (blood) or affinity (marriage), as described by Subchapter B, Chapter 573, Texas Government Code. The ending of a marriage by divorce or the death of a spouse ends rela�onships by affinity created by that marriage unless a child of that marriage is living, in which case the marriage is considered to con�nue as long as a child of that marriage lives.

“Family rela�onship” means a rela�onship 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, Texas Government Code.

Who are officers of Hood County?

Officers are the members of the Hood County Commissioners’ Court and any agent or employee who exercises discre�on in the planning, recommending, selec�ng, or contrac�ng with a vendor. An agent may include Elected or Appointed Department Heads, as well as others, who assist the County in making a decision on some contract or purchase.

When must a vendor file the Conflict of Interest ques�onnaire?

No later than seven days a�er the date the vendor: (a) begins contract discussions or nego�a�ons with the County, or (b) submits an applica�on or response to a request for proposals, qualifica�ons or bids, correspondence, or another wri�ng related to a poten�al agreement with a County, or (c) becomes aware of an employment or other business rela�onship with an officer or family member of the officer that the vendor

(i) has made one or more gi�s of more than $100 or (ii) has a family rela�onship with.

How do I go about filling out the Conflict of Interest Ques�onnaire form?

Sec�on 1: Fill in the full name of the person or company who is trying to do business with the County. If the

“person” is a corpora�on, partnership, etc., then it is the name of that corpora�on, partnership, etc., that is required on Form CIQ. If a sole proprietorship, then just the name of the individual is needed. If the “person” is an individual ac�ng as an agent for some other person or a company, then it is the agent’s name. Any �me an agent is involved, two FORM CIQs must be completed and submi�ed: one for the agent, and one for the person or company that the agent acted for. The agent’s FORM CIQ must note the vendor that the agent acted for.

Sec�on 2: Check box if the form is an update to a form previously completed. Updates are required by the 7th business day a�er an event that makes a statement in a previously filed ques�onnaire incomplete or inaccurate.

Sec�on 3: Insert the name of Hood County officer with whom there is an affilia�on to or business rela�onship. If there is more than one County officer with whom there is an affilia�on or business rela�onship, a separate form should be completed for each officer.

Sec�on 4: Check the “Yes” or “No” box in Sec�on 4 A or B.

4.A: State whether the officer named on the form receives or is likely to receive taxable income, other than investment income, from the vendor filing the ques�onnaire.

4.B: State whether the vendor receives or is likely to receive taxable income, other than investment income, from or at the direc�on of the officer named on the form AND the taxable income is not received from the County.

Sec�on 5: Describe each employment or business rela�onship with the local government officer named on the form.

Sec�on 6: Check box to acknowledge gi�s made that require disclosure.

Sec�on 7: Person comple�ng form must date and sign the form. If the form is being completed for a corpora�on, partnerships, etc., the person signing should be someone who is authorized to act on behalf of that en�ty. A signature is required in box #4 regardless of any other entry on the form.

If you have any ques�ons about compliance, please consult your own legal counsel. Compliance is the responsibility of each individual, business, and agent who is subject to the law’s filing requirement.

A copy of Chapter 176 of the Texas Local Government Code can be found at:

h�p://www.statutes.legis.state.tx.us/SOTWDocs/LG/htm/LG.176.htm

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

FORM CIQ

OFFICE USE ONLY

Date Received

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.

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

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 ownership interest of one percent or more.

Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021

Revised 1/1/2021Form provided by Texas Ethics Commission www.ethics.state.tx.us

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

A complete copy of Chapter 176 of the Local Government Code may be found at http://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form.

Local Government Code § 176.001(1-a): "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 and that is subject to regular examination by, and reporting to, that agency.

Local Government Code § 176.003(a)(2)(A) and (B):

(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:

(2) the vendor:

(A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that

(i) a contract between the local governmental entity and vendor has been executed;

or

(ii) the local governmental entity is considering entering into a contract with the vendor;

(B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that:

(i) a contract between the local governmental entity and vendor has been executed; or

(ii) the local governmental entity is considering entering into a contract with the vendor.

Local Government Code § 176.006(a) and (a-1)

(a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and:

(1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A);

(2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or

(3) has a family relationship with a local government officer of that local governmental entity.

(a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of:

(1) the date that the vendor:

(A) begins discussions or negotiations to enter into a contract with the local governmental entity; or

(B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or

(2) the date the vendor becomes aware:

(A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a);

(B) that the vendor has given one or more gifts described by Subsection (a); or

(C) of a family relationship with a local government officer.

11 Form W-9