3-Contract Forms A-E v.July 2026.docx

DISCLOSURE OF RELATIONSHIPS

FORM A

Failure to Disclose Relationships and to submit the appropriate Conflict of Interest Disclosure Forms will be Sufficient Cause for the Immediate Termination of this Agreement

Please contact IPS Purchasing at purchasing@myips.org to complete appropriate Conflict of Interest Disclosure Forms if any relationship(s) exist as outlined below.

Any Conflict of Interest Disclosure must be approved by the Board of School Commissioners of the City of Indianapolis prior to beginning any work on this Contract.

Agreement dated Click or tap to enter a date. between the Board of School Commissioners of the City of Indianapolis and Click or tap here to enter text.

Please describe below your relationship (by blood or marriage), or the relationship of any sole proprietor, partner, owner, co-owner, principal, corporate officer, (by blood or marriage) with any member of the Board of School Commissioners or Indianapolis Public School staff that may be directly or indirectly involved in any of the following (state “NONE” if no relationship exists):

· the procurement, administration and/or execution of this Agreement

· review or approval of payments for this Agreement Please disclose if you, or any sole proprietor, partner, owner, co-owner, principal, or corporate officer of the Consultant/Vendor is also an employee of the Board of School Commissioners of the City of Indianapolis or Indianapolis Public Schools (state “NONE” if there is no employment relationship):

Company Name

Title

Signature

Date

DIVERSE & LOCAL SUPPLIER UTILIZATION

FORM B

☐ YES

☐ NO

1. Is the contractor a certified MBE, WBE, VBE, DOBE or Local Business?

If yes, which status(s)? ☐MBE ☐WBE ☐VBE ☐DOBE ☐Local Certifying Organization: Click here to enter text.

☐ YES

☐ NO

2. Does the contractor intend to utilize a MBE, WBE, VBE, DOBE or Local Business to help participate in the above project?

What good faith efforts were utilized to increase MBE, WBE, VBE, DOBE and local businesses?

Check all that apply and verify, if requested.

☐ Our firm could not identify a minority, women, veteran, disability owned, or local business to participate in this contract. We have pursued the following efforts below to identify MBE, WBE, VBE, DOBE & local business for this contract.

☐ A. Worked with community groups identified as resources in the MBE, WBE, VBE & Local Business community to identify contractors/suppliers. (i.e. State, NAWBO, City, WBEC, Mid-State MSDC, etc.)

☐ B. Utilize MBE/WBE/VBE/DOBE & local business web directories provided by the State of Indiana and City of Indianapolis to identify certified firms.

☐ C. Negotiated in good faith with interested and certified MBE, WBE, VBE, DOBE & local business to maximize participation.

☐ D. Efforts made to divide total requirements into smaller tasks so that MBE, WBE, VBE, DOBE & local business participation can be maximized.

☐ E. Attended networking events dedicated to MBE, WBE, VBE, DOBE, & local business participation.

List of businesses the respondent plans to utilize.

Acceptable local certifications include, but are not limited to: State of Indiana, City of Indianapolis, Mid-State Minority Supplier Development Council (MSDC), National Minority Supplier Development Council (NMSDC), Women Business Enterprise National Council (WBENC) or Department of Veterans Affairs (VA).

(calculated) Estimated Start and End Date

The contractor representative, on behalf of the bidding firm, verifies that the information provided is correct.

LETTER OF INTENT TO PERFORM SERVICES

FORM C

(To be completed by the MBE, WBE, VBE and Local Business listed on Supplier Diversity Form B Utilization Statement that will participate in the aforementioned project; and submitted to the Board by the Contractor).

The undersigned intends to perform work in connection with the above project as (check one):

The MBE, WBE, VBE & Local Business status of the undersigned must be confirmed prior to contract award (a copy of the certification from a qualifying agency must be provided).

The undersigned has agreed to provide the following work, trades, services or supplies:

Click or tap here to enter text.

at the following price $:

The undersigned will enter into a formal contract or purchase order agreement with Enter Company Name here. for the above work, trades, services, or supplies contingent upon prior execution of a contract between said company and Enter Name here.

MBE, WBE, VBE, or Local Business Name

Address

Phone No.

Business Name & Title (please Print)

Signature

E-VERIFY CERTIFICATION

FORM D

Dear Independent Contractor, The Indiana General Assembly has passed new legislation, I.C. 22-5-1.7, which requires Indianapolis Public Schools ("IPS") to obtain from any entity with which it contracts for services (EXCEPT a self-employed individual who does not employ any employees) certification that the Contractor participates in the E-Verify program and does not knowingly employ unauthorized aliens. Please read the Certification below, sign and return it with the other Required Independent Contractor Information and W-9. Thank you for assisting IPS in complying with this new legislation.

Certification

1. I possess sufficient knowledge of the personnel practices of Contractor to execute this Certification on Contractor's behalf.

2. Contractor has reviewed Indiana Code 22-5-1.7 sections 11 through 16 and has had the opportunity to consult with legal counsel concerning all matters addressed in this Certification and is not relying on IPS's advice or counsel in complying with the legal requirements this Certification addresses.

3. To the extent Contractor is entering into a Public contract for services with IPS (hereafter "Services Contract") and is not a self-employed person who does not employ any employees, Contractor certifies that

a. Contractor has enrolled in and is verifying the work eligibility status of all of Contractor's newly hired employees through the E-Verify program for the duration of this and any future Services Contract with IPS, unless and until the E-Verify program no longer exists.

b. Contractor affirms that it does not knowingly employ or retain in its employ any unauthorized aliens.

c. Contractor requires all of its Subcontractors before performing services pursuant to any IPS Services Contract, in any amount, to provide to Contractor a Certification that, at the time of Certification.

i. Subcontractor does not knowingly employ or contract with an unauthorized alien; and

ii. Subcontractor has enrolled in and is participating in the E-Verify program.

d. Contractor certifies that it will keep on file the Certifications referenced in paragraph 3(c) above for the duration of any contract with Subcontractor to provide services to IPS.

e. I am an authorized agent of Contractor and acknowledge that if Contractor fails timely to remedy a violation of the provisions of paragraph 3(a) and (b) above under its Services Contract with IPS, IPS will terminate the Services Contract and Contractor is liable to IPS for actual damages.

4. Contractor acknowledges that, to the extent Contractor is not a self-employed person who does not employ any employees, upon execution, this Certification becomes an enforceable provision of any existing or future Services Contract between Contractor and IPS.

I declare under penalty of perjury, a Class D Felony, that the foregoing representations are true:

Company Name

Title

Signature

Date

CERTIFICATION NOT SUSPENDED DEBARRED

FORM E

CERTIFICATION THAT CONTRACTOR, ITS PRINCIPALS OR SUBRECIPIENTS ARE NOT

SUSPENDED OR DEBARRED FROM DOING BUSINESS WITH THE FEDERAL GOVERNMENT

By signing below, Contractor certifies that the Contractor, its principals and/or subrecipients are not suspended or debarred by the Federal Government, nor is any known suspension or debarment procedure pending. Contractor agrees to notify the Board of School Commissioners in writing of any suspension or debarment, or potential suspension or debarment proceeding. Failure to report any suspension or debarment, or any potential suspension or debarment will be sufficient cause to terminate this Contract and report such termination to Federal authorities. The Contractor representative certifies that he/she has authorization to make such certification and to bind the Contractor to all representations herein

Company Name

Title

Signature

Date

NATIONAL EXPANDED CRIMINAL HISTORY

YOUR CONTRACT WILL NOT BE APPROVED WITHOUT THE SUBMISSION OF CURRENT EXPANDED CRIMINAL HISTORY and Expanded Child Protection Index Checks MEETING THE REQUIREMENTS OF HOUSE ENROLLED ACT 1462 FOR ALL CONTRACTORS OR INDIVIDUALS THAT WILL HAVE DIRECT OR ONGOING CONTACT WITH IPS STUDENTS.

Effective July 1, 2009, House Enrolled Act 1462 passed by the Indiana General Assembly requires that a current expanded criminal history check must be filed with the Board for each Contractor and Contractor employee that is likely to have direct or ongoing contact with IPS students.

An expanded criminal history check as defined by House Enrolled Act 1462, is a criminal history background check that includes a:

1. Search of records of all counties in Indiana and all counties or other governmental units in all states in which the individual resided or a national criminal history background check as defined in Indiana Code 10-13-3-12*, and

2. Check of sex offender registries in all 50 states or the national sex offender registry maintained by the United States Department of Justice and expanded Child Protection Index Check (DCS check)

*10-13-3-12: National Criminal History Background Check: As used in this chapter, “national criminal history background check” means the criminal history record system maintained by the Federal Bureau of Investigation based on fingerprint identification or any other method of positive identification.

Contractors and their legal counsel shall review the requirements of House Enrolled Act 1462 (which defines an expanded criminal history check and modifies Indiana Code 2026-5-10) and file with the Board a current (no older than 90 days) expanded criminal history report meeting the requirements of House Enrolled Act 1462 for each Contractor, Contractor employee, or any person engaged by the Contractor who will have direct or on-going contact with IPS students during its course of work for the Board.

It is the full responsibility of the Contractor to obtain and file the expanded criminal history checks meeting the requirements of House Enrolled Act 1462 for every individual that will provide services and have direct or on-going contact with IPS students during the Contractor’s course of work for the Board.

Contractor will pay all expenses related to obtaining the expanded criminal history check.

These requirements are in addition to all requirements related to criminal history stated in your contract with the Board. Failure to meet these requirements will be sufficient cause for the immediate termination of your contract.