3-RFP-04-Forms.pdf

Form W-9 (Rev. March 2024)

Request for Taxpayer Identification Number and Certification

Department of the Treasury Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information.

Give form to the requester. Do not send to the IRS.

Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.

P ri nt o r ty p e.

S ee S p ec if ic

In st ru ct io n s on p ag e 3.

1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.)

2 Business name/disregarded entity name, if different from above.

3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor C corporation S corporation Partnership Trust/estate

LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) Note: Check the “LLC” box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner.

Other (see instructions)

3b If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if you have any foreign partners, owners, or beneficiaries. See instructions

4 Exemptions (codes apply only to certain entities, not individuals;

see instructions on page 3):

Exempt payee code (if any)

Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any)

(Applies to accounts maintained outside the United States.)

5 Address (number, street, and apt. or suite no.). See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number or Employer identification number

Part II Certification Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign Here

Signature of U.S. person Date

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

What’s New Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the “LLC” box and enter its appropriate tax classification.

New line 3b has been added to this form. A flow-through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow-through entity in which it has an ownership interest. This change is intended to provide a flow-through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065).

Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS is giving you this form because they

Cat. No. 10231X Form W-9 (Rev. 3-2024)

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 Date ownership interest of one percent or more.

Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 8/14/2024

Name of signatory

Certification Regarding Lobbying

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form – LLL, “Disclosure of Lobbying Activities,” in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Name of Proposer / Company:

Program / Project Name: Disaster Recovery – Home Repair Services Contract Number (to be completed by City upon award):

Name of Authorized Representative:

Title of Authorized Representative:

Signature: Date:

Certification Regarding Debarment, Suspension, and Other Responsibility Matters

The undersigned certifies, to the best of his or her knowledge and belief, that neither the Proposer nor its principals:

1. Are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency;

2. Have, within a three-year period preceding this proposal, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are presently indicted for or otherwise criminally or civilly charged by a governmental entity with commission of any of the offenses enumerated in paragraph (2) of this certification; and

4. Have not, within a three-year period preceding this application, had one or more public transactions (Federal, State, or local) terminated for cause or default.

Where the Proposer is unable to certify to any of the statements in this certification, such Proposer shall attach an explanation to this proposal.

Name of Proposer / Company:

Program / Project Name: Disaster Recovery – Home Repair Services Contract Number (to be completed by City upon award):

Name of Authorized Representative:

Drug-Free Workplace and Equal Employment Opportunity Certification

The undersigned certifies that it will provide a drug-free workplace in compliance with the Drug-Free Workplace Act of 1988 (41 U.S.C. 701 et seq.) and will comply with all applicable equal employment opportunity (EEO) requirements as set forth in Executive Order 11246, 41 CFR Part 60, and related laws and regulations.

1. The workplace is free from the unlawful manufacture, distribution, dispensing, possession, or use of controlled substances;

2. Employees are notified that unlawful acts in the workplace are prohibited and will result in disciplinary action; and

3. The Proposer will take affirmative action to ensure equal employment opportunity without regard to race, color, religion, sex (including sexual orientation and gender identity), national origin, disability, or veteran status.

Name of Proposer / Company:

Program / Project Name: Disaster Recovery – Home Repair Services Contract Number (to be completed by City upon award):

Name of Authorized Representative:

Davis-Bacon Act and HUD Section 3 Act of 1968 Acknowledgment Form

The undersigned acknowledges that all work performed under this contract is subject to the Davis-Bacon Act and Section 3 of the Housing and Urban Development Act of 1968 (12 U.S.C. 1701u; 24 CFR Part 75).

1. The Proposer agrees to comply with all applicable Federal labor standards and prevailing wage requirements as determined by the U.S. Department of Labor, and to maintain certified payroll records as required.

2. The Proposer agrees to make good-faith efforts to provide employment, training, and contracting opportunities to low- and very low-income persons and businesses in accordance with Section 3 requirements.

3. The Proposer understands that failure to comply with Davis-Bacon or Section 3 requirements may result in sanctions, withholding of payments, or termination of the contract.

Name of Proposer / Company:

Program / Project Name: Disaster Recovery – Home Repair Services Contract Number (to be completed by City upon award):

Name of Authorized Representative:

Environmental and Safety Compliance Certification

The undersigned acknowledges that all work performed under this contract shall comply with applicable environmental and safety regulations, including but not limited to:

1. The National Environmental Policy Act (NEPA) and related environmental review procedures established by the U.S. Department of Housing and Urban Development (HUD);

2. The Texas Environmental Lead Reduction Rules (TELRR) and all applicable state and local environmental health and safety laws;

3. The HUD Lead-Based Paint Poisoning Prevention in Certain Residential Structures regulations (24 CFR Part 35);

4. Applicable provisions of the Occupational Safety and Health Administration (OSHA) and local building safety codes; and

5. Any additional environmental and safety requirements identified by the City of Fort Worth or HUD during the course of the program.

The Proposer certifies that it will ensure all employees, subcontractors, and agents performing work under this program are trained and equipped to comply with the above regulations and that all hazardous materials will be handled, stored, and disposed of in accordance with applicable law.

Failure to comply with environmental or safety requirements may result in contract termination, suspension of payments, or other sanctions as determined by the City or

HUD.

Name of Proposer / Company:

Program / Project Name: Disaster Recovery – Home Repair Services Contract Number (to be completed by City upon award):

Name of Authorized Representative:

Category Selection Form

Proposers shall indicate the service categories for which they are submitting a proposal, by checking ‘Yes’ or ‘No’. For each selected category, provide a brief description of relevant experience and years of experience, and list any applicable licenses or certifications.

Category Yes/No Brief Description of Experience, Years of Experience & Applicable Licenses/Certifications

1. Bathroom Services ☐ Yes ☐ No

2. Electrical Services ☐ Yes ☐ No

3. Flooring Services ☐ Yes ☐ No

4. Foundation Repair ☐ Yes ☐ No

5. General Construction ☐ Yes ☐ No

6. HVAC Services ☐ Yes ☐ No

7. Insulation Services ☐ Yes ☐ No

8. Kitchen Services ☐ Yes ☐ No

9. Lead Hazard Control Services ☐ Yes ☐ No

10. Moving and Storage ☐ Yes ☐ No

11. Plumbing Services ☐ Yes ☐ No

12. Roofing Services ☐ Yes ☐ No

13. Weatherization Services ☐ Yes ☐ No

Name of Proposer / Company:

Name & Title of Authorized Representative:

Subcontractor Information Form

Each Proposer shall identify all subcontractors anticipated to be used under this contract. Provide the information below for each subcontractor, including the type of work to be performed and any relevant license or certification information.

Attach additional sheets if necessary. All subcontractors are subject to City approval prior to the issuance of any job order.

No. Subcontractor Name Trade/Type of Work Business Address

Contact Name & Phone / Email

1.

2.

3.

4.

5.

6.

7.

8.

9.

By signing below, the Proposer certifies that any listed subcontractor is not debarred, suspended, or otherwise excluded from participation in federal programs (per 2 CFR 180).

Name of Proposer / Company:

Name & Title of Authorized Representative: