4-Form 7 - Disclosure of Interest.pdf

FY26 – Version 2 Procurement Department October 2025

Form 7 – Disclosure Of Interest

Purpose

This form ensures compliance with the City of Brownsville’s transparency and ethics requirements by disclosing any ownership, employment, or financial interest in the Respondent’s business held by City officials, employees, or members of City boards and commissions.

All Respondents submitting to a formal solicitation, cooperative contract purchase, or agreement requiring City Commission approval must complete and submit this form.

Disclosure Statement

Please select one of the following options:

☐ No Interests to Disclose: The Respondent affirms that no City official, employee, or board or commission member has any financial interest, ownership interest, or employment relationship with the Respondent or its affiliates.

☐ Interests to Disclose: The following individuals have a financial interest, ownership interest, or employment relationship with the Respondent or its affiliates:

Name of City Official / Employee / Board Member

Title / Department / Board

Nature of Interest (Employment, Ownership, Investment, etc.)

% of Ownership or Compensation

Attach additional pages if necessary.

FY26 – Version 2 Procurement Department October 2025

Certification

By signing below, the Respondent certifies that the information provided herein is true and correct to the best of their knowledge and belief. The Respondent further understands that failure to disclose an interest or providing false, misleading, or incomplete information may result in disqualification, termination of contract, or prosecution under Texas Penal Code § 37.10 (Tampering with a Governmental Record).

Signature: ____________________________________________

Printed Name: _________________________________________

Title: _________________________________________________

Date: ______________________

Company Name: ________________________________________

Phone: ______________________

Section 40-7 – Prohibited Contractor Contributions Acknowledgment

The Respondent acknowledges the provisions of City Code Sec. 40-7 (Prohibited Contractor Contributions), which make it unlawful for any contractor to contribute or offer any contribution to a candidate, or for any candidate to solicit or accept any contribution from a contractor during a contract award period. The Respondent further agrees to provide, upon request, a complete list of all persons included in the term “contractor” as defined in that section, and understands that such list may be forwarded to the City Secretary in accordance with the ordinance.

Definitions

For the purposes of this form:

• City Official – Any elected official of the City of Brownsville and any appointed member of a board, commission, or committee established by the City Commission.

• Employee – Any individual employed by the City of Brownsville, whether full-time, part-time, or temporary.

• Financial Interest – Any ownership, employment, or compensation arrangement involving the Respondent, its affiliates, or subsidiaries that results in direct or indirect monetary benefit.

• Ownership Interest – Having legal or equitable title to at least ten percent (10 %) of the voting shares, capital stock, or other ownership interest of the Respondent.

• Affiliate – Any business entity that directly or indirectly controls, is controlled by, or is under common control with the Respondent.