5-4. Conflict of Interest Questions.pdf

CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ

For vendor or other person doing business with local governmental entity

This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session. OFFICE USE ONLY Date Received

This questionnaire is being in accordance with Chapter 176, Local Government Code by a person who has a business relationship as defined by Section 176.00 (1-a) with a local governmental entity and the person meets requirements under Section 176.006 (a).

By law this questionnaire must be filed with the record administrator of the local Governmental entity not later that the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code.

A person commits an offense if the person knowingly violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.

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

2. □ Check this box if you are filing an update to a previously filed questionnaire.

(The law requires that you file an update completed questionnaire with the appropriate filing authority not Later than the 7th business day after the date the originally filed questionnaire becomes incomplete or Inaccurate.)

3. Name of local government officer with whom filer has employment or business relationship.

Name of Officer

This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an employment or other business relationship as defined by Section 176.001 (1-a), Local Government Code.

Attach additional pages to this Form CIQ as necessary.

A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the filer of the questionnaire?

Yes No

B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity?

Yes No

C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the Local government officer serves as an officer or director, or holds an ownership of 10 percent or more?

Yes No

D. Describe each employment relationship with the local government officer named in this section.

4.

Signature of person doing business with the governmental entity Date kbridwell Cross-Out

Note: A completed Profile of Firm Form must be submitted for each subcontractor.

Proposed Subcontractors Item Company Name Address Phone Specialty W/M/BE

I understand and agree that if awarded a contract as a result of this solicitation that the use of the above subcontractors is subject to the approval of FWHS and becomes a part of the contract.

I further understand that any change in subcontractors also requires the pre‐approval of

FWHS.

(Signature)

(Printed Name & Title)

Note: A completed Profile of Firm Form must be submitted for each subcontractor

FORT WORTH HOUSING SOLUTIONS

(This Form must be fully completed by all Proposers and Subcontractors)

(1) Prime _ _Joint Venture/Partner Sub‐contractor _ (This form shall be completed by and for each).

(2) Name of Firm: Telephone: Fax:

(3) Street Address, City, State, Zip:

(4) Identify Principals/Partners in Firm

% OF

NAME TITLE OWNERSHIP

(5) Please indicate the operating structure of your company.

□Publicly Held □Privately Held □ Government □ Non‐Profit □ Partnership □ Sole Corporation Corporation Agency Organization Proprietorship

(6) Respondent’s Diversity Statement: You must check all of the following that apply to the ownership of this firm and enter where provided the correct percentage (%) of ownership of each:

Minority‐ (MBE), or Woman‐Owned (WBE) Business Enterprises qualify by virtue of 51% or more Ownership and active management by one or more of the following:

□African □**Native □Hispanic □Asian/Pacific □Hasidic □Asian/Indian

American American American American Jew American

□Woman‐Owned

(MBE)

□Woman‐Owned

(Caucasian)

□Disabled Veteran

□Caucasian

American (Male)

□Other (Specify):

(7) Is the business 51% or more owned by a public housing resident? _ Yes _ _ No. If yes, provide name and address of the public housing facility:

Facility Name:

Facility Address: City:

SWMBE Certification Number:

Certification Agency:

(Note: A CERTIFICATION/NUMBER IS NOT REQUIRED – ENTER IF AVAILABLE)

FORT WORTH HOUSING SOLUTIONS

PROFILE OF FIRM FORM (Page 1 of 2)

(Form must be completed, 9-10 if applicable)

(8) Federal Tax ID Number:

(9) City of Fort Worth Business License No:

(10) State of Texas License Type and No:

(11) Has your firm or any member of your firm been a party to litigation with a public entity? If yes, when, with whom and state the circumstances and any resolution.

Yes No

(12) Has your firm or any member of your firm ever sued or been sued by the Fort Worth Housing Solutions or its affiliated entities? If yes, when and state the circumstances and any resolution of the lawsuit.

Yes No

(13) Has your firm or any member of your firm ever had a claim brought against because of breach of contract or Non‐performance? If yes, when and state the circumstances and any resolution of the matter.

Yes No

(14) Debarred Statement: Has this firm, or any principal(s) ever been debarred from providing any services by the Federal Government, any state government, the State of Texas, or any local Government agency within or without the State of Texas? If “Yes,” please attach a full detailed explanation, including dates, circumstances and current status.

Yes No

(15) Disclosure Statement: Does this firm or any principals thereof have any current, past, personal or Professional relationship with any Commissioner or Officer of FWHA? If “Yes,” please attach a full detailed explanation, including dates, circumstances and current status.

Yes No

(16) Verification Statement: The undersigned Offeror hereby states that by completing and submitting this form he/she is verifying that all information provided herein is, to the best of his/her knowledge, true and accurate, and agrees that if the FWHS discovers that any information entered herein is false, that shall entitle the FWHS to not consider nor make award or to cancel any award with the undersigned party.

Signature Date Printed Name Company

PROFILE OF FIRM FORM (Page 2 of 2)