6-Vendor Litigation Disclosure Form.pdf
PDF 188 KB Posted
- Solicitation number
- 1189
- Issued by
- Denton County, Texas
About this file
This is a Vendor Litigation Disclosure Form required for submission to the City of Corinth, Texas, in response to a Request for Proposal for Health and Welfare Employee Benefits Insurance Plans covering medical, prescription drug, and dental coverage. The form applies to all vendors responding to this solicitation and must be completed and certified by an authorized representative of the applying company.
The form requires vendors to disclose any litigation, arbitration, or administrative proceedings involving the company or its owners, officers, or key employees within the past five years, including case names, numbers, jurisdiction, filing dates, and current status. Additionally, vendors must disclose any criminal charges, regulatory enforcement actions, or government investigations the company has faced within the same five-year period. The form includes a certification statement in which the authorized signatory attests that all provided information is true, complete, and accurate, with explicit warning that failure to disclose relevant information may result in disqualification from consideration or termination of any awarded contract.
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Text version
pg. 1
Vendor Litigation Disclosure Form
Solicitation # __________
1. Vendor Information
• Legal Business Name: ____________________________________________________
• DBA (if applicable): ______________________________________________________
• Address: ____________________________________________________________
• Contact Person: _________________________________________________________
• Phone: _________________________________________________________________
• Email: _________________________________________________________________
2. Litigation Disclosure
• Has your company, or any of its owners, officers, or key employees, been involved in any litigation, arbitration, or administrative proceedings within the past five (5) years? (please circle)
Yes / No
• If yes, provide details for each case:
• Case Name & Number: ___________________________________________________
• Jurisdiction: ____________________________________________________________
• Date Filed: ______________________________________________________________
• Status (Pending, Settled, Resolved): _________________________________________
• Brief Description of the Matter: ____________________________________________
pg. 2
3. Criminal or Regulatory Actions
• Has your company been subject to any criminal charges, regulatory enforcement actions, or government investigations in the past five (5) years? (please circle)
Yes / No
• If yes, provide details: ____________________________________________________
4. Certification
I hereby certify that the information provided above is true, complete, and accurate to the best of my knowledge. I understand that failure to disclose relevant information may result in disqualification from consideration or termination of any awarded contract.
• Authorized Signatory (print): _____________________________________________
• Title: _________________________________________________________________
• Date: _________________________________________________________________
• Signature: _____________________________________________________________
File details come from the government source that posted it. Updated .