ESBD_369737_1722363909839_9 Attachment H - Disclosure of Potential Conflicts of Interest Form.pdf

IFB No. 608-24-96172 Page 1 of 3 Court Reporting and Transcription Services

Attachment H

Disclosure of Potential Conflicts of Interest Form

Note to Respondents: TxDMV will not accept information provided in other areas of the Solicitation Response as satisfaction in lieu of full completion of this Exhibit. Respondents must incorporate this completed form into a separate and distinct tab in their Solicitation Response. Failure to furnish this information will result in disqualification of the Solicitation Response.

It is the policy of the state of Texas and TxDMV that a state officer or a state employee may not have direct or indirect interest, including financial and other interest, or engage in a business transaction or professional activity, or incur an obligation in any nature that conflicts with the proper discharge of the officer or employee’s duties in the public interest (Tex. Gov’t Code § 572.001(a)). TxDMV is committed to vetting any conflict of interest or any appearance of conflict of interest that may arise in the procurement process.

TxDMV will use the information provided in this form to review conflicts of interest or potential conflicts of interest for this Solicitation.

1. Respondent’s Disclosure of Ownership, Consultants, and Interested Parties

1.1. List the names of Respondent’s partners, major stockholders, or other owners. A “major stockholder” is a person who directly or indirectly owns or controls more than a ten percent interest or a pecuniary interest with a value exceeding $25,000.00 in Respondent. Please state the percentage of ownership or control for each owner.

Name Indicate Whether Owner is a Partner, Major Stockholder, or Other Owner Disclosure Statement

1.2. List any paid consultants with a contract with a value more than $25,000.00 with Respondent, and state whether the contract requires the consultant to actively participate in facilitating the proposed contract with TxDMV or negotiating the terms of the proposed contract with TxDMV. (If not applicable then insert “N/A”.)

Name Type of Contract Disclosure Statement

1.3. List the name(s) of any interested party, as well as the nature of the interest (controlling or intermediary).

An “interested party” is a person who has a controlling interest in the Respondent or who has or will act as an intermediary for Respondent regarding this Solicitation.

A “controlling interest” is:

https://statutes.capitol.texas.gov/Docs/GV/htm/GV.572.htm#572.001

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a) An ownership interest or participating interest in Respondent by units, percentage, shares, stock, or otherwise that exceeds ten percent;

b) Membership on the board of directors or other governing body of Respondent if the board or other governing body is composed of not more than ten members; or

c) Service as an officer of Respondent if Respondent has four or fewer officers, or service as one of the four officers most highly compensated by Respondent if Respondent has more than four officers.

An “intermediary” is a person who actively participates in the facilitation of the potential contract with TxDMV or will negotiate the potential contract, including a broker, adviser, attorney, or representative of or agent for the Respondent if the person:

a) Receives or will receive compensation from the Respondent for the person’s participation;

b) Communicates directly with or will communicate directly with TxDMV on behalf of

Respondent regarding the proposed contract; and

c) Is not an employee of the Respondent or an entity with a controlling interest in Respondent’s agency/organization.

Note: This subsection does not apply if Respondent is a publicly traded business entity or a wholly owned subsidiary of a publicly traded business entity. If Respondent is a publicly traded business entity or a wholly owned subsidiary of a publicly traded business entity, please disclose this fact under the column for Name.

Name Describe Nature of Controlling Interest, if applicable Describe What Makes the Person an

Intermediary, if applicable

1.4. Attach the Respondent’s organization chart.

2. Subcontractor and/or Supplier Information

2.1. Indicate below the name, address, and phone number of all successful subcontractors and/or suppliers that provided quotes for the Solicitation Response. Please list the dollar value of the subcontract. (If not applicable then insert “N/A”.)

Name Address Telephone Disclosure Statement

2.2. Attach an organizational chart for any subcontractor and/or supplier providing services as part of this response.

3. Prohibited Gifts, Donations, Favors, Services, or Benefits

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State of Texas standards of conduct require TxDMV to rigorously evaluate whether a Respondent has offered any gift, favor, or service that might reasonably tend to influence a state officer or employee in the discharge of official duties, or that the officer or employee knows or should know is being offered with the intent to influence the officer or employee’s official conduct.

3.1. List below any gift or donation the Respondent has offered to TxDMV, an agency board member or agency employee during the two calendar years before submitting its Solicitation. Respondents are required to state the date the gift or donation was offered, to provide a description of the gift or donation, and to provide the monetary value. Indicate whether the value is an estimated or actual value. List the individual at TxDMV you corresponded with regarding the gift or donation. (If not applicable then insert “N/A”.)

Date of Gift or Donation Description of Gift or Donation Monetary Value

(actual or estimated) TxDMV Board Member(s) or Employee(s) Name

3.2. Has the Respondent (includes its employees, agents, or representatives) or any subcontractors related to the Solicitation Response requested a meeting with TxDMV’s senior officials in the past calendar year? (Senior official is defined as Executive Director, Deputy Executive Director, Division Director, Deputy Division Director, or Director of Purchasing.) If yes, list the date of the meeting, the purpose of the meeting, and the TxDMV senior staff member(s) attending. (If not applicable then insert “N/A”.)

Date of Meeting Description of Meeting and Topics Discussed TxDMV Senior Staff

Member(s) Name

4. Information about the Individual that Completed this Form:

Full Name:

Title: