ESBD_383080_1731698258618_EXHIBIT C - Acknowledgement of Receipt Form.pdf

Exhibit C Acknowledgment of Receipt Form

In acknowledgment of receipt of this Request for Qualifications, the undersigned agrees that he/she has received a complete copy, beginning with the title page and Table of Contents and Exhibits.

The acknowledgment of receipt should be signed, returned, and included with the Respondent's submittal. Complete (Legal) Name of Proposer:

Proposer Tax Identification Number:

Business Address:

Telephone Number:

Type of Organization: Individual Partnership Corporation Association

Other (please describe)

If incorporated, state of incorporation:

Date organization was formed (month/year):

The number of years providing services/systems similar to those requested in this Solicitation:

Description of Proposer’s organization, locations, and number of staff (including subcontractors as applicable) that will provide services/support outlined in this Solicitation):

Please certify the following by placing an “X” in the appropriate column:

Certification Yes No Is Proposer/Respondent currently in the process of filing for bankruptcy?

Has Proposer/Respondent filed for bankruptcy within the past five (5) years?

Is the Proposer/Responder delinquent on any taxes owed to Travis County?

Do you certify that the Proposer/Responder is not currently under suspension or debarment by any governmental entity (City of Austin/state/federal government)?

Do you acknowledge that if the Proposer/Responder is currently under suspension or debarment, its submittal may not be considered?

Acknowledged Addenda of

Individual authorized to bind Proposer/Respondent to contract:

Name/Title:

Telephone: E-mail:

Point of contact information for this Solicitation (if different from authorized individual):

Name/Title:

Telephone: E-mail:

Contract Terms and Conditions

The contract terms and conditions identified in the Exhibit L, the Contract Template of this Solicitation, will form the contract resulting from this Solicitation, and the Proposer /Respondent’s submission will be incorporated into the contract. Please identify whether there are any requested exceptions or deviations.

I do not request any exceptions or deviations to the stated contract terms.

I request the following exceptions or deviations to the stated contract terms.

Litigation History:

Description of litigation to which the firm has been a party in the most recent five-year period. Please include the following details:

1) Name of case

2) Date filed

3) Court in which filed

4) Judgment or result

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Important: The Proposer/Respondent must respond to all questions. The Proposer/Respondent may attach additional documents to the questionnaire to provide additional details.

Authorized Respondent Signature Date

Printed Name Title