ESBD_533035_1782845701580_Form 1 - Execution of Response.docx

Request for Proposal (RFP) Form 1 – Execution of Response [Number and Title of Solicitation] Respondent must complete the following information, sign, and return this page. By signing below, Respondent acknowledges receipt of all TWC Terms and Conditions in the RFP—including all Attachments, agrees to provide the items/services described in this RFP, and agrees to abide by all TWC Terms and Conditions as specified in this RFP, its Attachments, and in any Contract resulting from an award.

Any exceptions taken to the Terms and Conditions as set forth in this document must be identified in detail and accompany the Response. Any exceptions not identified in detail at the time the Response is submitted will not be considered. Please complete the following:

No exceptions taken OR Yes, exception taken due to (state your reason(s)):

Please attach additional forms if additional space is needed. Please label any relevant pages with this same Attachment number and the RFP Number.

Signature of person authorized to contractually bind the organization and enter into a Contract with TWC affirms that:

(1) the Respondent meets the Minimum Qualifications identified in Section 5.2 – Minimum Qualifications of the RFP;

(2) if awarded a Contract under this Solicitation, Respondent affirms its obligations regarding Subcontractors, as identified in RFP Form 6, VetHUB Subcontracting Plan (HSP);

(3) [Other] Respondent will notify TWC of a change in its financial condition prior to the award or if the Successful Respondent, and there is a substantial change in its financial condition during the term of the Contract and any renewal thereof, TWC must be notified of the change in writing at the time the change occurs but no later than ten (10) days after its occurrence.

The Successful Respondent shall notify TWC in writing of any substantial change in the ownership or control of the Successful Respondent as soon as possible, but no later than thirty (30) days prior to its occurrence. Examples of a substantial change in financial condition are events such as insolvency, bankruptcy or receivership.

The Successful Respondent shall provide thirty (30) days’ notice to TWC’s Contract Manager of any pending litigation, investigations or adverse actions that may materially impact their ability to perform under this Contract. Such notice shall include: the date of initiation, the nature of the litigation or adverse action, and the parties involved in the action, and when resolved, the resolution.

Signature: ____________________________________ Date Signed: ______________ Printed name of person signing above: ______________________________

RESPONDENT INFORMATION

Name of Respondent:

Mailing Address:

Billing Address (if different from above):

City, State & Zip Code:

Phone No./Fax No.:

E-Mail Address:

Employer Identification No.:

Texas Identification No.:

RESPONDENT POINT OF CONTACT FOR RESPONSE

Name of Contact:

Mailing Address:

Billing Address (if different from above):

City, State & Zip Code:

Phone No./Fax No.:

E-Mail Address:

RESPONDENT POINT OF CONTACT FOR CONTRACT

Respondent Legal Name:

Other business names used:

Mailing Address:

Billing Address (if different from above):

City, State & Zip Code:

Phone No./Fax No.:

E-Mail Address:

To minimize identity theft, every company/individual MUST have an Employer Identification Number (EIN), also known as a federal tax identification number prior to award of a contract. For information on obtaining your EIN, you may call 800-829-4933 or visit the following website: https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online The Texas Identification Number (TIN) is the payee identification number assigned and used by the Texas Comptroller of Public Accounts to process payment for goods/services. Enter this number in the space provided above if number is not pre-printed. If this number is not known, please visit https://mycpa.cpa.state.tx.us/coa/. To obtain a TIN, please visit https://fmx.cpa.texas.gov/fm/pubs/payment/payee_setup/?s=forms_payee_maint&p=app_tin.

Check here if you are a sole ownership or partnership.

Check below to claim a preference under Statute:

Goods produced or offered by a Texas bidder that is owned by a Texas resident service-disabled veteran.

Goods produced in Texas or offered by a Texas bidder that is not owned by a Texas resident service-disabled veteran.

Agricultural products grown in Texas.

Agricultural products offered by Texas bidder.

Services offered by a Texas bidder that is owned by a Texas resident service-disabled veteran.

Services offered by a Texas bidder that is not owned by a Texas resident service- disabled veteran.

Texas vegetation native to the region.

USA produced supplies, materials or equipment.

Products of persons with mental or physical disabilities.

Products made of recycled, remanufactured, or environmentally sensitive materials including recycled steel.

Energy Efficient Products.

Rubberized asphalt paving material.

Recycled motor oil and lubricants.

Products produced at facilities located on formerly contaminated property.

Products and services from economically depressed or blighted areas.

Vendors that meet or exceed air quality standards.

Recycled or reused computer equipment of other manufacturers.

Foods of higher nutritional value.